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Exhibit 10.2

    
      

    

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    Exhibit
      10.2

     

     

    

      Contract
        No. FAR009

      

      STATE
        OF FLORIDA

      AGENCY
        FOR HEALTH CARE ADMINISTRATION

      STANDARD
        CONTRACT

      

      THIS
        CONTRACT is
        entered into between the State of Florida,
        AGENCY FOR HEALTH CARE ADMINISTRATION,
        hereinafter referred to as the "Agency",
        whose
        address is 2727 Mahan Drive, Tallahassee, Florida 32308, and WELLCARE
        OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA
        hereinafter referred to as the "Vendor",
        whose
        address is P.O.
        Box
        26011, Tampa, Florida 33623-6011,
        a
Florida
        for profit corporation, to
        deliver
        health care services at the component level and to the TANF and SSI
        populations.

      

      	I.  	
              THE
                VENDOR HEREBY AGREES:

            

      

      A. General
        Provisions

      

      
        	 	 	
                1.

              	
                To
                  provide services according to the terms and conditions set forth
                  in this
                  Contract, Attachment
                  I,
                  Scope of Services, and all other attachments named herein which
                  are
                  attached hereto and incorporated by
                  reference.

              

      

      

      	2.  	
              To
                perform as an independent vendor and not as an agent, representative,
                or
                employee of the Agency.

            

      

      	3.  	
              To
                recognize that the State of Florida, by virtue of its sovereignty,
                is not
                required to pay any taxes on the services or goods purchased under
                the
                terms of this Contract.

            

      

      	B.  	
              Federal
                Laws and Regulations

            

      

      	1.  	
              The
                Vendor shall comply with the provisions of 45 CFR, Part 74, and/or
                45 CFR,
                Part 92, and other applicable regulations as specified in Attachments
                I and II.

            

      

      	2.  	
              This
                Contract contains federal funding in excess of $25,000. Pursuant
                to 45
                CFR, Part 76, if this Contract contains federal funding in excess
                of
                $25,000, the Vendor must, upon Contract execution, complete the
                Certification Regarding Debarment, Suspension, Ineligibility, and
                Voluntary Exclusion Contracts/Subcontracts, Attachment
                IV.

            

      

      	3.  	
              This
                Contract contains federal funding in excess of $100,000. The Vendor
                must,
                upon Contract execution, complete the Certification Regarding Lobbying
                form, Attachment
                V.
                If a Disclosure of Lobbying Activities form, Standard Form LLL, is
                required, it may be obtained from the Agency’s Contract Manager. All
                disclosure forms as required by the Certification Regarding Lobbying
                form
                must be completed and returned to the Agency’s Contract
                Manager.

            

      

      	C.  	
              Audits
                and Records

            

      

      
        	 	
                1.

              	
                To
                  maintain books, records, and documents (including electronic storage
                  media) pertinent to performance under this Contract in accordance
                  with
                  generally accepted accounting procedures and practices which sufficiently
                  and properly reflect all revenues and expenditures of funds provided
                  by
                  the Agency under this Contract.

              

      

      

      
        	 	
                2.

              	
                To
                  assure that these records shall be subject at all reasonable times
                  to
                  inspection, review, or audit by state personnel and other personnel
                  duly
                  authorized by the Agency, as well as by federal
                  personnel.

              

      

      

      
        	 	
                3.

              	
                To
                  maintain and file with the Agency such progress, fiscal and inventory
                  reports as specified in Attachment
                  II,
                  and other reports as the Agency may require within the period of
                  this
                  Contract. In addition, access to relevant computer data and applications
                  which generated such reports should be made available upon
                  request.

              

      

      

      
        	 	
                4.

              	
                To
                  ensure that all related party transactions are disclosed to the
                  Agency
                  Contract Manager. 

              

      

      

      
        	 	 	
                5.

              	
                To
                  include these aforementioned audit and record keeping requirements
                  in all
                  approved subcontracts and
                  assignments.

              

      

      

      	D.  	
              Retention
                of Records

            

      

      
        	 	 	
                1.

              	
                To
                  retain all financial records, supporting documents, statistical
                  records,
                  and any other documents (including electronic storage media) pertinent
                  to
                  performance under this Contract for a period of five (5) years
                  after
                  termination of this Contract, or if an audit has been initiated
                  and audit
                  findings have not been resolved at the end of five (5) years, the
                  records
                  shall be retained until resolution of the audit
                  findings.

              

      

      

      2.Persons
        duly authorized by the Agency and federal auditors, pursuant to 45 CFR, Part
        74
        and/or 45 CFR, Part 92, shall have full access to and the right to examine
        any
        of said records and documents.

      

      3.The
        rights of access in this section must not be limited to the required retention
        period but shall last as long as the records are retained.

      

      	E.  	
              Monitoring

            

      

      
        	 	 	
                1.

              	
                To
                  provide reports as specified in Attachment
                  II.
                  These reports will be used for monitoring progress or performance
                  of the
                  contractual services as specified in Attachment
                  II.

              

      

      

      
        	 	 	
                2.

              	
                To
                  permit persons duly authorized by the Agency to inspect any records,
                  papers, documents, facilities, goods and services of the Vendor
                  which are
                  relevant to this Contract.

              

      

      

      	F.  	
              Indemnification

            

      

      The
        Vendor shall save and hold harmless and indemnify the State of Florida and
        the
        Agency against any and all liability, claims, suits, judgments, damages or
        costs
        of whatsoever kind and nature resulting from the use, service, operation
        or
        performance of work under the terms of this Contract, resulting from any
        act, or
        failure to act, by the Vendor, his subcontractor, or any of the employees,
        agents or representatives of the Vendor or subcontractor.

      

      G. Insurance

      

      
        	 	 	
                1.

              	
                To
                  the extent required by law, the Vendor will be self-insured against,
                  or
                  will secure and maintain during the life of the Contract, Worker’s
                  Compensation Insurance for all his employees connected with the
                  work of
                  this project and, in case any work is subcontracted, the Vendor
                  shall
                  require the subcontractor similarly to provide Worker’s Compensation
                  Insurance for all of the latter’s employees unless such employees engaged
                  in work under this Contract are covered by the Vendor’s self insurance
                  program. Such self insurance or insurance coverage shall comply
                  with the
                  Florida Worker’s Compensation law. In the event hazardous work is being
                  performed by the Vendor under this Contract and any class of employees
                  performing the hazardous work is not protected under Worker’s Compensation
                  statutes, the Vendor shall provide, and cause each subcontractor
                  to
                  provide, adequate insurance satisfactory to the Agency, for the
                  protection
                  of his employees not otherwise
                  protected.

              

      

      

      
        	 	
                2.

              	
                The
                  Vendor shall secure and maintain Commercial General Liability insurance
                  including bodily injury, property damage, personal & advertising
                  injury and products and completed operations. This insurance will
                  provide
                  coverage for all claims that may arise from the services and/or
                  operations
                  completed under this Contract, whether such services and/or operations
                  are
                  by the Vendor or anyone directly, or indirectly employed by him.
                  Such
                  insurance shall include a Hold Harmless Agreement in favor of the
                  State of
                  Florida and also include the State of Florida as an Additional
                  Named
                  Insured for the entire length of the Contract. The Vendor is responsible
                  for determining the minimum limits of liability necessary to provide
                  reasonable financial protections to the Vendor and the State of
                  Florida
                  under this Contract.

              

      

      

      
        	 	
                3.

              	
                All
                  insurance policies shall be with insurers licensed or eligible
                  to transact
                  business in the State of Florida. The Vendor’s current certificate of
                  insurance shall contain a provision that the insurance will not
                  be
                  canceled for any reason except after thirty (30) days written notice
                  to
                  the Agency’s Contract Manager.

              

      

      

      H. Assignments
        and Subcontracts

      

      To
        neither assign the responsibility of this Contract to another party nor
        subcontract for any of the work contemplated under this Contract without
        prior
        written approval of the Agency.
        No
        such approval by the Agency of any assignment or subcontract shall be deemed
        in
        any event or in any manner to provide for the incurrence of any obligation
        of
        the Agency in addition to the total dollar amount agreed upon in this Contract.
        All such assignments or subcontracts shall be subject to the conditions of
        this
        Contract and to any conditions of approval that the Agency shall deem
        necessary.

      

      I. Financial
        Reports

       

      To
        provide financial reports to the Agency as specified in Attachment
        II.

      

      J. Return
        of Funds

      

      To
        return
        to the Agency any overpayments due to unearned funds or funds disallowed
        pursuant to the terms of this Contract that were disbursed to the Vendor
        by the
        Agency. The Vendor shall return any overpayment to the Agency within forty
        (40)
        calendar days after either discovery by the Vendor, its independent auditor,
        or
        notification by the Agency, of the overpayment.

      

      K. Purchasing

      

      1. P.R.I.D.E.

      

      It
        is
        expressly understood and agreed that any articles which are the subject of,
        or
        required to carry out this Contract shall be purchased from the corporation
        identified under Chapter 946, Florida Statutes, if available, in the same
        manner
        and under the same procedures set forth in Section 946.515(2), (4), Florida
        Statutes; and for purposes of this Contract the person, firm or other business
        entity carrying out the provisions of this Contract shall be deemed to be
        substituted for this agency insofar as dealings with such corporation are
        concerned.

      

      The
        “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
        ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:

      

      P.R.I.D.E.

      2720-G
        Blair Stone Road

      Tallahassee,
        Florida 32301

      (850)
        487-3774

      Toll
        Free: 1-800-643-8459

      Website:
        www.pridefl.com

      

      
        	 	 	 	
                2.

              	
                RESPECT
                  of Florida

              

      

      

      It
        is
        expressly understood and agreed that any articles that are the subject of,
        or
        required to carry out, this Contract shall be purchased from a nonprofit
        agency
        for the blind or for the severely handicapped that is qualified pursuant
        to
        Chapter 413, Florida Statutes, in the same manner and under the same procedures
        set forth in Section 413.036(1) and (2), Florida Statutes; and for purposes
        of
        this Contract the person, firm, or other business entity carrying out the
        provisions of this Contract shall be deemed to be substituted for the state
        agency insofar as dealings with such qualified nonprofit agency are
        concerned.

      

      The
        "nonprofit agency” identified is RESPECT of Florida which may be contacted
        at:

      

      
        	
                RESPECT
                  of Florida.

                2475
                  Apalachee Parkway, Suite 205

                Tallahassee,
                  Florida 32301-4946

                (850)
                  487-1471

                Website:
                  www.respectofflorida.org

              

      

      

      
        	 	
                3.

              	
                Procurement
                  of Products or Materials with Recycled
                  Content

              

      

      

      It
        is
        expressly understood and agreed that any products which are required to carry
        out this Contract shall be procured in accordance with the provisions of
        Section
        403.7065, Florida Statutes.

      

      L. Civil
        Rights Requirements/Vendor Assurance

      

      The
        Vendor assures that it will comply with:

      

      
        	 	 	
                1.

              	
                Title
                  VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
                  seq., which prohibits discrimination on the basis of race, color,
                  or
                  national origin.

              

      

      
        	 	 	
                2.

              	
                Section
                  504 of the Rehabilitation Act of 1973, as amended,
                  29 U.S.C. 794, which prohibits discrimination on the basis of
                  handicap.

              

      

      
        	 	 	
                3.

              	
                Title
                  IX of the Education Amendments of 1972, as amended,
                  20 U.S.C. 1681 et seq., which prohibits discrimination on the
                  basis of sex.

              

      

      
        	 	 	
                4.

              	
                The
                  Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
                  which
                  prohibits discrimination on the basis of
                  age.

              

      

      
        	 	 	
                5.

              	
                Section
                  654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
                  42 U.S.C. 9849, which prohibits discrimination on the basis of
                  race, creed, color, national origin, sex, handicap, political affiliation
                  or beliefs.

              

      

      
        	 	 	
                6.

              	
                The
                  Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
                  discrimination on the basis of disability and requires reasonable
                  accommodation for persons with
                  disabilities.

              

      

      
        	 	 	
                7.

              	
                All
                  regulations, guidelines, and standards as are now or may be lawfully
                  adopted under the above statutes.

              

      

      

      The
        Vendor agrees that compliance with this assurance constitutes a condition
        of
        continued receipt of or benefit from funds provided through this Contract,
        and
        that it is binding upon the Vendor, its successors, transferees, and assignees
        for the period during which services are provided. The Vendor further assures
        that all contractors, subcontractors, subgrantees, or others with whom it
        arranges to provide services or benefits to participants or employees in
        connection with any of its programs and activities are not discriminating
        against those participants or employees in violation of the above statutes,
        regulations, guidelines, and standards.

      

      M. Discrimination

      

      An
        entity
        or affiliate who has been placed on the discriminatory vendor list may not
        submit a bid, proposal, or reply on a contract to provide any goods or services
        to a public entity; may not submit a bid, proposal, or reply on a contract
        with
        a public entity for the construction or repair of a public building or public
        work; may not submit bids, proposals, or replies on leases of real property
        to a
        public entity; may not be awarded or perform work as a contractor, supplier,
        subcontractor, or consultant under a contract with any public entity; and
        may
        not transact business with any public entity. The Florida Department of
        Management Services is responsible for maintaining the discriminatory vendor
        list and intends to post the list on its website. Questions regarding the
        discriminatory vendor list may be directed to the Florida Department of
        Management Services, Office of Supplier Diversity at (850)
        487-0915.

      

      N. Requirements
        of Section 287.058, Florida Statutes

      

      
        	 	
                1.

              	
                To
                  submit bills for fees or other compensation for services or expenses
                  in
                  sufficient detail for a proper pre-audit and post-audit
                  thereof.

              

      

      

      
        	 	 	
                2.

              	
                Where
                  applicable, to submit bills for any travel expenses in accordance
                  with
                  Section 112.061, Florida Statutes.

              

      

      

      
        	 	
                3.

              	
                To
                  provide units of deliverables, including reports, findings, and
                  drafts, in
                  writing and/or in an electronic format agreeable to both parties,
                  as
                  specified in Attachment
                  II, to
                  be received and accepted by the Contract Manager prior to
                  payment.

              

      

      

      
        	 	
                4.

              	
                To
                  comply with the criteria and final date by which such criteria
                  must be met
                  for completion of this Contract as specified in Section III, Paragraph
                  A.
                  of this Contract.

              

      

      

      
        	 	
                5.

              	
                To
                  allow public access to all documents, papers, letters, or other
                  material
                  made or received by the Vendor in conjunction with this Contract,
                  unless
                  the records are exempt from Section 24(a) of Article I of the State
                  Constitution and Section 119.07(1), Florida Statutes. It is expressly
                  understood that substantial evidence of the Vendor's refusal to
                  comply
                  with this provision shall constitute a breach of
                  Contract.

              

      

      

      O. Sponsorship

      

      As
        required by Section 286.25, Florida Statutes, if the Vendor is a
        nongovernmental organization which sponsors a program financed wholly or
        in part
        by state funds, including any funds obtained through this Contract, it shall,
        in
        publicizing, advertising or describing the sponsorship of the program,
        state:

      

      "Sponsored
        by WELLCARE
        OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA and
        the
        State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION".

      

      If
        the
        sponsorship reference is in written material, the words "State of Florida,
        AGENCY FOR HEALTH CARE ADMINISTRATION" shall appear in the same size letters
        or
        type as the name of the organization.

      

      P. Final
        Invoice

      

      The
        Vendor must submit the final invoice for payment to the Agency no more than
        365
        days
        after the Contract ends or is terminated. If the Vendor fails to do so, all
        right to payment is forfeited and the Agency will not honor any requests
        submitted after the aforesaid time period. Any payment due under the terms
        of
        this Contract may be withheld until all reports due from the Vendor and
        necessary adjustments thereto have been approved by the Agency.

      

      
        	 	
                Q.

              	
                Use
                  Of Funds For Lobbying
                  Prohibited

              

      

      

      To
        comply
        with the provisions of Section 216.347, Florida Statutes, which prohibits
        the
        expenditure of Contract funds for the purpose of lobbying the Legislature,
        the
        judicial branch or a state agency. 

      

      R. Public
        Entity Crime

      

      A
        person
        or affiliate who has been placed on the convicted vendor list following a
        conviction for a public entity crime may not be awarded or perform work as
        a
        contractor, supplier, subcontractor, or consultant under a contract with
        any
        public entity, and may not transact business with any public entity in excess
        of
        the threshold amount provided in Section 287.017, Florida Statutes, for category
        two, for a period of 36 months from the date of being placed on the convicted
        vendor list.

      

      S. Health
        Insurance Portability and Accountability Act

       

      To
        comply
        with the Department of Health and Human Services Privacy Regulations in the
        Code
        of Federal Regulations, Title 45, Sections 160 and 164, regarding disclosure
        of
        protected health information as specified in Attachment
        III.

      

      T. Confidentiality
        of Information

      

      Not
        to
        use or disclose any confidential information, including social security numbers
        that may be supplied under this Contract pursuant to law, and also including
        the
        identity or identifying information concerning a Medicaid recipient or services
        under this Contract for any purpose not in conformity with state and federal
        laws, except upon written consent of the recipient, or his/her
        guardian.

      

      U. Employment

      

      To
        comply
        with Section 274A (e) of the Immigration and Nationality Act. The Agency
        shall
        consider the employment by any contractor of unauthorized aliens a violation
        of
        this Act. If the Vendor knowingly employs unauthorized aliens, such violation
        shall be cause for unilateral cancellation of this Contract. The Vendor shall
        be
        responsible for including this provision in all subcontracts with private
        organizations issued as a result of this Contract.

      

      V. Vendor
        Performance

      

      Penalties
        or sanctions for unsatisfactory performance under this Contract are specified
        in
Attachment
        II,
        if
        applicable.

      

       

      II. THE
        AGENCY HEREBY AGREES:

      

      A. Contract
        Amount

      

      To
        pay
        for contracted services according to the conditions of Attachment
        I
        in an
        amount not to exceed $195,884,629.00
        subject
        to the availability of funds. The State of Florida's performance and obligation
        to pay under this Contract is contingent upon an annual appropriation by
        the
        Legislature. 

      

      B. Contract
        Payment

      

      Section
        215.422, Florida Statutes, provides that agencies have 5 working days to
        inspect
        and approve goods and services, unless bid specifications, Contract or purchase
        order specifies otherwise. With the exception of payments to health care
        providers for hospital, medical, or other health care services, if payment
        is
        not available within forty (40) days, measured from the latter of the date
        the
        invoice is received or the goods or services are received, inspected and
        approved, a separate interest penalty set by the Comptroller pursuant to
        Section
        55.03, F. S., will be due and payable in addition to the invoice amount.
        To
        obtain the applicable interest rate, please contact the Agency’s Fiscal Section
        at (850) 488-5869, or utilize the Department of Financial Services website
        at
www.dfs.state.fl.us/interest.html.
        Payments to health care providers for hospitals, medical or other health
        care
        services, shall be made not more than 35 days from the date of eligibility
        for
        payment is determined, and the daily interest rate is .0003333%. Invoices
        returned to a vendor due to preparation errors will result in a payment delay.
        Invoice payment requirements do not start until a properly completed invoice is
        provided to the Agency. A Vendor Ombudsman, whose duties include acting as
        an
        advocate for vendors who may be experiencing problems in obtaining timely
        payment(s) from a State agency, may be contacted at (850) 410-9724 or by
        calling
        the State Comptroller’s Hotline, 1-800-848-3792.

      

      III. THE
        VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

      

      A. Effective/End
        Date

      

      This
        Contract shall begin upon execution by both parties or on July
        1, 2006, (whichever
        is later) and end August
        31, 2009,
        inclusive.

      

       

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      
         

        
          
          

          
          

        

        
          
          

        

      

      B. Termination

      

      1. Termination
        at Will

      

      This
        Contract may be terminated by either party upon no less than thirty (30)
        calendar days written notice, without cause, unless a lesser time is mutually
        agreed upon by both parties. Said notice shall be delivered by certified
        mail,
        return receipt requested, or in person with proof of delivery.

      

      2. Termination
        Due To Lack of Funds

      

      In
        the
        event funds to finance this Contract become unavailable, the Agency may
        terminate the Contract upon no less than twenty-four (24) hours written notice
        to the Vendor. Said notice shall be delivered by certified mail, return receipt
        requested, or in person with proof of delivery. The Agency shall be the final
        authority as to the availability of funds.

      

      3. Termination
        for Breach

      

      Unless
        the Vendor's breach is waived by the Agency in writing, the Agency may, by
        written notice to the Vendor, terminate this Contract upon no less than
        twenty-four (24) hours written notice. Said notice shall be delivered by
        certified mail, return receipt requested, or in person with proof of delivery.
        If applicable, the Agency may employ the default provisions in
        Chapter 60A-1.006(4), Florida Administrative Code.

      

      Waiver
        of
        breach of any provisions of this Contract shall not be deemed to be a waiver
        of
        any other breach and shall not be construed to be a modification of the terms
        of
        this Contract. The provisions herein do not limit the Agency's right to remedies
        at law or to damages.

      

      C. Contract
        Managers

      

      
        	 	 	
                1.

              	
                The
                  Agency’s Contract Manager’s name, address and telephone number for this
                  Contract is as follows:

              

      

      

      G.
        Douglas Harper

      Agency
        for Health Care Administration

      2727
        Mahan Drive, MS #50 

      Tallahassee,
        FL 32308

      (850)
        487-2355

      

      	2.  	
              The
                Vendor’s Contract Manager’s name, address and telephone number for this
                Contract is as follows:

            

      

      Imtiaz
        ("MT") Sattaur

      Wellcare
        of Florida, Inc.

      d/b/a
        Staywell Health Plan of Florida

      P.O.
        Box 26011

      Tampa,
        FL 33623-6011

      (813)
        290-6279

      

      
        	 	 	
                3.

              	
                All
                  matters shall be directed to the Contract Managers for appropriate
                  action
                  or disposition. A change in Contract Manager by either party shall
                  be
                  reduced to writing through an amendment to this Contract by the
                  Agency.

              

      

      

      D. Renegotiation
        or Modification

      

      
        	 	 	
                1.

              	
                Modifications
                  of provisions of this Contract shall only be valid when they have
                  been
                  reduced to writing and duly signed during the term of the Contract.
                  The
                  parties agree to renegotiate this Contract if federal and/or state
                  revisions of any applicable laws, or regulations make changes in
                  this
                  Contract necessary.

              

      

      

      
        	 	 	 	
                2.

              	
                The
                  rate of payment and the total dollar amount may be adjusted retroactively
                  to reflect price level increases and changes in the rate of payment
                  when
                  these have been established through the appropriations process
                  and
                  subsequently identified in the Agency's operating
                  budget.

              

      

      E. Name,
        Mailing and Street Address of Payee

      

      
        	 	 	
                1.

              	
                The
                  name (Vendor name as shown on Page 1 of this Contract) and mailing
                  address
                  of the official payee to whom the payment shall be
                  made:

              

      

      

      Wellcare
        of Florida, Inc.

      d/b/a
        Staywell Health Plan of Florida

      P.O.
        Box 26011

      Tampa,
        FL 33623-6011

      

      
        	 	
                2.

              	
                The
                  name of the contact person and street address where financial and
                  administrative records are
                  maintained:

              

      

      

      Paul
        L. Behrens

      Renaissance
        One

      8735
        Henderson Road

      Tampa,
        FL 33634

      

      F. All
        Terms and Conditions

      

      
        	 	 	 	
                This
                  Contract and its attachments as referenced herein contain all the
                  terms
                  and conditions agreed upon by the
                  parties.

              

      

      

      IN
        WITNESS THEREOF,
        the
        parties hereto have caused this two-hundred
        and ninety-six
        (296)
        page
        Contract, which includes any referenced attachments, to be executed by their
        undersigned officials as duly authorized. This Contract is not valid until
        signed and
        dated by
        both parties.

      

      
        	
                WELLCARE
                  OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF
                  FLORIDA

              	
                STATE
                  OF FLORIDA, AGENCY FOR

                HEALTH
                  CARE ADMINISTRATION

              
	 	 	 	 	 
	
                SIGNED
                  BY:

              	  
                /s/  Todd S.
                Farha         	
                SIGNED
                  BY:

              	   /s/
                 Thomas Arnold     	 
	 	 	 	 	 
	
                NAME:

              	
                 Todd
                  S. Farha

              	
                NAME:

              	
                Thomas
                  W. Arnold

              	 
	 	 	 	 	 
	
                TITLE:

              	
                 President
                  & CEO

              	
                TITLE:

              	
                Deputy
                  Secretary, Medicaid

              	 
	 	 	 	 	 
	
                DATE:

              	 6/26/06	
                DATE:

              	 6/26/06	 
	 	 	 	 	 

      

       

      
 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      FEDERAL
        ID NUMBER: 59-2583622

      

      VENDOR
        FISCAL YEAR ENDING DATE: December
        31st 

      

      List
        of
        attachments included as part of this Contract:

      

      Attachment I Scope
        of
        Services (16
        Pages)

      Attachment II Medicaid
        Reform Health Plan Model Contract (265 Pages)

      Attachment III Business
        Associate Agreement (3 Pages)

      Attachment IV Debarment
        Certification (1 Page)

      Attachment V Lobbying
        Certification (1 Page)

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    ATTACHMENT
      I

    SCOPE
      OF SERVICES

    

    

    A. Service
      (s) to be Provided:

    

    The
      Vendor (Health Plan) shall deliver health care services at the component level
      and to the specific population(s) approved below:

    

    (___)
      PSN
      - Prepaid - Comprehensive Component

    (___)
      PSN
      - Prepaid - Comprehensive and Catastrophic Components

    (___)
      HMO
      - Prepaid - Comprehensive Component

    (_X_)
      HMO -
      Prepaid - Comprehensive and Catastrophic Components

    (___)
      Other Authorized Health Plan - Prepaid - Comprehensive Component

    (___)
      Other Authorized Health Plan - Prepaid - Comprehensive 

    and
      Catastrophic Components

    (_X_)
      Temporary Assistance for Needy Families (TANF)

    (_X_)
      Supplemental Security Income (SSI)

    (___)
      Children with Chronic Conditions (CCC)

    (___)
      HIV/AIDS

    

    

    B. Manner
      of Service (s) Provision:

    

    
      	1.  	
              Policies
                and Procedures

            

    

    

    The
      Health Plan shall comply with all provisions of this Contract and any subsequent
      amendments, and shall act in good faith in the performance of the Contract's
      provisions. The Health Plan shall develop, maintain and implement written
      policies and procedures covering all provisions of this Contract. All policies
      and procedures shall be prior-approved by the Agency in writing. The Health
      Plan
      agrees that failure to comply with all provisions of this Contract shall result
      in the assessment of penalties and/or termination of this Contract, in whole
      or
      in part, as set forth in this Contract.

    

    
      	2.  	
              Benefit
                Grid/Customized Benefit Package

            

    

    

    Exhibit
      1, Benefit Grid (Grid), attached hereto, describes the Health Plan’s Customized
      Benefit Package (CBP). The CBP includes all Covered Services, Qualified Benefits
      and Expanded Services as specified in Attachment II, Section V, Covered
      Services, and VI, Behavioral Health Care. The CBP has been determined to meet
      actuarial equivalency and sufficiency standards for the population or
      populations covered by the CBP. The Health Plan is required to provide these
      services to all Enrollees in accordance with Contract provisions.

    

    The
      Health Plan shall submit its CBP for recertification of actuarial equivalency
      and sufficiency standards for the upcoming year no later than June 30 of each
      year. CBPs may be changed on a Contract-Year basis and only if approved by
      the
      Agency in writing.

    C. Method
      of Payment:

    

    1. General

    

    Notwithstanding
      the payment amounts which may be computed with the rate tables specified in
      Tables 2-6, the sum of total capitation payments under this Contract shall
      not
      exceed the total Contract amount of $195,884,629.00.
      

    

    
      	 	
              a.

            	
              The
                Health Plan shall be paid capitation payments for each Agency Service
                Area, based upon Exhibits 3 through 7, Tables 2 through 6, attached
                hereto, depending on whether the Health Plan contracts for both the
                Comprehensive Component and the Catastrophic Component, or Comprehensive
                Component only, and whether the Health Plan is a Specialty Plan.
                Kick
                Payments shall be paid based upon the amounts specified in Exhibit
                8,
                Table 7, attached hereto, for covered transplant services and Exhibit
                9,
                Table 8, attached hereto, for covered obstetrical delivery
                services.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plans overall payment will be dependent upon the actual Plan
                Factor
                and the percentage adjustment deducted for the Enhanced Benefits
                Accounts.
                Each month the Agency will provide, in writing, the Health Plan with
                its
                Plan Factor. 

            

    

    

    
      	 	
              c.

            	
              All
                payments made to the Health Plan shall be in accordance with this
                section
                (Section C, Method of Payment) and Attachment II, Section XIII, Payment
                Methodology.

            

    

    

    2. Enrollment
      Levels

    

    The
      Agency assigns the Health Plan an authorized maximum Enrollment level for each
      operational county. The authorized maximum Enrollment level is in effect on
      September 1, 2006, or upon Contract execution, whichever is later. 

    

    
      	a.  	
              The
                Agency must approve, in writing, any increase in the Health Plan’s maximum
                Enrollment level for each operational county and subpopulation to
                be
                served, as applicable. Such approval shall not be unreasonably withheld,
                and shall be based upon the Health Plan’s satisfactory performance of
                terms of the Contract and upon the Agency’s approval of the Health Plan’s
                administrative and service resources, as specified in this Contract,
                in
                support of each Enrollment level. 

            

    

    

    
      	b.  	
              Exhibit
                2, Table 1, attached hereto, indicates the Health Plan’s maximum
                authorized Enrollment levels for each Medicaid Reform county and
                each
                applicable authorized eligibility category.

            

    

    

    
       

      
        
        

        
          

        

      

      
        
        

      

    

    

    3. Capitation
      Rate Tables

    

    Tables
      2
      through 6 provide the capitation rates respective to the authorized areas of
      operation, as identified in subsection C, Method of Payment, Item 2, above,
      and
      for the specific populations identified in subsection A, Service(s) To Be
      Provided, above. The Capitation Rate payment shall be in accordance with
      Attachment II, Section XIII, Payment Methodology.

    

    
      	a.  	
              Table
                2 - Capitation Rates for Comprehensive Component and Catastrophic
                Component Health Plans for each Medicaid Reform county for Children
                and
                Families and the Aged and Disabled without Medicare eligibility
                categories. .

            

    

    

    
      	b.  	
              Table
                3 - Capitation Rates for Comprehensive Component Only Health Plans
                for
                each Medicaid Reform county for Children and Families and the Aged
                and
                Disabled without Medicare eligibility categories.
                

            

    

    

    
      	c.  	
              Table
                4 - Capitation Rate Table for SSI Medicare Part B Only and SSI Medicare.
                Parts A and B Enrollees for all Medicaid Reform Counties.
                

            

    

    

    
      	d.  	
              Table
                5 - Capitation Rates for HIV/AIDS Populations for each Medicaid Reform
                county. 

            

    

    

    
      	e.  	
              Table
                6 - Capitation Rates for Medicaid Reform counties for All Medicaid
                Reform
                counties. 

            

    

    

    4. Kick
      Payment Tables

    

    Beginning
      September 1, 2006, the Health Plan shall be paid Kick Payments for each Kick
      Payment service provided in accordance with the following tables:

    

    
      	a.  	
              Table
                7 - Covered Transplant Services. 

            

    

    

    
      	b.  	
              Table
                8 - Obstetrical Delivery Services, regardless of whether or not the
                Health
                Plan is at risk for the Comprehensive Component only, or is at risk
                for
                both the Comprehensive Component and the Catastrophic Component.
                

            

    

    

    The
      Kick
      Payments shall be in accordance with Attachment II, Section XIII, Payment
      Methodology.

     

    
 

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    EXHIBIT
      1

    BENEFIT
      GRID

    
      	(i)  	
              Broward
                - Children and Families

            

      

      
        	
                Covered
                  Service Category

              	
                 

              	
                Visit/Script
                  Limit

              	
                Limit
                  Period

              	
                Dollar
                  Limit

              	
                Limit
                  Period (Annual)

              	
                Copay
                  Amount

              	
                Copay
                  Application

              
	
                (Annual/
                  Monthly)

              
	
                Hospital
                  Inpatient

              
	
                Behavioral
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                Physical
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                 

              
	
                Transplant
                  Services

              
	
                Transplant
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient-services

              
	
                Emergency
                  Room

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Medical/Drug
                  Therapies (Chemo, Dialysis)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Ambulatory
                  Surgery - ASC

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Hospital
                  Outpatient Surgery

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Lab/X-ray

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                day

              
	
                Hospital
                  Outpatient Services NOS

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Outpatient
                  Therapy (PT/RT)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                Outpatient
                  Therapy (OT/ST)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Maternity
                  and Family Planning Services

              
	
                Inpatient
                  Hospital

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Birthing
                  Centers

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Physician
                  Care

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Family
                  Planning

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Pharmacy

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Physician
                  and Phys Extender Services (non maternity)

              
	
                EPSDT

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Primary
                  Care Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Specialty
                  Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                ARNP/Physician
                  Assistant

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (FQHC, RHC)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (CHD)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Other

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Outpatient Professional Services

              
	
                Home
                  Health Services

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Chiropractor

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Podiatrist

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Dental
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                coinsurance

              
	
                Vision
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Hearing
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient
                  Mental Health

              
	
                Outpatient
                  Mental Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                 

              
	
                Outpatient
                  Pharmacy

              
	
                Outpatient
                  Pharmacy

              	
                 

              	
                9

              	
                Monthly

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Services

              
	
                Ambulance

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Non-emergent
                  Transporation

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                trip

              
	
                Durable
                  Medical Equipment

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              

      

      Expanded
        Benefit

      
        	
                Adult
                  Dental

              	
                Adult
                  dental expanded to include unlimited fillings, periodontic deep
                  cleanings,
                  annual exam, two cleanings per year, and x-rays.

              
	
                Circumcision

              	
                Routine
                  newborn circumcision up to one year of age

              
	
                Over
                  the Counter Benefit

              	
                Agency
                  approved over-the-counter drug benefit, not to exceed $25 per household,
                  per month. Limited to non-prescription drugs containing a National
                  Drug
                  Code number, first aid and birth control supplies. Benefit must
                  be offered
                  through a plan’s pharmacy or plan’s
                  subcontractor.

              

      

       

      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

          

          EXHIBIT
            1

          BENEFIT
            GRID

        

      

      

      	(ii)  	
              Broward
                - Elderly and Disabled

            

      

      
        	
                Covered
                  Service Category

              	
                 

              	
                Visit/Script
                  Limit

              	
                Limit
                  Period

              	
                Dollar
                  Limit

              	
                Limit
                  Period (Annual)

              	
                Copay
                  Amount

              	
                Copay
                  Application

              
	
                (Annual/
                  Monthly)

              
	
                Hospital
                  Inpatient

              
	
                Behavioral
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                Physical
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                 

              
	
                Transplant
                  Services

              
	
                Transplant
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient-services

              
	
                Emergency
                  Room

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Medical/Drug
                  Therapies (Chemo, Dialysis)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Ambulatory
                  Surgery - ASC

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Hospital
                  Outpatient Surgery

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Lab/X-ray

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                day

              
	
                Hospital
                  Outpatient Services NOS

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Outpatient
                  Therapy (PT/RT)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                Outpatient
                  Therapy (OT/ST)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Maternity
                  and Family Planning Services

              
	
                Inpatient
                  Hospital

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Birthing
                  Centers

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Physician
                  Care

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Family
                  Planning

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Pharmacy

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Physician
                  and Phys Extender Services (non maternity)

              
	
                EPSDT

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Primary
                  Care Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Specialty
                  Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                ARNP/Physician
                  Assistant

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (FQHC, RHC)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (CHD)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Other

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Outpatient Professional Services

              
	
                Home
                  Health Services

              	
                 

              	
                120

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Chiropractor

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Podiatrist

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Dental
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                coinsurance

              
	
                Vision
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Hearing
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient
                  Mental Health

              
	
                Outpatient
                  Mental Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                 

              
	
                Outpatient
                  Pharmacy

              
	
                Outpatient
                  Pharmacy

              	
                 

              	
                16

              	
                Monthly

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Services

              
	
                Ambulance

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Non-emergent
                  Transporation

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                trip

              
	
                Durable
                  Medical Equipment

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              

      

      Expanded
        Benefit

      
        	
                Adult
                  Dental

              	
                Adult
                  dental expanded to include unlimited fillings, periodontic deep
                  cleanings,
                  crowns, clear fillings, restorations, annual exam, two cleanings
                  per year
                  and x-rays.

              
	
                Circumcision

              	
                Routine
                  newborn circumcision up to one year of age.

              
	
                Over
                  the Counter Benefit

              	
                Agency
                  approved over-the-counter drug benefit, not to exceed $25 per household,
                  per month. Limited to non-prescription drugs containing a National
                  Drug
                  Code number, first aid and birth control supplies. Benefit must
                  be offered
                  through a plan’s pharmacy or plan’s subcontractor.

              
	
                Meals
                  on Wheels

              	
                10
                  meals within 15 days of post discharge (medically
                  necessary)

              

      

      

      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          

          EXHIBIT
            1

          BENEFIT
            GRID

        

      

      

      	(iii)  	
              Duval
                - Children and Families

            

      

      
        	
                Covered
                  Service Category

              	
                 

              	
                Visit/Script
                  Limit

              	
                Limit
                  Period

              	
                Dollar
                  Limit

              	
                Limit
                  Period (Annual)

              	
                Copay
                  Amount

              	
                Copay
                  Application

              
	
                (Annual/
                  Monthly)

              
	
                Hospital
                  Inpatient

              
	
                Behavioral
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                Physical
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                 

              
	
                Transplant
                  Services

              
	
                Transplant
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient-services

              
	
                Emergency
                  Room

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Medical/Drug
                  Therapies (Chemo, Dialysis)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Ambulatory
                  Surgery - ASC

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Hospital
                  Outpatient Surgery

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Lab/X-ray

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                day

              
	
                Hospital
                  Outpatient Services NOS

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Outpatient
                  Therapy (PT/RT)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                Outpatient
                  Therapy (OT/ST)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Maternity
                  and Family Planning Services

              
	
                Inpatient
                  Hospital

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Birthing
                  Centers

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Physician
                  Care

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Family
                  Planning

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Pharmacy

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Physician
                  and Phys Extender Services (non maternity)

              
	
                EPSDT

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Primary
                  Care Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Specialty
                  Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                ARNP/Physician
                  Assistant

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (FQHC, RHC)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (CHD)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Other

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Outpatient Professional Services

              
	
                Home
                  Health Services

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Chiropractor

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Podiatrist

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Dental
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                coinsurance

              
	
                Vision
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Hearing
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient
                  Mental Health

              
	
                Outpatient
                  Mental Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                 

              
	
                Outpatient
                  Pharmacy

              
	
                Outpatient
                  Pharmacy

              	
                 

              	
                9

              	
                Monthly

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Services

              
	
                Ambulance

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Non-emergent
                  Transporation

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                trip

              
	
                Durable
                  Medical Equipment

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              

      

      Expanded
        Benefit

      
        	
                Adult
                  Dental

              	
                Adult
                  dental expanded to include unlimited fillings, periodontic deep
                  cleanings,
                  annual exam, two cleanings per year and x-rays.

              
	
                Circumcision

              	
                Routine
                  newborn circumcision up to one year of age.

              
	
                Over
                  the Counter Benefit

              	
                Agency
                  approved over-the-counter drug benefit, not to exceed $25 per household,
                  per month. Limited to non-prescription drugs containing a National
                  Drug
                  Code number, first aid and birth control supplies. Benefit must
                  be offered
                  through a plan’s pharmacy or plan’s
                  subcontractor.

              

      

      

      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          

          EXHIBIT
            1

          BENEFIT
            GRID

        

      

      

      	(iv)  	
              Duval
                - Elderly and Disabled

            

      

      
        	
                Covered
                  Service Category

              	
                 

              	
                Visit/Script
                  Limit

              	
                Limit
                  Period

              	
                Dollar
                  Limit

              	
                Limit
                  Period (Annual)

              	
                Copay
                  Amount

              	
                Copay
                  Application

              
	
                (Annual/
                  Monthly)

              
	
                Hospital
                  Inpatient

              
	
                Behavioral
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                Physical
                  Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                admit

              
	
                 

              
	
                Transplant
                  Services

              
	
                Transplant
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient-services

              
	
                Emergency
                  Room

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Medical/Drug
                  Therapies (Chemo, Dialysis)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Ambulatory
                  Surgery - ASC

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Hospital
                  Outpatient Surgery

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Lab/X-ray

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                day

              
	
                Hospital
                  Outpatient Services NOS

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Outpatient
                  Therapy (PT/RT)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                Outpatient
                  Therapy (OT/ST)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Maternity
                  and Family Planning Services

              
	
                Inpatient
                  Hospital

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Birthing
                  Centers

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Physician
                  Care

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Family
                  Planning

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Pharmacy

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Physician
                  and Phys Extender Services (non maternity)

              
	
                EPSDT

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Primary
                  Care Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Specialty
                  Physician

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                ARNP/Physician
                  Assistant

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (FQHC, RHC)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                Clinic
                  (CHD)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Other

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Outpatient Professional Services

              
	
                Home
                  Health Services

              	
                 

              	
                120

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Chiropractor

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Podiatrist

              	
                 

              	
                24

              	
                Annual

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Dental
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                coinsurance

              
	
                Vision
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                0

              	
                visit

              
	
                Hearing
                  Services

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Outpatient
                  Mental Health

              
	
                Outpatient
                  Mental Health

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                visit

              
	
                 

              
	
                Outpatient
                  Pharmacy

              
	
                Outpatient
                  Pharmacy

              	
                 

              	
                16

              	
                Monthly

              	
                 

              	
                Annual

              	
                 

              	
                 

              
	
                 

              
	
                Other
                  Services

              
	
                Ambulance

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                Non-emergent
                  Transporation

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0

              	
                trip

              
	
                Durable
                  Medical Equipment

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Annual

              	
                 

              	
                 

              

      

      Expanded
        Benefit

      
        	
                Adult
                  Dental

              	
                Adult
                  dental expanded to include unlimited fillings, periodontic deep
                  cleanings,
                  crowns, clear fillings, restorations, annual exam, two cleanings
                  per year,
                  and x-rays. 

              
	
                Circumcision

              	
                Routine
                  newborn circumcision up to one year of age.

              
	
                Over
                  the Counter Benefit

              	
                Agency
                  approved over-the -counter drug benefit, not to exceed $25 per
                  household,
                  per month. Limited to non-prescription drugs containing a National
                  Drug
                  Code number, first aid and birth control supplies. Benefit must
                  be offered
                  through a plan’s pharmacy or plan’s subcontractor.

              
	
                Meals
                  on Wheels

              	
                10
                  meals within 15 days of post discharge (medically
                  necessary)

              

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
            EXHIBIT
              2

            ENROLLMENT LEVELS

          

        

      

       

      TABLE
        1 (Duval - Area 4, Broward - Area 10)

      

      Agency
        Area
        04

       

      

        

        
          	
                  Eligibility
                    Category/ Population

                	
                  County

                	
                  Health
                    Plan Provider Number

                	
                  Plan
                    Type

                  (Comp
                    or Comp & Catastrophic)

                	
                  Maximum
                    Enrollment Level

                
	
                  TANF

                	
                  Duval

                	 	
                  Comprehensive
                    & Catastrophic

                	
                   

                  3,500

                
	
                  SSI

                	
                  Duval

                	 	
                  Comprehensive
                    & Catastrophic

                
	
                  HIV/AIDS

                	 	 	 	 
	
                  Children
                    with Chronic Conditions

                	 	 	 	 

        

        

        Agency
          Area __10__

        

        
          	
                  Eligibility
                    Category/ Population

                	
                  County

                	
                  Health
                    Plan Provider Number

                	
                  Plan
                    Type

                  (Comp
                    or Comp & Catastrophic)

                	
                  Maximum
                    Enrollment Level

                
	
                  TANF

                	
                  Broward

                	 	
                  Comprehensive
                    & Catastrophic

                	
                   

                  25,000

                
	
                  SSI

                	
                  Broward

                	 	
                  Comprehensive
                    & Catastrophic

                
	
                  HIV/AIDS

                	 	 	 	 
	
                  Children
                    with Chronic Conditions

                	 	 	 	 

        

        

        REMAINDER
          OF PAGE INTENTIONALLY LEFT BLANK

      

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
          EXHIBIT
            3

          COMPREHENSIVE
            COMPONENT AND

          CATASTROPHIC
            COMPONENT CAPITATION RATES

        

      

       

      Table 2

       

      Area:
        04       County:
        Duval         September 1,
        2006
        Area:
          04   

        (ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY
          CMS)

        

          
            	
                    Age
                      Range

                  	
                    FY0607
                      Discounted Reform rates Under Current Methodology

                  	
                    Percentage
                      of Current Methodology

                  	
                    75%
                      of Current Methodology

                  	
                    Preliminary
                      FY0607 Base rates for Risk Adjusted Methodology

                  	
                    Budget
                      Neutrality Factor 

                  	
                    FY0607
                      Base rates for Risk Adjusted Methodology after Budget
                      Neutrality

                  	
                    Percentage
                      of Risk Adjusted Methodology

                  	
                    25%
                      of Risk Adjusted Methodology

                  	
                    Final
                      Rate (with Enhanced Benefit Adjustment)

                  
	
                    a
                      

                  	
                    b

                  	
                    c

                  	
                    d

                  	
                    e

                  	
                    f

                  	
                    g

                  	
                    h
                      

                  	
                    i

                  	
                    j

                  
	
                    Eligibility
                      Category:
                      Children and Family

                  	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                    Month
                      0-2 All

                  	
                    $738.35
                      

                  	
                    75%

                  	
                    $553.76

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $589.19

                  
	
                    Month
                      3-11 All

                  	
                    $192.52
                      

                  	
                    75%

                  	
                    $144.39

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $179.81

                  
	
                    1-5
                      All

                  	
                    $98.55
                      

                  	
                    75%

                  	
                    $73.91

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $109.33

                  
	
                    6-13
                      All

                  	
                    $74.83
                      

                  	
                    75%

                  	
                    $56.12

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $91.55

                  
	
                    14-20
                      Female

                  	
                    $109.44
                      

                  	
                    75%

                  	
                    $82.08

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $117.50

                  
	
                    14-20
                      Male

                  	
                    $73.83
                      

                  	
                    75%

                  	
                    $55.37

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $90.80

                  
	
                    21-54
                      Female

                  	
                    $192.76
                      

                  	
                    75%

                  	
                    $144.57

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $179.99

                  
	
                    21-54
                      Male

                  	
                    $139.38
                      

                  	
                    75%

                  	
                    $104.53

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $139.95

                  
	
                    55+
                      All

                  	
                    $305.74
                      

                  	
                    75%

                  	
                    $229.31

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $264.73

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Composite
                      Based on Total Casemonths

                  	
                    $119.67

                  	 	 	 	 	
                    $141.69

                  	 	 	
                    $125.17

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Eligibility
                      Category:
                      Aged and Disabled

                  	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                    Month
                      0-2 All

                  	
                    $13,652.29
                      

                  	
                    75%

                  	
                    $10,239.22

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $10,420.52

                  
	
                    Month
                      3-11 All

                  	
                    $2,911.78
                      

                  	
                    75%

                  	
                    $2,183.83

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $2,365.13

                  
	
                    1-5
                      All

                  	
                    $493.16
                      

                  	
                    75%

                  	
                    $369.87

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $551.16

                  
	
                    6-13
                      All

                  	
                    $300.32
                      

                  	
                    75%

                  	
                    $225.24

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $406.54

                  
	
                    14-20
                      All

                  	
                    $294.02
                      

                  	
                    75%

                  	
                    $220.51

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $401.81

                  
	
                    21-54
                      All

                  	
                    $741.27
                      

                  	
                    75%

                  	
                    $555.95

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $737.25

                  
	
                    55+
                      All

                  	
                    $736.02
                      

                  	
                    75%

                  	
                    $552.01

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $733.31

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Composite
                      Based on Total Casemonths

                  	
                    $606.11
                      

                  	 	 	 	 	
                    $725.19

                  	 	 	
                    $635.88

                  

          

           

           

        

      

    

    
      
        
        

      

      
        
        

        
          

        

      

      
         
          
          EXHIBIT
            3

          COMPREHENSIVE
            COMPONENT AND

          CATASTROPHIC
            COMPONENT CAPITATION RATES

        

      

    

     

    
      E
        2

      

      Area:
        10    Table
        2

              Area:  
        10          County: Broward        September
        1, 2006

      

      ESTIMATED
        HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

       

      
        
          	
                  Age
                    Range

                	
                  FY0607
                    Discounted Reform rates Under Current Methodology

                	
                  Percentage
                    of Current Methodology

                	
                  75%
                    of Current Methodology

                	
                  Preliminary
                    FY0607 Base rates for Risk Adjusted Methodology

                	
                  Budget
                    Neutrality Factor 

                	
                  FY0607
                    Base rates for Risk Adjusted Methodology after Budget
                    Neutrality

                	
                  Percentage
                    of Risk Adjusted Methodology

                	
                  25%
                    of Risk Adjusted Methodology

                	
                  Final
                    Rate (with Enhanced Benefit Adjustment)

                
	
                  a
                    

                	
                  b

                	
                  c

                	
                  d

                	
                  e

                	
                  f

                	
                  g

                	
                  h
                    

                	
                  i

                	
                  j

                
	
                  Eligibility
                    Category:

                	
                  Children
                    and Family

                	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                  Month
                    0-2 All

                	
                  $688.92
                    

                	
                  75%

                	
                  $516.69

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $551.66

                
	
                  Month
                    3-11 All

                	
                  $180.09
                    

                	
                  75%

                	
                  $135.07

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $170.04

                
	
                  1-5
                    All

                	
                  $94.03
                    

                	
                  75%

                	
                  $70.52

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $105.49

                
	
                  6-13
                    All

                	
                  $77.55
                    

                	
                  75%

                	
                  $58.16

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $93.13

                
	
                  14-20
                    Female

                	
                  $107.54
                    

                	
                  75%

                	
                  $80.65

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $115.62

                
	
                  14-20
                    Male

                	
                  $74.59
                    

                	
                  75%

                	
                  $55.94

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $90.91

                
	
                  21-54
                    Female

                	
                  $181.88
                    

                	
                  75%

                	
                  $136.41

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $171.37

                
	
                  21-54
                    Male

                	
                  $131.39
                    

                	
                  75%

                	
                  $98.54

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $133.51

                
	
                  55+
                    All

                	
                  $288.52
                    

                	
                  75%

                	
                  $216.39

                	
                  $117.60

                	
                  1.18930

                	
                  $139.86

                	
                  25%

                	
                  $34.97

                	
                  $251.36

                
	 	 	 	 	 	 	 	 	 	 
	
                  Composite
                    Based on Total Casemonths

                	
                  $110.18

                	 	 	 	 	
                  $139.86

                	 	 	
                  $117.60

                
	 	 	 	 	 	 	 	 	 	 
	
                  Eligibility
                    Category:

                	
                  Aged
                    and Disabled

                	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                  Month
                    0-2 All

                	
                  $15,308.07
                    

                	
                  75%

                	
                  $11,481.05

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $11,715.71

                
	
                  Month
                    3-11 All

                	
                  $3,277.86
                    

                	
                  75%

                	
                  $2,458.40

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $2,693.06

                
	
                  1-5
                    All

                	
                  $550.34
                    

                	
                  75%

                	
                  $412.75

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $647.42

                
	
                  6-13
                    All

                	
                  $317.37
                    

                	
                  75%

                	
                  $238.03

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $472.69

                
	
                  14-20
                    All

                	
                  $319.91
                    

                	
                  75%

                	
                  $239.93

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $474.59

                
	
                  21-54
                    All

                	
                  $825.64
                    

                	
                  75%

                	
                  $619.23

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $853.89

                
	
                  55+
                    All

                	
                  $833.65
                    

                	
                  75%

                	
                  $625.24

                	
                  $777.12

                	
                  1.20785

                	
                  $938.64

                	
                  25%

                	
                  $234.66

                	
                  $859.90

                
	 	 	 	 	 	 	 	 	 	 
	
                  Composite
                    Based on Total Casemonths

                	
                  $723.28
                    

                	 	 	 	 	
                  $938.64

                	 	 	
                  $777.12

                

        

      

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          

            EXHIBIT
              4

            COMPREHENSIVE
              COMPONENT ONLY

          

        

      

       

      Table
        3

       

      Table
        3

       

      Area:_______________        County:
        _______________        September
        1,
        2006

      
        

         

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNELSS APPROVED BY CMS)

         

        
          	
                  Area
                    ________

                	 	 	 	 	 	 	 	 	 	 	 
	
                  Age
                    Range

                	 	
                  FY0607
                    Discounted Reform rates Under Current Methodology

                	
                  Percentage
                    of Current Methodology

                	
                  75%
                    of Current Methodology

                	
                  FY0607
                    Base Rates for Risk-Adjusted Methodology

                	
                  Percentage
                    of Risk-Adjusted Methodology

                	
                  25%
                    of Risk-Adjusted Methodology

                	
                  Budget
                    Neutrality Factor 

                	
                  Budget
                    Adjusted of 25% of Risk Adjusted Method-ology 

                	
                  Blended
                    Rate (Risk = 1.00)

                	
                  Final
                    Rate (with Enhanced Benefit Adjustment)

                
	
                  (a)

                	 	
                  (b)

                	
                  (c)

                	
                  (d)

                	
                  (e)

                	
                  (f)

                	
                  (g)

                	
                  (h)

                	
                  (i)

                	
                  (j)

                	
                  (k)

                
	
                  Eligibility
                    Category:

                	
                  Children
                    and Family

                	 	 	 	 	 	 	 	 	 
	
                  Month
                    0-2 All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  Month
                    3-11 All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  1-5
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  6-13
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  14-20
                    Female

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  14-20
                    Male

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  21-54
                    Female

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  21-54
                    Male

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  55+
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  Composite

                	
                   

                	 	 	 	 	 	 	
                  $

                	 	
                  $

                	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Eligibility
                    Category:

                	 	
                  Aged
                    and Disabled

                	 	 	 	 	 	 	 	 	 
	
                  Month
                    0-2 All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  Month
                    3-11 All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  1-5
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  6-13
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  14-20
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  21-54
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  55+
                    All

                	 	
                  $

                	
                  75%

                	
                  $

                	
                  $

                	
                  25%

                	
                  $

                	
                  $

                	 	
                  $

                	 
	
                  Composite

                	 	 	 	 	 	 	 	
                  $

                	 	
                  $

                	 
	 	 	 	 	 	 	 	 	 	 	 	 

        

        

        

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            EXHIBIT
              5

            CAPITATION
              RATES

            SSI
              MEDICARE PART B ONLY

            AND

            SSI
              MEDICARE PARTS A AND B ENROLLEES

            FOR
              ALL MEDICAID REFORM COUNTIES

          

        

      

       

      

        TABLE
          4 

        

        

        Area:
          4
           County:
          Duval

        

        

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

        
          	 	
                  Under
                    Age 65

                	
                  Age
                    65 & Over

                
	
                   

                  SSI/Parts
                    A & B 

                	
                   

                  $146.72

                	
                   

                  $98.34

                
	
                   

                  SSI/Part
                    B Only

                	
                   

                  $300.24

                	
                   

                  $300.24

                

        

        

        

        

        

        

        

        Area:
          10
           County:
          Broward

        

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

        
          	 	
                  Under
                    Age 65

                	
                  Age
                    65 & Over

                
	
                   

                  SSI/Parts
                    A & B 

                	
                   

                  $136.17

                	
                   

                  $91.25

                
	
                   

                  SSI/Part
                    B Only

                	
                   

                  $210.84

                	
                   

                  $210.84

                

        

         

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              EXHIBIT
                6

              CAPITATION
                RATES FOR HIV/AIDS POPULATIONS FOR 

              EACH
                MEDICAID REFORM COUNTY

            

          

        

      

       

      

        TABLE
          5

        

        

        Area:
          4
           County:
          Duval

        

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

         

        
          	 	
                  Capitation
                    Rate

                
	 	 
	
                  HIV
                    (No Medicare)

                	
                  $950.48

                
	
                  AIDS
                    (No Medicare)

                	
                  $2133.29

                
	
                  HIV-SSI/Parts
                    A & B, SSI Part B Only

                	
                  $177.88

                
	
                  AIDS-SSI/Parts
                    A & B, SSI Part B Only 

                	
                  $249.55

                

        

        

        

        

        

        Area:
          10
           County:
          Broward

        

        

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

         

        
          	 	
                  Capitation
                    Rate

                
	 	 
	
                  HIV
                    (No Medicare)

                	
                  $1484.87

                
	
                  AIDS
                    (No Medicare)

                	
                  $3155.16

                
	
                  HIV-SSI/Parts
                    A & B, SSI Part B Only

                	
                  $213.18

                
	
                  AIDS-SSI/Parts
                    A & B, SSI Part B Only 

                	
                  $299.07

                

        

        

        

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            EXHIBIT
              7

            CAPITATION
              RATES FOR MEDICAID REFORM COUNTIES FOR ALL MEDICAID REFORM
              COUNTIES

          

        

      

       

      

        TABLE
          6

        

        

        Area:
          _____________  County:
          ________________________

        

        

        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

        
          	 	
                  Age
                    

                  <
                    1 Yr

                	
                  Age
                    1 Yr

                	
                  Age
                    2 - 20 Yrs

                
	 	 	 	 
	
                  Children
                    with Chronic Conditions

                	
                  $

                	
                  $

                	
                  $

                

        

        

        

        
          

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              EXHIBIT
                8

              KICK
                PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES

            

          

        

        

          TABLE
            7

          

          Areas:
            10
             County:
            Broward

          Area:
            4
              County:
            Duval

          

          
            	
                    CPT
                      Code

                  	
                    Transplant
                      CPT Code Description

                  	
                    Children/Adolescents
                      or Adult

                  	
                    Payment
                      Amount

                  
	
                    32851

                     

                  	
                    lung
                      single, without bypass

                     

                  	
                    Children/Adolescents

                     

                  	
                    $320,800.00

                     

                  
	
                    32851

                     

                  	
                    lung
                      single, without bypass

                     

                  	
                    Adult

                     

                  	
                    $238,000.00

                  
	
                    32852

                     

                  	
                    lung
                      single, with bypass

                     

                  	
                    Children/Adolescents

                     

                  	
                    $320,800.00

                     

                  
	
                    32852

                     

                  	
                    lung
                      single, with bypass

                     

                  	
                    Adult

                     

                  	
                    $238,000.00

                  
	
                    32853

                     

                  	
                    lung
                      double, without bypass

                     

                  	
                    Children/Adolescents

                     

                  	
                    $320,800.00

                     

                  
	
                    32853

                     

                  	
                    lung
                      double, without bypass

                     

                  	
                    Adult

                     

                  	
                    $238,000.00

                  
	
                    32854

                     

                  	
                    lung
                      double, with bypass

                     

                  	
                    Children/Adolescents

                     

                  	
                    $320,800.00

                     

                  
	
                    32854

                     

                  	
                    lung
                      double, with bypass

                     

                  	
                    Adult

                     

                  	
                    $238,000.00

                  
	
                    33945

                     

                  	
                    heart
                      transplant with or without recipient cardiectomy

                     

                  	
                    Children/Adolescents

                     

                  	
                    $162,000.00

                     

                  
	
                    33945

                     

                  	
                    heart
                      transplant with or without recipient cardiectomy

                     

                  	
                    Adult

                     

                  	
                    $162,000.00

                     

                  
	
                    47135

                     

                  	
                    liver,
                      allotransplation, orthotopic, partial or whole from cadaver
                      or living
                      donor

                     

                  	
                    Children/Adolescents

                     

                  	
                    $122,600.00

                  
	
                     

                    47135

                     

                  	
                     

                    liver,
                      allotransplation, orthotopic, partial or whole from cadaver
                      or living
                      donor

                     

                  	
                     

                    Adult

                     

                  	
                     

                    $122,600.00

                     

                  
	
                     

                    47136

                     

                  	
                     

                    liver,
                      heterotopic, partial or whole from cadaver or living donor
                      any
                      age

                     

                  	
                     

                    Children/Adolescents

                     

                  	
                     

                    $122,600.00

                     

                  
	
                     

                    47136

                     

                  	
                     

                    liver,
                      heterotopic, partial or whole from cadaver or living donor
                      any
                      age

                     

                  	
                     

                    Adult

                     

                  	
                     

                    $122,600.00

                     

                  

          

          

          

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            EXHIBIT
              9

            KICK
              PAYMENT AMOUNTS FOR COVERED 

            OBSTETRICAL
              DELIVERY SERVICES

          

        

      

       

      

        TABLE
          8

        

        Area:
          10      County:
          Broward

        
 

        
          	
                  CPT
                    Code

                	
                  Obstetrical
                    Delivery CPT Code Description

                	
                  Payment
                    Amount

                
	
                  59409

                	
                  Vaginal
                    delivery only

                	
                  $4,143.00

                
	
                  59410

                	
                  Vaginal
                    delivery including postpartum care

                
	
                  59515

                	
                  Cesarean
                    delivery including postpartum care

                
	
                  59612

                	
                  Vaginal
                    delivery only, after previous cesarean delivery

                
	
                  59614

                	
                  Vaginal
                    delivery only, after previous cesarean delivery including postpartum
                    care

                
	
                  59622

                	
                  Cesarean
                    delivery only, following attempted vaginal delivery after previous
                    cesarean delivery including postpartum
                    care

                

        

        

            Area:
          04     County:
          Duval

        
 

        
          	
                  CPT
                    Code

                	
                  Obstetrical
                    Delivery CPT Code Description

                	
                  Payment
                    Amount

                
	
                  59409

                	
                  Vaginal
                    delivery only

                	
                  $4,097.62

                
	
                  59410

                	
                  Vaginal
                    delivery including postpartum care

                
	
                  59515

                	
                  Cesarean
                    delivery including postpartum care

                
	
                  59612

                	
                  Vaginal
                    delivery only, after previous cesarean delivery

                
	
                  59614

                	
                  Vaginal
                    delivery only, after previous cesarean delivery including postpartum
                    care

                
	
                  59622

                	
                  Cesarean
                    delivery only, following attempted vaginal delivery after previous
                    cesarean delivery including postpartum
                    care

                

        

        

        

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      ATTACHMENT
        II

      

      

      

      

      

      Medicaid
        Reform 

      Health
        Plan Model Contract

      

      July
        2006

      

      

      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

      Table
        of Contents

      

      Section
        I Definitions and Acronyms

      A. Definitions 

      B. Acronyms 

      

      Section
        II General Overview

      A. Background 

      B. Purpose 

      C. Responsibilities
        of the State of Florida (the
        State) and the Agency for Health Care Administration (the
        Agency) 

      D. General
        Responsibilities of the Health
        Plan 

      

       Section
        III Eligibility and Enrollment

      A. Eligibility 

      B. Enrollment 

      C. Disenrollment 

      

      Section
        IV Enrollee Services and Marketing

      A. Enrollee
        Services 

      B. Marketing 

      

      Section
        V Covered Services

      A. Covered
        Services 

      B. Expanded
        Services 

      C. Excluded
        Services 

      D. Moral
        or Religious
        Objections 

      E. Customized
        Benefit Package

      F. Coverage
        Provisions

      

      Section
        VI Behavioral Health Care

      A. General
        Provisions 

      B. Service
        Requirements 

      

      Section
        VII Provider Network

      A. General
        Provisions 

      B. Primary
        Care Providers 

      C. Minimum
        Standards 

      D. Appointment
        Waiting Times and Geographic Access
        Standards 

      E. Behavioral
        Health Services

      F. Specialists
        and Other Providers

      H. Continuity
        of Care 

      I. Network
        Changes

      

      Section
        VIII Quality Management

      A. Quality
        Improvement 

      B. Utilization
        Management (UM) 

       

      

      Section
        IX Grievance System

      A. General
        Requirements 

      B. Grievance
        Process 

      C. Appeal
        Process 

      D. Medicaid
        Fair Hearing
        System 

      
 

      Section
        X Administration and Management

      A. General
        Provisions 

      B. Staffing 

      C. Provider
        Contracts
        Requirements 

      D. Provider
        Termination 

      E. Provider
        Services

      F. Medical
        Records Requirements

      G. Claims
        Payment 

      H. Encounter
        Data 

      I. Fraud
        Prevention

      
 

      Section
        XI Information Management and Systems

      A. General
        Provisions 

      B. Data
        and Document Management
        Requirements 

      C. System
        and Data Integration
        Requirements 

      D. Systems
        Availability, Performance and Problem
        Management Requirements 

      E. System
        Testing and Change Management
        Requirements

      F. Information
        Systems Documentation
        Requirements

      G. Reporting
        Requirements - Specific to Information
        Management and Systems Functions and Capabilities - and Technological
        Capabilities 

      H. Other
        Requirements 

      I. Compliance
        with Standard Coding
        Schemes

      J. Data
        Exchange and Formats and Methods Applicable
        to Health Plans

      
 

      Section
        XII Reporting Requirements

      A. Health
        Plan Reporting Requirements 

      B. Enrollment/Disenrollment
        Reports: 

      C. Grievance
        System 

      D. Provider
        Reporting 

      E. Marketing
        Representative Report

      F. Enhanced
        Benefits Report

      G. Catastrophic
        Component Threshold and Benefit
        Maximum Report 

      H. Critical
        Incidents 

      I. Hernandez
        Settlement Agreement (HAS)
        Report

      J. Performance
        Measure Report

      K. Financial
        Reporting 

      L. Suspected
        Fraud Reporting

      M.Denials
        of Authorization Reporting
        Requirements 

      N.
        Systems Availability and Performance
        Report 

      O. Claims
        Inventory Summary
        Report 

      P.
        Child Health Check-Up Reports 

      Q. Pharmacy
        Encounter Data 

      R. Health
        Plan Benefit Package 

      S. Transportation
        Services

      T. Enrollee
        Satisfaction Survey
        Summary

      U. Stakeholders’
Satisfaction
        Survey
        Summary 

      V. Behavioral
        Health Services Grievance and Appeals
        Reporting Requirements

      W. Critical
        Incident Reporting 

      X. Required
        Staff/Providers

      Y. FARS/CFARS

      Z. Behavioral
        Health Encounter
        Report

      AA. Minority
        Participation
        Report 

      
 

      Section
        XIII Method of Payment

      
 

      Section
        XIV Sanctions

      A. General
        Provisions 

      B. Specific
        Sanctions 

      
 

      Section
        XV Financial Requirements

      A. Insolvency
        Protection 

      B. Insolvency
        Protection for a Capitated Provider
        Service Network (PSN) 

      C. Surplus
        Start Up Account 

      D. Surplus
        Requirement 

      E. Interest

      F. Inspection
        and Audit of Financial
        Records

      G. Physician
        Incentive Plans 

      H. Third
        Party Resources 

      I. Fidelity
        Bonds

      
 

      Section
        XVI Terms and Conditions

      A. Agency
        Contract Management 

      B. Applicable
        Laws and
        Regulations 

      C. Assignment 

      D. Attorney's
        Fees 

      E. Conflict
        of Interest

      F. Contract
        Variation

      G. Court
        of Jurisdiction or
        Venue 

      H. Damages
        for Failure to Meet Contract
        Requirements 

      I. Disputes

      J. Force
        Majeure

      K. Legal
        Action Notification 

      L. Licensing

      M. Misuse
        of Symbols, Emblems, or Names in Reference
        to Medicaid 

      N. Offer
        of Gratuities 

      O. Subcontracts 

      P. Hospital
        Subcontracts

      Q. Termination
        Procedures 

      R. Waiver 

      S. Withdrawing
        Services from a
        County

      T. MyFloridaMarketPlace
        Vendor
        Registration

      U. MyFloridaMarketplace
        Vendor Registration and
        Transaction Fee Exemption 

      V. Ownership
        and Management
        Disclosure

      W. Minority
        Recruitment and Retention
        Plan 

      X. Independent
        Provider

      Y. General
        Insurance Requirements

      Z. Worker's
        Compensation Insurance

      AA. State
        Ownership 

      BB. Disaster
        Plan 

      
 

      

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      Section
        I

       

      Definitions
        and Acronyms

       

      

      	A.  	
              Definitions

            

       

      

      The
        following terms as used in this Contract shall be construed and/or interpreted
        as follows, unless the Contract otherwise expressly requires a different
        construction and/or interpretation. 

      

      Abandoned
        Call—
A
        call
        in which the caller elects an option and is either not permitted access to
        that
        option or disconnects from the system.

      

      Abuse — Provider
        practices that are inconsistent with generally accepted business or medical
        practices and that result in an unnecessary cost to the Medicaid program
        or in
        reimbursement for goods or services that are not medically necessary or that
        fail to meet professionally recognized standards for health care; or recipient
        practices that result in unnecessary cost to the Medicaid program.

      

      Action—
The
        denial or limited authorization of a requested service, including the type
        or
        level of service, pursuant to 42 CFR 438.400(b). The reduction, suspension
        or
        termination of a previously authorized service. The denial, in whole or in
        part,
        of payment for a service. The failure to provide services in a timely manner,
        as
        defined by the State. The failure of the Health Plan to act within ninety
        (90)
        days from the date the Health Plan receives a Grievance, or 45 days from
        the
        date the Health Plan receives an Appeal. For a resident of a rural area with
        only one (1) managed care entity, the denial of an Enrollee's request to
        exercise his or her right to obtain services outside the network.

      

      Advance
        Directive—
A
        written instruction, such as a living will or durable power of attorney for
        health care, recognized under State law (whether statutory or as recognized
        by
        the courts of the State), relating to the provision of health care when the
        individual is incapacitated.

      

      Advanced
        Registered Nurse Practitioner (ARNP) — A
        licensed advanced registered nurse practitioner who works in collaboration
        with
        a physician according to protocol, to provide diagnostic and clinical
        interventions. An ARNP must be authorized to provide these services by Chapter
        464, F.S., and protocols filed with the Board of Medicine. 

      

      Agency—
State
        of Florida, Agency for Health Care Administration.

      

      Agent—
        When
        spelled with a capital "A" herein, is a term that refers to certain independent
        contractors with the state that perform administrative functions, including
        but
        not limited to: Fiscal Agent activities; outreach, eligibility and Enrollment
        activities; Systems and Technical Support. The term as used herein does not
        create a principal-agent relationship.

      

      Ancillary
        Provider—
A
        Provider of ancillary medical services who has contracted with a Health Plan
        to
        provide ancillary medical services to the Health Plan's Enrollees.

      

      Authoritative
        Host—
A
        system that contains the master or “authoritative” data for a particular data
        type, e.g. Enrollee, Provider, Health Plan, etc. The Authoritative Host may
        feed
        data from its master data files to other systems in real time or in batch
        mode.
        Data in an Authoritative Host is expected to be up-to-date and
        reliable.

      

      Automatic
        Assignment (or Auto-Assign)—
The
        Enrollment of an eligible Medicaid Recipient, for whom Enrollment is mandatory,
        in a Health Plan chosen by AHCA or its Agent, and/or the assignment of a
        new
        Enrollee to a PCP chosen by the Health Plan. 

      

      Appeal—
A
        request for review of an Action, pursuant to 42 CFR 438.400(b).

      

      Baker
        Act—
The
        Florida Mental Health Act, pursuant to Sections 394.479 through 394.484,
        Florida
        Statutes. 

      

      Behavioral
        Health Services—
        Services listed in the Community Mental Health Services Coverage &
Limitations Handbook and the Targeted Case Management Coverage & Limitations
        Handbook as specified in this Contract in Section VI.A Behavioral Health
        Care,
        General Provisions.

      

      Behavioral
        Health Care Case Manager—
An
        individual who provides mental health care Case Management services directly
        to
        or on behalf of an Enrollee on an individual basis in accordance with 65E-15,
        F.A.C., and the Medicaid Targeted Case Management Handbook.

      

      Behavioral
        Health Care Provider—
A
        licensed mental health professional, such as a "Clinical Psychologist," or
        registered nurse qualified due to training or competency in mental health
        care,
        who is responsible for the provision of mental health care to patients, or
        a
        physician licensed under Chapters 458 or 459, F.S., who is under contract
        to
        provide Behavioral Health Services to Enrollees.

      

      Beneficiary
        Assistance Program
        - An
        external grievance program, similar to the Subscriber Assistance Program,
        available to Medicaid Reform recipients that will allow an additional avenue
        to
        resolve a grievance.

      

      Benefit
        Maximum
        - The
        point when the cost of Covered Services received by a non-pregnant Enrollee,
        ages 21 and older reaches $550,000 in a state fiscal year, based on Medicaid
        Fee-for-Service payment levels. Care coordination services must continue
        to be
        offered by the Health Plan but the cost of additional services will not be
        covered by the Medicaid program for the remainder of the Contract Year in
        which
        the Benefit Maximum is met. 

      

      Benefits—
A
        schedule of health care services to be delivered to Enrollees covered by
        the
        Health Plan as set forth in Section V and Section VI of this Contract.

      

      Blocked
        Call—
A
        call
        that cannot be connected immediately because no circuit is available at the
        time
        the call arrives or the telephone system is programmed to block calls from
        entering the queue when the queue backs up behind a defined
        threshold.

      

      Business
        Days—
        Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday, and
        Friday. State holidays are excluded. 

      

      Calendar
        Days—
All
        seven (7) days of the week. 

      

      Capitation
        Rate—
The
        per
        member per month amount, including any adjustments, that is paid by the Agency
        to a capitated Health Plan for each Medicaid Recipient enrolled under a contract
        for the provision of Medicaid services during the payment period.

      

      Care
        Coordination/Case Management—
A
        process which assesses, plans, implements, coordinates, monitors and evaluates
        the options and services required to meet an Enrollee's health needs using
        communication and all available resources to promote quality cost-effective
        outcomes. Proper Case Management occurs across a continuum of care, addressing
        the ongoing individual needs of an Enrollee rather than being restricted
        to a
        single practice setting. For purposes of this contract Care Coordination
        and
        Case Management are the same.

      

      Catastrophic
        Component --
        The
        amount of financial risk assumed by a Health Plan or the Agency to provide
        Covered Services above $50,000 per Enrollee, based on Medicaid Fee-for-Service
        payment levels, and up to the overall annual Benefit Maximum.

      

      Catastrophic
        Component Threshold
        - The
        point when the cost of Covered Services, based on Medicaid Fee-for-Service
        payment levels, reaches $50,000 for an Enrollee in a state fiscal year. For
        a
        Health Plan that accepts the Comprehensive Capitation Rate only, the Agency
        begins reimbursing the Health Plan for the cost of Covered Services received
        by
        the Enrollee for the remainder of the Contract Year. This reimbursement is
        based
        on a percentage of Medicaid Fee-for-Service payment levels,. 

      

      Cause—
Special
        reasons that allow Mandatory Enrollees to change their Health Plan option
        outside their Open Enrollment period. May also be referred to as “Good
        Cause.”

      

      Centers
        for Medicare & Medicaid Services (CMS) —
The
        agency within the United States Department of Health & Human Services that
        provides administration and funding for Medicare under Title XVIII, Medicaid
        under Title XIX, and the State Children’s Health Insurance Program under Title
        XXI of the Social Security Act.

      

      Certification—
The
        process of determining that a facility, equipment or an individual meets
        the
        requirements of federal or State law, or whether Medicaid payments are
        appropriate or shall be made in certain situations.

      

      Child
        Health Check-Up Program (CHCUP) —
A
        comprehensive and preventative health examinations provided on a periodic
        basis
        that are aimed at identifying and correcting medical conditions in
        Children/Adolescents. Policies and procedures are described in the Child
        Health
        Check-Up Services Coverage and Limitations Handbook.

      

      Children/Adolescents—
        Enrollees under the age of 21.

      

      Children
        & Families Services Program Office—
Also
        referred to as the Children & Families Safety & Preservation Program
        Office, located in the DCF; the State agency responsible for overseeing programs
        that identify and protect abused and neglected Children and attempt to prevent
        domestic violence.

      

      Choice
        Counselor/Enrollment Broker—
The
        State’s contracted or designated entity that performs functions related to
        outreach, education, counseling, Enrollment, and Disenrollment of Potential
        Enrollees into a Health Plan. 

      

      Choice
        Counseling Specialists—
        Certified individuals authorized by an Agency-approved process who provide
        one-on-one information to Medicaid Recipients, to assist the Medicaid Recipients
        in choosing the Health Plan that best meets their health care needs and those
        of
        their family. 

      

      Cold
        Call Marketing—
Any
        unsolicited personal contact with a Medicaid Recipient by the Health Plan,
        its
        staff, its volunteers or its vendors with the purpose of influencing the
        Medicaid Recipient to enroll in the Health Plan or either to not enroll in,
        or
        disenroll from, another Health Plan.

       

      Community
        Living Support Plan -
        A
        written document prepared by a mental health resident of an assisted living
        facility with a limited mental health license and the resident's mental health
        case manager in consultation with the administrator or the administrator's
        designee of the assisted living facility with a limited mental health license.
        A
        copy must be provided to the administrator. The plan must include information
        about the supports, services, and special needs of the resident which enable
        the
        resident to live in the assisted living facility and a method by which facility
        staff can recognize and respond to the signs and symptoms particular to that
        resident which indicate the need for professional services.

      

      Comprehensive
        Component --
        The
        amount of financial risk assumed by a Health Plan to provide covered service
        up
        to 50,000 dollars per Enrollee based on Medicaid Fee-for-Service payment
        levels.

      

      Continuous
        Quality Improvement—
A
        management philosophy that mandates continually pursuing efforts to improve
        the
        quality of products and services produced by an organization.

      

      Contract—
The
        agreement between the Health Plan and the Agency to provide Medicaid services
        to
        Enrollees, comprised of the Contract, any addenda, appendices, attachments,
        or
        amendments thereto.

      

      Contract
        Period
        - The
        term of the contract from July 1, 2006 through August 31, 2009. 

      

      Contract
        Year -
        The
        period of time from September 1 through August 31 of each calendar
        year.

      

      Contracting
        Officer—
        The
        Secretary of the Agency or his/her delegate.

      

      County
        Health Department (CHD)—
CHDs
        are organizations administered by the Department of Health for the purpose
        of
        providing health services as defined in Chapter 154, F.S., which include
        the
        promotion of the public's health, the control and eradication of preventable
        diseases, and the provision of primary health care for special
        populations.

      

      Coverage
        & Limitations Handbook (Handbook)—
A
        document that provides information to a Medicaid Provider regarding Enrollee
        eligibility, claims submission and processing, Provider participation, covered
        care, goods and services, limitations, procedure codes and fees, and other
        matters related to participation in the Medicaid program.

      

      Covered
        Services—
Those
        services provided by the Health Plan in accordance with this Contract, as
        outlined in Section V, Covered Services, and Section VI, Behavioral Health
        Care,
        in this Contract.

      

      Crisis
        Support—
        Services for persons initially perceived to need emergency mental health
        services, but upon assessment, do not meet the criteria for such emergency
        care.
        These are acute care services that are available twenty-four (24) hours a
        day,
        seven (7) days a week, for intervention. Examples include: mobile crisis,
        crisis/emergency screening, crisis hot-line and emergency walk-in.

      

      Customized
        Benefit Package (CBP)
        -
        Covered Services, which may vary in amount, scope and/or duration from those
        listed in Section V, Covered Services and Section VI, Behavioral Health
        Services. The CBP must meet State standards for actuarial equivalency and
        sufficiency.

      

      Direct
        Ownership Interest —
        The
        ownership of stock, equity in capital or any interest in the profits of the
        disclosing entity. A disclosing entity is defined as a Medicaid provider
        or
        supplier, or other entity that furnishes services or arranges for furnishing
        services under Medicaid, or health related services under the social services
        program.

      

      Direct
        Service Behavioral Health Care Provider—
An
        individual qualified by training or experience to provide direct behavioral
        health services under the supervision of the Health Plan’s medical
        director.

      

      Disease
        Management
        - A
        system
        of coordinated health care intervention and communication for populations
        with
        conditions in which patient self-care efforts are significant. Disease
        Management supports the physician or practitioner/patient relationship and
        plan
        of care; emphasized prevention of exacerbations and complications utilizing
        evidence-based practice guidelines and patient empowerment strategies, and
        evaluates clinical, humanistic and economic outcomes on an ongoing basis
        with
        the goal of improving overall health.

      

      Disenrollment—
The
        Agency-approved discontinuance of an Enrollee's Enrollment in a Health
        Plan.

      

      Disclosing
        Entities—
A
        Medicaid provider, other than an individual practitioner or group of
        practitioners, or a fiscal agent that furnishes services or arranges for
        furnishing services under Medicaid, or health related services under the
        social
        services program.

      

      Downward
        Substitution of Care—
The
        use
        of less restrictive, lower cost services than otherwise might have been
        provided, that are considered clinically acceptable and necessary to meet
        specified objectives outlined in an Enrollee's plan of treatment, provided
        as an
        alternative to higher cost services. For services related to mental health,
        Downward Substitution of Care may include care provided by private practice
        psychologists and social workers, psycho-social rehabilitation, Medicaid
        community mental health services or Medicaid mental health targeted Case
        Management, and other services considered clinically appropriate, more
        cost-effective and less restrictive. 

      

      Durable
        Medical Equipment (DME)—
Medical
        equipment that can withstand repeated use, is customarily used to serve a
        medical purpose, is generally not useful in the absence of illness or injury
        and
        is appropriate for use in the Enrollee's home.

      

      Early
        and Periodic Screening, Diagnosis and Treatment Program
        (EPSDT)—
See
        Child Health Check-Up Program.

      

      Emergency
        Behavioral Health Services—
Those
        services required to meet the needs of an individual who is experiencing
        an
        acute crisis, resulting from a mental illness, which is a level of severity
        that
        would meet the requirements for an involuntary examination as specified in
        Section 394.463, Florida Statutes, and in the absence of a suitable alternative
        or psychiatric medication, would require hospitalization.

      

      Emergency
        Medical Condition—
(a)
        A
        medical condition manifesting itself by acute symptoms of sufficient severity,
        which may include severe pain or other acute symptoms, such that a prudent
        layperson who possesses an average knowledge of health and medicine, could
        reasonably expect that the absence of immediate medical attention could
        reasonably be expected to result in any of the following: (1) Serious jeopardy
        to the health of a patient, including a pregnant woman or fetus; (2) Serious
        impairment to bodily functions; (3) Serious dysfunction of any bodily organ
        or
        part. (b) With respect to a pregnant woman: (1) That there is inadequate
        time to
        effect safe transfer to another Hospital prior to delivery; (2) That a transfer
        may pose a threat to the health and safety of the patient or fetus; (3) That
        there is evidence of the onset and persistence of uterine contractions or
        rupture of the membranes, in accordance with Section 395.002, F.S.

      

      Emergency
        Services and Care—
Medical
        screening, examination and evaluation by a physician or, to the extent permitted
        by applicable laws, by other appropriate personnel under the supervision
        of a
        physician, to determine whether an Emergency Medical Condition exists. If
        an
        Emergency Medical Condition exists, Emergency Services and Care includes
        the
        care or treatment that is necessary to relieve or eliminate the Emergency
        Medical Condition within the service capability of the facility.

      

      Encounter
        Data
        - A
        record of covered services provided to Enrollees of a Health Plan. An Encounter
        is an interaction between a patient and provider (health plan, rendering
        physician, pharmacy, lab, etc.) who delivers services or is professionally
        responsible for services delivered to a patient.

      

      Enhanced
        Benefit —
An
        activity or behavior identified by the State as beneficial to the health
        of an
        individual and designated to earn a credit in the Enhanced Benefit
        Program.

      

      Enhanced
        Benefit Account—
The
        individual account resulting from an Enrollee earning rewards for healthy
        behaviors under the Enhanced Benefit Program.

      

      Enhanced
        Benefit Program—
A
        program offered through Medicaid Reform whereby Enrollees are rewarded, through
        individual Enhanced Benefit Accounts, for healthy behaviors.

      

      Enrollee—
A
        Medicaid Recipient currently enrolled in the Health Plan.

      

      Enrollment—
The
        process by which an eligible Medicaid Recipient becomes an Enrollee in a
        Health
        Plan.

      

      Enrollee
        Suicide Attempt—
An
        act
        which clearly reflects an attempt by an Enrollee to cause his or her own
        death,
        which results in bodily injury requiring medical treatment by a licensed
        health
        care professional.

      

      Expanded
        Services—
A
        Health Plan Covered Service for which the Health Plan receives no direct
        payment
        from the Agency.

      

      Expedited
        Appeal Process—
The
        process by which the Appeal of an Action is accelerated because the standard
        time-frame for resolution of the Appeal could seriously jeopardize the
        Enrollee's life, health or ability to obtain, maintain or regain maximum
        function.

      

      External
        Quality Review (EQR) —
The
        analysis and evaluation by an EQRO
        of
        aggregated information on quality, timeliness, and access to the health care
        services that are furnished to Medicaid recipients by a Health
        Plan.

      

      External
        Quality Review Organization (EQRO)—
An
        organization that meets the competence and independence requirements set
        forth
        in federal regulations 42 CFR 438.354, and performs EQR, other related
        activities as set forth in federal regulations or both.

      

      Federal
        Fiscal Year
        - The
        United States government’s fiscal year starts October 1 and ends on September
        30.

      

      Federally
        Qualified Health Center (FQHC)—
An
        entity that is receiving a grant under section 330 of the Public Health Service
        Act, as amended, and Section 1905(1)(2)(B) of the Social Security
        Act.
        FQHCs
        provide primary health care and related diagnostic services and may provide
        dental, optometric, podiatry, chiropractic and mental health
        services.

      

      Fee-for-Service
        (FFS)—
A
        method of making payment by which the Agency sets prices for defined medical
        or
        allied care, goods or services.

      

      Fiscal
        Agent—
Any
        corporation or other legal entity that enters into a contract with the Agency
        to
        receive, process and adjudicate claims under the Medicaid program. 

      

      Fiscal
        Year — The
        State
        of Florida’s Fiscal Year starts July 1 and ends on June 30.

      

      Florida
        Medicaid Management Information System (FMMIS)—
        The
        information system used to process Florida Medicaid claims and payments to
        Health Plans, and to produce management information and reports relating
        to the
        Florida Medicaid program. This system is used to maintain Medicaid eligibility
        data and provider enrollment data.

      

      Florida
        Mental Health Act —
        Includes
        the Baker Act that covers admissions for persons who are considered to have
        an
        emergency mental health condition (a threat to themselves or others), as
        specified in Sections 394.479 through 394.484, Florida Statutes.

      

      Fraud —
An
        intentional deception or misrepresentation made by a person with the knowledge
        that the deception results in unauthorized benefit to herself or himself
        or
        another person. The term includes any act that constitutes fraud under
        applicable federal or state law.

      

      Full-Time
        Equivalent Position (FTE)—
The
        equivalent of one (1) full-time employee who works 40 hours per week.

      

      Good
        Cause—
See
        Cause.

      

      Grievance—
An
        expression of dissatisfaction about any matter other than an Action. Possible
        subjects for grievances include, but are not limited to, the quality of care,
        the quality of services provided and aspects of interpersonal relationships
        such
        as rudeness of a Provider or employee or failure to respect the Enrollee's
        rights.

      

      Grievance
        Procedure—
The
        procedure for addressing Enrollees' grievances.

      

      Grievance
        System—
The
        system for reviewing and resolving Enrollee Grievances and Appeals. Components
        must include a Grievance process, an Appeal process and access to the Medicaid
        Fair Hearing system.

      

      Health
        Assessment—
A
        complete health evaluation combining health history, physical assessment
        and the
        monitoring of physical and psychological growth and development.

      

      Health
        Care Professional—
A
        physician or any of the following: podiatrist, optometrist, chiropractor,
        psychologist, dentist, Physician Assistant, physical or occupational therapist,
        therapist assistant, speech-language pathologist, audiologist, Registered
        or
        practical Nurse (including nurse practitioner, clinical nurse specialist,
        certified Registered Nurse anesthetist and certified nurse midwife), a licensed
        certified social worker, registered respiratory therapist and certified
        respiratory therapy technician.

      

      Health
        Fair—
An
        event conducted in a setting that is open to the public or segment of the
        public
        (such as the "elderly" or "school children") during which information about
        health-care services, facilities, research, preventative techniques or other
        health-care subjects is disseminated. At least two (2) health-related
        organizations that are not affiliated under common ownership must actively
        participate in the Health Fair.

      

      Health
        Maintenance Organization (HMO)—
An
        organization or entity licensed in accordance with Section 641 of the Florida
        Statutes or in accordance with the Florida Medicaid State plan definition
        of an
        HMO. 

      

      Health
        Plan—
An
        entity that integrates financing and management with the delivery of health
        care
        services to an enrolled population. It employs or contracts with an organized
        system of Providers, which deliver services and frequently shares financial
        risk. For the purposes of this Contract, a Health Plan has also contracted
        with
        the Agency to provide Medicaid services under the Florida Medicaid Reform
        program, and includes health maintenance organizations authorized under chapter
        641 of the Florida Statutes, exclusive provider organizations as defined
        in
        Chapter 627 of the Florida Statutes, health insurers authorized under chapter
        624 of the Florida Statutes, and Provider Service Networks as defined in
        Section
        409.912, Florida Statutes. 

      

      Hospital—
A
        facility licensed in accordance with the provisions of Chapter 395, Florida
        Statutes, or the applicable laws of the state in which the service is
        furnished.

      

      Hospital
        Services Agreement—
The
        agreement between the Health Plan and a Hospital to provide medical services
        to
        the Health Plan's Enrollees.

      

      Indirect
        Ownership Interest — Ownership
        interest in an entity that has direct or indirect ownership interest in the
        disclosing entity. The amount of indirect ownership in the disclosing entity
        that is held by any other entity is determined by multiplying the percentage
        of
        ownership interest at each level. An indirect ownership interest must be
        reported if it equates to an ownership interest of five percent (5%) or more
        in
        the disclosing entity. Example: If “A” owns ten percent (10%) of the stock in a
        corporation that owns eighty percent (80) of the stock of the disclosing
        entity,
“A’s” interest equates to an eight percent (8%) indirect ownership and must be
        reported.

      

      Individuals
        with Special Health Care Needs —
Adults
        and Children/Adolescents, who face physical, mental or environmental challenges
        daily that place at risk their health and ability to fully function in society.
        Factors include individuals with mental retardation or related conditions;
        individuals with serious chronic illnesses, such as human immunodeficiency
        virus
        (HIV), schizophrenia or degenerative neurological disorders; individuals
        with
        disabilities resulting from many years of chronic illness such as arthritis,
        emphysema or diabetes; and Children/Adolescents and adults with certain
        environmental risk factors such as homelessness or family problems that lead
        to
        the need for placement in foster care.

      

      Information—
(a)
        Structured Data: Data that adhere to specific properties and Validation criteria
        that are stored as fields in database records. Structured queries can be
        created
        and run against structured data, where specific data can be used as criteria
        for
        querying a larger data set; (b) Document: Information that does not meet
        the
        definition of structured data includes text, files, spreadsheets, electronic
        messages and images of forms and pictures.

      

      Information
        System(s)—
A
        combination of computing hardware and software that is used in: (a) the capture,
        storage, manipulation, movement, control, display, interchange and/or
        transmission of information, i.e. structured data (which may include digitized
        audio and video) and documents; and/or (b) the processing of such information
        for the purposes of enabling and/or facilitating a business process or related
        transaction.

      

      Insolvency—
A
        financial condition that exists when an entity is unable to pay its debts
        as
        they become due in the usual course of business, or when the liabilities
        of the
        entity exceeds its assets.

      

      Licensed — A
        facility, equipment, or an individual that has formally met state, county,
        and
        local requirements, and has been granted a license by a local, state or federal
        government entity. 

      

      Kick
        Payment -
        The
        method of reimbursing managed care organizations in the form of a separate
        one-time fixed payment for specific services.

      

      Licensed
        Practitioner of the Healing Arts — A
        psychiatric nurse, Registered Nurse, advanced registered nurse practitioner,
        Physician Assistant, clinical social worker, mental health counselor, marriage
        and family therapist, or psychologist. 

      

      List
        of Excluded Individuals and Entities (LEIE)—
A
        database maintained by the Department of Health & Human Services, Office of
        the Inspector General. The LEIE provides information to the public, health
        care
        providers, patients and others relating to parties excluded from participation
        in Medicare, Medicaid and all other federal health care programs.

      

      Managed
        Behavioral Health Organization (MBHO)—
A
        behavioral health-care delivery system managing quality, utilization and
        cost of
        services. Additionally, an MBHO measures performance in the area of mental
        disorders.

      

      Mandatory
        Assignment—
The
        process the Agency uses to assign Potential Enrollees to a Health Plan. The
        Agency automatically assigns those Mandatory Potential Enrollees who did
        not
        voluntarily choose a Health Plan.

      

      Mandatory
        Enrollee—
The
        categories of eligible beneficiaries who must be enrolled in a Health
        Plan.

      

      Mandatory
        Potential Enrollee—
A
        Medicaid Recipient who is required to enroll in a Health Plan, but has not
        yet
        chosen a Health Plan in which to enroll.

      

      Market
        Area—
The
        geographic area in which the Health Plan is authorized to market and/or conduct
        pre-enrollment activities.

      

      Marketing—
Any
        activity or communication conducted by or on behalf of any Health Plan to
        a
        Medicaid Recipient who is not Enrolled with the Health Plan, that can reasonably
        be interpreted as intended to influence the Medicaid Recipient to enroll
        in the
        particular Health Plan.

      

      Marketing
        Representative — A
        person
        who provides information, pre-enrollment assistance, or otherwise promotes
        a
        Health Plan. Marketing Representatives shall be limited to licensed insurance
        agents. 

      

      Medicaid
        Area — The
        specific counties designated by the Agency.

      

      Medicaid—
The
        medical assistance program authorized by Title XIX of the Social Security
        Act,
        42 U.S.C. §1396 et seq., and regulations there under, as administered in the
        State of Florida by the Agency under 409.901 et seq., F.S.

      Medicaid
        Recipient—
Any
        individual whom DCF, or the Social Security Administration on behalf of the
        DCF,
        determines is eligible, pursuant to federal and State law, to receive medical
        or
        allied care, goods or services for which the Agency may make payments under
        the
        Medicaid program, and who is enrolled in the Medicaid program.

      

      Medicaid
        Reform—
The
        program resulting from Chapter 409.91211, F.S.

      

      Medical
        Record—
        Documents corresponding to medical or allied care, goods or services furnished
        in any place of business. The records may be on paper, magnetic material,
        film
        or other media. In order to qualify as a basis for reimbursement, the records
        must be dated, legible and signed or otherwise attested to, as appropriate
        to
        the media.

      

      Medically
        Necessary or Medical Necessity—
        Services that include medical or allied care, goods or services furnished
        or
        ordered to:

      

      1. Meet
        the
        following conditions:

      

      a. Be
        necessary to protect life, to prevent significant illness or significant
        disability or to alleviate severe pain;

      

      b. Be
        individualized, specific and consistent with symptoms or confirm diagnosis
        of
        the illness or injury under treatment and not in excess of the patient's
        needs;

      

      c. Be
        consistent with the generally accepted professional medical standards as
        determined by the Medicaid program, and not be experimental or
        investigational;

      

      d. Be
        reflective of the level of service that can be furnished safely and for which
        no
        equally effective and more conservative or less costly treatment is available
        statewide; and

      

      e. Be
        furnished in a manner not primarily intended for the convenience of the
        Enrollee, the Enrollee's caretaker or the provider.

      

      
        	 	
                2.

              	
                Medically
                  Necessary or Medical Necessity for those services furnished in
                  a Hospital
                  on an inpatient basis cannot, consistent with the provisions of
                  appropriate medical care, be effectively furnished more economically
                  on an
                  outpatient basis or in an inpatient facility of a different
                  type.

              

      

      

      
        	 	
                3.

              	
                The
                  fact that a provider has prescribed, recommended or approved medical
                  or
                  allied goods or services does not, in itself, make such care, goods
                  or
                  services Medically Necessary, a Medical Necessity or a Covered
                  Service/Benefit.

              

      

      

      Medicare —
        The
        medical assistance program authorized by Title XVIII of the Social Security
        Act.

      

      Meds
        AD—
Those
        recipients up to 88% of FPL with assets up to $5,000 for an individual and
        $6,000 for a couple without Medicare and those with Medicare that are not
        receiving institutional care, hospice care, or home and community based
        services.

      

      Neglect —
A
        failure or omission to provide care, supervision, and services necessary
        to
        maintain enrollee’s physical and mental health, including but not limited to,
        food, nutrition, supervision and medical services that are essential for
        the
        well-being of the enrollee. Neglect might be a single incident or repeated
        conduct that results in, or could reasonably expected to result in, serious
        physical or psychological injury, or a substantial risk of death.

      Newborn—
A
        live
        child born to an Enrollee, who is a member of the Health Plan.

      

      Non-Covered
        Service—
A
        service that is not a Covered Service/Benefit of the Medicaid State Plan
        or of
        the Health Plan.

      

      Nursing
        Facility—
An
        institutional care facility that furnishes medical or allied inpatient care
        and
        services to individuals needing such services. See Chapters 395 and 400,
        F.S.

      

      Open
        Enrollment—
The
        sixty (60) day period before the end of an Enrollee's Enrollment year, during
        which an Enrollee may choose to change Health Plans for the following Enrollment
        year. 

      

      Outpatient—
A
        patient of an organized medical facility, or distinct part of that facility,
        who
        is expected by the facility to receive, and who does receive, professional
        services for less than a twenty-four (24) hour period, regardless of the
        hours
        of admission, whether or not a bed is used and/or whether or not the patient
        remains in the facility past midnight.

      

      Overpayment —
        Includes any amount that is not authorized to be paid by the Medicaid program
        whether paid as a result of inaccurate or improper cost reporting, improper
        claiming, unacceptable practices, fraud, abuse, or mistake. 

      

      Participating
        Specialist—
A
        physician, licensed to practice medicine in the State of Florida, who contracts
        with the Health Plan to provide specialized medical services to the Health
        Plan's Enrollees.

      

      Peer
        Review—
An
        evaluation of the professional practices of a provider by the provider's
        peers
        in order to assess the necessity, appropriateness and quality of care furnished
        as such care is compared to that customarily furnished by the provider's
        peers
        and to recognized health care standards.

      

      Penultimate
        Saturday—
The
        Saturday preceeding the last Saturday of the month.

      

      Penultimate
        Sunday —
        The
        Sunday preceeding the last Sunday of the month.

      

      Pharmacy
        Benefits Administrator—
An
        entity contracted to or included in a health plan accepting pharmacy
        prescription claims for enrollees in the plan, assuring these claims conform
        to
        coverage policy and determining the allowed payment.

      

      Physician’s
        Assistant — A
        person
        who is a graduate of an approved program or its equivalent or meets standards
        approved by the Board of Medicine and is certified to perform medical services
        delegated by the supervising physician in accordance with Chapter 458, F.S.
        

      

      Physicians'
        Current Procedural Terminology (CPT)—A
        systematic listing and coding of procedures and services published annually
        by
        the American Medical Association.

      

      Plan
        Factor
        - A
        budget-neutral adjustment using a Health Plan's available historical Enrollee
        diagnosis data grouped by a health-based risk assessment model.  A Health
        Plan's Plan Factor is developed from the aggregated individual risk scores
        of
        the Health Plan's prior Enrollment.  The Plan Factor modifies a Health
        Plan's monthly capitation payment to reflect the health status of its
        Enrollees.

      

      Portable
        X-Ray Equipment—
X-ray
        equipment transported to a setting other than a hospital, Clinic or office
        of a
        physician or other Licensed Practitioner of the Healing Arts.

      

      Post-Stabilization
        Care Services—
Covered
        Services related to an Emergency Medical Condition that are provided after
        an
        Enrollee is stabilized in order to maintain the condition, or to improve
        or
        resolve the Enrollee's condition pursuant to 42 CFR 422.113.

      

      Potential
        Enrollee — Pursuant
        to 42 CFR 438.10(a), an eligible Medicaid Recipient who is subject to Mandatory
        Assignment or may voluntarily elect to enroll in a given Health Plan, but
        is not
        yet an Enrollee of a specific Health Plan. 

      

      Pre-Enrollment —
The
        provision of Marketing and educational materials to a Medicaid Recipient
        and
        assistance in completing the Request for Benefit Information (RBI).

      

      Pre-Enrollment
        Application—
See
        Request for Benefit Information.

      

      Prepaid
        Health Plan—
A
        Health Plan reimbursed on a prepaid basis. (see Health Plan)

      

      Primary
        Care—
        Comprehensive, coordinated and readily-accessible medical care including:
        health
        promotion and maintenance; treatment of illness and injury; early detection
        of
        disease; and referral to specialists when appropriate. 

      

      Primary
        Care Case Management—
The
        provision or arrangement of Enrollees’ primary care and the referral of
        Enrollees for other necessary medical services on a 24-hour basis. 

      

      Primary
        Care Provider
        (PCP)—
A
        Health Plan staff or contracted physician practicing as a general or family
        practitioner, internist, pediatrician, obstetrician, gynecologist, advanced
        registered nurse practitioners, physician assistants or other specialty approved
        by the Agency, who furnishes Primary Care and patient management services
        to an
        Enrollee. See sections 641.19, 641.31 and 641.51, Florida Statutes.

      

      Prior
        Authorization—
The
        act
        of authorizing specific services before they are rendered. 

      

      Protocols—
Written
        guidelines or documentation outlining steps to be followed for handling a
        particular situation, resolving a problem or implementing a plan of medical,
        nursing, psychosocial, developmental and educational services.

      

      Provider — A
        person
        or entity that is eligible to provide Medicaid services and has a contractual
        agreement with the Health Plan to provide Medicaid services. 

      

      Provider
        Contract — An
        agreement between the Health Plan and a health care Provider as described
        above.

      

      Provider
        Service Network — A
        network
        established or organized and operated by a health care provider, or group
        of
        affiliated health care providers, including minority physician networks and
        emergency room diversion programs that meet the requirements of s.
        409.91211, which
        provides a substantial proportion of the health care items and services under
        a
        contract directly through the provider or affiliated group of providers and
        may
        make arrangements with physicians or other health care professionals, health
        care institutions, or any combination of such individuals or institutions
        to
        assume all or part of the financial risk on a prospective basis for the
        provision of basic health services by the physicians, by other health
        professionals, or through the institutions. The health care providers must
        have
        a controlling interest in the governing body of the provider service
        network organization.
        For
        purposes of this Contract, the PSN shall operate in accordance with section
        409.91211(3)(e), F.S., and is exempt from licensure under Chapter 641, F.S.
        The
        PSN shall be responsible for meeting certain standards in Chapter 641, F.S.
        as
        required in this Contract.

      

      Public
        Event—
An
        event sponsored for the public or segment of the public by two (2) or more
        actively participating organizations, one (1) of which may be a health
        organization.

      

      Quality—
        The
        degree to which a Health Plan increases the likelihood of desired health
        outcomes of its Enrollees through its structural and operational characteristics
        and through the provision of health services that are consistent with current
        professional knowledge. 

      

      Quality
        Enhancements
        - Certain
        health-related, community-based services that the Health Plan must offer
        and
        coordinate access to for its Enrollees, such as children’s programs, domestic
        violence classes, pregnancy prevention, smoking cessation, or substance abuse
        programs. Health Plans are not reimbursed by the Agency for these types of
        services. 

      

      Quality
        Improvement (QI) —
        The
        process of monitoring and assuring that the delivery of health care services
        are
        available, accessible, timely, Medically Necessary, and provided in sufficient
        quantity, of acceptable Quality, within established standards of excellence,
        and
        appropriate for meeting the needs of the Enrollees. 

       

      Quality
        Improvement Program (QIP) —
        The
        process of assuring the delivery of health care is appropriate, timely,
        accessible, available and Medically Necessary.

      

      Registered
        Nurse (RN) —
        An
        individual who is licensed to practice professional nursing in accordance
        with
        Chapter 464, F.S.

       

      Request
        for Benefit Information (RBI)—
The
        form completed by a Potential Enrollee with the assistance of a Health Plan
        representative and submitted by the Health Plan to the Choice
        Counselor/Enrollment Broker to initiate the receipt of information for the
        Enrollment process. Also known as Pre-Enrollment Application.

      

      Residential
        Services —
        As
        applied to DJJ, refers to the out-of-home placement for use in a level 4,
        6, 8
        or 10 facility as a result of a delinquency disposition order. Also referred
        to
        as a Residential Commitment Program.

      

      Risk
        Adjustment (also Risk-Adjusted)
        - A
        process to adjust Capitation Rates to reflect the health conditions relative
        to
        the health status of the enrolled population. This process includes but is
        not
        limited to, risk assessment models, demographics, or population grouping.
        

      

      Risk
        Assessment —
        The
        process of collecting information from a person about hereditary, lifestyle
        and
        environmental factors to determine specific diseases or conditions for which
        the
        person is at risk.

      

      Rural—
        An
        area
        with a population density of less than 100 individuals per square mile, or
        an
        area defined by the most recent United State Census as rural, i.e.
        lacking a metropolitan statistical area (MSA). 

      

      Rural
        Health Clinic (RHC)—
A
        clinic that is located in an area that has a health-care provider shortage.
        An
        RHC provides primary health care and related diagnostic services and may
        provide
        optometric, podiatry, chiropractic and mental health services. An RHC employs,
        contracts or obtains volunteer services from licensed health care practitioners
        to provide services.

      

      Sales
        Activities —
        Actions
        performed by an agent of any Health Plan, including the acceptance of
        Pre-Enrollment Application Requests for Benefit Information, for the purpose
        of
        Enrollment of Potential Enrollees.

      

      Screen
        or Screening—
        Assessment of an Enrollee's physical or mental condition to determine evidence
        or indications of problems and need for further evaluation or
        services.

      

      Service
        Area—
The
        designated geographical area within which the Health Plan is authorized by
        the
        Contract to furnish Covered Services to Enrollees.

      

      Service
        Authorization—
        The
        Health Plan’s approval for services to be rendered. The process of authorization
        must at least include a Health Plan Enrollee’s or a Provider’s request for the
        provision of a service. 

      

      Service
        Location —
        Any
        location at which an Enrollee obtains any health care service provided by
        the
        Health Plan under the terms of the Contract.

      

      Sick
        Care —
        Non-urgent problems that do not substantially restrict normal activity, but
        could develop complications if left untreated (e.g., chronic
        disease).

      

      Span
        of Control —
        Information systems and telecommunications capabilities that the Health Plan
        itself operates or for which it is otherwise legally responsible according
        to
        the terms and Conditions of this Contract. The Health Plan span of control
        also
        includes Systems and telecommunications capabilities outsourced by the Health
        Plan.

      

      Special
        Supplemental Nutrition Program for Women, Infants & Children
        (WIC)—
Program
        administered by the Department of Health that provides nutritional counseling;
        nutritional education; breast-feeding promotion and nutritious foods to
        pregnant, postpartum and breast-feeding women, infants and children up to
        the
        age of five (5) who are determined to be at nutritional risk and who have
        a low
        to moderate income. An individual who is eligible for Medicaid is automatically
        income eligible for WIC benefits. Additionally, WIC income eligibility is
        automatically provided to an Enrollee's family that includes a pregnant woman
        or
        infant certified eligible to receive Medicaid.

      

      Specialty
        Plan
        - A
        Health Plan designed for a specific population and whose Enrollees are primarily
        composed of Medicaid Recipients, Children with Chronic Conditions or for
        Medicaid Recipients who have been diagnosed with the human immunodeficiency
        virus or acquired immunodeficiency syndrome (HIV/AIDS). A Health Plan must
        be
        licensed under Chapter 641, Florida Statutes, in order to offer a Specialty
        Plan
        for the population with HIV/AIDS.

      

      State —
        State of
        Florida.

      

      Subcontract —
        An
        agreement entered into by the Health Plan for provision of administrative
        services on its behalf. 

      

      Subcontractor —
        Any
        person or entity with which the Health Plan has contracted or delegated some
        of
        its functions, services or responsibilities for providing services under
        this
        Contract.

      

      Surface
        Mail —
        Mail
        delivery via land, sea, or air, rather than via electronic transmission.
        

       

      Surplus —
        Net
        worth, i.e., total assets minus total liabilities.

      

      System
        Unavailability —
        As
        measured within the Health Plan’s information systems Span of Control, when a
        system user does not get the complete, correct full-screen response to an
        input
        command within three (3) minutes after depressing the “Enter” or other function
        key.

      

      Systems —
        See
        Information Systems.

      

      Temporary
        Assistance to Needy Families (TANF)—
Public
        financial assistance provided to low-income families.

      

      Transportation—
An
        appropriate means of conveyance furnished to an Enrollee to obtain Medicaid
        authorized/covered services.

      

      Unborn
        Activation—
The
        process by which an unborn child, who has been assigned a Medicaid ID number
        is
        made Medicaid eligible upon birth.

      

      Urban — An
        area
        with a population density of greater than 100 individuals per square mile
        or an
        area defined by the most recent United State Census as urban, i.e. as
        having
        a metropolitan statistical area (MSA). 

      

      Urgent
        Behavioral Health Care—
Those
        situations that require immediate attention and assessment within twenty-three
        (23) hours even though the Enrollee is not in immediate danger to
        himself/herself or others and is able to cooperate in treatment.

      

      Urgent
        Care—
        Services for conditions, which, though not life-threatening, could result
        in
        serious injury or disability unless medical attention is received (e.g.,
        high
        fever, animal bites, fractures, severe pain, etc.) or do substantially restrict
        an Enrollee's activity (e.g., infectious illnesses, flu, respiratory ailments,
        etc.).

      

      Validation — The
        review of information, data, and procedures to determine the extent to which
        they are accurate, reliable, free from bias and in accord with standards
        for
        data collection and analysis.

      

      Vendor — An
        entity
        submitting a proposal to become a Health Plan contractor. 

      

      Violation—
A
        determination by the Agency that a Health Plan failed to act as specified
        in
        this Contract or applicable statutes, rules or regulations governing Medicaid
        Health Plans. Each day that an ongoing violation continues shall be considered,
        for the purposes of this Contract, to be a separate Violation. In addition,
        each
        instance of failing to furnish necessary and/or required medical services
        or
        items to Enrollees shall be considered, for purposes of this Contract, to
        be a
        separate Violation. As well, each day that a Health Plan fails to furnish
        necessary and/or required medical services or items to Enrollees shall be
        considered, for purposes of this Contract, to be a separate
        Violation.

      

      Voluntary
        Enrollee—
An
        Enrollee that is not mandated to enroll in a Health Plan, but chooses to
        enroll
        in a Health Plan.

      

      Voluntary
        Potential Enrollee—
A
        Potential Enrollee that is not mandated to enroll in a Health Plan, and is
        not
        yet Enrolled in a Health Plan. 

       

      Well
        Care Visit—
A
        routine medical visit for one (1) of the following: CHCUP visit, family
        planning, routine follow-up to a previously treated condition or illness,
        adult
        physicals or any other routine visit for other than the treatment of an
        illness.

      

       

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

      	B.  	
              Acronyms

            

       

      

      ADL
        — Activities
        of Daily Living

       

      ADM—
        Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
        Children & Families (aka SAMH — listed below)

       

      ALF—
        Assisted Living Facility

       

      APD—
Agency
        for People with Disabilities

       

      BBA
        —
        Balanced Budget Act of 1997

       

      CAP
        — Corrective
        Action Plan

       

      CARES
        — Comprehensive
        Assessment & Review for Long-Term Care Services

       

      CDC
        — Centers
        for Disease Control

       

      CHD
        — County
        Health Department

       

      CMS
        — Centers
        for Medicare & Medicaid Services

       

      CFR
        — Code
        of
        Federal Regulations

       

      CHCUP
        — Child
        Health Check-Up Program

       

      CPT—
        Physicians’ Current Procedural Terminology

       

      DCF—
        Department of Children & Families

       

      DFS
        -
        Department of Financial Services

       

      DHHS—
United
        States Department of Health & Human Services

       

      DOH—
        Department of Health

       

      DJJ—
        Department of Juvenile Justice

       

      DEA—
Drug
        Enforcement Administration

       

      DME—
Durable
        Medical Equipment

       

      EDI
        —
        Electronic Data Interchange 

       

      EDT
        -
        Eastern Daylight Time

       

      EPSDT—
Early
        and Periodic Screening, Diagnosis & Treatment Program

       

      EQR
        —
        External Quality Review

       

      EQRO—
        External Quality Review Organization

       

      EST—
Eastern
        Standard Time

       

      FAC—
Florida
        Administrative Code

       

      FFS—
        Fee-for-Service

       

      FQHC—
        Federally Qualified Health Center

       

      FTE—
Full
        Time Equivalent Position

       

      HIPAA—
Health
        Insurance Portability & Accountability Act

       

      HMO—
Health
        Maintenance Organization

       

      IBNR
        -
        Incurred but not reported

       

      LEIE—
List
        of
        Excluded Individuals & Entities

       

      MBHO—
Managed
        Behavioral Health Organization

       

      ODBC
        —
Open
        Database Connectivity

       

      PCCB
        - Per
        capita capitation benchmark

       

      PCP—
Primary
        Care Physician

       

      QI
        -
        Quality
        Improvement

       

      QIP—
Quality
        Improvement Program

       

      RBI
        -
        Request for Benefit Information

       

      RFP—
Request
        for Proposal

       

      RHC—
Rural
        Health Clinic

       

      SAMH—
        Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
        Children & Families (aka ADM — listed above)

       

      SFTP—
Secure
        File Transfer Protocol

       

      SOBRA—
Sixth
        Omnibus Budget Reconciliation Act

       

      SQL
        —
        Structured Query Language

       

      SSI
        —
        Supplemental Security Income 

       

      UM
        —
        Utilization Management

       

      WIC—
Special
        Supplemental Nutrition Program for Women, Infants & Children

       

      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Section
        II

       

      General
        Overview 

       

      

      	A.  	
              Background

            

       

      

      
        	 	
                1.

              	
                Effective
                  July 1, 2006, the Agency for Health Care Administration will begin
                  implementing Medicaid Reform in the counties of Broward and Duval.
                  At the
                  end of the first year of implementation, Medicaid Reform will be
                  extended
                  to Nassau, Clay and Baker counties. Medicaid Reform will transform
                  the
                  Medicaid program by empowering Medicaid Recipients to take control
                  of
                  their health care, providing more choices for Recipients, and enhancing
                  their health status through increased health literacy and incentives
                  to
                  engage in healthy behaviors. 

              

      

      

      
        	 	
                2.

              	
                The
                  principles governing Medicaid Reform
                  are:

              

      

      

      	a.  	
              Patient
                Responsibility and Empowerment;

            

      

      	b.  	
              Marketplace
                Decisions;

            

      

      	c.  	
              Bridging
                Public and Private Coverage; and

            

      

      	d.  	
              Sustainable
                Growth Rate.

            

      

      
        	 	
                3.

              	
                These
                  principles will empower Medicaid Recipients, provide flexibility
                  to
                  Providers, and facilitate program management for government.
                  

              

      

      

      	B.  	
              Purpose

            

       

      

      One
        of
        the key goals of Medicaid Reform is the expansion of health care choices
        for
        Medicaid Recipients and enhanced access to services. To achieve this goal
        the
        Agency proceeded with an open application process to obtain the services
        of
        Health Plans. This Contract is the agreement between the Agency and entities
        operating under Medicaid Reform as a Health Plan.

      

      	C.  	
              Responsibilities
                of the State of Florida (the State) and the Agency for Health Care
                Administration (the Agency)

            

       

      

      	1.  	
              The
                Agency will be responsible for administering the Medicaid program,
                including all aspects of Medicaid Reform. The Agency will administer
                contracts, monitor Health Plan performance, and provide oversight
                in all
                aspects of the Health Plan’s operations.

            

      

      	2.  	
              The
                State of Florida has sole authority for determining eligibility for
                Medicaid and whether Medicaid Recipients are mandated to enroll in,
                may
                enroll in, or may not enroll in Medicaid
                Reform.

            

      

      	3.  	
              The
                Agency or its Agent will review the Florida Medicaid Management
                Information System (FMMIS) file daily and will send written notification
                and information to all Potential Enrollees. A Potential Enrollee
                will have
                thirty (30) Calendar Days to select a Health Plan.
                

            

      

      	4.  	
              The
                Agency or its Agent will Auto-Assign Mandatory Potential Enrollees
                who do
                not select a Health Plan during their choice period to a Health Plan
                using
                a pre-established algorithm.

            

      

      	5.  	
              Enrollment
                in a Health Plan, whether chosen or Auto-Assigned, will be effective
                at
                12:01 a.m. on the first (1st) Calendar Day of the month following
                Potential Enrollee selection or Auto-Assignment, for those Potential
                Enrollees who choose or are Auto- Assigned to a Health Plan on or
                between
                the first (1st) Calendar Day of the month and the Penultimate Saturday
                of
                the month. For those Enrollees who choose or are Auto-Assigned a
                Health
                Plan between the Sunday after the Penultimate Saturday and before
                the last
                Calendar Day of the month, Enrollment in a Health Plan will be effective
                on the first (1st) Calendar Day of the second (2nd) month after choice
                or
                Auto-assignment.

            

      

      	6.  	
              The
                Agency or its Agent will notify the Health Plan of an Enrollee’s selection
                or assignment to a Health Plan. 

            

      

      	7.  	
              The
                Agency or it Agent will send a written confirmation notice to Enrollees
                identifying the chosen or Auto-Assigned Health Plan. If the Enrollee
                has
                not chosen a PCP, the confirmation notice will advise the Enrollee
                that a
                PCP will be chosen for him/her. Notice to the Enrollee will be made
                in
                writing and sent via Surface Mail. Notice to the Health Plan will
                be made
                via file transfer. 

            

      

      	8.  	
              Conditioned
                on continued eligibility, Mandatory Enrollees will have a Lock-In
                period
                of twelve (12) consecutive months. After an initial ninety (90) day
                change
                period, Mandatory Enrollees will only be able to disenroll from their
                Health Plan for Cause. The Agency or its Agent will notify Enrollees
                at
                least once every twelve (12) months, and at least sixty (60) Calendar
                Days
                prior to the date the Lock-In period ends (the Open Enrollment period),
                that they have the opportunity to change Health Plans. Enrollees
                who do
                not make a choice will be deemed to have chosen to remain with their
                current Health Plan, unless the current Health Plan no longer participates
                in Medicaid Reform. In this case, the Enrollee will be Auto-Assigned
                to a
                new Health Plan.

            

      

      	9.  	
              The
                Agency or its Agent will automatically re-enroll an Enrollee into
                the
                Health Plan in which he or she was most recently enrolled if the
                Enrollee
                has a temporary loss of eligibility, defined for purposes of this
                Contract
                as less than 180 Calendar Days. In this instance, for Mandatory Potential
                Enrollee, the Lock-In period will continue as though there had been
                no
                break in eligibility, keeping the original twelve (12) month period.
                

            

      

      	10.  	
              If
                a temporary loss of eligibility has caused the Enrollee to miss the
                Open
                Enrollment period, the Agency or its Agent will enroll the Enrollee
                in the
                Health Plan in which he or she was enrolled prior to the loss of
                eligibility. The Enrollee will have ninety (90) Calendar Days to
                disenroll
                without Cause.

            

      

      	11.  	
              The
                State will issue a Medicaid identification (ID) number to a newborn
                upon
                notification from the Health Plan, the hospital, or other authorized
                Medicaid provider, consistent with the unborn activation process.
                

            

      

      	12.  	
              The
                Agency or its Agent will notify Enrollees of their right to request
                Disenrollment as follows:

            

      

      a. For
        Cause
        at any time, or

      

      b. Without
        Cause, at the following times:

      

      
        	 	
                (1)

              	
                During
                  the ninety (90) days following the Enrollee's initial Enrollment,
                  or the
                  date the Agency or its Agent sends the Enrollee notice of the enrollment,
                  whichever is later;

              

      

      

      
        	 	
                (2)

              	
                At
                  least every twelve (12) months;

              

      

      

      
        	 	
                (3)

              	
                If
                  the temporary loss of Medicaid eligibility has caused the Enrollee
                  to miss
                  the Open Enrollment period; or

              

      

      

      	(4)  	
              When
                the Agency or its Agent grants the Enrollee the right to terminate
                Enrollment without Cause. The Agency or its Agent determines the
                Enrollee's right to terminate Enrollment on a case-by-case basis.
                

            

      

      	(5)  	
              If
                the individual chooses to opt out and enroll in their employer-sponsored
                health insurance plan.

            

      

      	13.  	
              The
                Agency or its Agent will process all Disenrollments from the Health
                Plan.
                The Agency or its Agent will make final determinations about granting
                Disenrollment requests and will notify the Health Plan via file transfer
                and the Enrollee via Surface Mail of any Disenrollment decision.
                Enrollees
                dissatisfied with an Agency determination may have access to the
                Medicaid
                Fair Hearing process.

            

      

      	14.  	
              When
                Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
                Disenrollment shall be immediate. 

            

      

      	15.  	
              The
                Agency and/or its Agent shall determine the activities and behaviors
                that
                qualify for contributions to the individual’s Enhanced Benefit Account.
                

            

      

      	16.  	
              The
                Agency will conduct periodic monitoring of the Health Plan’s operations
                for compliance with the provisions of the Contract and applicable
                federal
                and State laws and regulations.

            

      

      	D.  	
              General
                Responsibilities of the Health Plan 

            

       

      

      	1.  	
              The
                Health Plan shall comply with all provisions of this Contract and
                its
                amendments, if any, and shall act in good faith in the performance
                of the
                Contract's provisions. The Health Plan shall develop and maintain
                written
                policies and procedures to implement all provisions of this Contract.
                The
                Health Plan agrees that failure to comply with all provisions of
                this
                Contract shall result in the assessment of penalties and/or termination
                of
                the Contract, in whole or in part, as set forth in this
                Contract.

            

      

      	2.  	
              The
                Health Plan shall comply with all pertinent Agency rules in effect
                throughout the duration of the Contract.

            

      

      	3.  	
              The
                Health Plan shall comply with all current Florida Medicaid Handbooks
                ("Handbooks") as noticed in the Florida Administrative Weekly ("FAW"),
                or
                incorporated by reference in rules relating to the provision of services
                set forth in Section V Covered Services, and Section VI, Behavioral
                Health
                Care, except where the provisions of the Contract alter the requirements
                set forth in the Handbooks promulgated in the Florida Administrative
                Code
                (FAC) unless a customized benefit package has been certified by the
                Agency. In addition, the Health Plan shall comply with the limitations
                and
                exclusions in the Handbooks, unless otherwise specified by this Contract.
                In no instance may the limitations or exclusions imposed by the Health
                Plan be more stringent than those specified in the Handbooks, unless
                authorized in the Customized Benefit Package by the Agency. The Health
                Plan may not arbitrarily deny or reduce the amount, duration or scope
                of a
                required service solely because of the diagnosis, type of illness,
                or
                condition. The Health Plan may exceed Handbook limits by offering
                Expanded
                Services, as described in Section V, Covered Services or through
                its
                approved Customized Benefit package. 

            

      

      	4.  	
              The
                Capitated PSN may only choose to offer a Specialty Plan for Medicaid
                Recipients in:

            

      

      
        	 	
                a.

              	
                Temporary
                  Assistance to Needy Families (TANF) eligibility
                  category;

              

      

      

      
        	 	
                b.

              	
                Supplemental
                  Security Income (SSI) eligibility category;
                  or

              

      

      

      
        	 	
                c.

              	
                Children
                  with Chronic Conditions.

              

      

      

      	5.  	
              The
                Health Plan may offer Expanded Services, as described in Section
                V,
                Covered Services to Enrollees, in addition to the required services
                and
                Quality Enhancements. The Health Plan shall define with specificity
                its
                Expanded Services in regards to amount, duration and scope, and obtain
                approval, in writing, by the Agency prior to
                implementation.

            

      

      	6.  	
              This
                Contract including all attachments and exhibits, represents the entire
                agreement between the Health Plan and the Agency and supersedes all
                other
                contracts between the parties when it is executed by duly authorized
                signatures of the Health Plan and the Agency. Correspondence and
                memoranda
                of understanding do not constitute part of this Contract. In the
                event of
                a conflict of language between the Contract and the attachments,
                the
                provisions of the Contract shall govern. The Agency reserves the
                right to
                clarify any contractual relationship in writing and such clarification
                shall govern. Pending final determination of any dispute over any
                Agency
                decision, the Health Plan shall proceed diligently with the performance
                of
                its duties as specified under the Contract and in accordance with
                the
                direction of the Agency's Division of
                Medicaid.

            

      

      	7.  	
              The
                Health Plan shall have a Quality Improvement program that ensures
                enhancement of quality of care and emphasizes improving the quality
                of
                patient outcomes. The Agency may restrict the Health Plan’s Enrollment
                activities if the Health Plan does not meet acceptable Quality Improvement
                and performance indicators, based on HEDIS reports and other outcome
                measures to be determined by the Agency. Such restrictions may include,
                but shall not be limited to, the termination of mandatory
                assignments.

            

      

      	8.  	
              The
                Health Plan must demonstrate that it has adequate knowledge of Medicaid
                programs, provision of health care services, disease management
                initiatives, medical claims data, and the capability to design and
                implement cost savings methodologies. The Health Plan must demonstrate
                the
                capacity for financial analyses, as necessary to fulfill the requirements
                of this Contract. Additionally, the Health Plan must meet all requirements
                for doing business in the State of Florida.

            

      

      	9.  	
              The
                Health Plan may be required to provide to the Agency or its Agent
                information or data that is not specified under this Contract. In
                such
                instances, and at the direction of the Agency, the Health Plan shall
                fully
                cooperate with such requests and furnish all information in a timely
                manner, in the format in which it is requested. The Health Plan shall
                have
                at least thirty (30) Calendar Days to fulfill such ad hoc
                requests.

            

      

      	10.  	
              The
                Health Plan shall fully cooperate with, and provide necessary data
                to, the
                Agency and its Agent for the design, management, operations and monitoring
                of the Enhanced Benefits Program.

            

      

      	11.  	
              A
                Health Plan, who accepts the Comprehensive Component of the Capitation
                Rate only, shall continue to provide all Covered Services to each
                Enrollee, who reaches the Catastrophic Component Threshold. The Health
                Plan shall continue to apply its QM and UM program components, as
                well as
                other administrative policies and protocols to the delivery of care
                and
                services to the Enrollees who meet the threshold. The Health Plan
                may
                submit documentation for reimbursement for Covered Services costs
                as
                outlined in Section XIII., Method of Payment, subsection D. Claims
                Payment
                for Health Plans Providing the Comprehensive Component Only.
                

            

      

      	12.  	
              When
                the cost of an Enrollee’s Covered Services reaches the Benefit Maximum of
                $550,000 in a Contract Year, the Health Plan shall assist the Enrollee
                in
                obtaining necessary health care services in the community. The Health
                Plan
                shall continue to coordinate the care received by the Enrollee in
                the
                community. The Health Plan shall resume all responsibilities for
                the
                provision of Covered Services at the beginning of the Contract Year
                (September 1) following the year in which the Maximum Benefit was
                reached
                by the Enrollee.

            

      

      	13.  	
              Health
                Maintenance Organizations and other licensed managed care organizations
                shall enroll all network providers with the Agency’s Fiscal Agent, no
                later than November 30, 2006, using the Agency’s streamlined Provider
                Enrollment process. All Capitated PSNs shall use the streamlined
                Provider
                Enrollment process to enroll network providers prior to contract
                execution.

            

      

      	14.  	
              The
                Health Plans shall collect and submit Encounter Data for each Contract
                Year in the format required by the Agency and within the time frames
                specified by the Agency. An encounter guide along with technical
                assistance will be forthcoming. At a minimum the Health Plans shall
                be
                responsible for the following:

            

      

      	a.  	
              Health
                Plans shall collect and submit to the Agency or its designee, enrollee
                service level encounter data for all covered
                services.

            

      	b.  	
              Encounter
                data shall be submitted following HIPAA standards, namely the ANSI
                X12N
                837 Transaction formats (P - Professional, I - Institutional, and
                D -
                Dental), and the National Council for Prescription Drug Programs
                NCPDP
                format (for Pharmacy services).

            

      	c.  	
              All
                covered services rendered to health plan enrollees shall result in
                the
                creation of an encounter record.

            

      

      

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      Section
        III

       

      Eligibility
        and Enrollment

       

      

      	A.  	
              Eligibility

            

       

      

      The
        following Populations represent broad categories that contain multiple
        eligibility groups. Certain exceptions may apply within the broad categories
        and
        will be determined by the Agency.

      

      	1.  	
              Mandatory
                Populations 

            

      

      The
        categories of eligible recipients authorized to be enrolled in the Health
        Plan
        are: Low Income Families and Children; Sixth Omnibus Budget Reconciliation
        Act
        (SOBRA) Children; Supplemental Security Income (SSI) Medicaid Only, Refugees,
        and the Meds AD population. 

      

      Title
        XXI
        MediKids are eligible for enrollment in the plan in accordance with section
        409.8132, F.S. Except as otherwise specified in this contract, Title XXI
        MediKids eligible participants are entitled to the same conditions and services
        as currently eligible Title XIX Medicaid beneficiaries. 

      

      Women
        enrolled in the plan who change eligibility categories to the SOBRA eligibility
        category due to the pregnancy will remain eligible for enrollment in the
        plan.

      

      	2.  	
              Voluntary
                Populations 

            

      

      The
        following categories describe beneficiaries who may enroll in a health plan
        but
        are not required to do so:

      

      a. Foster
        care Children/Adolescents;

      

      b. Individuals
        diagnosed with developmental disabilities, as defined by the
        Agency;

      

      c. Children
        with chronic conditions who are eligible to participate in the Children’s
        Medical Services Program or a Specialty Plan for children with chronic
        conditions but not enrolled in the program; 

      

      d.
         Individuals
        with Medicare coverage (e.g. dual eligible individuals); and

      

      e. Children
        and adolescents who have an open case for services in the Department of Children
        and Families’ HomeSafenet database system.

      

      	3.  	
              Excluded
                Populations

            

      

      The
        following categories describe Medicaid Recipients who are not eligible to
        enroll
        in a Health Plan: 

      

      a. Pregnant
        women who have not enrolled in Medicaid Reform prior to the effective date
        of
        their SOBRA eligibility;

      

      

      

      b. Medicaid
        Recipients who, at the time of application for Enrollment and/or at the time
        of
        Enrollment, are domiciled or residing in an institution, including nursing
        facilities (and have been CARES assessed), sub-acute inpatient psychiatric
        facility for individuals under the age of 21, or an Intermediate Care
        Facility/Developmentally Disabled (ICF-DD);

      

      c. Medicaid
        Recipients whose Medicaid eligibility was determined through the medically
        needy
        program.

      

      d. Qualified
        Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries
        (SLMBs), or Qualified Individuals at Level 1 (QI-1s).

      

      e. Medicaid
        Recipients who have other creditable health-care coverage, such as TriCare
        or a
        private health maintenance organization (HMO).

      

      f. Medicaid
        Recipients who reside in the following:

      

      (1) Residential
        commitment programs/facilities operated through the Department of Juvenile
        Justice (DJJ);

      

      (2) Residential
        group care operated by the Family Safety & Preservation Program of the
        DCF;

      

      (3) Children's
        residential treatment facilities purchased through the Substance Abuse &
Mental Health District ("SAMH") Offices of the DCF (also referred to as
        Purchased Residential Treatment Services - "PRTS");

      

      (4) SAMH
        residential treatment facilities licensed as Level I and Level II facilities;
        and

      

      (5) Residential
        Level I and Level II substance abuse treatment programs, as described in
        Sections
        65D-30.007(2)(a) and (b), F.A.C.

      

      g. Medicaid
        Recipients participating in the Family Planning waiver.

      

      h. Participants
        in the Sub-acute Inpatient Psychiatric Program ("SIPP").

      

      i. Title
        XXI-funded children with chronic conditions who are enrolled in Children’s
        Medical Services Network.

      

      j. Women
        eligible for Medicaid due to breast and/or cervical cancer.

      

      k. Individuals
        eligible under a hospice-related eligibility group.

      

      	B.  	
              Enrollment

            

      

      	1.  	
              General
                Provisions

            

      

      a. Only
        Medicaid Recipients who are included in the mandatory or voluntary group
        and
        living in counties with authorized Health Plans are eligible to enroll and
        receive services from the Health Plan.

      

      b. The
        Agency or its Agent shall be responsible for Enrollment, including Enrollment
        into a Health Plan, Disenrollment, and outreach and education activities.
        The
        Health Plan shall coordinate with the Agency and its Agent as necessary for
        all
        Enrollment and Disenrollment functions.

      

      c.
         The
        Health Plan shall accept Medicaid Recipients without restriction and in the
        order in which they enroll. The Health Plan shall not discriminate against
        Medicaid Recipients on the basis of religion, gender, race, color, age, or
        national origin, and shall not use any policy or practice that has the effect
        of
        discriminating on the basis of religion, gender, race, color, or national
        origin, or on the basis of health, health status, pre-existing condition,
        or
        need for health care services.

      

      d. The
        Health Plan shall accept new Enrollees through-out the Contract period up
        to the
        authorized maximum enrollment levels approved in Attachment I. 

      

      	2.  	
              Enrollment
                in a Specialty Plan

            

      

      Enrollment
        in a plan authorized to serve individuals diagnosed with HIV/AIDS or Children
        with Chronic Conditions will be limited to individuals in a mandatory or
        voluntary population who are diagnosed with such a condition and their family
        members. For a specialty plan for children with chronic conditions, only
        sibling
        family members under the age of 18 years of age may enroll when an eligible
        sibling is enrolled.

      

      	3.  	
              Enrollment
                with a Primary Care Provider
                (PCP)

            

      

      a. The
        Health Plan shall offer each Enrollee a choice of PCPs. After making a choice,
        each Enrollee shall have a single PCP.

      

      b. The
        Health Plan shall assign a PCP to those Enrollees who did not choose a PCP
        at
        the time of Health Plan selection. The Health Plan shall take into consideration
        the Enrollee's last PCP (if the PCP is known and available in the Health
        Plan's
        network), closest PCP to the Enrollee's home address, ZIP code location,
        keeping
        Children/Adolescents within the same family together, age (adults versus
        Children/Adolescents) and gender (OB/GYN).

      

      c. The
        Health Plan shall provide written notice via Surface Mail to the Enrollees,
        by
        the first day of the Enrollee's enrollment, of the following:

      

      (1) The
        Enrollee's PCP assignment;

      

      (2) The
        Enrollee's ability to choose a different PCP;

      

      (3) A
        list of
        Participating Providers from which to make a choice; and

       

      (4) The
        procedures for changing PCPs.

      

      d. The
        Health Plan shall permit Enrollees to change PCPs at any time. 

      

      e. The
        Health Plan shall assign all Enrollees that are reinstated after a temporary
        loss of eligibility to the PCP who was treating them prior to loss of
        eligibility, unless the Enrollee specifically requests another PCP, the PCP
        no
        longer participates in the Health Plan or is at capacity, or the Enrollee
        has
        changed geographic areas.

      

      	4.  	
              Newborn
                Enrollment

            

      

      a. The
        Health Plan shall utilize the unborn activation process to facilitate enrollment
        and shall be responsible for newborns from the date they are enrolled in
        the
        Health Plan. 

      

      b. Upon
        unborn activation, the newborn shall be enrolled in the Health Plan in which
        his/her mother was enrolled during the next enrollment cycle. 

      

      c. Newborn
        Enrollment shall occur through the following procedures:

      

      (1) Upon
        identification of an Enrollee's pregnancy, the Health Plan shall immediately
        notify DCF of the pregnancy and any relevant information known (i.e., due
        date
        and gender). The Health Plan must provide this notification by completing
        the
        DCF-ES 2039 Form and submitting the completed form to DCF. The Health Plan
        shall
        indicate its name and number as the entity initiating the referral. The DCF-ES
        2039 form is located on the Medicaid web site: http://www.fdhc.state.fl.us/Medicaid/Newborn.
        

      

      (2) DCF
        will
        generate a Medicaid ID number and the unborn child will be added to the Medicaid
        file. This information will be transmitted to the Medicaid Fiscal Agent.
        The
        Medicaid ID number will remain inactive until after the child is
        born.

      

      (3) The
        Health Plan shall comply with all requirements set forth by the Agency or
        its
        Agent related to Unborn Activation (see Policy Transmittal 06-02, Unborn
        Activation Process). To ensure the prompt Enrollment of newborns, the Health
        Plan shall ensure that the form DCF-ES 2039 is completed and submitted, via
        electronic submission, to the local DCF Economic Self-Sufficiency Services
        Office immediately upon the birth of the child. If the hospital is not a
        Participating Hospital, the Plan must submit Form 2039 to DCF. With regard
        to
        Participating Hospitals, the Plan must include, as part of its Participating
        Hospital Agreement, a clause that states whether the Plan or the Participating
        Hospital will complete the Form 2039 for all who lack an unborn
        record.

      

      (4) Upon
        notification that a pregnant Enrollee has presented to the Hospital for
        delivery, the Health Plan shall inform the Hospital, the pregnant Enrollee’s
        attending physician and the newborn’s attending and consulting physicians that
        the newborn is an Enrollee only if the Health Plan has verified that the
        newborn
        has an unborn record on the system that is awaiting activation. At this time
        the
        Health Plan shall initiate the Unborn Activation process.

      

      (5) Upon
        activation, the newborn shall be enrolled in the Health Plan in which his/her
        mother was enrolled during the month of birth.  

      

      	5.  	
              Enrollment
                Cessation

            

      

      The
        Health Plan may request that the Agency halt or reduce Enrollment temporarily
        if
        continued full Enrollment would exceed its capacity to provide required services
        under the Contract. The Agency may also limit Health Plan Enrollments when
        such
        action is considered to be in the Agency's best interest. 

      

      

      

      	6.  	
              Enrollment
                Notice

            

      

      a. Prior
        to
        or upon Enrollment, the Health Plan shall provide the following information
        to
        all new Enrollees:

      

      (1) A
        written
        notice providing the actual date of Enrollment, and the name, telephone number
        and address of the Enrollee’s PCP assignment.

      

      (2) Notification
        that Enrollees can change their Health Plan selection, subject to Medicaid
        limitations.

      

      (3) Enrollment
        materials regarding PCP choice as described in Section III, B.

      

      (4) New
        Enrollee Materials as described in Section IV.

      

      	C.  	
              Disenrollment

            

       

      

      	1.  	
              General
                Provisions

            

      

      a. If
        the
        Contract is renewed, the Enrollment status of all Enrollees shall continue
        uninterrupted.

      

      b. The
        Health Plan shall ensure that it does not restrict the Enrollee's right to
        disenroll voluntarily in any way. 

      

      c. The
        Health Plan or its agents shall not provide or assist in the completion of
        a
        Disenrollment request or assist the Agency’s Choice Counselor/Enrollment Broker
        in the Disesnrollment process.

      

      d. The
        Health Plan shall ensure that Enrollees that are disenrolled and wish to
        file an
        appeal have the opportunity to do so. All Enrollees shall be afforded the
        right
        to file an appeal except for the following reasons for Disenrollment:

      

      (1) Moving
        out of the Service Area; 

      (2) Loss
        of
        Medicaid eligibility; and 

      (3) Enrollee
        death.

      

      e. An
        Enrollee may submit to the Agency or its Agent a request to disenroll from
        the
        Health Plan without Cause during the ninety (90) Calendar Day change period
        following the date of the Enrollee's initial Enrollment with the Health Plan,
        or
        the date the Agency or its Agent sends the Enrollee notice of the Enrollment,
        whichever is later. An Enrollee may request Disenrollment without Cause every
        twelve (12) months thereafter.

      

      f. The
        effective date of an approved Disenrollment shall be the last Calendar Day
        of
        the month in which Disenrollment was made effective by the Agency or its
        Agent,
        but in no case shall Disenrollment be later than the first (1st) Calendar
        Day of
        the second (2nd) month following the month in which the Enrollee or the Health
        Plan files the Disenrollment request. If the Agency or its Agent fails to
        make a
        Disenrollment determination within this timeframe, the Disenrollment is
        considered approved. 

      

      g. The
        Health Plan shall keep a daily written log or electronic documentation of
        all
        oral and written Enrollee Disenrollment requests and the disposition of such
        requests. The log shall include the following: 

      

      (1) The
        date
        the request was received by the Health Plan;

      

      (2) The
        date
        the Enrollee was referred to the Agency's Choice Counselor/Enrollment Broker
        or
        the date of the letter advising the Enrollee of the Disenrollment procedure,
        as
        appropriate; and

      

      (3) The
        reason that the Enrollee is requesting Disenrollment.

      

      h. The
        Health Plan shall send to the Agency or its Agent a monthly summary report
        of
        all submitted Disenrollment requests. This report must specify the reason
        for
        such Disenrollment requests. It shall be reconciled to the Health Plan
        Enrollment Report processed by the Agency or its Agent for the applicable
        month
        and shall be reviewed by the Agency or its Agent for compliance with acceptable
        reasons for Disenrollment. The Agency may reinstate Enrollment for any Enrollee
        whose reason for Disenrollment is not consistent with established
        guidelines.

      

      	2.  	
              Cause
                for Disenrollment 

            

      

      a. A
        Mandatory Enrollee may request Disenrollment from the Health Plan for Cause
        at
        any time. Such request shall be submitted to the Agency or its Agent. The
        following reasons constitute Cause for Disenrollment from the Health
        Plan:

      

      
        	 	
                (1)

              	
                The
                  Enrollee moves out of the Service Area or his/her address is
                  incorrect.

              

      

      

      
        	 	
                (2)

              	
                The
                  Provider is no longer with the Health
                  Plan.

              

      

      

      
        	 	
                (3)

              	
                The
                  Enrollee is excluded from
                  enrollment.

              

      

      

      
        	 	
                (4)

              	
                A
                  substantiated marketing violation
                  occurred.

              

      

      

      
        	 	
                (5)

              	
                The
                  Enrollee is prevented from participating in the development of
                  his/her
                  treatment plan.

              

      

      

      
        	 	
                (6)

              	
                The
                  Enrollee has an active relationship with a provider who is not
                  on the
                  Health Plan's panel, but is on the panel of another Health
                  Plan.

              

      

      

      
        	 	
                (7)

              	
                The
                  Enrollee is in the wrong Health Plan due to an
                  error.

              

      

      

      
        	 	
                (8)

              	
                The
                  Health Plan no longer participates in the
                  county.

              

      

      

      
        	 	
                (9)

              	
                The
                  State has imposed intermediate sanctions upon the Health Plan,
                  as
                  specified in 42 CFR 438.702(a)(3).

              

      

      

      
        	 	
                (10)

              	
                The
                  Enrollee needs related services to be performed concurrently, but
                  not all
                  related services are available within the Health Plan network;
                  or, the
                  Enrollee's PCP has determined that receiving the services separately
                  would
                  subject the Enrollee to unnecessary
                  risk.

              

      

      

      
        	 	
                (11)

              	
                The
                  Health Plan does not, because of moral or religious objections,
                  cover the
                  service the Enrollee seeks.

              

      

      

      
        	 	
                (12)

              	
                The
                  Enrollee missed his/her Open Enrollment due to a temporary loss
                  of
                  eligibility, defined as 180 days or
                  less.

              

      

      

      
        	 	
                (13)

              	
                Other
                  reasons per 42 CFR 438.56(d)(2), including, but not limited to,
                  poor
                  quality of care; lack of access to services covered under the Contract;
                  inordinate or inappropriate changes of PCPs; service access impairments
                  due to significant changes in the geographic location of services;
                  lack of
                  access to Providers experienced in dealing with the Enrollee’s health care
                  needs; or fraudulent Enrollment. 

              

      

      

      b. Voluntary
        Enrollees may disenroll from the Health Plan at any time. 

      

      	3.  	
              Involuntary
                Disenrollment

            

      

      a. With
        proper written documentation, the following are acceptable reasons for which
        the
        Health Plan shall submit involuntary Disenrollment requests to the
        Agency:

      

      (1) Enrollee
        has moved out of the Service Area;

      

      (2) Enrollee
        death;

      

      (3) Determination
        that the Enrollee is ineligible for Enrollment based on the criteria specified
        in this Contract in Section III.A.3, Excluded Populations, and

      

      (4) Fraudulent
        use of the Enrollee ID card. 

      

      b. The
        Health Plan shall promptly submit such Disenrollment requests to the Agency.
        In
        no event shall the Health Plan submit the Disenrollment request at such a
        date
        as would cause the Disenrollment to be effective later than forty-five (45)
        Calendar Days after the Health Plan’s receipt of the reason for involuntary
        Disenrollment. The Health Plan shall ensure that involuntary Disenrollment
        documents are maintained in an identifiable Enrollee record.

      

      c. If
        the
        Health Plan submitted the Disenrollment request for one of the above reasons,
        the Health Plan shall verify that the information is accurate.

      

      d. If
        the
        Health Plan discovers that an ineligible Enrollee has been enrolled, then
        it
        shall request Disenrollment of the Enrollee and shall notify the Enrollee
        in
        writing that the Health Plan is requesting Disenrollment and the Enrollee
        will
        be disenrolled in the next Contract month, or earlier if necessary. Until
        the
        Enrollee is Disenrolled, the Health Plan shall be responsible for the provision
        of services to that Enrollee.

      

      e. On
        a
        monthly basis, the Health Plan shall review its ongoing Enrollment report
        (FLMR
        8200-R0004) to ensure that all Enrollees are residing in the Health Plan’s
        authorized Service Area. For Enrollees with out-of-Service Area addresses
        on the
        Enrollment report, the Health Plan shall notify the Enrollee in writing that
        the
        Enrollee should contact the Choice Counselor/Enrollment Broker to choose
        another
        Health Plan, or other managed care option available in the Enrollee’s new
        Service Area, and that the Enrollee will be Disenrolled.

      f. The
        Health Plan may submit involuntary Disenrollment requests to the Agency or
        its
        Agent for assigned Enrollees that meet both of the following
        requirements:

      

      (1) The
        Health Plan was unable to contact the Enrollee by mail, phone, or personal
        visit
        within the first three (3) months of Enrollment; and

      

      (2) The
        Enrollee did not use Health Plan services within the first three (3) months
        of
        Enrollment. Such Disenrollments shall be submitted in accordance with Section
        XII, Reporting Requirements, of this Contract. The Health Plan shall maintain
        documentation of its inability to contact the Enrollee and that it has no
        record
        of providing services to the Enrollee, or to another family unit member,
        in the
        Enrollee's file.

      

      g. The
        Health Plan may submit an involuntary Disenrollment request to the Agency
        or its
        Agent after providing to the Enrollee at least one (1)verbal warning and
        at
        least one (1) written warning of the full implications of his/her failure
        of
        actions:

      

      
        	 	
                (1)

              	
                For
                  an Enrollee who continues not to comply with a recommended plan
                  of health
                  care or misses three (3) consecutive appointments within a continuous
                  six
                  (6) month period. Such requests must be submitted at least sixty
                  (60)
                  Calendar Days prior to the requested effective
                  date.

              

      

      

      
        	 	
                (2)

              	
                For
                  an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
                  to the extent that his or her Enrollment in the Health Plan seriously
                  impairs the organization's ability to furnish services to either
                  the
                  Enrollee or other Enrollees. This Section does not apply to Enrollees
                  with
                  mental health diagnoses if the Enrollee’s behavior is attributable to the
                  mental illness.

              

      

      

      h. The
        Agency may approve such requests provided that the Health Plan documents
        that
        attempts were made to educate the Enrollee regarding his/her rights and
        responsibilities, assistance which would enable the Enrollee to comply was
        offered through case management, and it has been determined that the Enrollee’s
        behavior is not related to the Enrollee’s medical or behavioral condition. All
        requests will be reviewed on a case-by-case basis and subject to the sole
        discretion of the Agency. Any request not approved is final and not subject
        to
        dispute or appeal.

      

      i. The
        Health Plan shall not request Disenrollment of an Enrollee due to:

      

      	(1)  	
              Health
                diagnosis;

            

      

      	(2)  	
              Adverse
                changes in an Enrollee’s health status;

            

      

      	(3)  	
              Utilization
                of medical services;

            

      

      	(4)  	
              Diminished
                mental capacity;

            

      

      	(5)  	
              Pre-existing
                medical condition;

            

      

      	(6)  	
              Uncooperative
                or disruptive behavior resulting from the Enrollee’s special needs (with
                the exception of C.3.g.2 above);

            

      

      	(7)  	
              Attempt
                to exercise rights under the Health Plan's Grievance System;
                or

            

      

      	(8)  	
              Request
                of one (1) PCP to have an Enrollee assigned to a different Provider
                out of
                the Health Plan.

            

      

      

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      Section
        IV

      Enrollee
        Services and Marketing

       

      

      A. Enrollee
        Services

       

      

      	1.  	
              General
                Provisions

            

      

      a. The
        Health Plan shall have written policies and procedures for the provision
        of
        Enrollee Services, as specified in this Contract. Such policies and procedures
        shall be submitted to the Agency for approval.

      

      b. The
        Health Plan shall ensure that Enrollees are aware of their rights and
        responsibilities, the role of PCPs, how to obtain care, what to do in an
        emergency or urgent medical situation, how to request a Grievance, Appeal
        or
        Medicaid Fair Hearing, how to report suspected Fraud and Abuse, procedures
        for
        obtaining required Behavioral Health Services, including any additional Health
        Plan phone numbers to be used for obtaining services, and all other requirements
        and Benefits of the Health Plan. 

      

      c. The
        Health Plan shall have the capability to answer Enrollee inquiries via written
        materials, telephone, electronic transmission, and face-to-face
        communication.

      

      d. Mailing
        envelopes for Enrollee materials shall contain a request for address correction.
        For Enrollees whose Enrollee Materials are returned to the Health Plan as
        undeliverable, the Health Plan shall use and maintain in a file a record
        of all
        of the following methods to contact the Enrollee: 

      

      
        	 	
                (1)

              	
                Telephone
                  contact at the telephone number obtained from the local telephone
                  directory, directory assistance, city directory, or other
                  directory.

              

      

      

      
        	 	
                (2)

              	
                Telephone
                  contact with DCF and Families Economic Self-Sufficiency Services
                  Office
                  staff to determine if they have updated address information and
                  telephone
                  number.

              

      

      

      
        	 	
                (3)

              	
                Routine
                  checks (at least once a month for the first three (3) months of
                  Enrollment) on services or claims authorized or denied by the Health
                  Plan
                  to determine if the Enrollee has received services, and to locate
                  updated
                  address and telephone number
                  information.

              

      

      

      e. New
        Enrollee materials are not required for a former Enrollee who was disenrolled
        because of the loss of Medicaid eligibility and who regains his/her eligibility
        within 180 days and is automatically reinstated as a Health Plan Enrollee.
        In
        addition, unless requested by the Enrollee, new Enrollee materials are not
        required for a former Enrollee subject to Open Enrollment who was disenrolled
        because of the loss of Medicaid eligibility, who regains his/her eligibility
        within 6 months of his/her managed care enrollment, and is reinstated as
        a
        Health Plan Enrollee. A notation of the effective date of the reinstatement
        is
        to be made on the most recent application or conspicuously identified in
        the
        Enrollee's administrative file. Enrollees, who were previously enrolled in
        a
        Health Plan, lose and regain eligibility after 180 days, will be treated
        as new
        Enrollees.

      

      f. The
        Health Plan shall notify, in writing, each person who is to be reinstated,
        of
        the effective date of the reinstatement and the assigned primary care physician.
        The notifications shall distinguish between Enrollees subject to Open Enrollment
        and Enrollees not subject to Open Enrollment and shall include information
        regarding change procedures for cause, or general Health Plan change procedures
        through the Agency’s toll-free Choice Counselor/Enrollment Broker telephone
        number as appropriate. The notification shall also instruct the Enrollee
        to
        contact the Health Plan if a new Enrollee card and/or a new Enrollee handbook
        are needed. The Health Plan shall provide such notice to each affected Enrollee
        by the first (1st) Calendar Day of the month following the Health Plan’s receipt
        of the notice of reinstatement.

      

      	2.  	
              Requirements
                for Written Materials

            

      

      a. The
        Health Plan shall make all written materials available in alternative formats
        and in a manner that takes into consideration the Enrollee's special needs,
        including those who are visually impaired or have limited reading proficiency.
        The Health Plan shall notify all Enrollees and Potential Enrollees that
        information is available in alternative formats and how to access those
        formats.

      

      b. The
        Health Plan shall make all written material available in English, Spanish,
        and
        all other appropriate foreign languages. The appropriate foreign languages
        comprise all languages in the Health Plan Service Area spoken by approximately
        five percent (5%) or more of the total population. The Health Plan shall
        provide, free of charge, interpreters for Potential Enrollees or Enrollees
        whose
        primary language is a foreign language.

      

      c. The
        Health Plan shall provide Enrollee information in accordance with 42 CFR
        438.10,
which
        addresses information requirements related to written and oral information
        provided to Enrollees, including: languages; format; Health Plan features,
        such
        as benefits, cost sharing, service area, Provider network, and physician
        incentive plans; Enrollment and Disenrollment rights and responsibilities;
        Grievance Systems; and Advance Directives.
        The
        Health Plan shall notify Enrollees on at least an annual basis of their right
        to
        request and obtain information in accordance with the above
        regulations.

      

      d. All
        written materials shall be at or near the fourth (4th) grade comprehension
        level. Suggested reference materials to determine whether the Health Plan’s
        written materials meet this requirement are:

      

      
        	 	
                (1)

              	
                Fry
                  Readability Index;

              

      

      

      
        	 	
                (2)

              	
                PROSE
                  The Readability Analyst (software developed by Education Activities,
                  Inc.);

              

      

      

      
        	 	
                (3)

              	
                Gunning
                  FOG Index;

              

      

      

      
        	 	
                (4)

              	
                McLaughlin
                  SMOG Index;

              

      

      

      
        	 	
                (5)

              	
                The
                  Flesch-Kincaid Index; or

              

      

      

      
        	 	
                (6)

              	
                Other
                  software approved by the Agency.

              

      

      

      e. The
        Health Plan shall provide written notice to the Agency of any changes to
        any
        written materials provided to Enrollees. Written materials shall be provided
        to
        the Agency at least forty-five (45) Calendar Days prior to the effective
        date of
        the change. Written notice of such changes shall be provided to Enrollees
        at
        least thirty (30) days prior to the effective date of the change.

      

      f. All
        written materials, including any materials for the Health Plan Web site,
        shall
        be submitted to the Agency for approval prior to being distributed.

      

      	3.  	
              New
                Enrollee Materials 

            

      

      Immediately
        upon the assigned Enrollees Enrollment, the Health Plan shall mail to the
        new
        Enrollee: the Enrollee Handbook; the Provider Directory; the Enrollee
        Identification; and the following additional materials:

      

      a. A
        request
        for the following information to be updated: Enrollee’s name, address (home and
        mailing), county of residence, and telephone number; 

      

      b. A
        completed, signed and dated release form authorizing the Health Plan to release
        medical information to the federal and State governments or their duly appointed
        agents; and, current behavioral health care provider information;

      

      c. A
        notice
        that Enrollees who lose eligibility and are disenrolled shall be automatically
        re-Enrolled in the Health Plan if eligibility is regained within 180
        days;

      

      d. Each
        mailing shall include a postage paid, pre-addressed return envelope; and
        

      

      e. The
        initial mailing may be combined with the PCP assignment notification. Each
        mailing shall be documented in the Health Plan’s records.

      

      	4.  	
              Enrollee
                Handbook Requirements 

            

      

      a. The
        Enrollee services handbook shall include the following information:

      

      
        	 	
                (1)

              	
                Table
                  of Contents;

              

      

      

      
        	 	
                (2)

              	
                Terms
                  and conditions of Enrollment including the reinstatement process;
                  

              

      

      

      
        	 	
                (3)

              	
                Description
                  of the Open Enrollment process;

              

      

      

      
        	 	
                (4)

              	
                Description
                  of services provided, including limitations and general restrictions
                  on
                  Provider access, exclusions and out-of-network use;
                  

              

      

      

      
        	 	
                (5)

              	
                Procedures
                  for obtaining required services, including second opinions, and
                  authorization requirements, including those services available
                  without
                  Prior Authorization; 

              

      

      

      
        	 	
                (6)

              	
                Toll-free
                  telephone number of the appropriate Area Medicaid Office;
                  

              

      

      

      
        	 	
                (7)

              	
                Emergency
                  Services and procedures for obtaining services both in and out
                  of the
                  Health Plan’s Service Area, including explanation that Prior Authorization
                  is not required for Emergency Services, the locations of any emergency
                  settings and other locations at which Providers and Hospitals furnish
                  Emergency Services and Post-Stabilization Care Services, and use
                  of the
                  911-telephone system or its
                  equivalent;

              

      

      

      
        	 	
                (8)

              	
                The
                  extent to which, and how, after-hours and emergency coverage is
                  provided,
                  and that the Enrollee has a right to use any Hospital or other
                  setting for
                  Emergency Care;

              

      

      

      
        	 	
                (9)

              	
                Procedures
                  for Enrollment, including Enrollee rights and protections;
                  

              

      

      

      (10) A
        notice
        advising Enrollees how to change PCPs; 

      

      (11) Grievance
        System components and procedures; 

      

      (12) Enrollee
        rights and procedures for Disenrollment, including the toll-free telephone
        number for the Agency’s contracted Choice Counselor/Enrollment Broker;

      

      (13) Procedures
        for filing a request for Disenrollment for Cause; 

      

      (14) Information
        regarding newborn enrollment, including the mother’s responsibility to notify
        the Health Plan and the mother’s DCF case worker of the newborn’s birth and
        selection of a PCP; 

      

      (15) Enrollee
        rights and responsibilities, including the extent to which, and how, Enrollees
        may obtain services from out-of-network providers and the right to obtain
        family
        planning services from any participating Medicaid provider without Prior
        Authorization for such services, and other provisions in accordance with
        42 CFR
        438.100; 

      

      (16) Information
        on emergency transportation and non-emergency transportation, counseling
        and
        referral services available under the Health Plan; and how to access these
        services; 

      

      (17) Information
        that interpretation services and alternative communication systems are
        available, free of charge, for all foreign languages, and how to access these
        services; 

      

      (18) Information
        that Post-Stabilization Services are provided without Prior Authorization
        and
        other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c);
        

      

      (19) Information
        that services will continue upon appeal of a suspended authorization and
        that
        the Enrollee may have to pay in case of an adverse ruling; 

      

      (20) Information
        regarding health care Advance Directives pursuant to Chapter 765, F.S., and
        42
        CFR 422.128; 

      

      (21) Cost
        sharing for the Enrollee, if any; 

      

      (22) Instructions
        explaining how Enrollees may obtain information from the Health Plan regarding
        quality performance indicators, including beneficiary information; 

      

      (23) How
        and
        where to access any benefits that are available under the Medicaid State
        Plan
        but are not covered under the Contract, including any cost sharing;

      

      (24) Any
        restrictions on the Enrollee's freedom of choice among network Providers;
        

      

      (25) A
        release
        document for each Enrollee authorizing the Health Plan to release medical
        information to the federal and State governments or their duly appointed
        Agents.

      

      (26) A
        notice
        that clearly states that the Enrollee may select an alternative behavioral
        health case manager or direct service provider within the Health Plan, if
        one is
        available;

      

      (27) A
        description of Behavioral Health Services provided, including limitations,
        exclusions and out-of-network use;

      

      (28) An
        explanation that Enrollees may choose to have all family members served by
        the
        same PCP or they may choose different PCPs based on each Enrollee’s
        needs

      

      (29) A
        description of Emergency Behavioral Health Services procedures both in and
        out
        of the Health Plan's Service Area; 

      

      (30) Information
        to assist the Enrollee in assessing a potential behavioral health
        problem;

      

      (31)
        Procedures for reporting fraud, abuse and overpayment; and

      

      (32) Information
        regarding HIPAA relative to the Enrollee’s personal health information (PHI).

      

      b. For
        a
        counseling or referral service that the Health Plan does not cover because
        of
        moral or religious objections, the Health Plan need not furnish information
        on
        how and where to obtain the service. 

      

      c. Written
        information regarding Advance Directives provided by the Health Plan must
        reflect changes in State law as soon as possible, but no later than ninety
        (90)
        days after the effective date of the change.

      

      d. The
        Health Plan, in its Enrollee handbook and provider manual, shall clearly
        specify
        required procedural steps in the Grievance process, including the address,
        telephone number and office hours of the Grievance staff. The Health Plan
        shall
        specify phone numbers for a grievant to call to present a Grievance or to
        contact the Grievance staff. Each phone number shall be toll-free within
        the
        grievant’s geographic area and provide reasonable access to the Health Plan
        without undue delays. The Grievance System must provide an adequate number
        of
        phone lines to handle incoming Grievances and Appeals.

      

      e. The
        Health Plan shall make information available upon request regarding the
        structure and operation of the health plan and any physician incentive plans,
        as
        set forth in 42 CFR 438.10(g)(3).

      

      	5.  	
              Provider
                Directory

            

      

      a. The
        Health Plan shall mail a Provider Directory to all new Enrollees, including
        Enrollees re-Enrolled after an Open Enrollment period. This Provider Directory
        shall be the most current printed Directory with an addendum providing the
        most
        up to date Provider information. The Health Plan shall update and re-print
        the
        Provider Directory at least annually. The Provider Directory shall include
        names, locations, office hours, telephone numbers of, and non-English languages
        spoken by, current Health Plan Providers. This includes at a minimum,
        information on PCPs, specialists, pharmacies, hospitals, certified nurse
        midwives and licenses midwives, and Ancillary Providers. The Provider Directory
        shall also identify Providers that are not accepting new patients.

      

      b. The
        Health Plan shall maintain an on-line Provider Directory. Such on-line Provider
        Directory shall be updated at least monthly. The Health Plan shall file an
        attestation to this effect with the Bureau of Managed Health Care and the
        Bureau
        of Health Systems Development.

      

      c. If
        the
        Health Plan elects to use a more restrictive pharmacy network than the network
        available to Medicaid Recipients enrolled in the non-Medicaid Reform FFS
        program, then the directory shall include the names of the pharmacies. If
        all
        pharmacies that are part of a chain and are within the Health Plan's Service
        Area are under contract with the Health Plan, the Provider Directory need
        only
        list the chain name.

      

      d. In
        accordance with section 1932(b)(3) of the Social Security Act, the Provider
        Directory shall include an advisement that some Providers may not perform
        certain services based on religious or moral beliefs.

      

      e. Lists
        of
        Providers shall be arranged alphabetically, showing the Provider's name and
        specialty, and separately, by specialty, in alphabetical order.

      

      f. List
        of
        the Health Plan's behavioral health service centers, including city and
        county.

      

      	6.  	
              Enrollee
                ID Card

            

      

      a. Immediately
        upon the Enrollee’s enrollment with the Health Plan, the Health Plan shall mail,
        via Surface Mail, an Enrollee Identification (ID) Card. The Enrollee ID Card
        shall include, at a minimum:

      

      
        	 	
                (1)

              	
                The
                  Enrollee's name and Medicaid ID
                  number;

              

      

      

      (2) The
        Health Plan's name, address and Enrollee services number;  and

      

      
        	 	
                (3)

              	
                A
                  telephone number that a non-contracted provider may call for billing
                  information.

              

      

      

      	7.  	
              Toll-free
                Help Line

            

      

      a. The
        Health Plan shall operate a toll-free telephone help line. Such help line
        shall
        respond to all areas of Enrollee inquiry.

      

      b. If
        the
        Health Plan has authorization requirements for prescribed drug services and
        is
        subject to the Hernandez Settlement Agreement (HSA), the Health Plan may
        allow
        the telephone help line staff to act as Hernandez Ombudsman, pursuant to
        the
        terms of the HSA, so long as the Health Plan maintains a Hernandez Ombudsman
        Log. The Health Plan may maintain the Hernandez Ombudsman Log as part of
        the
        Health Plan’s telephone help line log, so long as the Health Plan can access the
        Hernandez Ombudsman Log information separately for reporting purposes. The
        log
        shall contain information as described in Section V.D.14, Prescribed Drug
        Services, of this Contract.

      

      b. The
        Health Plan shall have telephone call policies and procedures that shall
        include
        requirements for staffing, personnel, hours of operation, call response times,
        maximum hold times, and maximum abandonment rates, monitoring of calls via
        recording or other means, and compliance with standards. 

      

      c. The
        telephone helpline shall handle calls from non-English speaking Enrollees,
        as
        well as calls from Enrollees who are hearing impaired.

      

      d. The
        telephone help line shall be fully staffed between the hours of 8:00 a.m.
        and
        7:00 p.m., EDT or EST, as appropriate, Monday through Friday, excluding State
        holidays. The telephone help line staff shall be trained to respond to Enrollee
        questions in all areas, including but not limited to, Covered Services, the
        Provider network, and non-emergency transportation. 

      

      e. The
        Health Plan shall develop performance standards and monitor telephone help
        line
        performance by recording calls and employing other monitoring activities.
        Such
        standards shall be submitted and approved by the Agency. At a minimum, the
        standards shall require that, measured on a monthly basis: 

      

      
        	 	
                (1)

              	
                One
                  hundred percent (100%) of all calls are answered within four (4)
                  rings
                  (these calls may be placed in a
                  queue);

              

      

      

      
        	 	
                (2)

              	
                The
                  wait time in the queue shall not exceed three (3)
                  minutes;

              

      

      

      
        	 	
                (3)

              	
                The
                  Blocked Call rate does not exceed one percent (1%); and
                  

              

      

      

      
        	 	
                (4)

              	
                The
                  rate of Abandoned Calls does not exceed five percent (5%).
                  

              

      

      

      f. The
        Health Plan shall have an automated system available between the hours of
        7:00
        p.m. and 8:00 a.m., EDT or EST, as appropriate, Monday through Friday and
        at all
        hours on weekend and holidays. This automated system must provide callers
        with
        operating instructions on what to do in case of an emergency and shall include,
        at a minimum, a voice mailbox for callers to leave messages. The Health Plan
        shall ensure that the voice mailbox has adequate capacity to receive all
        messages. A Health Plan Representative shall return messages on the next
        Business Day.

      

      	8.  	
              Cultural
                Competency

            

      

      a. In
        accordance with 42 CFR 438.206, the Health Plan shall have a comprehensive
        written Cultural Competency Plan describing how the Health Plan will ensure
        that
        services are provided in a culturally competent manner to all Enrollees,
        including those with limited English proficiency. The Cultural Competency
        Plan
        must describe how the Providers, Health Plan employees, and systems will
        effectively provide services to people of all cultures, races, ethnic
        backgrounds, and religions in a manner that recognizes values, affirms, and
        respects the worth of the individual Enrollees and protects and preserves
        the
        dignity of each.

      

      b. The
        Health Plan may distribute a summary of the Cultural Competency Plan to network
        Providers if the summary includes information on how the Provider may access
        the
        full Cultural Competency Plan on the Web site. This summary shall also detail
        how the Provider can request a hard-copy from the Health Plan at no charge
        to
        the Provider.

      

      	9.  	
              Translation
                Services

            

      

      The
        Health Plan is required to provide oral translation services of information
        to
        any Enrollee who speaks any non-English language regardless of whether an
        Enrollee speaks a language that meets the threshold of a prevalent non-English
        language. The Health Plan is required to notify its Enrollees of the
        availability of oral interpretation services and to inform them of how to
        access
        oral interpretation services. Oral interpretation services are required for
        all
        Health Plan information provided to Enrollees and includes notices of Action.
        There shall be no charge to the Enrollee for translation services.

      

      B. Marketing

      

      	1.  	
              General
                Provisions

            

      

      a. For
        each
        new Contract period, the Health Plan shall submit to the Agency for written
        approval, pursuant to section 409.912, F.S., its Marketing plan and all
        Marketing and pre-Enrollment materials no later than sixty (60) Calendar
        Days
        prior to Contract renewal, and for any changes in Marketing and pre-Enrollment
        materials during the re-contracting and renewal period, no later than sixty
        (60)
        Calendar Days prior to implementation. The Marketing materials shall be
        distributed in the Health Plan’s entire Service Area in accordance with 42 CFR
        438.104.

      

      b. Marketing
        materials include, but are not limited to, all solicitation materials, forms,
        brochures, fact sheets, posters, lectures, ad copy for radio or television,
        Medicaid recruitment materials and presentations, Request for Benefit
        Information forms (previously known as pre-enrollment applications),
        etc.

      

      c. To
        announce a specific event, the Health Plan shall submit a request to market
        pursuant to Section IV.B.4, Approval Process, of this Contract, and shall
        include the announcement of the event that will be given out to the
        public.

      

      d. The
        Health Plan shall be responsible for developing and implementing a written
        plan
        designed to solicit Enrollment from Potential Enrollees and to control the
        actions of its Marketing staff. All of the Marketing policies set forth in
        this
        Contract apply to staff, Subcontractors, Health Plan volunteers and all persons
        acting for or on behalf of the Health Plan. All materials developed shall
        be
        governed by the requirements set forth in this Section. Additionally, the
        Health
        Plan is vicariously liable for any Marketing violations of its employees,
        agents
        or Subcontractors.

      

      e. The
        Health Plan shall limit its Market Area to residents of the Service Area
        and
        shall not market to residents of a Service Area not approved by the
        Agency.

      

      	2.  	
              Prohibited
                Activities

            

      

      The
        Health Plan is prohibited from engaging in the following non-exclusive list
        of
        activities: 

      

      a. In
        accordance with section 409.912 and 409.91211, F.S., practices that are
        discriminatory, including, but not limited to, attempts to discourage Enrollment
        or reenrollment on the basis of actual or perceived health status.

      

      b. Direct
        or
        indirect Cold Call Marketing for solicitation of Medicaid Recipients, either
        by
        door-to-door, telephone or other means, in accordance with section 4707 of
        the
        Balanced Budget Act of 1997, and section 409.912, F.S. 

      

      c. Overly
        aggressive solicitation, such as repeated telephoning, continued recruitment
        after an offer for Enrollment is declined by a Medicaid Recipient, or similar
        techniques. Health Plan representatives shall not directly solicit Potential
        Enrollees for the purpose of enrolling in the Health Plan except as provided
        in
        Section IV.B.3., Permitted Activities. 

      

      d. In
        accordance with section 409.912, F.S., activities that could mislead or confuse
        Medicaid Recipients, or misrepresent the Health Plan, its Marketing
        Representatives, or the Agency. No fraudulent, misleading, or misrepresentative
        information shall be used in Marketing, including information regarding other
        governmental programs. Statements that could mislead or confuse include,
        but are
        not limited to, any assertion, statement or claim (whether written or oral)
        that:

      

      
        	 	
                (1)

              	
                The
                  Medicaid Recipient must enroll in the Health Plan in order to obtain
                  Medicaid, or in order to avoid losing Medicaid benefits;
                  

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan is endorsed by any federal, State or county government,
                  the
                  Agency, or CMS, or any other organization which has not certified
                  its
                  endorsement in writing to the Health
                  Plan;

              

      

      

      
        	 	
                (3)

              	
                Marketing
                  Representatives are employees or representatives of the federal,
                  State or
                  county government, or of anyone other than the Health Plan or the
                  organization by whom they are
                  reimbursed;

              

      

      

      
        	 	
                (4)

              	
                The
                  State or county recommends that a Medicaid Recipient enroll with
                  the
                  Health Plan; and/or

              

      

      

      
        	 	
                (5)

              	
                A
                  Medicaid Recipient will lose benefits under the Medicaid program
                  or any
                  other health or welfare benefits to which the Recipient is legally
                  entitled, if the Recipient does not enroll with the Health
                  Plan.

              

      

      

      e. In
        accordance with section 409.912, F.S., granting or offering of any monetary
        or
        other valuable consideration for Enrollment, except as authorized by section
        409.912, F.S.

      

      f. Offers
        of
        insurance, such as but not limited to, accidental death, dismemberment,
        disability or life insurance.

      

      g. Enlisting
        the assistance of any employee, officer, elected official or agent of the
        State
        in recruitment of Medicaid Recipients except as authorized in writing by
        the
        Agency.

      

      h. Offers
        of
        material or financial gain to any persons soliciting, referring or otherwise
        facilitating Medicaid Recipient Enrollment, except for authorized licensed
        Marketing Representatives. The Health Plan shall ensure that only licensed
        Marketing Representatives market the Health Plan to Medicaid
        Recipients.

      

      i. Giving
        away promotional items in excess of $1.00 retail value to attract attention.
        Items to be given away shall bear the Health Plan's name and shall only be
        given
        away at Health Fairs or other general Public Events. In addition, such
        promotional items must be offered to the general public and shall not be
        limited
        to Medicaid Recipients who indicate they will enroll in the Health
        Plan.

      

      j. In
        accordance with section 409.912, F.S., Marketing to Medicaid Recipients in
        State
        offices unless approved in writing and approved by the affected State Agency
        when solicitation occurs in the office of another State Agency. The Agency
        shall
        ensure that Marketing Representatives stationed in State offices market to
        Medicaid Recipients only in designated areas and in such a way as to not
        interfere with the Medicaid Recipients' activities in the State office. The
        Health Plan shall not use any other State facility, program, or procedure
        in the
        recruitment of Medicaid Recipients except as authorized in writing by the
        Agency. Request for approval of activities at State offices must be submitted
        to
        the Agency at least thirty (30) Calendar Days prior to the
        activity.

      

      k. Marketing
        face-to-face to assigned Enrollees or Medicaid Recipients unless the Enrollee
        or
        Recipient contacts the Health Plan and requests information. Upon such request
        the Health Plan shall notify the Choice Counselor/Enrollment Broker of such
        request, and the Health Plan shall keep documentation of such contacts and
        visits in the Enrollee’s file. 

      

      l. Providing
        any gift, commission, or any form of compensation to the Choice
        Counselor/Enrollment Broker, including the Choice Counselor/Enrollment Broker's
        full-time, part-time or temporary employees and Subcontractors. 

      

      m. The
        Health Plan shall not market, prior to the Enrollment, the incentives that
        shall
        be offered to the Enrollee as described in Section VIII.B.7., Incentive
        Programs. Marketing may describe the programs (not the incentives) that shall
        be
        offered (e.g., prenatal classes). The Health Plan may inform Enrollees once
        they
        are actually enrolled in the Health Plan about the specific incentives
        available.

      

      n. All
        activities included in section 641.3903, F.S. 

      

      	3.  	
              Permitted
                Activities

            

      

      The
        Health Plan may engage in the following activities under the supervision
        and
        with the written approval of the Agency: 

      

      a. The
        Health Plan upon written approval of the Agency, may have a marketer in Provider
        offices as long as the Provider approves and the marketer provides information
        to the Potential Enrollee only upon request. In addition, the Health Plan
        and
        the Provider shall not require the Potential Enrollee to visit the marketer,
        nor
        shall the marketer approach the Potential Enrollee. No Sales Activities shall
        be
        allowed in Provider offices. 

      

      b. The
        Health Plan may leave Request for Benefit Information (RBI) cards (as described
        in Section V, B.7) in Provider offices, at Public Events and Health Fairs.
        These
        cards may be completed by Potential Enrollees and delivered to the Health
        Plan
        or turned in at the Provider office. Information on the card is limited to
        name,
        address and telephone number of the Potential Enrollee and space for signature.
        A space to note a contact time may be provided. A follow up visit to the
        Potential Enrollee’s home may not occur prior to the referral being logged by
        the Health Plan’s regional or headquarters Enrollee services office. Twenty-four
        (24) hours or the next Business Day shall elapse after the request is logged
        before the home visit may occur.

      

      c. The
        Health Plan may market at State offices, Health Fairs and Public Events and
        contact thereafter, in person, Potential Enrollees who request further
        information about the Health Plan, in accordance with section 4707 of the
        BBA.
        The Health Plan shall submit, for review and approval by the Agency, its
        intent
        to market at Health Fairs and Public Events at least two (2) weeks prior
        to the
        event. The Health Plan shall obtain complete disclosure of information, in
        a
        format to be approved by the Agency, from each organization participating
        in a
        Health Fair or Public Event prior to the event. The information disclosure
        is
        only required when the Health Plan is the primary organizer of the Health
        Fair
        or Public Event. If the Health Plan has been invited by a community organization
        to be a sponsor of an event, the Health Plan shall provide the Agency with
        a
        copy of the invitation in lieu of the information disclosure. All disclosure
        information shall be sent to the Agency with the Health Plan’s request for
        approval of the event.

      

      d. The
        main
        purpose of a Health Fair or a Public Event shall not be Medicaid Health Plan
        marketing, but Medicaid Health Plan marketing may be provided at these events,
        subject to Agency rules and oversight.

      

      e. Upon
        the
        effective date of Enrollment, Health Plan marketing staff or other Health
        Plan
        staff may visit Enrollees in order to obtain completed new Enrollee materials.
        All such visits must be documented in the Enrollee's file.

      

      f. The
        Health Plan may leave Agency approved written materials (brochures or posters,
        etc) in Provider Offices, at Public Events, and at Health Fairs.

      

      g. Marketing
        face-to-face to Potential Enrollees may be allowed if the Potential Enrollee
        contacts the Health Plan’s headquarters or regional Enrollee services office
        directly to request a home visit. The Health Plan shall not allow the visit
        to
        the Potential Enrollee’s home to occur before the next Business Day or
        twenty-four (24) hours have elapsed since the request for the visit. The
        Health
        Plan must be able to provide evidence to the Agency that the twenty-four
        (24)
        hour or next Business Day requirement has been met. The Health Plan will
        be
        required, upon request by the Agency, to provide a log that shows how initial
        contact with the Potential Enrollee was made. Only Agency registered Marketing
        Representatives shall be allowed to make home visits. Each Health Plan shall
        make available to the Agency, as requested, a report of the number of home
        visits made by each Agency registered Marketing Representative to Potential
        Enrollee’s homes.

      

      	4.  	
              Approval
                Process

            

      

      a. The
        Health Plan shall submit a detailed description of its Marketing plan and
        copies
        of all Marketing materials, the Health Plan or its Subcontractors plan to
        distribute, to the Agency for prior approval. This requirement includes,
        but is
        not limited to: posters, brochures, Web sites, and any materials that contain
        statements regarding the Benefit package and Provider network-related materials.
        Neither the Health Plan nor its Subcontractors shall distribute any Marketing
        materials without prior approval from the Agency.

      

      b. Health
        Fairs and Public Events shall be approved or denied by the Agency using the
        following process:

      

      
        	 	
                (1)

              	
                A
                  Health Plan shall submit its bi-monthly Marketing schedule to the
                  Agency,
                  two (2) weeks in advance of each month. The Marketing Schedule
                  may be
                  revised if a Health Plan provides notice to the Agency one (1)
                  week prior
                  to the Public Event or the Health Fair. The Agency may expedite
                  this
                  process as needed.

              

      

      

      
        	 	
                (2)

              	
                The
                  Agency will approve or deny the Health Plan's bi-monthly Marketing
                  schedule and revision request no later than five (5) Business Days
                  from
                  receipt of the schedule and/or revision request.
                  

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall use the standard Agency format. Such format will
                  include
                  minimum requirements for necessary information. The Agency will
                  explain in
                  writing what is sufficient information for each
                  requirement.

              

      

      

      
        	 	
                (4)

              	
                The
                  Agency will establish a statewide log to track the approval and
                  disapproval of Health Fairs and Public
                  Events.

              

      

      

      
        	 	
                (5)

              	
                The
                  Agency may provide verbal approvals or disapprovals to meet the
                  five (5)
                  Business Day requirement, but the Agency will follow up in writing
                  with
                  specific reasons for disapprovals within five (5) Business Days
                  of verbal
                  disapprovals.

              

      

      

      

      

      	5.  	
              Provider
                Compliance

            

      

      The
        Health Plan shall ensure its health care Providers comply with the following
        Marketing requirements:

      

      a. Health
        care Providers may give out Health Plan brochures at Health Fairs or in their
        own offices comparing the Benefits of different Health Plans with which they
        contract. However, they cannot orally compare Benefits among Health Plans,
        unless Marketing Representatives from each Health Plan are present.

      

      b. Health
        care Providers may co-sponsor events, such as Health Fairs and cooperatively
        market and advertise with the Health Plan in indirect ways; such as television,
        radio, posters, fliers, and print advertisement.

      

      c. Health
        care Providers may announce a new affiliation with a Health Plan or give
        a list
        of Health Plans with which they contract to their patients.

      

      d. Health
        care Providers shall not furnish lists of their Medicaid Recipients to Health
        Plans with which they contract, or any other entity, nor can Providers furnish
        other Health Plans' membership lists to any Health Plan, nor can Providers
        take
        applications in their offices.

      

      	6.  	
              Marketing
                Representatives

            

      

      a. The
        Health Plan shall not Subcontract with any brokerage firm or independent
        agent
        for purposes of Marketing.

      

      b. The
        Health Plan shall be required to register each Marketing Representative with
        the
        Agency. The registration shall consist of providing the Agency with the
        representative's name; address; telephone number; cellular telephone number;
        DFS
        license number; the names of all Medicaid Health Plans with which the Marketing
        Representative was previously employed; and the name of the Medicaid Health
        Plan
        with which the Marketing Representative is presently employed. 

      

      c. The
        Health Plan shall provide the Agency, on a monthly basis, information on
        terminations of all Marketing Representatives. The Health Plan shall maintain
        and make available to the Agency upon request evidence of current licensure
        and
        contractual agreements with all Marketing Representatives used by the Health
        Plan to recruit Medicaid Recipients. 

      

      d. The
        Health Plan shall report to DFS and the Agency any Marketing Representative
        who
        violates any requirements of this Contract, within fifteen (15) Calendar
        Days of
        knowledge of such violation.

      

      e. While
        Marketing, Marketing Representatives shall wear picture identification that
        includes their DFS license number and identifies the Health Plan
        represented.

      

      f. The
        Marketing Representative shall inform the Medicaid Recipient that the
        Representative is not an employee of the State and is not a Choice Counseling
        Specialist, but is a Representative of the Health Plan.

      

      g. The
        Health Plan shall not pay commission compensation, or shall recoup commissions
        paid, to Marketing Representatives for new Enrollees whose voluntary
        Disenrollment is effective within the first (1st) three (3) months of their
        initial Enrollment, unless the Disenrollment is due to the Enrollee moving
        out
        of the county in which the Health Plan has been authorized to operate. In
        addition, the Health Plan shall not pay commission compensation, or shall
        recoup
        commission paid, to Marketing Representatives for excluded Medicaid Recipients,
        per Section III.A.3, Excluded Populations, who were enrolled in error. A
        Marketing Representative's total monthly commission cannot exceed forty percent
        (40%) of the Marketing Representative's total monthly compensation, excluding
        benefits.

      

      h. The
        Health Plan shall instruct and provide initial and periodic training to its
        Marketing Representatives regarding the Marketing provisions of this
        Contract.

      

      i. The
        Health Plan shall implement procedures for background and reference checks
        for
        use in its Marketing Representative hiring practices.

      

      	7.  	
              Request
                for Benefit Information (RBI)
                Activities

            

      

      a. The
        Health Plan shall refer Potential Enrollees interested in enrolling in the
        Health Plan to the Choice Counselor/Enrollment Broker.

      

      b. In
        accordance with section 409.912, F.S., and Agency guidelines, and upon approval
        of the Agency, the Health Plan may assist Potential Enrollees in obtaining
        information through the completion of a RBI, previously known as a
        pre-Enrollment application for information.

      

      c. RBIs
        may
        be for an individual or for a family. No health status information may be
        asked
        on the RBI. Each RBI shall include an option for the Potential Enrollee to
        request information about all Health Plan choices and shall include the name
        of
        the Choice Counselor/Enrollment Broker Help Line. All RBIs shall contain
        at
        least the following information for each Potential Enrollee

      

      
        	 	
                (1)

              	
                Name;

              

      

      
        	 	
                (2)

              	
                Address
                  (home and mailing);

              

      

      
        	 	
                (3)

              	
                County
                  of residence; 

              

      

      
        	 	
                (4)

              	
                Telephone
                  number;

              

      

      
        	 	
                (5)

              	
                Date
                  of Application;

              

      

      
        	 	
                (6)

              	
                Applicant’s
                  signature or signature of parent or guardian;
                  and,

              

      

      
        	 	
                (7)

              	
                Marketing
                  Representative’s signature and DFS license
                  number.

              

      

      

      d. At
        the
        time of completion of the RBI, the Health Plan shall furnish the Potential
        Enrollee with a copy of the completed RBI.

      

      e. The
        Health Plan shall accept RBIs only from Potential Enrollees who reside within
        the authorized Service Area. In addition, the Health Plan shall use the Provider
        number associated with the county in which the Potential Enrollee
        resides.

      

      f. If
        the
        Voluntary Potential Enrollee is recognized to be in foster care by the Health
        Plan, and is dependent, prior to Enrollment, the Health Plan must receive
        written authorization from (1) a parent, (2) a legal guardian, or (3) DCF
        or
        DCF’s delegate. If a parent is unavailable, the Health Plan shall obtain
        authorization from DCF. The RBI shall include information that the Potential
        Enrollee is in foster care.

      

      g. The
        Health Plan shall provide a reasonable written explanation of the Health
        Plan
        Benefits to the Potential Enrollee prior to accepting the RBI. The Health
        Plan
        shall explain to all Potential Enrollees that the family may choose to have
        all
        members served by the same PCP or they may choose different PCPs based on
        each
        Enrollee’s needs. The information must comply with 42 CFR 438.10.

      

      h. Upon
        completion of the RBI and all pre-Enrollment Marketing to Potential Enrollees,
        the Health Plan shall submit the RBI to the Choice Counselor/Enrollment Broker
        for further education and counseling and verification that the Potential
        Enrollee made an informed, voluntary choice, free from duress. 

      

      

      

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      Section
        V

      Covered
        Services 

       

      

      A. Covered
        Services 

       

      1. The
        Health Plan shall ensure the provision of services in sufficient amount,
        duration and scope to be reasonably expected to achieve the purpose for which
        the services are furnished and shall ensure the provision of the following
        covered services as defined and specified in this Contract. The Health Plan
        may
        implement appropriate utilization management techniques and procedures, as
        established in this Contract and the Health Plans approved policies and
        procedures manuals.

      

      2. The
        Health Plan’s policies and procedures manuals shall be prior approved by the
        Agency and shall incorporate provider, service and product standards specified
        in the Agency’s Medicaid Services Coverage and Limitations Handbooks, as
        appropriate, and this Contract.

      

      3. The
        Health Plan must require out-of-network providers to coordinate with respect
        to
        payment and must ensure that cost to the beneficiary is no greater than it
        would
        be if the covered services were furnished within the network. 

      

      4. The
        Health Plan may submit a Customized Benefit Package (CBP), which may vary
        the
        co-pays or the amount, duration and scope of the following services for
        non-pregnant adults: hospital outpatient not otherwise specified (NOS), home
        health, dental, pharmacy, chiropractic, podiatry, vision, durable medical
        equipment and physical therapy services as specified below. 

      

      
        	 	
                a.

              	
                Amount,
                  duration and scope may vary for durable medical supplies (DME)
                  with the
                  exception of any prosthetic/orthotic supply priced over $3,000
                  on the
                  Medicaid fee schedule and except for motorized wheelchairs, which
                  must be
                  covered up to the State Plan limit.

              

      

      

      
        	 	
                b.

              	
                Dialysis
                  services, contraceptives, and chemotherapy-related medical and
                  pharmaceutical services must be covered up to the State Plan limit.
                  

              

      

      

      
        	 	
                c.

              	
                Hearing
                  services for non-pregnant adults may vary amount, duration and
                  scope
                  except for hearing aid services, which must be covered up to the
                  State
                  Plan limit. 

              

      

      

      
        	 	
                d.

              	
                The
                  CBP must meet the Agency’s actuarial equivalency and sufficiency standards
                  for the population or populations which will be covered by the
                  CBP.
                  

              

      

      

      
        	 	
                e.

              	
                The
                  Health Plan shall submit its CBP to the Agency for recertification
                  of
                  actuarial equivalency and sufficiency standards on an annual basis.
                  

              

      

      

      5. The
        Health Plan shall provide all medically necessary services in accordance
        with
        Medicaid Handbook requirements for pregnant women, Children/Adolescents,
        and
        Enrollees with a HIV/AIDS diagnoses as identified by the Agency.

      

      

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      6. The
        Health Plan shall ensure the provision of the services listed below.

      

      

        
          	
                  Health
                    Plan Covered Service Chart

                
	
                  Advanced
                    Registered Nurse Practitioner Services

                
	
                  Ambulatory
                    Surgical Centers

                
	
                  Birth
                    Center Services

                
	
                  Child
                    Health Check-Up Services

                
	
                  Chiropractic
                    Services

                
	
                  Community
                    Mental Health Services

                
	
                  County
                    Health Department Services

                
	
                  Dental
                    Services 

                
	
                  Durable
                    Medical Equipment and Medical Supplies

                
	
                  Dialysis
                    Services

                
	
                  Emergency
                    Room Services

                
	
                  Family
                    Planning Services 

                
	
                  Federally
                    Qualified Health Center Services 

                
	
                  Freestanding
                    Dialysis Centers

                
	
                  Hearing
                    Services 

                
	
                  Home
                    Health Care Services

                
	
                  Hospital
                    Services - Inpatient

                
	
                  Hospital
                    Services - Outpatient 

                
	
                  Immunizations

                
	
                  Independent
                    Laboratory Services 

                
	
                  Licensed
                    Midwife Services

                
	
                  Optometric
                    Services 

                
	
                  Physician
                    Services 

                
	
                  Physician
                    Assistant Services

                
	
                  Podiatry
                    Services

                
	
                  Portable
                    X-ray Services

                
	
                  Prescribed
                    Drugs

                
	
                  Primary
                    Care Case Management Services

                
	
                  Rural
                    Health Clinic Services

                
	
                  Targeted
                    Case Management

                
	
                  Therapy
                    Services: Occupational 

                
	
                  Therapy
                    Services: Physical 

                
	
                  Therapy
                    Services: Respiratory 

                
	
                  Therapy
                    Services: Speech 

                
	
                  Transplant
                    Services 

                
	
                  Transportation
                    Services

                
	
                  Vision
                    Services 

                

        

      

      

      B. Expanded
        Services

       

      

      Expanded
        services are those services offered by the Health Plan as specified in
        Attachment I of this contract and approved in writing by the Agency. These
        services are in excess of the amount, duration and scope of those services
        listed in Section V. Covered Services and Section VI. Behavioral Health Care.
        Such services may include, but are not limited to:

      

      
        	 	
                1.

              	
                Expanded
                  Behavioral Health Services - respite care services, prevention
                  services in
                  the community, parental education programs, community-based therapeutic
                  services for adults, and any other new and innovative interventions
                  or
                  services designed to improve the mental well-being of
                  Enrollees.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan may offer an Agency-approved over-the-counter expanded
                  drug
                  benefit, not to exceed twenty-five dollars ($25.00) per household,
                  per
                  month. Such benefits shall be limited to nonprescription drugs
                  containing
                  a National Drug Code ("NDC") number, first aid supplies and birth
                  control
                  supplies. Such benefits must be offered through the Health Plan's
                  pharmacy
                  or the Health Plan's agreement with a pharmacy. The Health Plan
                  shall make
                  payments for the over-the-counter drug benefit directly to the
                  pharmacy.

              

      

      

      
        	 	
                3.

              	
                Adult
                  Dental Services - routine preventive services, diagnostic and restorative
                  services, radiology services and discounts on dental
                  services.

              

      

      

      
        	 	
                4.

              	
                Adult
                  Vision Services - eye exams, eye glasses and contact
                  lens.

              

      

      

      
        	 	
                5.

              	
                Adult
                  Hearing Services - hearing evaluations, hearing aid devices and
                  hearing
                  aid repairs.

              

      

      

      C. Excluded
        Services 

       

      

      
        	 	
                1.

              	
                The
                  Health Plan is not obligated to provide for any services not specified
                  in
                  this Contract. Enrollees who require services available through
                  Medicaid
                  but not specified by this Contract shall receive the services through
                  the
                  Medicaid Fee-for-Service reimbursement system unless those services
                  have
                  been limited by the Health Plan’s Agency-approved CBP. In such cases, the
                  Health Plan's responsibility is limited to case management and
                  referral.
                  Therefore, the Health Plan shall determine the need for the services
                  and
                  refer the Enrollee to the appropriate service provider. The Health
                  Plan
                  may request assistance from the local Medicaid Field Office for
                  referral
                  to the appropriate service setting.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall consult the DCF office to identify appropriate
                  methods
                  of assessment and referral for those Enrollees requiring long-term
                  care
                  institutional services, institutional services for persons with
                  developmental disabilities or state hospital services. The Health
                  Plan is
                  responsible for transition and referral of these Enrollees to appropriate
                  service providers, including helping the Enrollees to obtain an
                  attending
                  physician. The Plan shall disenroll all Enrollees requiring these
                  services
                  in accordance with Section III.C.3.a.(3) of this
                  Contract.

              

      

      

      D. Moral
        or Religious Objections

       

      

      The
        Health Plan is required to provide or arrange for all Covered Services. If,
        during the course of the Contract period, pursuant to 42 CFR 438.102, the
        Health
        Plan elects not to provide, reimburse for, or provide coverage of a counseling
        or referral service because of an objection on moral or religious grounds,
        the
        Health Plan shall notify:

      

      
        	 	
                1.

              	
                The
                  Agency within one hundred and twenty (120) Calendar Days prior
                  to adopting
                  the policy with respect to any
                  service.

              

      

      

      
        	 	
                2.

              	
                Enrollees
                  thirty (30) Calendar Days prior to adopting the policy with respect
                  to any
                  service.

              

      

      

      

      E. Customized
        Benefit Package

       

      

      
        	 	
                1.

              	
                The
                  Health Plans may choose to have a benefit package for non-pregnant
                  adults,
                  which includes all of the Covered Services described above in this
                  section
                  and those in Section VI, Behavioral Health Care, or may choose
                  to offer a
                  Customized Benefit Package (CBP).

              

      

      

      
        	 	
                2.

              	
                Should
                  a Health Plan choose to offer a CBP, the Health Plan shall provide all of
                  the Covered Services described above in this section and those
                  in Section
                  VI, Behavioral Health Care, to pregnant women, Children/Adolescents,
                  and
                  Enrollees with a HIV/AIDS diagnoses as identified by the
                  Agency.

              

      

      

      
        	 	
                3.

              	
                Approved
                  CBPs must comport with the Benefit Grid and the attached instructions
                  found in Attachment I that have been tested for actuarial equivalency
                  and
                  sufficiency of benefits, before being approved by the
                  Agency.

              

      

      

      
        	 	
                a.

              	
                Actuarial
                  equivalency is tested by using a Benefit Plan Evaluation Model
                  that:

              

      

      

      
        	 	
                (1)

              	
                Compares
                  the value of the level of benefits in the proposed package to the
                  value of
                  the current Medicaid State Plan package for the average member
                  of the
                  covered population; and

              

      

      

      
        	 	
                (2)

              	
                Ensures
                  that the overall level of benefits is
                  appropriate.

              

      

      

      
        	 	
                b.

              	
                Sufficiency
                  is tested by comparing the proposed CBP to State established standards.
                  The standards are based on the covered population’s historical use of
                  Medicaid State Plan services. These standards are used to ensure
                  that the
                  proposed CBP is adequate to cover the needs of the vast majority
                  of the
                  Enrollees. 

              

      

      

      
        	 	
                c.

              	
                If,
                  in its CBP, the Health Plan limits a service to a maximum annual
                  dollar
                  value, the Health Plan must calculate the dollar value of the service
                  using the Medicaid fee schedule. If the Health Plan limits pharmacy
                  services to a maximum annual dollar value, pharmacy dollar values
                  are
                  evaluated at a pre-rebate level.

              

      

      

      F. Coverage
        Provisions 

       

      

      The
        Health Plan shall provide the following services in accordance with the
        provisions herein, and in accordance with the Florida Medicaid Coverage and
        Limitations Handbooks and the Florida Medicaid State Plan unless certified
        in a
        Customized Benefit Package in the Benefit Grid. The Health Plan shall comply
        with all State and federal laws pertaining to the provision of such
        services.

      

      
        	 	
                1.

              	
                Advance
                  Directives

              

      

      

      a. In
        compliance with 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128, the Health Plan
        shall
        maintain written policies and procedures for Advance Directives, including
        mental health Advance Directives. Such Advance Directives shall be included
        in
        each Enrollee's medical record. The Health Plan shall provide these policies
        to
        all Enrollee's eighteen (18) years of age and older and shall advise Enrollees
        of:

      

      
        	 	
                (1)

              	
                Their
                  rights under the law of the State of Florida, including the right
                  to
                  accept or refuse medical, surgical, or behavioral health treatment
                  and the
                  right to formulate Advance Directives;
                  and

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan's written policies respecting the implementation of
                  those
                  rights, including a statement of any limitation regarding the
                  implementation of Advance Directives as a matter of
                  conscience.

              

      

      

      b. The
        information must include a description of State law and must reflect changes
        in
        State law as soon as possible, but no later than ninety (90) Calendar Days
        after
        the effective change.

      

      c. The
        Health Plan's information must inform Enrollees that complaints may be filed
        with the State's complaint hotline.

      

      d. The
        Health Plan shall educate its staff about its policies and procedures on
        Advance
        Directives, situations in which Advance Directives may be of benefit to
        Enrollees, and their responsibility to educate Enrollees about this tool
        and
        assist them to make use of it.

      

      e. The
        Health Plan shall educate Enrollees about their ability to direct their care
        using this mechanism and shall specifically designate which staff and/or
        network
        Providers are responsible for providing this education.

      

      
        	 	
                2.

              	
                Child
                  Health Check-Up Program (CHCUP)

              

      

      

      a. The
        Health Plan shall provide a health screening evaluation that shall consist
        of:
        comprehensive health and developmental history, including assessment of past
        medical history, developmental history and behavioral health status;
        comprehensive unclothed physical examination; developmental assessment;
        nutritional assessment; appropriate immunizations according to the appropriate
        Recommended Childhood Immunization Schedule for the United States; laboratory
        testing (including blood lead testing); health education (including anticipatory
        guidance); dental screening (including a direct referral to a dentist for
        Enrollees beginning at three (3) years of age or earlier as indicated); vision
        screening, including objective testing as required; hearing screening, including
        objective testing as required; diagnosis and treatment; and referral and
        follow-up as appropriate.

      

      b. For
        Children/Adolescents who the Health Plan identifies through blood lead
        screenings as having abnormal levels of lead, the Health Plan shall provide
        Case
        Management follow-up services as required in Chapter Two (2) of the Child
        Health
        Check-Up Services Coverage and Limitations Handbook. Screening for lead
        poisoning is a required component of this Contract. The Health Plan shall
        require all Providers to screen all Enrolled Children for lead poisoning
        at
        twelve (12) and twenty-four (24) months of age. In addition,
        Children/Adolescents between the ages of twenty-four (24) months and seventy-two
        (72) months of age must receive a screening blood lead test if there is no
        record of a previous test. The Health Plan shall provide additional diagnostic
        and treatment services determined to be Medically Necessary to a
        Child/Adolescent diagnosed with an elevated blood lead level. The Health
        Plan
        shall recommend, but shall not require, the use of paper filter tests as
        part of
        the lead screening requirement.

      

      c. The
        Health Plan shall inform Enrollees of all testing/screenings due in accordance
        with the periodicity schedule specified in the Medicaid Child Health Check-Up
        Services Coverage and Limitations Handbook. The Health Plan shall contact
        Enrollees to encourage them to obtain health assessment and preventative
        care.

      

      d.
         The
        Health Plan shall refer Enrollees to appropriate service Providers within
        six
        (6) months of the examination for further assessment and treatment of conditions
        found during the examination.

      

      e. The
        Health Plan shall offer scheduling assistance and Transportation to Enrollees
        in
        order to assist them to keep, and travel to, medical appointments.

      

      f. The
        CHCUP
        program includes the maintenance of a coordinated system to follow the Enrollee
        through the entire range of screening and treatment, as well as supplying
        CHCUP
        training to medical care Providers.

      

      g. The
        Health Plan shall achieve a CHCUP screening rate of at least sixty percent
        (60%)
        for those Enrollees who are continuously enrolled for at least eight (8)
        months
        during the Federal Fiscal Year (October 1 - September 30) in accordance with
        section 409.912, F.S. This screening compliance rate shall be based on the
        CHCUP
        screening data reported by the Health Plan and due to the Agency by January
        15
        following the end of each Federal Fiscal Year as specified in Section XII,
        Reporting, of this Contract. The data shall be monitored by the Agency for
        accuracy and, if the Health Plan does not achieve the 60 percent (60%) screening
        rate for the Federal Fiscal Year reported, the Health Plan shall file a
        corrective action plan (CAP) with the Agency no later than February 15,
        following the fiscal year reported. Any data reported by the Health Plan
        that is
        found to be inaccurate shall be disallowed by the Agency and the Agency shall
        consider such findings as being in violation of the Contract and may sanction
        the Health Plan accordingly.

      

      h. The
        Health Plan shall adopt annual screening and participation goals to achieve
        at
        least an eighty percent (80%) CHCUP screening and participation rate. For
        each
        Federal Fiscal Year that the Health Plan does not meet the eighty percent
        (80%)
        screening and participation rate, it must file a CAP with the Agency no later
        than February 15 following the Federal Fiscal Year being reported.

      

      
        	 	
                3.

              	
                Cost
                  Sharing

              

      

      

      Cost-sharing
        amounts shall be delineated in the Florida State Medicaid Plan, and the Florida
        Coverage and Limitations Handbooks, as promulgated in Florida Administrative
        Code. The Health Plan may choose to eliminate cost sharing requirements as
        approved by the Agency. Attachment I outlines the approved cost sharing
        limits.

      

      

      

      
        	 	
                4.

              	
                Dental

              

      

      

      The
        Health Plan shall cover diagnostic services, preventive treatment, CHCUP
        dental
        screening (including a direct referral to a dentist for Enrollees beginning
        at
        three (3) years of age or earlier as indicated); restorative treatment,
        endodontic treatment, periodontal treatment, restorative treatment, surgical
        procedures and/or extractions, orthodontic treatment, complete and partial
        dentures, complete and partial denture relines and repairs, and adjunctive
        and
        emergency services for Enrollees under the age of twenty-one (21). Adult
        services include medically necessary emergency dental procedures to alleviate
        pain or infection. Emergency dental care shall be limited to emergency oral
        examinations, necessary radiographs, extractions, and incisions and drainage
        of
        abscesses. Adult dental services shall also include dentures. 

      

      
        	 	
                5.

              	
                Emergency
                  Services 

              

      

      

      a. The
        Health Plan shall advise all Enrollees of the provisions governing Emergency
        Services and Care. The Health Plan shall not deny claims for Emergency Services
        and Care received at a Hospital due to lack of parental consent. In addition,
        the Health Plan shall not deny payment for treatment obtained when a
        representative of the Health Plan instructs the Enrollee to seek Emergency
        Services and Care.

      

      

      b. The
        Health Plan shall not:

      

      
        	 	
                (1)

              	
                Require
                  Prior Authorization for an Enrollee to receive pre-Hospital transport
                  or
                  treatment or for Emergency Services and
                  Care;

              

      

      

      
        	 	
                (2)

              	
                Specify
                  or imply that Emergency Services and Care are covered by the Health
                  Plan
                  only if secured within a certain period of
                  time;

              

      

      

      
        	 	
                (3)

              	
                Use
                  terms such as "life threatening" or "bona fide" to qualify the
                  kind of
                  emergency that is covered; or

              

      

      

      
        	 	
                (4)

              	
                Deny
                  payment based on a failure by the Enrollee or the Hospital to notify
                  the
                  Health Plan before, or within a certain period of time after, Emergency
                  Services and Care were given.

              

      

      

      c. The
        Health Plan shall provide pre-Hospital and Hospital-based trauma services
        and
        Emergency Services and Care to Enrollees. See
        sections 395.1041, 395.4045 and 401.45, F.S.

      

      d. When
        an
        Enrollee presents himself/herself at a Hospital seeking Emergency Services
        and
        Care, the determination that an Emergency Medical Condition exists shall
        be
        made, for the purposes of treatment, by a physician of the Hospital or, to
        the
        extent permitted by applicable law, by other appropriate personnel under
        the
        supervision of a Hospital physician. See
        sections 409.9128 and 409.901, F.S 

      

      
        	 	
                (1)

              	
                The
                  physician, or the appropriate personnel, shall indicate on
                  the Enrollee's chart the results of all screenings, examinations
                  and
                  evaluations.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall compensate the provider for all screenings, evaluations
                  and examinations that are reasonably calculated to assist the provider
                  in
                  arriving at the determination as to whether the Enrollee's condition
                  is an
                  Emergency Medical Condition.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall for all Emergency Services and
                  Care.

              

      

      

      
        	 	
                (4)

              	
                If
                  the provider determines that an Emergency Medical Condition does
                  not
                  exist, the Health Plan is not required to pay for services rendered
                  subsequent to the provider's
                  determination.

              

      

      

      e. If
        the
        provider determines that an Emergency Medical Condition exists, and the Enrollee
        notifies the Hospital or the Hospital emergency personnel otherwise have
        knowledge that the patient is an Enrollee of the Health Plan, the Hospital
        must
        make a reasonable attempt to notify the Enrollee's PCP, if known, or the
        Health
        Plan, if the Health Plan has previously requested in writing that said
        notification be made directly to the Health Plan, of the existence of the
        Emergency Medical Condition.

      

      f. If
        the
        Hospital, or any of its affiliated providers, do not know the Enrollee's
        PCP, or
        have been unable to contact the PCP, the Hospital must:

      

      
        	 	
                (1)

              	
                Notify
                  the Health Plan as soon as possible before discharging the Enrollee
                  from
                  the emergency care area; or

              

      

      

      
        	 	
                (2)

              	
                Notify
                  the Health Plan within twenty-four (24) hours or on the next Business
                  Day
                  after admission of the Enrollee as an inpatient to the
                  Hospital.

              

      

      

      g. If
        the
        Hospital is unable to notify the Health Plan, the Hospital must document
        its attempts to notify the Health Plan, or the circumstances that precluded
        the
        Hospital's attempts to notify the Health Plan. The Health Plan shall not
        deny
        payment for Emergency Services and Care based on a Hospital's failure to
        comply
        with the notification requirements of this Section.

      

      h. If
        the
        Enrollee's PCP responds to the Hospital's notification, and the Hospital
        physician and the PCP discuss the appropriate care and treatment of the
        Enrollee, the Health Plan may have a member of the Hospital staff with whom
        it
        has a Participating Provider contract participate in the treatment of the
        Enrollee within the scope of the physician's Hospital staff
        privileges.

      

      i. The
        Health Plan may transfer the Enrollee, in accordance with State and federal
        law,
        to a Participating Hospital that has the service capability to treat the
        Enrollee's Emergency Medical Condition. The attending emergency physician,
        or
        the provider actually treating the Enrollee, is responsible for determining
        when
        the Enrollee is sufficiently stabilized for transfer discharge, and that
        determination is binding on the entities identified in 42 CFR 438.114(b)
        as
        responsible for coverage and payment.

      

      j. Notwithstanding
        any other State law, a Hospital may request and collect any insurance or
        financial information necessary to determine if the patient is an Enrollee
        of
        the Health Plan, in accordance with federal law, from an Enrollee, so long
        as
        Emergency Services and Care are not delayed in the process.

      

      k. In
        accordance with 42 CFR 438.411 and 42 CFR 422.113(c), the Health Plan shall
        cover Post Stabilization Care Services without authorization, regardless
        of
        whether the Enrollee obtains a service within or outside the Health Plan's
        network for the following situations:

      

      
        	 	
                (1)

              	
                Post-Stabilization
                  Care Services that were pre-approved by the Health
                  Plan;

              

      

      

      
        	 	
                (2)

              	
                Post-Stabilization
                  Care Services that were not pre-approved by the Health Plan because
                  the
                  Health Plan did not respond to the treating provider's request
                  for
                  pre-approval within one (1) hour after the treating provider sent
                  the
                  request; 

              

      

      

      
        	 	
                (3)

              	
                The
                  treating Provider could not contact the Health Plan for pre-approval;
                  and

              

      

      

      
        	 	
                (4)

              	
                Those
                  Post-Stabilization Care Services that a treating physician viewed
                  as
                  Medically Necessary after stabilizing an Emergency Medical Condition.
                  These are non-emergency services; the Health Plan can choose not
                  to cover
                  if provided by a nonparticipating provider, except in those circumstances
                  detailed in k. (1), (2), and (3) above.

              

      

      

      l. The
        Health Plan shall not deny claims for the provision of Emergency Services
        and
        Care submitted by a nonparticipating provider solely based on the period
        between
        the date of service and the date of clean claim submission, unless that period
        exceeds 365 days.

      

      m. Reimbursement
        for services provided to an Enrollee under this Section by a nonparticipating
        provider shall be the lesser of:

      

      
        	 	
                (1)

              	
                The
                  nonparticipating provider's
                  charges;

              

      

      

      
        	 	
                (2)

              	
                The
                  usual and customary provider charges for similar services in the
                  community
                  where the services were provided;

              

      

      

      
        	 	
                (3)

              	
                The
                  amount mutually agreed to by the Health Plan and the nonparticipating
                  provider within sixty (60) Calendar Days after the nonparticipating
                  provider submits a claim; or

              

      

      

      
        	 	
                (4)

              	
                The
                  Medicaid rate.

              

      

      

      n. Notwithstanding
        the requirements set forth in this Section, the Health Plan shall make payment
        on all claims for Emergency Services and Care by nonparticipating providers
        pursuant to the requirements set forth in section 641.3155, F.S.

      

      
        	 	
                6.

              	
                Emergency
                  Services - Behavioral Health
                  Services

              

      

      

      a. An
        out-of-area, non-participating provider shall notify the Health Plan within
        twenty-four (24) hours of the Enrollee presenting for Emergency Behavioral
        Health Services. In cases in which the Enrollee has no identification, or
        is
        unable to verbally identify himself/herself when presenting for Behavioral
        Health Services, the out of area, non-participating provider shall notify
        the
        Health Plan within twenty-four (24) hours of learning the Enrollee's identity.
        The out of area, non-participating provider shall deliver to the Health Plan
        the
        Medical Records that document that the identity of the Enrollee could not
        be
        ascertained at the time the Enrollee presented for Emergency Behavioral Health
        Services due to the Enrollee's condition.

      

      b. If
        the
        out-of-area, non-participating provider fails to provide the Health Plan
        with an
        accounting of the Enrollee's presence and status within twenty-four (24)
        hours
        after the Enrollee presents for treatment and provides identification, the
        Health Plan shall only approve claims for the time period required for treatment
        of the Enrollee's Emergency Behavioral Health Services, as documented by
        the
        Enrollee's Medical Record.

      

      c. The
        Health Plan shall review and approve or disapprove all out-of-plan Emergency
        Behavioral Health Service claims within the time frames specified for emergency
        claims payment in Section V.D.3., Emergency Care Requirements.

      

      d. The
        Health Plan shall submit to the Agency for review and final determination
        all
        denied Appeals from behavioral health care providers and out-of-plan,
        non-participating Behavioral Health Care Providers for denied Emergency
        Behavioral Health Service claims. The provider, whether a participating provider
        or not, must submit the denied Appeal to the Agency within ten (10) days
        after
        receiving notice of the Health Plan's final Appeal determination. 

      

      e. The
        Health Plan must evaluate and authorize or deny services for Enrollees
        presenting at non-participating receiving facilities (that are not Crisis
        Stabilization Units), within the Health Plan's service area, for involuntary
        examination within three (3) hours of being notified by phone by the receiving
        facility.

      

      f. The
        receiving facility must notify the Health Plan within four (4) hours of the
        Enrollee presenting. If the Receiving Facility fails to notify the Health
        Plan
        of the Enrollee's presence and status within four (4) hours, the Health Plan
        shall pay only for the first four (4) hours of the Enrollee's treatment,
        subject
        to Medical Necessity.

      

      g. If
        the
        receiving facility is a non-participating receiving facility and documents
        in
        the Medical Record that it is unable, after a good faith effort, to identify
        the
        Enrollee and, therefore, fails to notify the Health Plan of the Enrollee's
        presence, the Health Plan shall pay for medical stabilization lasting no
        more
        than three (3) days from the date the Enrollee presented at the receiving
        facility, as documented by the Enrollee's Medical Record and subject to Medical
        Necessity, unless there is irrefutable evidence in the Medical Record that
        a
        longer period was required to treat the Enrollee.

      

      
        	 	
                7.

              	
                Family
                  Planning Services

              

      

      

      The
        Health Plan shall provide family planning services for the purpose of enabling
        Enrollees to make comprehensive and informed decisions about family size
        and/or
        spacing of births. The Health Plan shall provide the following services:
        planning and referral, education and counseling, initial examination, diagnostic
        procedures and routine laboratory studies, contraceptive drugs and supplies,
        and
        follow-up care in accordance with the Medicaid Physicians Services Coverage
        and
        Limitations Handbook. Policy requirements include: 

      

      a. The
        Health Plan shall furnish services on a voluntary and confidential
        basis. 

      

      b. The
        Health Plan shall allow Enrollees freedom of choice of family planning methods
        covered under the Medicaid program, including Medicaid covered implants,
        where
        there are no medical contra-indications.

      

      c. The
        Health Plan shall render the services to Enrollees under the age of eighteen
        (18) provided the Enrollee is married, a parent, pregnant, has written consent
        by a parent or legal guardian, or in the opinion of a physician, the Enrollee
        may suffer health hazards if the services are not provided. See
        section 31.0051, F.S.

      

      d. The
        Health Plan shall allow each Enrollee to obtain family planning services
        from
        any Medicaid Provider and require no prior authorization for such services.
        If
        the Enrollee receives services from a non-network Medicaid provider, then
        the
        Health Plan must reimburse at the Medicaid reimbursement rate, unless another
        payment rate is negotiated.

      

      e. The
        Health Plan shall make available and encourage all pregnant women and mothers
        with infants to receive postpartum visits for the purpose of voluntary family
        planning, including discussion of all appropriate methods of contraception,
        counseling and services for family planning to all women and their partners.
        The
        Health Plan shall direct Providers to maintain documentation in the Enrollee's
        Medical Records to reflect this provision. See
        section 409.912, F.S.

      

      f. The
        provisions of this subsection shall not be interpreted so as to prevent a
        health
        care provider or other person from refusing to furnish any contraceptive
        or
        family planning service, supplies or information for medical or religious
        reasons. A health care provider or other person shall not be held liable
        for
        such refusal.

      

      
        	 	
                8.

              	
                Hospital
                  Services — Inpatient

              

      

      

      Inpatient
        Services - Medically Necessary services ordinarily furnished by a State licensed
        acute care Hospital for the medical care and treatment of inpatients provided
        under the direction of a physician or dentist in a Hospital maintained primarily
        for the care and treatment of patients with disorders other than mental
        diseases. Inpatient psychiatric Hospital services are Medically Necessary
        Behavioral Health Care Services and may be provided in a general Hospital
        psychiatric unit or in a specialty Hospital.

      

      a. Inpatient
        services include, but are not limited to, rehabilitation Hospital care (which
        are counted as inpatient Hospital days), medical supplies, diagnostic and
        therapeutic services, use of facilities, drugs and biologicals, room and
        board,
        nursing care and all supplies and equipment necessary to provide adequate
        care.
See
        the
        Medicaid Hospital Services Coverage & Limitations Handbook. 

      

      b. Inpatient
        services also include inpatient care for any diagnosis including psychiatric
        and
        mental health (Baker Act and non-Baker Act), tuberculosis and renal failure
        when
        provided by general acute care Hospitals in both emergent and non-emergent
        conditions. 

      

      c. The
        Health Plan may provide services in a nursing home as downward substitution
        for
        Inpatient Services. Such services shall not be counted as inpatient hospital
        days.

      

      d. The
        Health Plan shall provide Medically Necessary transplants covered in the
        Handbook, including pre-transplant care and post-transplant care. For other
        transplants not covered by Medicaid, the Health Plan shall cover pre-transplant
        care and post-transplant follow-up.

       

      e. The
        Health Plan shall cover physical therapy services when Medically Necessary
        and
        when provided during an Enrollee's inpatient stay.

      

      f. The
        Health Plan shall provide up to twenty-eight (28) inpatient hospital days
        in an
        inpatient Hospital substance abuse treatment program for pregnant substance
        abusers who meet ISD Criteria with Florida Medicaid modifications, as specified
        in InterQual Level of Care 2003-Acute Criteria-Pediatric and/or InterQual
        Level
        of Care 2003-Acute Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”),
        2003 Edition or the most current edition, for use in screening cases admitted
        to
        rehabilitative Hospitals and CON approved rehabilitative units in acute care
        Hospitals with admission dates of January 1, 2003 and after. In addition,
        the
        Health Plan shall provide inpatient Hospital treatment for severe withdrawal
        cases exhibiting medical complications which meet the severity of illness
        criteria under the alcohol/substance abuse system-specific set which generally
        requires treatment on a medical unit where complex medical equipment is
        available. Withdrawal cases (not meeting the severity of illness criteria
        under
        the alcohol/substance abuse criteria) and substance abuse rehabilitation
        (other
        than for pregnant women), including court ordered services, are not covered
        in
        the inpatient Hospital setting.

      

      g. The
        Health Plan shall adhere to the provisions of the Newborns and Mothers Health
        Protection Act (NMHPA) of 1996 regarding postpartum coverage for mothers
        and
        their newborns. Therefore, the Health Plan shall provide for no less than
        a
        forty-eight (48) hour Hospital length of stay following a normal vaginal
        delivery, and at least a ninety-six (96) hour Hospital length of stay following
        a Cesarean section. In connection with coverage for maternity care, the Hospital
        length of stay is required to be decided by the attending physician in
        consultation with the mother.

      

      h. The
        Health Plan shall prohibit the following practices:

      

      
        	 	
                (1)

              	
                Denying
                  the mother or newborn child eligibility, or continued eligibility,
                  to
                  enroll or renew coverage under the terms of the Health Plan, solely
                  for
                  the purpose of avoiding the NMHPA
                  requirements;

              

      

      

      
        	 	
                (2)

              	
                Providing
                  monetary payments or rebates to mothers to encourage them to accept
                  less
                  than the minimum protections available under
                  NMHPA;

              

      

      

      
        	 	
                (3)

              	
                Penalizing
                  or otherwise reducing or limiting the reimbursement of an attending
                  physician because the physician provided care in a manner consistent
                  with
                  NMHPA;

              

      

      

      
        	 	
                (4)

              	
                Providing
                  incentives (monetary or otherwise) to an attending physician to
                  induce the
                  physician to provide care in a manner inconsistent with NMHPA;
                  and

              

      

      

      
        	 	
                (5)

              	
                Restricting
                  for any portion of the forty-eight (48) hour, or ninety-six (96)
                  hour,
                  period prescribed by NMHPA in a manner that is less favorable than
                  the
                  Benefits provided for any preceding portion of the Hospital
                  stay.

              

      

      

      
        	 	
                (6)

              	
                The
                  Health Plan shall pay for any Medically Necessary duration of stay
                  in a
                  noncontracted facility which results from a medical emergency until
                  such
                  time as the Plan can safely transport the Enrollee to a Plan participating
                  facility.

              

      

      

      

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                9.

              	
                Hospital
                  Services — Outpatient

              

      

      

      Outpatient
        hospital services consist of preventive, diagnostic, therapeutic or palliative
        care under the direction of a physician or dentist at a licensed acute care
        Hospital. Outpatient hospital services include Medically Necessary emergency
        room services, dressings, splints, oxygen and physician ordered services
        and
        supplies for the clinical treatment of a specific diagnosis or
        treatment.

      

      a. The
        Health Plan shall provide Emergency Services and Care as Medically Necessary.
        

      

      b. The
        Health Plan shall have a procedure for the authorization of dental care and
        associated ancillary medical services provided in an outpatient hospital
        setting
        if that care meets the following requirements:

      

      
        	 	
                (1)

              	
                Is
                  provided under the direction of a dentist at a licensed Hospital;
                  and

              

      

      

      
        	 	
                (2)

              	
                Is
                  Medically Necessary; or

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall pay for any Medically Necessary duration of stay
                  in a
                  noncontracted facility which results from a medical emergency until
                  such
                  time as the Plan can safely transport the Enrollee to a Plan participating
                  facility.

              

      

      

      
        	 	
                10.

              	
                Hospital
                  Services — Ancillary
                  Services

              

      

      

      a. The
        Health Plan shall provide Medically Necessary ancillary medical services
        at the
        Hospital without limitation. Ancillary Hospital services include, but are
        not
        limited to, radiology, pathology, neurology, neonatology, and anesthesiology.
        When the Health Plan or the Health Plan's authorized physician authorizes
        these
        services (either inpatient or outpatient), the Health Plan must reimburse
        the
        provider of the service at the Medicaid line item rate, unless the Health
        Plan
        and the Hospital have negotiated another reimbursement rate. Also, the Health
        Plan must reimburse non-network physicians for emergency ancillary services
        provided in a hospital setting.

      

      b. The
        Health Plan shall have a procedure for the authorization of Medically Necessary
        dental care and associated ancillary services provided in licensed ambulatory
        surgical center settings if that care is provided under the direction of
        a
        dentist as described in state plan.

      

      
        	 	
                11.

              	
                Hysterectomies,
                  Sterilizations and Abortions

              

      

      

      The
        Health Plan shall maintain a log of all hysterectomy, sterilization and abortion
        procedures performed for its Enrollees. The log must include, at a minimum,
        the
        Enrollee’s name and identifying information, date of procedure, and type of
        procedure. The Health Plan shall provide abortions only in the following
        situations:

      

      a. If
        the
        pregnancy is a result of an act of rape or incest; or

      

      b. The
        physician certifies that the woman is in danger of death unless an abortion
        is
        performed.

      

      

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                12.

              	
                Immunizations

              

      

      

      The
        Health Plan shall: 

      

      a. Provide
        immunizations in accordance with the Recommended Childhood Immunization Schedule
        for the United States, or when Medically Necessary for the Enrollee's
        health;

      

      b. Provide
        for the simultaneous administration of all vaccines for which an Enrollee
        up to
        the age of 20 is eligible at the time of each visit; and

      

      c. Follow
        only true contraindications established by the Advisory Committee on
        Immunization Practices ("ACIP"), unless:

      

      
        	 	
                (1)

              	
                In
                  making a medical judgment in accordance with accepted medical practices,
                  such compliance is deemed medically inappropriate;
                  or

              

      

      

      
        	 	
                (2)

              	
                The
                  particular requirement is not in compliance with Florida law, including
                  Florida law relating to religious or other
                  exemptions.

              

      

      

      d. Participate,
        or direct its Providers to participate, in the Vaccines For Children Program
        ("VFC"). See
        Section 1905(r)(1) of the Social Security Act. The VFC is administered by
        the
        Department of Health, Bureau of Immunizations, and provides vaccines at no
        charge to physicians and eliminates the need to refer children to CHDs for
        immunizations.

      

      e. The
        Health Plan shall provide coverage and reimbursement to the Participating
        Provider for immunizations covered by Medicaid, but not provided through
        VFC;

      

      f.
         Ensure
        that Providers have a sufficient supply of vaccines if the Health Plan is
        the
        VFC enrollee. The Health Plan shall direct those Providers that are directly
        enrolled in the VFC program to maintain adequate vaccine supplies;

      

      g. Pay
        no
        more than the Medicaid program vaccine administration fee of $10.00 per
        administration, unless another rate is negotiated with the Participating
        Provider.

      

      h. Pay
        the
        immunization administration fee at no less than the Medicaid rate when an
        Enrollee receives immunizations from a nonparticipating provider, so long
        as:...

      

      (i) The
        nonparticipating provider contacts the Health Plan at the time of service
        delivery;

      

      (ii) The
        Health Plan is unable to document to the nonparticipating provider that the
        Enrollee has already received the immunization; and

      

      (iii) The
        nonparticipating provider submits a claim for the administration of immunization
        services and provides medical records documenting the immunization to the
        Health
        Plan. 

       

      

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                13.

              	
                Pregnancy
                  Related Requirements

              

      

      

      The
        Health Plan must provide the most appropriate and highest level of Quality
        care
        for pregnant Enrollees. Required care includes the following: 

      

      a. Florida's
        Healthy Start Prenatal Risk Screening - The Health Plan shall ensure that
        the
        Provider offers Florida's Healthy Start prenatal risk screening to each pregnant
        Enrollee as part of her first prenatal visit. As
        required by section 383.14, F.S., 2004 and 64C-7.009, F.A.C. 

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall ensure that the Provider uses the DOH prenatal
                  risk form
                  (DH Form 3134), which can be obtained from the local CHD.
                  

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall ensure that the Provider retains a copy of the
                  completed
                  screening instrument in the Enrollee's Medical Record and provides
                  a copy
                  to the Enrollee.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall ensure that the Provider submits the completed
                  DH Form
                  3134 to the CHD in the county in which the prenatal screen was
                  completed
                  within ten (10) Business Days of
                  completion.

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan shall collaborate with the Healthy Start care coordinator
                  within the Enrollee's county of residence to assure risk appropriate
                  care
                  is delivered.

              

      

      

      b. Florida's
        Healthy Start Infant (Postnatal) Risk Screening Instrument - The Health Plan
        shall ensure that the Provider completes the Florida Healthy Start Infant
        (Postnatal) Risk Screening Instrument (DH Form 3135) with the Certificate
        of
        Live Birth and transmits the documents to the CHD in the county in which
        the
        infant was born within ten (10) Business Days of completion. The Health Plan
        shall ensure that the Participating Provider retains a copy of the completed
        DH
        Form 3135 in the Enrollee's Medical Record and provides a copy to the
        Enrollee.

      

      c. Pregnant
        Enrollees or infants who do not score high enough to be eligible for Healthy
        Start care coordination may be referred for services, regardless of their
        score
        on the Healthy Start risk screen, in the following ways: 

      

      
        	 	
                (1)

              	
                If
                  the referral is to be made at the same time the Healthy Start risk
                  screen
                  is administered, the Provider may indicate on the risk screening
                  form that
                  the Enrollee or infant is invited to participate based on factors
                  other
                  than score; or 

              

      

       

      
        	 	
                (2)

              	
                If
                  the determination is made subsequent to risk screening, the Participating
                  Provider may refer the Enrollee or infant directly to the Healthy
                  Start
                  care coordinator based on assessment of actual or potential factors
                  associated with high risk, such as HIV, hepatitis B, substance
                  abuse or
                  domestic violence.

              

      

      

      d. The
        Health Plan shall refer all pregnant women, breast-feeding and postpartum
        women,
        infants and Children up to age five (5) to the local WIC office. 

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall provide:

              

      

      

      i. A
        completed Florida WIC program Medical Referral Form with the current height
        or
        length and weight (taken within 60 Calendar Days of the WIC
        appointment);

      

      ii. Hemoglobin
        or hematocrit; and

      

      iii. Any
        identified medical/nutritional problems.

      

      
        	 	
                (2)

              	
                For
                  subsequent WIC certifications, the Health Plan shall ensure that
                  Providers
                  coordinate with the local WIC office to provide the above referral
                  data
                  from the most recent CHCUP.

              

      

      

      
        	 	
                (3)

              	
                Each
                  time the Health Plan completes a WIC Referral Form, the Health
                  Plan shall
                  ensure that the Provider gives a copy of the WIC Referral Form
                  to the
                  Enrollee and retains a copy in the Enrollee's Medical
                  Record.

              

      

      

      e. The
        Health Plan shall ensure that the Providers provide all women of childbearing
        age HIV counseling and offer them HIV testing. See Chapter
        381, F.S.

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall ensure that its Providers, in accordance with
                  Florida
                  law, offer all pregnant women counseling an HIV testing at the
                  initial
                  prenatal care visit and again at twenty-eight (28) to thirty-two
                  (32)
                  weeks.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall ensure that its Providers attempt to obtain a
                  signed
                  objection if a pregnant woman declines an HIV test. See Section
                  384.31,
                  F.S., 2004 and 64D-3.019, F.A.C.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall ensure that all pregnant women who are infected
                  with HIV
                  are counseled about and offered the latest antiretroviral regimen
                  recommended by the U.S. Department of Health & Human Services. (U.S.
                  Department of Health & Human Services, Public Health Service Task
                  Force Report entitled Recommendations for the Use of Antiretroviral
                  Drugs
                  in Pregnant HIV-1 Infected Women for Maternal Health and Interventions
                  to
                  Reduce Perinatal HIV-1 Transmission in the United States. To receive
                  a
                  copy of the guidelines, contact the DOH, Bureau of HIV/AIDS at
                  (850)
                  245-4334, or go to http://aidsinfo.nih.gov/guidelines/.)

              

      

      

      f. The
        Health Plan shall ensure that its Providers screen all pregnant Enrollees
        receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during
        the
        first prenatal visit.

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall ensure that the Providers perform a second HBsAg
                  test
                  between twenty-eight (28) and thirty-two (32) weeks of pregnancy
                  for all
                  pregnant Enrollees who tested negative at the first (1st) prenatal
                  visit
                  and are considered high-risk for Hepatitis B infection. This test
                  shall be
                  performed at the same time that other routine prenatal screening
                  is
                  ordered.

              

      

      

      
        	 	
                (2)

              	
                All
                  HBsAg-positive women shall be reported to the local CHD and to
                  Healthy
                  Start, regardless of their Healthy Start screening
                  score.

              

      

      

      g. The
        Health Plan shall ensure that infants born to HBsAg-positive Enrollees shall
        receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once
        they
        are physiologically stable, preferably within twelve (12) hours of birth
        and
        shall complete the Hepatitis B Maxine series according to the recommended
        vaccine schedule established by the Recommended Childhood Immunization Schedule
        for the United States.

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall ensure that its Providers test infants born to
                  HBsAg-positive Enrollees for HBsAg and Hepatitis B surface antibodies
                  (anti-HBs) six (6) months after the completion of the vaccine series
                  to
                  monitor the success or failure of the
                  therapy.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall ensure that Providers report to the local CHD
                  a positive
                  HBsAg result in any child aged twenty-four (24) months or less
                  within
                  twenty-four (24) hours of receipt of the positive test
                  results.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall ensure that infants born to Enrollees who are
                  HBsAg-positive are referred to Healthy Start regardless of their
                  Healthy
                  Start screening score.

              

      

      

      h. The
        Health Plan shall report to the Perinatal Hepatitis B Prevention Coordinator
        at
        the local CHD all prenatal or postpartum Enrollees who test HBsAg-positive.
        The
        Health Plan also shall report said Enrollees’ infants and contacts to the
        Perinatal Hepatitis B Prevention Coordinator at the local CHD.

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall report the following information - name, date
                  of birth,
                  race, ethnicity, address, infants, contacts, laboratory test performed,
                  date the sample was collected, the due date or EDC, whether or
                  not the
                  Enrollee received prenatal care, and immunization dates for infants
                  and
                  contacts.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall use the Perinatal Hepatitis B Case and Contact
                  Report (DH Form 1876) for reporting purposes.

              

      

      

      i. The
        Health Plan shall ensure that the PCP maintains all documentation of Healthy
        Start screenings, assessments, findings and referrals in the Enrollees’ Medical
        Records. The Health Plan shall ensure quick access to Enrollees’ Medical Records
        in the Provider contract.

      

      j. The
        Health Plan shall provide the most appropriate and highest level of Quality
        care
        for pregnant Enrollees, including, but not limited to, the
        following:

      

      
        	 	
                (1)

              	
                Prenatal
                  Care - The Health Plan shall:

              

      

      

      i. Require
        a
        pregnancy test and a nursing assessment with referrals to a physician, PA
        or
        ARNP for comprehensive evaluation;

      

      ii. Require
        Case Management through the gestational period according to the needs of
        the
        Enrollee; 

      

      iii. Require
        any necessary referrals and follow-up;

      

      iv. Schedule
        return prenatal visits at least every four (4) weeks until the thirty-second
        (32nd) week, every two (2) weeks until the thirty-sixth (36th) week, and
        every
        week thereafter until delivery, unless the Enrollee’s condition requires more
        frequent visits; 

      

      v. Contact
        those Enrollees who fail to keep their prenatal appointments as soon as
        possible, and arrange for their continued prenatal care;

      

      vi. Assist
        Enrollees in making delivery arrangements, if necessary; and

      

      vii. Ensure
        that all Providers screen all pregnant Enrollees for tobacco use and make
        certain that the Providers make available to the pregnant Enrollees smoking
        cessation counseling and appropriate treatment as needed.

      

      
        	 	
                (2)

              	
                Nutritional
                  Assessment/Counseling - The Health Plan shall ensure that its Providers
                  supply nutritional assessment and counseling to all pregnant Enrollees.
                  The Health Plan shall:

              

      

      

      i. Ensure
        the provision of safe and adequate nutrition for infants by promoting
        breast-feeding and the use of breast milk substitutes;

      

      ii. Offer
        a
        mid-level nutrition assessment;

      

      iii. Provide
        individualized diet counseling and a nutrition care plan by a public health
        nutritionist, a nurse or physician following the nutrition assessment;
        and

      

      iv. Documentation
        of the nutrition care plan in the Medical Record by the person providing
        counseling.

      

      
        	 	
                (3)

              	
                Obstetrical
                  Delivery - The Health Plan shall develop and use generally accepted
                  and
                  approved protocols for both low risk and high risk deliveries which
                  reflect the highest standards of the medical profession, including
                  Healthy
                  Start and prenatal screening, and ensure that all Providers use
                  these
                  protocols.

              

      

      

      i. The
        Health Plan shall ensure that all Providers document preterm delivery risk
        assessments in the Enrollee’s Medical Record by the twenty-eighth (28th)
        week.

      

      ii. If
        the
        Provider determines that the Enrollee’s pregnancy is high risk, the Health Plan
        shall ensure that the Provider’s obstetrical care during labor and delivery
        includes preparation by all attendants for symptomatic evaluation and that
        the
        Enrollee progresses through the final stages of labor and immediate postpartum
        care.

      

      
        	 	
                (4)

              	
                Newborn
                  Care - The Health Plan shall make certain that its Providers supply
                  the
                  highest level of care for the Newborn beginning immediately after
                  birth.
                  Such level of care shall include, but not be limited to, the
                  following:

              

      

      

      i. Instilling
        of prophylactic eye medications into each eye of the Newborn;

      

      ii. When
        the
        mother is Rh negative, the securing of a cord blood sample for type Rh
        determination and direct Coombs test;

      

      iii. Weighing
        and measuring of the Newborn;

      

      iv. Inspecting
        the Newborn for abnormalities and/or complications;

      

      v. Administering
        of one half milligram of vitamin K;

      

      vi. APGAR
        scoring;

      

      vii. Any
        other
        necessary and immediate need for referral in consultation from a specialty
        physician, such as the Healthy Start (postnatal) infant screen; and

      

      viii. Any
        necessary Newborn and infant hearing screenings. (To
        be
        conducted by a licensed audiologist pursuant to Chapter 468, F.S., 2004,
        a
        physician licensed under Chapters 458 or 459, F.S., 2004, or an individual
        who
        has completed documented training specifically for newborn hearing screenings
        and who is directly or indirectly supervised by a licensed physician or a
        licensed audiologist.)

      

      
        	 	
                (5)

              	
                Postpartum
                  Care - The Health Plan shall:

              

      

      

      i. Provide
        a
        postpartum examination for the Enrollee within six (6) weeks after
        delivery;

      

      ii. Ensure
        that its Providers supply voluntary family planning, including a discussion
        of
        all methods of contraception, as appropriate;

      

      iii. Ensure
        that eligible Newborns are enrolled with the Health Plan and that continuing
        care of the Newborn be provided through the CHCUP program
        component.

      

      
        	 	
                14.

              	
                Prescribed
                  Drug Services

              

      

      

      a. The
        Health Plan shall provide those products and services associated with the
        dispensing of medicinal drugs pursuant to a valid prescription, as
        defined in Chapter 465, F.S.
        Prescribed Drug Services generally include all prescription drugs listed
        in the
        Agency’s Prescribed Drug List (“PDL,” See
        section 409.91195, F.S.),
        except for specific hemophilia-related drugs identified by the Agency to
        be
        reimbursed as Fee-for-Service beginning September 1, 2006. The PDL shall
        include
        at least two (2) products, when available, in each therapeutic class.
        Antiretroviral agents are not subject to the PDL Policy requirements, pursuant
        to
        section
        409.912(39), F.S.,
        include,
        but are not limited to, the following:

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall make available those drugs and dosage forms listed
                  in
                  the PDL.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall not arbitrarily deny or reduce the amount, duration
                  or
                  scope of prescriptions solely based on the Enrollee’s diagnosis, type of
                  illness or condition. The Health Plan may place appropriate limits
                  on
                  prescriptions based on criteria such as Medical Necessity, or for
                  the
                  purpose of utilization control, provided the Health Plan reasonably
                  expects said limits to achieve the purpose of the Prescribed Drug
                  Services
                  set forth in the Medicaid State Plan.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall make available those drugs not on the PDL, when
                  requested and approve, if the drugs on the PDL have been used in
                  a step
                  therapy sequence or when other documentation is provided.
                  

              

      

      

      b. The
        Health Plan shall provide to Enrollees, who desire to quit smoking, one (1)
        course of nicotine replacement therapy, of twelve (12) weeks duration, or
        the
        manufacturer’s recommended duration, per year. The Health Plan may use either
        nicotine transdermal patches or nicotine gum.

      

      c. If
        the
        Health Plan has authorization requirements for prescribed drug services,
        the
        Health Plan shall comply with all aspects of the Settlement Agreement to
        Hernandez, et. al. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA).
        An
        HSA situation arises when an Enrollee attempts to fill a prescription at
        a
        participating pharmacy location and is unable to receive his/her prescription
        as
        a result of:

      

      
        	 	
                (1)

              	
                An
                  unreasonable delay in filling the
                  prescription;

              

      

      

      
        	 	
                (2)

              	
                A
                  denial of the prescription;

              

      

      

      
        	 	
                (3)

              	
                The
                  reduction of a prescribed good or service;
                  and/or

              

      

      

      
        	 	
                (4)

              	
                The
                  termination of a prescription.

              

      

      

      d. The
        Health Plan shall ensure that its Enrollees are receiving the functional
        equivalent of those goods and services received by non-Medicaid Reform
        Fee-for-Service Medicaid Recipients in accordance with the HSA. 

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall maintain a log of all correspondences and communications
                  from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log”
                  shall contain, at a minimum, the Enrollee’s name, address and telephone
                  number and any other contact information, the reason for the participating
                  pharmacy location’s denial (and unreasonable delay in filling a
                  prescription, a denial of a prescription and/or the termination
                  of a
                  prescription), the pharmacy’s name (and store number, if applicable), the
                  date of the call, a detailed explanation of the final resolution,
                  and the
                  name of prescribed good or service.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan’s Enrollees are third party beneficiaries for this Section of
                  the Contract.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall conduct HSA surveys on an annual basis, of no
                  less than
                  five percent (5%) of all participating pharmacy locations to ensure
                  compliance with the HSA.

              

      

      

      	(a)  	
              The
                Health Plan may survey less than five percent (5%), with written
                approval
                from the Agency, if the Health Plan can show that the number of
                participating pharmacies it surveys is a statistically significant
                sample
                that adequately represents the pharmacies that have contracted with
                the
                Health Plan to provide pharmacy services.

            

      

      	(b)  	
              The
                Health Plan shall not include in the HSA Survey any participating
                pharmacy
                location that the Health Plan found to be in complete compliance
                with the
                HSA requirements within the last twelve
                months.

            

      

      	(c)  	
              The
                Health Plan shall require all participating pharmacy locations that
                fail
                any aspect of the HSA survey to undergo mandatory training within
                six (6)
                months and then be re-evaluated within one (1) month of the Health
                Plan’s
                HSA training to ensure that the participating pharmacy location is
                in
                compliance with the HSA.

            

      

      
        	 	
                (4)

              	
                The
                  Health Plan shall offer to train all new and existing participating
                  pharmacy locations regarding the HSA
                  requirements.

              

      

      

      
        	 	
                (5)

              	
                The
                  Health Plan may delegate any or all functions to one (1) or more
                  Pharmacy
                  Benefits Administrators (PBA), so long as none of the PBAs are
                  owned,
                  operated, related to, or subsidiaries of, any pharmacy. Before
                  entering
                  into a Subcontract, the Health Plan
                  shall:

              

      

      

      	(a)  	
              Provide
                a copy of the model Subcontract between the Health Plan and the PBA
                to the
                Bureau of Managed Health Care; 

            

      

      	(b)  	
              Receive
                written approval from the Bureau of Managed Health Care for the use
                of
                said model Subcontract; and 

            

      

      	(c)  	
              Work
                with the Fiscal Agent to integrate the
                systems.

            

      

      e. The
        Health Plan shall provide name brand drugs in compliance with State law.
        The
        Health Plan shall authorize claims from a pharmacy for the cost of a
        multi-source brand drug if the prescriber: 

      

      
        	 	
                (1)

              	
                Writes
                  in his or her own handwriting on the valid prescription that the
                  drug is
                  Medically Necessary; as determined by
                  section 465.025, F.S
                  and 

              

      

      

      
        	 	
                (2)

              	
                The
                  prescriber submits the functionally equivalent of the FDA MedWatch
                  form to
                  the Health Plan, in his or her own handwriting, that an Enrollee
                  has had
                  an adverse reaction to a generic drug or has had, in his or her
                  medical
                  opinion, better results when taking the brand-name
                  drug.

              

      

      

      f. Effective
        September 1, 2006, hemophilia-related drugs identified by the Agency for
        distribution through the Hemophilia Disease Management Pilot Program will
        be
        reimbursed on a Fee-for-Service basis. Upon implementation of the Hemophilia
        Disease Management Pilot Program, the Health Plan shall coordinate the care
        of
        its’ enrollees with Agency-approved organizations and shall not be responsible
        for the distribution of Hemophilia-related drugs.

      

      g. Health
        Plans shall submit pharmacy encounter data in a format supplied by the Agency
        on
        an ongoing quarterly payment schedule, as specified in Section XII of this
        Contract. For example, data for all claims paid during 04/01/06 and 06/30/06
        is
        due to the Agency by 07/31/06.

      

      
        	 	
                15.

              	
                Quality
                  Enhancements 

              

      

      

      In
        addition to the covered services specified in this Section, the Health Plan
        shall offer Quality Enhancements ("QEs") to Enrollees as specified
        below.

      

      a. The
        Health Plan shall offer QEs in community settings that are accessible to
        Enrollees.

      

      b. The
        Health Plan shall inform Enrollees and Providers of the QEs, and how to access
        services related to QEs, through the Enrollee and Provider
        Handbooks.

      

      c. The
        Health Plan shall develop and maintain written policies and procedures to
        implement QEs.

      

      d. The
        Health Plan may cosponsor the annual training of Providers, provided that
        the
        training meets the Provider training requirements for the programs listed
        below.
        The Plan is encouraged to actively collaborate with community agencies and
        organizations, including CHD's, local Early Intervention Programs, Healthy
        Start
        Coalitions and local school districts in offering these services. 

      

      e. If
        the
        Health Plan involves the Enrollee in an existing community program for purposes
        of meeting the QE requirement, the Health Plan shall document referrals to
        the
        community program, shall follow-up on the Enrollee's receipt of services
        from
        the community program and record the Enrollee's involvement in the Enrollee’s
        Medical Record.

      

      f. QE
        programs shall include, but not be limited to, the following:

      

      
        	 	
                (1)

              	
                Children's
                  Programs - The Health Plan shall provide regular general wellness
                  programs
                  targeted specifically toward Enrollees from birth to the age of
                  five (5),
                  or the Health Plan shall make a good faith effort to involve Enrollees
                  in
                  existing community Children's
                  Programs.

              

      

      

      i. Children's
        Programs shall promote increased utilization of prevention and early
        intervention services for at risk Enrollees with Children/Adolescents in
        the
        target population. The Health Plan shall approve claims for services recommended
        by the Early Intervention Program when they are Covered Services and Medically
        Necessary.

      

      ii. The
        Health Plan shall offer annual training to Providers that promote proper
        nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and
        early
        intervention services.

      

      
        	 	
                (2)

              	
                Domestic
                  Violence - The Health Plan shall ensure that PCPs screen Enrollees
                  for
                  signs of domestic violence and shall offer referral services to
                  applicable
                  domestic violence prevention community agencies.
                  

              

      

      

      
        	 	
                (3)

              	
                Pregnancy
                  Prevention - The Health Plan shall conduct regularly scheduled
                  Pregnancy
                  Prevention programs, or shall make a good faith effort to involve
                  Enrollees in existing community Pregnancy Prevention programs,
                  such a the
                  Abstinence Education Program. The programs shall be targeted towards
                  teen
                  Enrollees, but shall be open to all Enrollees, regardless of age,
                  gender,
                  pregnancy status or parental consent.

              

      

      

      
        	 	
                (4)

              	
                Prenatal/Postpartum
                  Pregnancy Programs - The Health Plan shall provide regular home
                  visits,
                  conducted by a home health nurse or aide, and counseling and educational
                  materials to pregnant and postpartum Enrollees who are not in compliance
                  with the Health Plan's prenatal and postpartum programs. The Health
                  Plan
                  shall coordinate its efforts with the local Healthy Start Care
                  Coordinator
                  to prevent duplication of services.

              

      

      

      
        	 	
                (5)

              	
                Smoking
                  Cessation - The Health Plan shall conduct regularly scheduled Smoking
                  Cessation programs as an option for all Enrollees, or the Health
                  Plan
                  shall make a good faith effort to involve Enrollees in existing
                  community
                  or Smoking Cessation programs. The Health Plan shall provide Smoking
                  Cessation counseling to Enrollees. The Health Plan shall provide
                  Participating PCPs with the Quick Reference Guide to assist in
                  identifying
                  tobacco users and supporting and delivering effective Smoking Cessation
                  interventions. (The Quick Reference Guide is a distilled version
                  of the
                  Public Health Service sponsored Clinical Practice Guideline, Treating
                  Tobacco Use & Dependence. The Plan can obtain copies of the Quick
                  Reference guide by contacting the DHHS, Agency for Health Care
                  Research
                  & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O.
                  Box 8547, Silver Spring, MD 20907.)

              

      

      

      
        	 	
                (6)

              	
                Substance
                  Abuse - The Health Plan shall offer Substance Abuse screening training
                  to
                  its Providers on an annual basis. 

              

      

      

      i. The
        Health Plan shall have all PCPs screen Enrollees for signs of Substance Abuse
        as
        part of prevention evaluation at the following times:

      

      
        	 	
                (a)

              	
                Initial
                  contact with a new Enrollee;

              

      

      

      
        	 	
                (b)

              	
                Routine
                  physical examinations;

              

      

      

      
        	 	
                (c)

              	
                Initial
                  prenatal contact;

              

      

      

      
        	 	
                (d)

              	
                When
                  the Enrollee evidences serious over-utilization of medical, surgical,
                  trauma or emergency services; and

              

      

      

      
        	 	
                (e)

              	
                When
                  documentation of emergency room visits suggests the
                  need.

              

      

      

      ii. The
        Health Plan shall offer targeted Enrollees either community or Health Plan
        sponsored Substance Abuse programs.

      

      
        	 	
                16.

              	
                Protective
                  Custody 

              

      

      

      The
        Health Plan shall provide a physical screening within seventy-two (72) hours,
        or
        immediately, if required, for all enrolled Children/Adolescsents taken into
        protective custody, emergency shelter or the foster care program by DCF,
        See
        Rule
        65C-12.002, F.A.C.

      

      a. The
        Health Plan shall provide these required examinations, or, if unable to do
        so
        within the required time frames, must approve the out of network claim and
        forward it to the Agency and/or its Agent. 

      

      b. For
        all
        CHCUP screenings for Children/Adolescents whose Enrollment and Medicaid
        eligibility are undetermined at the time of entry into the care and custody
        of
        DCF, and who are later determined to be Enrollees at the time the examinations
        took place, the Health Plan shall approve the claims and forward them to
        the
        Agency and/or the Fiscal Agent. 

      

      
        	 	
                17.

              	
                Therapy
                  Services 

              

      

      

      Medicaid
        Therapy Services are physical, speech-language (including augmentative and
        alternative communication systems), occupational and respiratory therapies.
        The
        Health Plan shall cover therapy services consistent with handbook requirements.
        Adults are covered for physical and respiratory therapy services under the
        Outpatient Hospital Services program. The Agency shall reimburse schools
        participating in the certified school match program for school-based Therapy
        Services rendered to Enrollees. The provision of school-based Therapy Services
        to an Enrollee does not replace, substitute or fulfill a service prescription
        or
        doctors' orders for Therapy Services external to the Health Plan. The Health
        Plan shall:

       

      
        	 	
                a.

              	
                Refer
                  Enrollees to appropriate Participating Providers for further assessment
                  and treatment of conditions;

              

      

      

      
        	 	
                b.

              	
                Offer
                  Enrollees scheduling assistance in making treatment appointments
                  and
                  obtaining transportation; and

              

      

      

      
        	 	
                c.

              	
                Provide
                  for care management in order to follow the Enrollee’s progress from
                  screening through his/her course of
                  treatment.

              

      

      

      
        	 	
                18.

              	
                Transportation

              

      

      

      a. Transportation
        services are the arrangement and provision of an appropriate mode of
        Transportation for Enrollees to receive medical care services. The Health
        Plan
        shall comply with the limitations and exclusions in the Medicaid Transportation
        Coverage, Limitations & Reimbursement Handbook (the “Transportation
        Handbook”) except where compliance conflicts with the terms of this Contract,
        the Contract terms shall take precedence. In no instance may the limitations
        or
        exclusions imposed by the Health Plan be more stringent than those specified
        in
        the Transportation Handbook. 

      

      b. The
        Health Plan shall have the option to provide
        Transportation services directly through the Health Plan’s network of
        Transportation Providers, or through a Provider contract relationship, which
        may
        include the Commission for the Transportation Disadvantaged (CTD).

      

      c. Regardless
        of whether the Health Plan chooses to coordinate with a Transportation Provider
        or provide Transportation services directly, the Health Plan shall be
        responsible for monitoring the provision of services. The Health
        Plan:

      

      
        	 	
                (1)

              	
                Shall
                  assure that Transportation providers are appropriately licensed
                  and
                  insured in accordance with the provisions of the Transportation
                  Handbook;

              

      

      

      
        	 	
                (2)

              	
                Must
                  provide Transportation Services for all Enrollees seeking necessary
                  Medicaid services;

              

      

      

      
        	 	
                (3)

              	
                Is
                  not obligated to follow the requirements of the Commission for
                  the
                  Transportation Disadvantaged or the Transportation Coordinating
                  Boards as
                  set forth in Chapter 427, F.S., 2004; unless the Health Plan has
                  chosen to
                  coordinate services with the CTD;

              

      

      

      
        	 	
                (4)

              	
                Shall
                  be responsible for the cost of transporting an Enrollee from a
                  nonparticipating facility or Hospital to a participating facility
                  or
                  Hospital if the reason for transport is solely for the Health Plan's
                  convenience; and

              

      

      

      
        	 	
                (5)

              	
                Shall
                  approve claims for Transportation Services providers in accordance
                  with
                  the requirements set forth in this
                  Contract.

              

      

      

      d. The
        Health Plan may delegate the provision of Transportation Services to a third
        party.

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall provide a copy of the model Participating Transportation
                  Subcontract to the Bureau of Managed Health
                  Care.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan may subcontract with more than one Transportation services
                  Provider.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall maintain oversight of any third party providing
                  services
                  on the Health Plan's behalf.

              

      

      

      e. The
        Health Plan shall provide the following non-emergency Transportation, at
        a
        minimum, as part of its line of Transportation Services:

      

      (1) Ambulatory
        Transportation;

      

      (2) Long
        haul
        ambulatory Transportation;

      

      (3) Wheelchair
        Transportation;

      

      (4) Stretcher
        Transportation;

      

      (5) Multiload
        Transportation;

      

      (6) Mass
        transit Transportation;

      

      (7) Over-the-road
        bus;

      

      (8) Over-the-road
        train;

      

      (9) Private
        volunteer Transportation; 

      

      (10) Escort
        services (including medical escort); and

      

      (11) Commercial
        air carrier Transportation.

      

      f. Before
        providing Transportation Services, the Health Plan shall provide to the Bureau
        of Managed Health Care a copy of its policies and procedures relating to
        the
        following:

      

      
        	 	
                (1)

              	
                How
                  the Health Plan will determine eligibility for each
                  Enrollee;

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan's course of action as to how it will determine what
                  type of
                  Transportation to provide to a particular
                  Enrollee;

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan's procedure for providing Prior Authorization to Enrollees
                  requesting Transportation Services;

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan's comprehensive employee training program to investigate
                  potential fraud;

              

      

      

      
        	 	
                (5)

              	
                How
                  the Health Plan will review Transportation Providers who demonstrate
                  a
                  pattern or practice of:

              

      

      

      (a) Falsified
        encounter or service reports; 

      

      (b) Overstated
        reports or up-coded levels of service; and/or

      

      (c) Fraud
        or
        abuse, as defined in section 409.913, F.S.

      

      
        	 	
                (6)

              	
                How
                  the Health Plan will review Transportation Providers
                  that:

              

      

      

      (a) Alter,
        falsify or destroy records prior to the end of the five (5) year records
        retention requirement;

      

      (b) Make
        false statements about credentials;

      

      (c) Misrepresent
        medical information to justify referrals;

      

      (d) Failed
        to
        provide scheduled Transportation for Enrollees; 

      

      (e) Charge
        Enrollees for covered services; and/or

      

      (f) Have,
        or
        been suspected of committing, fraud or abuse, as defined in section 409.913,
        F.S.

      

      
        	 	
                (7)

              	
                How
                  the Health Plan will provide Transportation Services outside of
                  the Health
                  Plan's service area. The Health Plan shall state clearly the guidelines
                  it
                  will use in order to control costs when providing Transportation
                  Services
                  outside of the Health Plan's service
                  area.

              

      

      

      g. The
        Health Plan shall report immediately, in writing to the Agency Contract Manager,
        the Bureau of Medicaid Program Integrity (MPI), and Medicaid Fraud Control
        Unit
        (MFCU), any aspect of Transportation Service delivery, by any Transportation
        services provider, any adverse or untoward incident. (See
        section 641.55, F.S.)
        The
        Health Plan shall also report, immediately upon identification, in writing
        to
        the Agency Contract Manager, the MPI and the MFCU, all instances of suspected
        Enrollee or Transportation Services Provider fraud or abuse.( As
        defined in section 409.913, F.S.)

      

      The
        Health Plan shall file a written report with the MPI, the MFCU, and the Agency
        Contract Manager immediately upon the detection of a potentially or suspected
        fraudulent or abusive action by a Transportation services provider. At a
        minimum, the report must contain the name, tax identification number and
        contract information of the Transportation services provider and a description
        of the suspected fraudulent or abusive act. The report shall be in the form
        of a
        narrative.

      

      h. Insurance,
        Safety Requirements and Standards (Including,
        but not limited to, 41-2, F.A.C.)

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall ensure compliance with the minimum liability
                  insurance
                  requirement of $100,000 per person and $200,000 per incident for
                  all
                  Transportation services purchased or provided for the Transportation
                  disadvantaged through the Health Plan. See
                  section 768.28(5), F.S.
                  The Health Plan shall indemnify and hold harmless the local, State,
                  and
                  federal governments and their entities and the Agency from any
                  liabilities
                  arising out of or due to an accident or negligence on the part
                  of the
                  Health Plan and/or all Transportation Providers under contract
                  to the
                  Health Plan. The Health Plan may act as a Transportation Provider,
                  in
                  which case it must follow all requirements set forth below for
                  Transportation Providers.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan, and all Transportation Providers, shall ensure that
                  all
                  operations and services are in compliance with all federal and
                  State
                  safety requirements, including, but not limited to, section 341.061(2)(a),
                  Florida Statutes, and Chapter 14-90,
                  F.A.C.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan, and all Transportation Providers, shall ensure continuing
                  compliance with all applicable State or federal laws relating to
                  drug
                  testing, including, but not limited to, to section 112.0455, Florida
                  Statutes, 2004, Rule 14-17.012, Chapters 59A-24 and 60L-19, F.A.C.,
                  41
                  U.S.C. 701, 49 C.F.R., Parts 29 and 382, and 46 C.F.R., Parts 4,
                  5, 14,
                  and 16.

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan and all Transportation Providers shall adhere to the
                  following
                  standards, including, but not limited to, the
                  following:

              

      

      

      (a) Drug
        and
        alcohol testing for safety sensitive job positions relating to the provision
        of
        Transportation Services regarding pre-employment, randomization, post-accident,
        and reasonable suspicion as required by the Federal Highway Administration
        and
        the Federal Transit Administration;

      

      (b) Use
        of
        child safety restraint devices, where the use of such devices would not
        interfere with the safety of a child (for example, a child in a
        wheelchair);

      

      (c)
         Enrollee
        property that can be carried by the passenger and/or driver, and can be stowed
        safely on the vehicle, shall be transported with the passenger at no additional
        charge. The driver shall provide Transportation of the following items, as
        applicable, within the capabilities of the vehicle: 

      

      
        	 	
                i.

              	
                Wheelchairs;

              

      

      

      
        	 	
                ii.

              	
                Child
                  seats;

              

      

      

      
        	 	
                iii.

              	
                Stretchers;

              

      

      

      
        	 	
                iv.

              	
                Secured
                  oxygen;

              

      

      

      
        	 	
                v.

              	
                Personal
                  assistive devices; and/or

              

      

      

      
        	 	
                vi.

              	
                Intravenous
                  devices.

              

      

      

      (d) Vehicle
        transfer points shall provide shelter, security, and safety of
        Enrollees;

      

      (e) Maintain
        inside all vehicles copies of the Health Plan’s toll-free phone number for
        Enrollee complaints;

      

      (f) The
        interior of all vehicles shall be free from dirt, grime, oil, trash, torn
        upholstery, damaged or broken seats, protruding metal or other objects or
        materials which could soil items placed in the vehicle or provide discomfort
        for
        Enrollees;

      

      (g) Maintain
        a passenger/trip database for each Enrollee transported by the Health
        Plan/Transportation Provider;

      

      (h) Ensure
        adequate seating for paratransit services for each Enrollee and escort, child,
        or personal care attendant, and shall ensure that the vehicle does not transport
        more passengers than the registered passenger seating capacity in a vehicle
        at
        any time; 

      

      (i) Ensure
        adequate seating space for transit services for each Enrollee and escort,
        child,
        or personal care attendant, and shall ensure that transit vehicles provide
        adequate seating or standing space to each rider, and shall ensure that the
        vehicle does not transport more passengers than the registered passenger
        seating
        or standing capacity in a vehicle at any time;

      

      (j) Drivers
        for paratransit services shall identify themselves by name and company in
        a
        manner that is conducive to communications with the specific passenger, upon
        pickup of each Enrollee, group of Enrollees, or representative, guardian,
        or
        associate of the Enrollee, except in situations where the driver regularly
        transports the Enrollee on a recurring basis;

      

      (k)
         Each
        driver must have photo identification that is viewable by the passenger.
        Name
        patches, inscriptions or badges that affix to driver clothing are acceptable.
        For transit services, the driver photo identification shall be in a conspicuous
        location in the vehicle;

      

      (l) The
        paratransit driver shall provide the Enrollee with boarding assistance, if
        necessary or requested, to the seating portion of the vehicle. The boarding
        assistance shall include, but not be limited to, opening the vehicle door,
        fastening the seat belt or utilization of wheel chair securement devices,
        storage of mobility assistive devices and closing the vehicle door. In the
        door-through-door paratransit service category, the driver shall open and
        close
        doors to buildings, except in situations in which assistance in opening and/or
        closing building doors would not be safe for passengers remaining in the
        vehicle. The driver shall provide assisted access in a dignified manner.
        Drivers
        may not assist wheelchair passengers up or down more than one (1) step, unless
        it can be performed safely as determined by the Enrollee, guardian, and
        driver;

      

      (m) Smoking,
        eating and drinking are prohibited in any vehicle, except in cases in which,
        as
        a Medical Necessity, the Enrollee requires fluids or sustenance during
        transport;

      

      (n) 
        Ensure
        that all vehicles are equipped with two-way communications, in good working
        order and audible to the driver at all times, by which to communicate with
        the
        Transportation Services hub or base of operations;

      

      (o) Ensure
        that all vehicles have working air conditioners and heaters. The Health Plan
        shall ensure that all vehicles that do not have a working air conditioner
        or
        heater are removed from the vehicle pool and scheduled for repair or
        replacement;

      

      (p) Develop
        and implement a first aid policy and cardiopulmonary resuscitation
        policy;

      

      (q) Ensure
        that all drivers providing Transportation Services undergo a background
        screening;

      

      (r) Establish
        Enrollee pick-up windows and communicate these windows to Transportation
        Providers and Enrollees;

      

      (s)
         Establish
        a minimum 24-hour advance notification policy to obtain Transportation Services.
        The Health Plan shall communicate said policy to Transportation Providers
        and
        Enrollees;

      

      (t) Establish
        a performance measure to evaluate the safety of the Transportation Services
        provided by Transportation Providers;

      

      (u) Establish
        a performance measure to evaluate the reliability of the vehicles utilized
        by
        Transportation Providers;

      

      (v) Establish
        a performance measure to evaluate the quality of service provided by a
        Transportation Provider;

      

      (w) The
        Health Plan shall submit these performance measures to the Agency for written
        approval by the end of the first month of this contract term;

      

      (x) The
        Health Plan shall report the results of these evaluation to the Agency as
        described in Section XI; and

      

      (y) Ensure
        that all drivers speak English.

      

      i. Operational
        Standards - Each Health Plan shall implement, or ensure that each Transportation
        Provider has implemented, policies and procedures that, at a minimum, comply
        with the following (For
        reference, see 14-90, F.A.C.):
        

      

      
        	 	
                (1)

              	
                Address
                  the following safety elements and
                  requirements:

              

      

      

      (a) Safety
        policies and responsibilities;

      

      (b) Vehicle
        and equipment standards and procurement criteria;

      

      (c) Operational
        standards and procedures;

      

      (d) Vehicle
        driver and employee selection;

      

      (e) Driving
        requirements;

      

      (f) Vehicle
        driver and employee training;

      

      (g) Vehicle
        maintenance;

      

      (h) Investigations
        of events described below;

      

      (i) Hazard
        identification and resolution;

      

      (j) Equipment
        for transporting wheelchairs;

      

      (k) Safety
        data acquisition and analysis;

      

      (l) Safety
        standards for private contract vehicle transit system(s) that provide(s)
        Transportation services for compensation as a result of a contractual agreement
        with the vehicle transit system.

      

      
        	 	
                (2)

              	
                Shall
                  submit an annual safety certification to the Agency verifying the
                  following:

              

      

      

      (a) Adoption
        of policies and procedures that, at a minimum, establish standard set forth
        in
        this Section; and

      

      (b) The
        Health Plan/Transportation Provider is in full compliance with the policies
        and
        procedures relating to Transportation Services, and that it has performed
        annual
        safety inspections on all vehicles operated by the Health Plan/Transportation
        Provider, by persons meeting the requirements set forth below.

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall suspend immediately a Transportation Provider
                  if, in the
                  sole discretion of the Health Plan, and at any time, continued
                  use of that
                  Transportation Provider, is unsafe for passenger service or poses
                  a
                  potential danger to public safety.

              

      

      

      
        	 	
                (4)

              	
                Address
                  the following security
                  requirements:

              

      

      

      (a) Security
        policies, goals, and objectives;

      

      (b) Organization,
        roles, and responsibilities;

      

      (c) Emergency
        management processes and procedures for mitigation, preparedness, response,
        and
        recovery;

      

      (d) Procedures
        for investigation of any event involving a vehicle, or taking place on vehicle
        transit system controlled property, resulting in a fatality, injury, or property
        damage as discussed below;

      

      (e) Procedures
        for the establishment of interfaces with emergency response
        organizations;

      

      (f) Employee
        security and threat awareness training programs;

      

      (g) Conduct
        and participate in emergency preparedness drills and exercises; and

      

      (h) Security
        requirements for Transportation Providers that provide Transportation Services
        for compensation as a result of a contractual agreement with the Health
        Plan/Transportation Provider.

      

      
        	 	
                (5)

              	
                Shall
                  establish criteria and procedures for selection, qualification,
                  and
                  training of all drivers. The criteria shall include, at a minimum,
                  the
                  following:

              

      

      

      (a) Driver
        qualifications and background checks with minimum hiring standards;

      

      (b) Driving
        and criminal background checks for all new drivers;

      

      (c) Verification
        and documentation of valid driver licenses for all employees who drive
        vehicles;

      

      (d) Training
        and testing to demonstrate and ensure adequate skills and capabilities to
        safely
        operate each type of vehicle or vehicle combination before driving
        unsupervised;

      

      (e) At
        a
        minimum, drivers shall be given explicit instructional and procedural training
        and testing in the following areas:

      

      
        	 	
                i.

              	
                The
                  Health Plan’s/Transportation Provider’s safety and operational policies
                  and procedures;

              

      

      

      
        	 	
                ii.

              	
                Operational
                  vehicle and equipment inspections;

              

      

      

      
        	 	
                iii.

              	
                Vehicle
                  equipment familiarization;

              

      

      

      
        	 	
                iv.

              	
                Basic
                  operations and maneuvering;

              

      

      

      
        	 	
                v.

              	
                Boarding
                  and alighting passengers;

              

      

      

      
        	 	
                vi.

              	
                Operation
                  of wheelchair lift and other special equipment and driving
                  conditions;

              

      

      

      
        	 	
                vii.

              	
                Defensive
                  driving;

              

      

      

      
        	 	
                viii.

              	
                Passenger
                  assistance and securement;

              

      

      

      
        	 	
                ix.

              	
                Handling
                  of emergencies and security threats;
                  and

              

      

      

      
        	 	
                x.

              	
                Security
                  and threat awareness.

              

      

      

      (f) Shall
        provide written operational and safety procedures to all vehicle drivers
        before
        the drivers are allowed to drive unsupervised. These procedures and instructions
        shall address, at a minimum, the following:

      

      
        	 	
                i.

              	
                Communication
                  and handling of unsafe conditions, security threats, and
                  emergencies;

              

      

      

      
        	 	
                ii.

              	
                Familiarization
                  and operation of safety and emergency equipment, wheelchair lift
                  equipment, and restraining devices;
                  and

              

      

      

      
        	 	
                iii.

              	
                Application
                  and compliance with applicable federal and State rules and regulations.
                  The provisions in Sections 10.8.14.h.5(e) and (f), above, shall
                  not apply
                  to personnel licensed and authorized by the Plan/Transportation
                  Provider
                  to drive, move, or road test a vehicle in order to perform repairs
                  or
                  maintenance services where it has been determined that such temporary
                  operation does not create an unsafe operating condition or create
                  a hazard
                  to public safety.

              

      

      

      (g) Shall
        maintain the following records for at least five (5) years:

      

      
        	 	
                i.

              	
                Records
                  of vehicle driver background checks and
                  qualifications;

              

      

      

      
        	 	
                ii.

              	
                Detailed
                  descriptions of training administered and completed by each vehicle
                  driver; 

              

      

      

      
        	 	
                iii.

              	
                A
                  record of each vehicle driver’s duty status, which shall include total
                  days worked, on-duty hours, driving hours and time of reporting
                  on- and
                  off-duty each day; and

              

      

      

      
        	 	
                iv.

              	
                Any
                  documents required to be prepared by this
                  Contract.

              

      

      

      (h) Shall
        establish a drug-free workplace policy statement, in accordance with 49 C.F.R.
        Part 29, and a substance abuse management and testing program; in accordance
        with 49 C.F.R. Parts 40 and 655, and
        

      

      (i) Shall
        require that drivers write and submit a daily vehicle inspection report,
        pursuant to Rule 14-90.006, F.A.C. 

      

      
        	 	
                (6)

              	
                Shall
                  establish a maintenance policy and procedures for preventative
                  and routine
                  maintenance for all vehicles. The maintenance policy and procedures
                  shall
                  ensure, at a minimum, that:

              

      

      

      (a) All
        vehicles, all parts and accessories on such vehicles, and any additional
        parts
        and accessories which may affect the safety of vehicle operation, including
        frame and frame assemblies, suspension systems, axles and attaching parts,
        wheels and rims, and steering systems, are regularly and systematically
        inspected, maintained and lubricated in accordance with the standards developed
        and established according to the vehicle manufacturer’s recommendations and
        requirements;

      

      (b) That
        a
        recording and tracking system is established for the types of inspections,
        maintenance, and lubrication intervals, including the date or mileage when
        these
        services are due. Required maintenance inspections shall be more comprehensive
        than daily inspections performed by the driver;

      

      (c) That
        proper preventive maintenance is performed when on all vehicles;
        and

      

      (d) That
        the
        Health Plan/Transportation Provider maintains and provides written documentation
        of preventive maintenance, regular maintenance, inspections, lubrication,
        and
        repairs performed for each vehicle under their control. Such records shall
        be
        maintained by the Health Plan/Transportation Provider for at least five (5)
        years and include, at a minimum, the following information:

      

      
        	 	
                i.

              	
                Identification
                  of the vehicle, including make, model, and license number or other
                  means
                  of positive identification and
                  ownership;

              

      

      

      
        	 	
                ii.

              	
                Date,
                  mileage, and type of inspection, maintenance, lubrication, or repair
                  performed;

              

      

      

      
        	 	
                iii.

              	
                Date,
                  mileage, and description of each inspection, maintenance, and lubrication
                  intervals performed;

              

      

      

      
        	 	
                iv.

              	
                If
                  not owned by the Health Plan/Transportation Provider, the name
                  of any
                  person or lessor furnishing any vehicle;
                  and

              

      

      

      
        	 	
                v.

              	
                The
                  name and address of any entity or contractor performing an inspection,
                  maintenance, lubrication, or
                  repair.

              

      

      

      
        	 	
                (7)

              	
                The
                  Health Plan/Transportation Provider shall investigate, or cause
                  to be
                  investigated, any event involving a vehicle or taking place on
                  Health
                  Plan/Transportation Provider controlled property resulting in a
                  fatality,
                  injury, or property damage as
                  follows:

              

      

      

      (a) 
        A
        fatality, where an individual is confirmed dead, within three (3) days of
        a
        Transportation Services related event, excluding suicides and deaths from
        illnesses. The Health Plan must file detailed report of the incident with
        the
        Agency within ten (10) days of the event (See section 641.55(6),
        F.S.);

      

      (b) Injuries
        requiring immediate medical attention away from the scene for two (2) or
        more
        individuals;

      

      (c) Property
        damage to Health Plan/Transportation Provider vehicles, other Health
        Plan/Transportation Provider property or facilities, or any other property,
        except the Health Plan/Transportation Provider shall have the discretion
        to
        investigate events resulting in property damage totaling less than $1,000;
        

      

      (d) Evacuation
        of a vehicle due where there is imminent danger to passengers on the vehicle,
        excluding evacuations due to vehicle operation issues;

      

      (e) Each
        investigation shall be documented in a final report that includes a description
        of investigation activities, identified causal factors and a corrective action
        plan;

      

      
        	 	
                i.

              	
                Each
                  corrective action plan shall identify the action to be taken by
                  the Health
                  Plan/Transportation Provider and the schedule for its implementation;
                  and

              

      

      

      
        	 	
                ii.

              	
                The
                  Health Plan/Transportation Provider must monitor and track the
                  implementation of each corrective action
                  plan.

              

      

      

      (f) The
        Health Plan/Transportation Provider shall maintain all investigation reports,
        corrective action plans, and related supporting documentation for a minimum
        of
        five (5) years from the date of completion of the investigation.

      

      j. Medical
        Examinations for Drivers - The Health Plan/Transportation Provider shall
        establish medical examination requirements for all applicants for driver
        positions and for existing drivers. The medical examination requirements
        shall
        include a pre-employment examination for applicants, an examination at least
        once every two (2) years for existing drivers, and a return to duty examination
        for any driver prior to returning to duty after having been off duty for
        thirty
        (30) or more days due to an illness, medical condition, or injury.

      

      
        	 	
                (1)

              	
                Medical
                  examinations may be performed and recorded according to qualification
                  standards adopted by the Health Plan/Transportation Provider, provided
                  the
                  medical examination qualification standards adopted by the Health
                  Plan/Transportation Provider meet or exceed those provided in Department
                  Form Number 725-030-11, Medical Examination Report for Bus Transit
                  System
                  Driver, Rev. 07/05, hereby incorporated by reference. Copies of
                  Form
                  Number 725-030-11 are available from the Florida Department of
                  Transportation, Public Transit Office, 605 Suwannee Street, Mail
                  Station
                  26, Tallahassee, Florida 32399-0450 or on-line at
                  www.dot.state.fl.us/transit.

              

      

      

      
        	 	
                (2)

              	
                Medical
                  examinations shall be performed by a Doctor of Medicine or Osteopathy,
                  a
                  Physician Assistant (PA) or ARNP licensed or certified by the State
                  of
                  Florida. The examination shall be conducted in person, and not
                  via the
                  Internet. If medical examinations are performed by a PA or ARNP,
                  they must
                  be performed under the supervision or review of a Doctor of Medicine
                  or
                  Osteopathy.

              

      

      

      (a) An
        ophthalmologist or optometrist licensed by the State of Florida may perform
        as
        much of the examination as pertains to visual acuity, field of vision and
        color
        recognition.

      

      (b) Upon
        completion of the examination, the examining medical professional shall
        complete, sign, and date the medical examination report.

      

      
        	 	
                (3)

              	
                The
                  Health Plan/Transportation Provider shall have on file proof of
                  medical
                  examination, i.e., a completed and signed medical examination report
                  for
                  each driver, dated within the past 24 months. Medical examination
                  reports
                  of employee drivers shall be maintained by the Health Plan/Transportation
                  Provider for a minimum of five (5) years from the date of the
                  examination.

              

      

      

      k. Operational
        and Driving Requirements

      

      
        	 	
                (1)

              	
                The
                  Health Plan/Transportation Provider shall not permit a driver to
                  drive a
                  vehicle when such driver’s license has been suspended, canceled or
                  revoked. The Health Plan/Transportation Provider shall require
                  a driver
                  who receives a notice that his or her license to operate a motor
                  vehicle
                  has been suspended, canceled, or revoked notify his or her employer
                  of the
                  contents of the notice immediately, and no later than the end of
                  the
                  business day following the day he or she received the
                  notice.

              

      

      

      
        	 	
                (2)

              	
                At
                  all times, the Health Plan/Transportation Provider shall operate
                  vehicles
                  in compliance with applicable traffic regulations, ordinances and
                  laws of
                  the jurisdiction in which they are being
                  operated.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan/Transportation Provider shall not permit or require
                  a driver
                  to drive more than twelve (12) hours in any one 24-hour period,
                  or drive
                  after having been on duty for sixteen (16) hours in any one twenty-four
                  (24) hour period. The Health Plan/Transportation Provider shall
                  not permit
                  a driver to drive until the driver fulfills the requirement of
                  a minimum
                  eight (8) consecutive hours off-duty. A driver’s work period shall begin
                  from the time he or she first reports for duty to his or her employer.
                  A
                  driver is permitted to exceed his or her regulated hours in order
                  to reach
                  a regularly established relief or dispatch point, provided the
                  additional
                  driving time does not exceed one (1)
                  hour.

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan/Transportation Provider shall not permit or require
                  a driver
                  to be on duty more than seventy-two (72) hours in any period of
                  seven (7)
                  consecutive days; however, twenty-four (24) consecutive hours off-duty
                  shall constitute the end of any such period of seven (7) consecutive
                  days.
                  The Health Plan/Transportation Provider shall ensure that a driver
                  who has
                  reached the maximum 72 hours of on-duty time during the seven (7)
                  consecutive days has a minimum of twenty-four (24) consecutive
                  hours
                  off-duty before returning to on-duty
                  status.

              

      

      

      
        	 	
                (5)

              	
                A
                  driver is permitted to drive for more than the regulated hours
                  for safety
                  and protection of the public due to conditions such as adverse
                  weather,
                  disaster, security threat, a road or traffic condition, medical
                  emergency
                  or an accident.

              

      

      

      
        	 	
                (6)

              	
                The
                  Health Plan/Transportation Provider shall not permit or require
                  any driver
                  to drive when his or her ability is impaired, or likely to be impaired,
                  by
                  fatigue, illness, or other causes, as to make it unsafe for the
                  driver to
                  begin or continue driving.

              

      

      

      
        	 	
                (7)

              	
                The
                  Health Plan/Transportation Provider shall require pre-operational
                  or daily
                  inspection of all vehicles and reporting of all defects and deficiencies
                  likely to affect safe operation or cause mechanical
                  malfunctions.

              

      

      

      (a) The
        Health Plan/Transportation Provider shall maintain a log detailing a daily
        inspection or test of the following parts and devices to ascertain that they
        are
        in safe condition and in good working order:

      

      
        	 	
                i.

              	
                Service
                  brakes;

              

      

      

      
        	 	
                ii.

              	
                Parking
                  brakes;

              

      

      

      
        	 	
                iii.

              	
                Tires
                  and wheels;

              

      

      

      
        	 	
                iv.

              	
                Steering;

              

      

      

      
        	 	
                v.

              	
                Horn;

              

      

      

      
        	 	
                vi.

              	
                Lighting
                  devices;

              

      

      

      
        	 	
                vii.

              	
                Windshield
                  wipers;

              

      

      

      
        	 	
                viii.

              	
                Rear
                  vision mirrors;

              

      

      

      
        	 	
                ix.

              	
                Passenger
                  doors and seats;

              

      

      

      
        	 	
                x.

              	
                Exhaust
                  system;

              

      

      

      
        	 	
                xi.

              	
                Equipment
                  for transporting wheelchairs; and

              

      

      

      
        	 	
                xii.

              	
                Safety,
                  security, and emergency equipment.

              

      

      

      (b) The
        Health Plan/Transportation Provider shall review daily inspection reports
        and
        document corrective actions taken as a result of any deficiencies identified
        by
        any inspections.

      

      (c) The
        Health Plan/Transportation Provider shall retain records of all inspections
        and
        any corrective action documentation for five (5) years.

      

      (8) The
        driver shall not operate a vehicle with passenger doors in the open position
        when passengers are aboard. The driver shall not open the vehicle’s doors until
        the vehicle comes to a complete stop. The Health Plan/Transportation Provider
        shall not operate a vehicle with inoperable passenger doors with passengers
        aboard, except to move the vehicle to a safe location.

      

      (9) During
        darkness, interior lighting and lighting in stepwells on vehicles shall be
        sufficient for passengers to enter and exit safely.

      

      (10) Passenger(s)
        shall not be permitted in the stepwell(s) of any vehicle while the vehicle
        is in
        motion, or to occupy an area forward of the standee line.

      

      (11) Passenger(s)
        shall not be permitted to stand on or in vehicles not designed and constructed
        for that purpose.

      

      (12) The
        Health Plan/Transportation Provider shall not refuel vehicles in a closed
        building. The Health Plan/Transportation Provider shall minimize the number
        of
        times a vehicle shall refuel when passengers are onboard.

      

      (13) The
        Health Plan/Transportation Provider shall require the driver to be properly
        secured to the driver’s seat with a restraining belt at all times while the
        vehicle is in motion.

      

      (14) The
        driver shall not leave vehicles unattended with passenger(s) aboard for longer
        than five (5) minutes. The Health Plan/Transportation Provider shall ensure
        that
        the driver sets the parking or holding brake any time the vehicle is left
        unattended.

      

      (15) The
        Health Plan/Transportation Provider shall not leave vehicles unattended in
        an
        unsafe condition with passenger(s) aboard at any time.

      

      l. Vehicle
        Equipment Standards and Procurement Criteria

      

      
        	 	
                (1)

              	
                The
                  Health Plan/Transportation Provider shall ensure that vehicles
                  procured
                  and operated meet the following requirements, at a
                  minimum:

              

      

      

      (a) The
        capability and strength to carry the maximum allowed load and not exceed
        the
        manufacturer’s gross vehicle weight rating (GVWR), gross axle weighting, or tire
        rating;

      

      (b) Structural
        integrity that mitigates or minimizes the adverse effects of collisions;
        and

      

      (c) Federal
        Motor Vehicle Safety Standards (FMVSS), 49 C.F.R. Part 571, Sections 102,
        103,
        104, 105, 108, 207, 209, 210, 217, 220, 221, 225, 302, 403, and 404, October
        1,
        2004, are hereby incorporated by reference. 

      

      
        	 	
                (2)

              	
                Proof
                  of strength and structural integrity tests on new vehicles procured
                  shall
                  be submitted by manufacturers or the Health Plan/Transportation
                  Providers
                  to the Department of Transportation. (See 14-90,
                  F.A.C.)

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan/Transportation Provider shall ensure that every vehicle
                  operated in the State in connection with this Contract shall be
                  equipped
                  as follows:

              

      

      

      (a) Mirrors
        -
        There must be at least two (2) exterior rear vision mirrors, one (1) at each
        side. The mirrors shall be firmly attached to the outside of the vehicle
        and so
        located as to reflect to the driver a view to the rear along both sides of
        the
        vehicle. 

      

      
        	 	
                i.

              	
                Each
                  exterior rear vision mirror, on Type I buses shall have a minimum
                  reflective surface of fifty (50) square inches and the right (curbside)
                  mirror shall be located on the bus so that the lowest part of the
                  mirror
                  and its mounting is a minimum eighty (80) inches above the ground.
                  All
                  Type I buses shall be equipped with an inside rear vision mirror
                  capable
                  of giving the driver a clear view of seated or standing passengers.
                  Buses
                  having a passenger exit door that is located inconveniently for
                  the
                  driver’s visual control shall be equipped with additional interior
                  mirror(s), enabling the driver to view the passenger exit door.
                  The
                  exterior right (curbside) rear vision mirror and its mounting on
                  Type I
                  buses may be located lower than 80 inches from the ground, provided
                  such
                  buses are used exclusively for paratransit services.  See
                  section 341.031, F.S. 

              

      

      

      
        	 	
                ii.

              	
                In
                  lieu of interior mirrors, trailer buses and articulated buses may
                  be
                  equipped with closed circuit video systems or adult monitors in
                  voice
                  control with the driver.

              

      

      

      (b) Wiring
        and Battery - Electrical wiring shall be maintained so as not to come in
        contact
        with moving parts, or heated surfaces, or be subject to chafing or abrasion
        which may cause insulation to become worn. 

      

      
        	 	
                i.

              	
                Every
                  Type I bus manufactured on or after February 7, 1988, shall be
                  equipped
                  with a storage battery(ies) electrical power main disconnect switch.
                  The
                  disconnect switch shall be practicably located in an accessible
                  location
                  adjacent to or near to the battery(ies) and be legibly and permanently
                  marked for identification. 

              

      

      

      
        	 	
                ii.

              	
                Every
                  storage battery on each public-sector bus shall be mounted with
                  proper
                  retainment devices in a compartment which provides adequate ventilation
                  and drainage.

              

      

      

      (c) Brake
        Interlock Systems - All Type I buses having a rear exit door shall be equipped
        with a rear exit door/brake interlock that automatically applies the brake(s)
        upon driver activation of the rear exit door to the open position. Interlock
        brake application shall remain activated until deactivation by the driver
        and
        the rear exit door returns to the closed position. The rear exit door interlock
        on such buses shall be equipped with an identified override switch enabling
        emergency release of the interlock function, which shall not be located within
        reach of the seated driver. Air pressure application to the brake(s) during
        interlock operation, on buses equipped with rear exit door/brake interlock,
        shall be regulated at the original equipment manufacturer’s
        specifications.

      

      
        	 	
                (4)

              	
                Standee
                  Line and Warning - Every vehicle designed and constructed to allow
                  standees shall be plainly marked with a line of contrasting color
                  at least
                  two (2) inches wide or be equipped with some other means to indicate
                  that
                  any passenger is prohibited from occupying a space forward of a
                  perpendicular plane drawn through the rear of the driver’s seat and
                  perpendicular to the longitudinal axis of the vehicle. A sign shall
                  be
                  posted at or near the front of the vehicle stating that it is a
                  violation
                  for a vehicle to be operated with passengers occupying an area
                  forward of
                  the line.

              

      

      

      
        	 	
                (5)

              	
                Handrails
                  and Stanchions - Every vehicle designed and constructed to allow
                  standees
                  shall be equipped with overhead grab rails for standee passengers.
                  Overhead grab rails shall be continuous, except for a gap at the
                  rear exit
                  door, and terminate into vertical stanchions or turn up into a
                  ceiling
                  fastener. 

              

      

      

      Every
        Type I and Type II bus designed for carrying more than sixteen (16) passengers
        shall be equipped with grab handles, stanchions, or bars at least ten (10)
        inches long and installed to permit safe on-board circulation, seating and
        standing assistance, and boarding and unloading by elderly and handicapped
        persons. Type I buses shall be equipped with a safety bar and panel directly
        behind each entry and exit stepwell.

      

      
        	 	
                (6)

              	
                Flooring,
                  Steps, and Thresholds - Flooring, steps, and thresholds on all
                  vehicles
                  shall have slip resistant surfaces without protruding or sharp
                  edges,
                  lips, or overhangs, to prevent tripping hazards. All step edges
                  and
                  thresholds shall have a band of color(s) running the full width
                  of the
                  step or edge which contrasts with the step tread and riser, either
                  light-on-dark or dark-on-light.

              

      

      

      
        	 	
                (7)

              	
                Doors
                  - Power activated doors on all vehicles shall be equipped with
                  a manual
                  device designed to release door closing
                  pressure.

              

      

      

      
        	 	
                (8)

              	
                Emergency
                  Exits - All vehicles shall have an emergency exit door, or in lieu
                  thereof, shall be provided with emergency escape push-out windows.
                  Each
                  emergency escape window shall be in a form of a parallelogram with
                  dimensions of not less than 18" by 24", and each shall contain
                  an area of
                  not less than 432 square inches. There shall be a sufficient number
                  of
                  such push-out or kick-out windows in each vehicle to provide a
                  total
                  escape area equivalent to 67 square inches per seat, including
                  the
                  driver’s seat.

              

      

      

      (a) No
        less
        than forty percent (40%) of the total escape area shall be on one (1) side
        of
        the vehicle. Emergency escape kick-out or push-out windows and emergency
        exit
        doors shall be conspicuously marked by a sign or light and shall always be
        kept
        in good working order so that they may be readily opened in an emergency.
        

      

      (b) All
        such
        windows and doors shall not be obstructed by bars or other such means located
        either inside or outside so as to hinder escape. Vehicles equipped with an
        auxiliary door for emergency exit shall be equipped with an audible alarm
        and
        light indicating to the driver when a door is ajar or opened while the engine
        is
        running. 

      

      (c) Supplemental
        security locks operable by a key are prohibited on emergency exit doors unless
        these security locks are equipped and connected with an ignition interlock
        system or an audio visual alarm located in the driver’s compartment. Any
        supplemental security lock system used on emergency exits shall be kept unlocked
        whenever a vehicle is in operation.

      

      
        	 	
                (9)

              	
                Tires
                  and Wheels - Tires shall be properly inflated in accordance with
                  manufacturer’s recommendations.

              

      

      

      (a) No
        vehicle shall be operated with a tread groove pattern depth:

      

      
        	 	
                i.

              	
                Less
                  than 4/32 (1/8) of an inch, measured at any point on a major tread
                  groove
                  for tires on the steering axle of all vehicles. The measurements
                  shall not
                  be made where tie bars, humps, or fillets are
                  located.

              

      

      

      
        	 	
                ii.

              	
                Less
                  than 2/32 (1/16) of an inch, measured at any point on a major tread
                  groove
                  for all other tires of all vehicles. The measurements shall not
                  be made
                  where tie bars, humps, or fillets are
                  located.

              

      

      

      (b) The
        Health Plan/Transportation Provider shall not operate any vehicle with recapped,
        regrooved, or retreaded tires on the steering axle.

      

      (c) The
        Health Plan/Transportation Provider shall ensure that all wheels are visibly
        free from cracks and distortion and shall not have missing, cracked, or broken
        mounting lugs.

      

      (10) Suspension
        - The suspension system of all vehicles, including springs, air bags, and
        all
        other suspension parts as applicable, shall be free from cracks, leaks, or
        any
        other defect which would or may cause its impairment or failure to function
        properly.

      

      (11) Steering
        and Front Axle - The steering system of all vehicles shall have no indication
        of
        leaks which would or may cause its impairment to function properly, and shall
        be
        free from cracks and excessive wear of components that would or may cause
        excessive free play or loose motion in the steering system or above normal
        effort in steering control.

      

      (12) Seat
        Belts - Every vehicle shall be equipped with an adjustable driver’s restraining
        belt in compliance with the requirements of FMVSS 209, “Seat Belt Assemblies”
(See 49 C.F.R. 571.209) and FMVSS 210, “Seat Belt Assembly Anchorages.” (See 49
        C.F.R. 571.210) 

      

      (13) Safety
        Equipment - Every vehicle shall be equipped with one (1) fully charged dry
        chemical or carbon dioxide fire extinguisher, having at least a 1A:BC rating
        and
        bearing the label of Underwriter’s Laboratory, Inc.

      

      (a) Each
        fire
        extinguisher shall be securely mounted on the vehicle in a conspicuous place
        or
        a clearly marked compartment and be readily accessible.

      

      (b) Each
        fire
        extinguisher shall be maintained in efficient operating condition and equipped
        with some means of determining if it is fully charged.

      

      (c) Every
        Type I bus shall be equipped with portable red reflector warning devices
        (See
        section 316.300, F.S.).

      

      (14) Vehicles
        used for the purpose of transporting individuals with disabilities shall
        meet
        the requirements set forth in 49 C.F.R. Part 38, hereby incorporated by
        reference, and the following:

      

      (a) Installation
        of a wheelchair lift or ramp shall not cause the manufacturer’s GVWR, gross axle
        weight rating, or tire rating to be exceeded.

      

      (b) Except
        in
        locations within 3 1/2 inches of the vehicle floor, all readily accessible
        exposed edges or other hazardous protrusions of parts of wheelchair lift
        assemblies or ramps that are located in the passenger compartment shall be
        padded with energy absorbing material to mitigate injury in normal use and
        in
        case of a collision. This requirement shall also apply to parts of the vehicle
        associated with the operation of the lift or ramp.

      

      (c) The
        controls for operating the lift shall be at a location where the driver or
        lift
        attendant has a full view, unobstructed by passengers, of the lift platform,
        its
        entrance and exit, and the wheelchair passenger, either directly or with
        partial
        assistance of mirrors. Lifts located entirely to the rear of the driver’s seat
        shall not be operable from the driver’s seat, but shall have an override control
        at the driver’s position that can be activated to prevent the lift from being
        operated by the other controls (except for emergency manual operation upon
        power
        failure).

      

      (d) The
        installation of the wheelchair lift or ramp and its controls and the method
        of
        attachment in the vehicle body or chassis shall not diminish the structural
        integrity of the vehicle nor cause a hazardous imbalance of the vehicle.
        No part
        of the assembly, when installed and stowed, shall extend laterally beyond
        the
        normal side contour of the vehicle or vertically beyond the lowest part of
        the
        rim of the wheel closest to the lift.

      

      (e) Each
        wheelchair lift or ramp assembly shall be legibly and permanently marked
        by the
        manufacturer or installer with the following minimum information:

      

      i. The
        manufacturer’s name and address;

      

      ii. The
        month
        and year of manufacture; and

      

      iii. A
        certificate that the wheelchair lift or ramp securement devices, and their
        installation, conform to State of Florida requirements applicable to accessible
        vehicles.

      

      (15) Wheelchair
        lifts, ramps, securement devices, and restraints shall be inspected and
        maintained as specified above. Instructions for normal and emergency operation
        of the lift or ramp shall be carried or displayed in every vehicle.

      

      m. Vehicle
        Safety Inspections

      

      
        	 	
                (1)

              	
                The
                  Health Plan/Transportation Provider shall require that all vehicles
                  be
                  inspected in accordance with the vehicle inspection procedures
                  set forth
                  above.

              

      

      

      
        	 	
                (2)

              	
                It
                  is the Health Plan’s/Transportation Provider’s responsibility to ensure
                  that each individual performing a vehicle safety inspection is
                  qualified
                  as follows:

              

      

      

      (a) Understands
        the requirements set forth in 14-90, F.A.C., 2004 and can identify defective
        components;

      

      (b) Is
        knowledgeable of, and has mastered the methods, procedures, tools, and equipment
        used when performing an inspection; and

      

      (c) Has
        at
        least one (1) year of training and/or experience as a mechanic or inspector
        in a
        vehicle maintenance program and has sufficient general knowledge of vehicles
        owned and operated by the Health Plan/Transportation Provider to recognize
        deficiencies or mechanical defects.

      

      
        	 	
                (3)

              	
                The
                  Health Plan/Transportation Provider shall ensure that each vehicle
                  receiving a safety inspection is checked for compliance with the
                  safety
                  devices and equipment requirements as referenced or specified above.
                  Specific operable equipment and devices include the
                  following:

              

      

      

      (a) Horn;

      

      (b) Windshield
        wipers;

      

      (c) Mirrors;

      

      (d) Wiring
        and battery(ies);

      

      (e) Service
        and parking brakes;

      

      (f) Warning
        devices;

      

      (g) Directional
        signals;

      

      (h) Hazard
        warning signals;

      

      (i) Lighting
        systems and signaling devices;

      

      (j) Handrails
        and stanchions;

      

      (k) Standee
        line and warning;

      

      (l) Doors
        and
        interlock devices;

      

      (m) Stepwells
        and flooring;

      

      (n) Emergency
        exits;

      

      (o) Tires
        and
        wheels;

      

      (p) Suspension
        system;

      

      (q) Steering
        system;

      

      (r) Exhaust
        system;

      

      (s) Seat
        belts; 

      

      (t) Safety
        equipment; and

      

      (u) Equipment
        for transporting wheelchairs.

      

      
        	 	
                (4)

              	
                A
                  safety inspection report shall be prepared by the individual(s)
                  performing
                  the inspection and shall include the
                  following:

              

      

      

      (a) Identification
        of the individual(s) performing the inspection;

      

      (b) Identification
        of the Health Plan/Transportation Provider operating the vehicle;

      

      (c) The
        date
        of the inspection;

      

      (d) Identification
        of the vehicle inspected;

      

      (e) Identification
        of the equipment and devices inspected including the identification of equipment
        and devices found deficient or defective; and

      

      (f) Identification
        of corrective action(s) for deficient or defective items and date(s) of
        completion of corrective action(s).

      

      
        	 	
                (5)

              	
                Records
                  of annual safety inspections and documentation of any required
                  corrective
                  actions shall be retained, for compliance review, a minimum of
                  five (5)
                  years by the Health Plan/Transportation
                  Provider.

              

      

      

      n. Certification
        - Each Health Plan/Transportation Provider shall submit an annual safety
        and
        security certification in accordance with 14-90.10, F.A.C., 2004 and shall
        submit to any and all safety and security inspections and reviews in accordance
        with 14-90.12, F.A.C., 2004.

      

      o. The
        Health Plan shall report the following by August 15th of each year:

      

      
        	 	
                (1)

              	
                The
                  estimated number of one-way passenger trips to be provided in the
                  following categories, as defined in the Transportation
                  Handbook:

              

      

      

      (a) Ambulatory
        Transportation;

      

      (b) Long
        haul
        ambulatory Transportation;

      

      (c) Wheelchair
        Transportation;

      

      (d) Stretcher
        Transportation;

      

      (e) Ambulatory
        multiload Transportation;

      

      (f) Wheelchair
        multiload Transportation;

      

      (g) Mass
        transit pending Transportation;

      

      (h) Mass
        transit Transportation;

      

      (i) Mass
        transit Transportation (Enrollee has pass); and

      

      (j) Mass
        transit Transportation (sent pass to Enrollee).

      

      
        	 	
                (2)

              	
                The
                  actual amount of funds expended and the total number of trips provided
                  during the previous fiscal year;
                  and

              

      

      

      
        	 	
                (3)

              	
                The
                  operating financial statistics for the previous fiscal
                  year.

              

      

      

      p. The
        Health Plan shall provide the total number of vehicles in each category,
        other
        than public Transportation, that will serve each county as well as a provider
        directory for all Transportation Services.

      

      

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      Section
        VI

      Behavioral
        Health Care

      

      
        	A.	
                 General
                  Provisions

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall provide Medically Necessary Behavioral Health
                  Services
                  for all Enrollees pursuant to this Contract. The Health Plan shall
                  provide
                  a full range of Behavioral Health Services authorized under the
                  State Plan
                  and specified by this Contract. 

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall provide the following services as described in
                  the
                  Hospital Inpatient Handbook, Mental Health Targeted Case Management
                  Coverage & Limitations Handbook, and the Community Behavioral Health
                  Services Coverage & Limitations Handbook (the Handbooks). The Health
                  Plan shall not alter the amount, duration and scope of such services
                  from
                  that specified in the Handbooks. The Health Plan shall not establish
                  service limitations that are lower than, or inconsistent with the
                  Handbooks. 

              

      

      

      
        	 	
                a.

              	
                Inpatient
                  hospital care for psychiatric conditions (ICD-9-CM codes 290 through
                  290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through
                  312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                  315.9);

              

      

      

      
        	 	
                b.

              	
                Outpatient
                  hospital care for psychiatric conditions (ICD-9-CM codes 290 through
                  290.43, 293 through 298.9, 300 through 301.9, 302.7, 306.51 through
                  312.4
                  and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                  315.9);

              

      

      

      
        	 	
                c.

              	
                Psychiatric
                  physician services (for psychiatric specialty codes 42, 43, 44
                  and
                  ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through
                  301.9,
                  302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31,
                  315.5, 315.8, and 315.9);

              

      

      

      
        	 	
                d.

              	
                Community
                  mental health services (ICD-9-CM codes 290 through 290.43, 293.0
                  through
                  298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and 312.81
                  through
                  314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these procedure
                  codes H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN;
                  H0031TS;
                  H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO;
                  H2010HE;
                  H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
                  H2019HO;
                  H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
                  T1023HE;
                  or T1023HF.

              

      

      

      
        	 	
                e.

              	
                Mental
                  Health Targeted Case Management (Children: T1017HA; Adults: T1017);
                  and

              

      

      

      
        	 	
                f.

              	
                Mental
                  Health Intensive Targeted Case Management (Adults:
                  T1017HK).

              

      

      

      3. Non
        Covered Services

      

      The
        following services are not covered by the Health Plan. Should the Health
        Plan
        determine the need for, or be advised of the need for, these or other services
        not customarily covered by the Health Plan, the Health Plan shall refer the
        Enrollee to the appropriate provider:

      

      
        	 	
                a.

              	
                Specialized
                  Therapeutic Foster Care;

              

      

      

      
        	 	
                b.

              	
                Therapeutic
                  Group Care Services;

              

      

      

      
        	 	
                c.

              	
                Behavioral
                  Health Overlay Services; 

              

      

      

      
        	 	
                d.

              	
                Community
                  Substance Abuse Services, except as required by this Contract;
                  

              

      

      

      
        	 	
                e.

              	
                Residential
                  Care;

              

      

      

      
        	 	
                f.

              	
                Sub-acute
                  Inpatient Psychiatric Program (SIPP) Services;

              

      

      

      
        	 	
                g.

              	
                Clubhouse
                  Services.

              

      

      

      
        	 	
                h.

              	
                Comprehensive
                  Behavioral Assessment, and 

              

      

      

      
        	 	
                i.

              	
                Florida
                  Assertive Community Treatment Services (FACT)

              

      

      
        	 	 	 

      

      
        	 	 	
                The
                  PSN shall NOT be responsible for the provision of mental health
                  services
                  to enrollees assigned to a FACT team by the DCF Substance Abuse
                  and Mental
                  Health Program (SAMH) Office. These individuals will be disenrolled
                  from
                  the plan and receive all mental health services through the funding
                  mechanism developed by DCF/SAMH and AHCA and re-enrolled in the
                  plan upon
                  discharge from the FACT Team Services. The FACT Team providers
                  are
                  responsible for notifying Medicaid of admissions and
                  discharges

              

      

      

      4. The
        Health Plan shall provide Outpatient Medical Services in accordance with
        Section
        V, Covered Services, of this Contract. 

      

      5. If
        an
        Enrollee makes a request for services to the Health Plan, the Health Plan
        shall
        provide the Enrollee with the name (or names) of qualified Behavioral Health
        Care Providers, and if requested, assist the Enrollee with making an appointment
        with the Provider that is within the required access times indicated in Section
        VII.D., Appointment Waiting Times and Geographic Access Standards, and Section
        VII.E., Behavioral Health Services.

      

      6. Services
        available under the Health Plan shall represent a comprehensive range of
        appropriate services for both Children/Adolescents and adults who experience
        impairments ranging from mild to severe and persistent. This Section outlines
        the Agency’s expectations and requirements related to each of the categories of
        service. 

       

      Optional
        services may be provided and are defined as additional services that will
        enhance the services mandated in the contract. A list of possible optional
        services is included in the Additional Service Requirements section as an
        example of services that may be beneficial for plan enrollees. Optional services
        may be provided under the Contract as a downward substitution of care. When
        a
        service is intended to be provided as a downward substitution, the provider
        must
        use clinical rationale for determining the benefit of the service for the
        enrollee.

      

      

      REMAINDER
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        	B.
                 	 Expanded
                Services

      

      
        	 	
                1.

              	
                Inpatient
                  Hospital Services

              

      

      

      Inpatient
        Hospital services are medically necessary mental health care services provided
        in a hospital setting (see Section V.B.8, Covered Services, Hospital Services
        -
        Inpatient, in this Contract). Services may be provided in a general Hospital
        psychiatric unit or in a specialty Hospital. The inpatient care and treatment
        services that an Enrollee receives must be under the direction of a licensed
        physician with the appropriate Medicaid specialty requirements.

      

      a. A
        hospital’s per diem (daily rate) for inpatient mental health hospital care and
        treatment covers all services and items furnished during a 24-hour period.
        The
        facilities, supplies, appliances, and equipment furnished by the hospital
        during
        the inpatient stay are included in the per diem as well as the related nursing,
        social, and other services furnished by the hospital during the inpatient
        stay.

      

      b.
         For
        all
        Child/Adolescent Enrollees, the Health Plan shall be responsible for the
        provision of up to 365 days of mental health-related Hospital inpatient care
        for
        each year.

      

      c.
         For
        all
        Enrollees, the Health Plan shall pay for inpatient mental health-related
        Hospital days determined Medically Necessary by the Health Plan’s medical
        director or designee, up to the maximum number of days required under the
        Contract. 

      

      d. If
        an
        Enrollee is admitted to a Hospital for a non-psychiatric diagnosis and during
        the same hospitalization transfers to a psychiatric unit or the treatment
        of a
        psychiatric diagnosis, the Health Plan is at risk for the Medically Necessary
        mental health treatment inpatient days up to the maximum number of days required
        under the Contract.

      

      e. The
        Health Plan shall be responsible to cover the cost of all Enrollees’ Medically
        Necessary stays resulting from a mental health emergency, until such time
        as
        Enrollees can be safely transported to a designated facility.

      

      f. Crisis
        Stabilization Units may be used as a downward substitution for inpatient
        psychiatric hospital care when determined medically appropriate. These bed
        days
        are included toward the 45-day coverage count discussed above in A.1. They
        are
        calculated on a two for one basis. Two CSU days count toward one inpatient
        day.
        Beds funded by the Department of Children and Families, Substance Abuse and
        Mental Health (SAMH) cannot be used for Enrollees if there are non-funded
        clients in need of the beds. If CSU beds are at capacity, and some of the
        beds
        are occupied by Enrollees, and a non-funded client presents in need of services,
        the Enrollees must be transferred to an appropriate facility to allow the
        admission of the non-funded client. Therefore, the Health Plan must demonstrate
        adequate capacity for inpatient hospital care in anticipation of such
        transfers.

      

      
        	 	
                2.

              	
                Outpatient
                  Hospital Services

              

      

      

      Outpatient
        Hospital services are Medically Necessary mental health care services provided
        in a hospital setting. The outpatient care and treatment services that an
        Enrollee receives must be under the direction of a licensed physician with
        the
        appropriate specialty.. 

       

      
        	 	
                3.

              	
                Physician
                  Services

              

      

      

      a. Physician
        services are those services rendered by a licensed physician who possesses
        the
        appropriate Medicaid specialty requirements when applicable. A psychiatrist
        must
        be certified as a psychiatrist by the American Board of Psychiatry and Neurology
        or the American Osteopathic Board of Neurology and Psychiatry, or have completed
        a psychiatry residency accredited by the Accreditation Council for Graduate
        Medical Education (ACGME) or the Royal College of Physicians and Surgeons
        of
        Canada.

      

      b. Physician
        services include specialty consultations for evaluations. A physician
        consultation shall include an examination and evaluation of the Enrollee
        with
        information from family member(s) or significant others as appropriate. The
        consultation shall include written documentation on an exchange of information
        with the attending Provider. The components of the evaluation and management
        procedure code and diagnosis code must be documented in the Enrollee's medical
        record. A Hospital visit to an Enrollee in an acute care Hospital for a mental
        health diagnosis must be documented with a mental health procedure code and
        mental health diagnosis code. All procedures with a minimum time requirement
        shall be documented in the medical record to show the time spent providing
        the
        service to the Enrollee. The Health Plan must be responsive to requests for
        consultations made by the PCP.

      

      c. Physicians
        are required to coordinate Medically Necessary mental health care with the
        PCP
        and other Providers involved with the care of the Enrollee. The Health Plan
        shall have a set of protocols that indicate when such coordination will be
        required.

      

      
        	 	
                4.

              	
                Community
                  Mental Health Services - Covered
                  Services

              

      

      

      a. General
        Provisions

       

      Community
        mental health services include mental health services that are provided for
        the
        maximum reduction of the Enrollee’s mental health disability and restoration to
        the best possible functional level. Community mental health services can
        reasonably be expected to improve the Enrollee’s condition or prevent further
        regression so that the services will no longer be needed. The health plan
        must
        provide services that are medically necessary and are rendered or recommended
        by
        a physician, psychiatrist, or licensed mental health professional and included
        in an individualized treatment plan. Medically Necessary community mental
        health
        services must be provided to Enrollees of all ages from very young children
        through the geriatric population. Provision of services very early may reduce
        the provision of expensive services later, and the health plan is encouraged
        to
        use creativity, flexibility, and outreach to provide mental health services
        to
        its enrollees. Services should be age appropriate and sensitive to the
        developmental level of the enrollee.

      

      The
        services provided must meet the intent of the services covered in the Florida
        Medicaid Community Mental Health Services Coverage and Limitations Handbook.
        Although the Health Plan can provide flexible services, the service limits
        and
        medical necessity criteria cannot be more restrictive than those in Medicaid
        policy as stated in Medicaid handbooks and this Contract. Additionally, the
        Health Plan may have available additional services, but must have the core
        services available as outlined and discussed below.

      

      The
        health plan shall establish “Medical Necessity” criteria, including admission
        criteria, continuing stay criteria, and discharge criteria for all mandatory
        and
        optional services. Criteria must be specific to enrollee ages and diagnoses
        and
        must account for orders for involuntary outpatient placement pursuant to
        394.4655, F.S. These criteria must be submitted for review by the Agency
        and
        approval.

      

      The
        following describes basic categories of mental health care services considered
        core services. The frequency, duration, and content of the services should
        be
        consistent with the age, developmental level and level of functioning of
        the
        enrollee. The health plan shall develop clinical care criteria appropriate
        for
        each service to be provided. The health plan shall consult the most recent
        the
        Community Behavioral Health Services Coverage and Limitations Handbook published
        by the Agency.

      

      b. Treatment
        Plan Development and Modification

      

      Treatment
        planning includes working with the Enrollee, their natural support system,
        and
        all involved treating Providers to develop an individualized plan for addressing
        identified clinical needs. A Behavioral Health Care Provider must complete
        a
        face-to-face interview with the Enrollee during the development of the plan.
        

      

      The
        Individualized Treatment Plan shall:

      

      •
be
        recovery-oriented and promote resiliency;

      •
be
        enrollee-directed;

      •
        accurately reflect the presenting problems of the enrollee;

      •
be
        based on the strengths of the enrollee, family, and other natural support
        systems;

      •
provide
        outcome-oriented objectives for the enrollee;

      •
include
        an outcome-oriented schedule of services that will be provided to meet
the
        enrollee’s needs;

      •
include
        the coordination of services not covered by the plan such as school- based
        services, vocational rehabilitation, housing supports, Medicaid fee-for service
        substance abuse treatment, and physical health care.

      

        Individualized
        Treatment Plan reviews shall be conducted at six-month intervals to assure
        that
        the services being provided are effective and remain appropriate for addressing
        individual needs. Additionally, a review is expected whenever clinically
        significant events occur. The provider is expected to use the Individualized
        Treatment Plan review process in the utilization management of medically
        necessary services. For further guidance see the most recent Community
        Behavioral Health Services and Coverage Handbook.

      

      c. 
        Assessment Services 

      

      
        	 	
                (1)
                  

              	
                These
                  services include psychological testing (standardized tests) and
                  evaluations that assess the enrollee’s functioning in all areas. All
                  evaluations must be appropriate to the age, developmental level
                  and
                  functioning of the enrollee. All evaluations must include a clinical
                  summary that integrates all the information gathered and identifies
                  enrollee’s needs. The evaluation should prioritize the clinical needs,
                  evaluate the effectiveness of any prior treatment, and include
                  recommendations for interventions and services to be
                  provided.

              

      

      

      (2)
        Evaluation or assessment services, when determined medically necessary, must
        include assessment of mental status, functional capacity, strengths, and
        service
        needs by trained mental health staff. Also included in this category is the
        administration of the functional assessments that are required by the Agency,
        DCF, the EQRO, or academic research center.

      

      (3)
        Prior
        to receiving any community mental health services, children ages 0-5 must
        have a
        current assessment (within one year) of presenting symptoms and behaviors;
        developmental and medical history; family psychosocial and medical history;
        assessment of family functioning; a clinical interview with the primary
        caretaker and an observation of the child’s interaction with the caretaker; and
        an observation of the child’s language, cognitive, sensory, motor, self-care,
        and social functioning.

      

      
        	 	
                d.

              	
                Medical
                  and Psychiatric Services

              

      

      

      (1) These
        services include Medically Necessary interventions that require the skills
        and
        expertise of a psychiatrist, psychiatric ARNP, or physician.

      

      (2) Medical
        psychiatric interventions include the prescribing and management of medications,
        monitoring of side effects associated with prescribed medications, individual
        or
        group medical psychotherapy, psychiatric evaluation, psychiatric review of
        treatment records for diagnostic purposes, and psychiatric consultation with
        an
        enrollee’s family or significant others, primary care providers, and other
        treatment providers.

      

      (3)
        Interventions related to specimen collections, taking vital signs and
        administering injections are also a covered service. 

      

      (4)
        These
        services are distinguished from the physician services outlined in Section
        C in
        that they are provided through a community mental health center. Psychiatric
        or
        physician services must be available at sites where substantial amounts of
        community mental health services are provided.

      

      
        	 	
                e.

              	
                Behavioral
                  Health Therapy Services:

              

      

      

      (1) These
        services include individual and family therapy, group therapy, and behavioral
        health day services. These services include psychotherapy or supportive
        counseling focused on assisting enrollees with the problems or symptoms
        identified in an assessment. The focus should be on identifying and utilizing
        the strengths of the enrollee, family, and other natural support systems.
        Therapy services should be geared to the individual needs of the enrollee
        and
        should be sensitive to the age, developmental level, and functional level
        of the
        enrollee.

      

      (2)
        Family or marital therapy is also included in this category. Examples of
        interventions include those that focus on resolution of a life crisis or
        an
        adjustment reaction to an external stressor or developmental
        challenge.

      

      (3)
        Behavioral Day Services are designed to enable individuals to function
        successfully in the community in the least restrictive environment and to
        restore or enhance ability for social and prevocational life management
        services. The primary functions of behavioral health day services are
        stabilization of the symptoms related to a behavioral health disorder to
        reduce
        or eliminate the need for more intensive levels of care, to provide transitional
        treatment after an acute episode, or to provide a level of therapeutic intensity
        not possible in a traditional outpatient setting.

      

      

      
        	 	
                f.

              	
                Community
                  Support and Rehabilitative
                  Services

              

      

      

      (1) These
        services include: Psychosocial Rehabilitation Services and Clubhouse services.
        Clubhouse services are excluded from the health plan’s covered services.
        Psychosocial rehabilitation services may be provided in a facility, home,
        or
        community setting. These services assist enrollees in functioning within
        the
        limits of a disability or disabilities resulting from a mental illness. Services
        focus on restoration of a previous level of functioning or improving the
        level
        of functioning. Services must be individualized and directly related to goals
        for improving functioning within a major life domain.

      

      (2)
        The
        coverage must include a range of social, educational, vocational, behavioral,
        and cognitive interventions to improve enrollees’ potential for social
        relationships, occupational/educational achievement and living skills
        development. Skills training development is also included in this category
        and
        includes activities aimed toward restoration of enrollees’ skills/abilities that
        are essential for managing their illness, actively participating in treatment,
        and conducting the requirements of daily independent living. Providers must
        offer the services in a setting best suited for desired outcomes, i.e., home
        or
        community-based settings.

      

      (3)
        Psychosocial Rehabilitative Services may also be provided to assist individuals
        in finding or maintaining appropriate housing arrangements or to maintain
        employment. Interventions should focus on the restoration of skills/abilities
        that are adversely affected by the mental health illness and supports required
        to manage the individual’s housing or employment needs. The provider must be
        knowledgeable about the local TANF initiative and is responsible for medically
        necessary mental health services that will assist the individual in finding
        and
        maintaining employment.

      

      

      
        	 	
                g.
                  

              	
                Therapeutic
                  Behavioral On-Site Services for Children and Adolescents
                  (TBOS):

              

      

      

      
        	 	 	
                Therapeutic
                  Behavioral On-Site Services are community services and natural
                  supports
                  for children with serious emotional disturbances. Clinical services
                  include the provision of a professional level therapeutic service
                  that may
                  include the teaching of problem solving skills, behavioral strategies,
                  normalization activities and other treatment modalities that are
                  determined to be medically necessary. These services should be
                  designed to
                  maximize strengths and reduce behavior problems or functional deficits
                  stemming from the existence of a mental health disorder. Social
                  services
                  include interventions designed for the restoration, modification,
                  and
                  maintenance of social, personal adjustment and basic living
                  skills.

              

      

      

      
        	 	
                 

              	
                These
                  services are intended to maintain the child in the home and to
                  prevent
                  reliance upon a more intensive, restrictive, and costly mental
                  health
                  placement. They are also focused on helping the child possess the
                  physical, emotional, and intellectual skills to live, learn and
                  work in
                  their own communities. Coverage must include the provision of these
                  services outside of the traditional office setting. The services
                  must be
                  provided where they are needed, in the home, school, childcare
                  centers or
                  other community sites.

              

      

      

      h. 
        Services for Children Ages 0 through 5-Years 

       

      Services
        to these children include behavioral health day services and Therapeutic
        Behavioral On-Site Services for Children Ages 0 through 5 years.

      

      Prior
        to
        receiving these services, the children in this age group must meet the criteria
        as stated in the Medicaid Community Behavioral Health Service Coverage and
        Limitations Handbook.

      

      i. Crisis
        Intervention Mental Health Services and Post-Stabilization Care Services
        

      

        Crisis
        intervention services include intervention activities of less than 24-hour
        duration (within a 24-hour period) designed to stabilize an individual in
        a
        Psychiatric emergency.

      

      Post-stabilization
        care services include any of the mandatory services that a treating physician
        views as medically necessary, that are provided after an enrollee is stabilized
        from an emergency mental health condition in order to maintain the stabilized
        condition, or under the circumstances described in 42 CFR 438.114(e) to improve
        or resolve the enrollee’s condition.

      

      j. Substance
        Abuse Services 

      

      Health
        plan Enrollees will receive Medicaid funded substance abuse services through
        the
        fee-for- service system. The health plan shall develop methods of coordinating
        and integrating mental health and substance abuse services for plan enrollees.
        The plan shall be required to use the Florida Supplement to the American
        Society
        of Addictions Medicine Patient Placement Criteria for the coordination of
        mental
        health treatment with substance abuse providers as part of the integration
        effort (Second Edition ASAM PPC-2, July 1998.) the coordination shall be
        reflected in their individualized Treatment Plan for enrollees with co-occurring
        disorder. The protocol for integrating mental health services with substance
        abuse services shall be monitored through the Quality of Care monitoring
        activities completed by the Agency’s EQRO contractor and the Quality Improvement
        requirements in Section D.34

      

      

      
        	 	
                5.

              	
                Mental
                  Health Targeted Case
                  Management

              

      

      

      a. The
        Health Plan must provide targeted Case Management services to
        Children/Adolescents with serious emotional disturbances and adults with
        a
        severe mental illness as defined below. The Health Plan shall meet the intent
        of
        the services as outlined below and in the Medicaid Mental Health Targeted
        Case
        Management Coverage and Limitations Handbook. The Health Plan shall set criteria
        and clinical guidelines for Case Management services. Service limits and
        criteria developed cannot be more restrictive than those in Medicaid policy
        and
        as stated below.

      

      At
        a
        minimum, case management services are to incorporate the principles of a
        strengths-based approach. Strengths-based case management services are an
        alternative service modality for working with individuals and families. This
        method stresses building on the strengths of individuals that can be used
        to
        resolve current problems and issues, countering more traditional approaches
        that
        focus almost exclusively on individuals’ deficits or needs.

      

      b. Target
        Populations: 

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall have Case Management services available to
                  Children/Adolescents who have a serious emotional disturbance as
                  defined
                  as: a Child/Adolescent with a defined mental disorder; a level
                  of
                  functioning which requires two or more coordinated mental health
                  services
                  to be able to live in the community; and be at imminent risk of
                  out of
                  home mental health treatment
                  placement.

              

      

      

      
        	 	
                (2)

              	
                The
                  health plan must have case management services available for adults
                  who:

              

      

      

      •
         Have
        been
        denied admission to a long-term mental health institution or residential
        treatment facility; or

      •
         Have
        been
        discharged from a long-term mental health institution or residential treatment
        facility.

      •
         Require
        numerous services from different providers and also require advocacy and
        coordination to implement or access services;

      •
         Would
        be
        unable to access or maintain consistent care within the service delivery
        system
        without case management services;

      •
         Do
        not
        possess the strengths, skills, or support system to allow them to access
        or
        coordinate services; The health plan will not be required to seek approval
        from
        the Department of Children and Families, District Substance Abuse and Mental
        Health (SAMH) Office for individual eligibility or mental health targeted
        case
        management agency or individual provider certification. The staffing
        requirements for case management services are listed below. Refer to section
        d.
        Additional Requirement For Case Management.

      

      
        	 	
                (3)

              	
                Mental
                  health targeted Case Management services shall be available to
                  all
                  Enrollees within the principles and guidelines described as
                  follows:

              

      

      

      (a) Enrollees,
        who require numerous services from different providers and also require advocacy
        and coordination to implement or access services are appropriate for Case
        Management services;

      

      (b) Enrollees
        who would be unable to access or maintain consistent care within the service
        delivery system without Case Management services are appropriate for the
        service;

      

      (c) Enrollees
        who do not possess the strengths, skills, or support system to allow them
        to
        access or coordinate services are appropriate for Case Management
        services;

      

      (d) Enrollees
        without the skills or knowledge necessary to access services may benefit
        from
        Case Management. Case Management provides support in gaining skills and
        knowledge needed to access services and enhances the Enrollee’s level of
        independence.

      

      
        	 	
                (4)

              	
                The
                  Health Plan will not be required to seek approval from the DCF,
                  District
                  Substance Abuse and Mental Health Program Office for client eligibility
                  or
                  mental health targeted Case Management agency or individual provider
                  certification. The staffing requirements for Case Management services
                  are
                  found in Section VII.E..7, Provider Network, Behavioral Health
                  Services,
                  in this Contract. 

              

      

       

      c. Required
        Mental Health Targeted Case Management Services 

      

      
        	 	
                (1)

              	
                Mental
                  Health Targeted Case Management services include working with the
                  Enrollee
                  and the Enrollee’s natural support system to develop and promote a needs
                  assessment-based service plan. The service plan reflects the services
                  or
                  supports needed to meet the needs identified in an individualized
                  assessment of the following areas: education or employment, physical
                  health, mental health, substance abuse, social skills, independent
                  living
                  skills, and support system status. The approach used should identify
                  and
                  utilize the strengths, abilities, cultural characteristics, and
                  informal
                  supports of the enrollee, family, and other natural support systems.
                  Targeted case managers focus on overcoming barriers by collaborating
                  and
                  coordinating with Providers and the Enrollee to assist in the attainment
                  of service plan goals. The targeted case manager takes the lead
                  in both
                  coordinating services/treatment and assessing the effectiveness
                  of the
                  services provided. A strengths-based approach to providing services
                  is
                  consistent with the values of individuality and uniqueness and
                  promotes
                  participant self-direction and choice. The planning process is
                  vital to
                  achieving desired outcomes for the individual. The person must
                  have a
                  sense of ownership about his/her goals, and the goals must have
                  true
                  meaning and vitality for him/her. 

              

      

      

      
        	 	
                (2)

              	
                When
                  targeted case management recipients enrolled in the health plan
                  are
                  hospitalized in an acute care setting or held in a county jail
                  or juvenile
                  detention facility, the health plan shall maintain contact with
                  the
                  individual and shall participate actively in the discharge planning
                  processes.

              

      

      

      
        	 	
                (3)

              	
                Case
                  managers are also responsible for coordination and collaboration
                  with the
                  parents or guardians of Children/Adolescents who receive mental
                  health
                  targeted Case Management services. The Health Plan shall make reasonable
                  efforts to assure that case managers include the parents or guardians
                  of
                  Enrollees in the process of providing targeted Case Management
                  services.
                  Integration of the parent’s input and involvement with the case manager
                  and other Providers shall be reflected in Medical Record documentation
                  and
                  monitored through the Health Plan’s quality of care monitoring activities.
                  Involvement with the child’s school and/or childcare center must also be a
                  component of case management with
                  children

              

      

      

      d. Additional
        Requirements for Targeted Case Management

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall have a Case Management program, including clinical
                  guidelines and protocol that addresses the issues
                  below:

              

      

      

      (a) Caseloads
        must be set to achieve the desired results. Size limitations must clearly
        state
        the ratio of enrollees to each individual case manager. The limits shall
        be
        specified for children and adults, with a description of the clinical rationale
        for determining each limitation. If the health plan permits “mixed” caseloads,
        i.e., children and adults, a separate limitation is expected along with the
        rationale for the determination. Ratios must be no greater than the requirements
        set forth in the Medicaid Mental Health Targeted Case Management Coverage
        and
        Limitations Handbook.

      

      (b) A
        system
        shall be in place to manage caseloads when positions become vacant.

      

      (c) The
        modality of service provision, and the location that services will be provided,
        shall be described.

      

      (d) Case
        Management protocol and clinical practice guidelines, which outline the expected
        frequency, duration and intensity of the service, shall be
        available.

      

      (e) Clinical
        guidelines shall address issues related to recovery and self-care, including
        services that will assist Enrollees in gaining independence from the mental
        health and Case Management system.

      

      
        	 	
                (2)

              	
                The
                  Case Management program shall have services available based on
                  the
                  individual needs of the Enrollees receiving the service. The service
                  should reflect a flexible system that allows movement within a
                  continuum
                  of care that addresses the changing needs and abilities of
                  Enrollees.

              

      

      

      (a) Case
        management staff must have expertise and training necessary to competently
        and
        promptly assist enrollees in working with Social Security Administration
        or
        Disability Determination in maintaining benefits from SSI and SSDI. For clients
        who wish to work, case management staff must have the expertise and training
        necessary to assist enrollees to access Social Security Work Incentives
        including development of Plans for Achieving Self-Support (PASS).

      

      (b) At
        a
        minimum, case management services are to incorporate the principles of a
        strengths-based approach. Strengths-based case management services are a
        preferred service modality for work with individuals and families. This method
        stresses building on the strengths of individuals and families that can be
        used
        to resolve current problems and issues. This approach counters more traditional
        approaches that focus almost exclusively on individuals’ deficits or needs.
        Service limits and criteria developed cannot be more restrictive than those
        in
        Medicaid policy.

      

      
        	 	
                6.

              	
                Intensive
                  Case Management

              

      

      

      a. Intensive
        Case Management is intended to provide intensive team Case Management to
        highly
        recidivistic adults who have a severe and persistent mental illness. The
        service
        is intended to help Enrollees remain in the community and avoid institutional
        care. Clinical care criteria for this level of Case Management shall address
        the
        same elements required above, as well as expanded elements related to access
        and
        twenty-four (24) hour coverage as described below. Additionally, the intensive
        Case Management team composition shall be expanded to include members of
        the
        team selected specifically to assist with the special needs of this population.
        The Health Plan shall include the team composition and how it will assist
        with
        special needs in the description of how this service will be
        provided.

      

      b. The
        Health Plan shall provide this service for all Enrollees for whom the service
        is
        determined to be Medically Necessary, to include enrollees who meet the
        following criteria:

      

      	·  	
              Has
                resided in a state mental health treatment facility for at least
                6 months
                in the past 36 months;

            

      	·  	
              Resides
                in the community and has had two or more admissions to a state mental
                health treatment facility in the past 36
                months;

            

      	·  	
              Resides
                in the community and has had three or more admissions to a crisis
                stabilization unit, short-term residential facility, inpatient psychiatric
                unit, or any combination of these facilities within the past 12 months;
                or

            

      	·  	
              Resides
                in the community and, due to a mental illness, exhibits behavior
                or
                symptoms that could result in long-term hospitalization if frequent
                interventions for an extended period of time were not
                provided.

            

      

      c. Intensive
        Case Management provides services through the use of a team of case managers.
        The team can be expanded to include other specialists that are qualified
        to
        address identified needs of the Enrollees receiving intensive Case Management.
        This level of care for Case Management is the most intensive and serves
        Enrollees with the most severe and disabling mental conditions. Services
        are
        frequent and intense with a focus on assisting the Enrollee with attaining
        the
        skills and supports needed to gain independent living skills. Intensive Case
        Management services are provided primarily in the Enrollee’s residence and
        include community-based interventions.

      

      d. The
        Health Plan shall provide this service in the least restrictive setting with
        the
        goal of improving the Enrollee’s level of functioning, and providing ample
        opportunities for rehabilitation, recovery, and self-sufficiency. Intensive
        Case
        Management services shall be accessible twenty-four (24) hours per day, seven
        (7) days per week. The Health Plan shall demonstrate adequate capacity to
        provide this service for the targeted population within the guidelines
        outlined.

      

      e. Intensive
        Case Management teams shall provide the same coordination and Case Management
        services for Enrollees admitted to inpatient facilities, State mental Hospitals,
        and forensic or corrections facilities as those listed above for mental health
        targeted case management services.

      

      7. Community
        Treatment of Patients Discharged from State Mental Health Hospitals

      

      a.  The
        health plan shall provide Medically Necessary Behavioral Health Services
        to
        Enrollees who have been discharged from any State mental Hospital, including,
        but not limited to, follow-up services and care. All Enrollees who have
        previously received services at the State mental Hospital must receive follow
        up
        and care.

      

      The
        plan
        of care shall be aimed at encouraging Enrollees to achieve a high quality
        of
        life while living in the community in the least restrictive environment that
        is
        medically appropriate and reducing the likelihood that the Enrollees will
        be
        readmitted to a State mental Hospital.

      

      b.
         The
        health plan shall follow the progress of all Enrollees who were enrolled
        in the
        health plan to admission to a State mental Hospital until the one
        hundred-eightieth (180th) day after Disenrollment from the health plan shall
        use
        behavioral health targeted case managers to follow the progress of Enrollees.
        The behavioral health targeted case manager must attend and participate in
        the
        discharge planning activities at the facility. Targeted case managers are
        responsible for working with the former Enrollee before discharge from the
        State
        facility to assure that Benefits are reinstated as soon as possible, and
        that
        the Enrollee receives community Behavioral Health Services within twenty-four
        (24) hours of his/her discharge from the State facility.

      

      c.
         
        If the
        Enrollee remains in the State facility more than one hundred eighty (180)
        days
        after Disenrollment, the health plan shall cooperate with DCF and the Enrollee
        to ensure that the Enrollee is assigned a DCF funded Case Management provider
        who will bear the responsibility of ongoing monthly follow-up care and discharge
        planning until such time that the Enrollee is again eligible for and enrolled
        in
        a Health plan.

      

      d. The
        health plan shall develop a cooperative agreement with the behavioral health
        care facility to enable the health plan to anticipate those Medicaid Recipients
        who were Enrollees of the health plan prior to admission to the Facility,
        and
        will be soon discharged from the Facility. The cooperative agreement must
        address arrangements for Medicaid Recipients, whom the Facility is discharging,
        but who are not eligible for immediate re-enrollment.

      

      
        	 	
                8.

              	
                Community
                  Services for Enrollees Involved with the Criminal Justice
                  System

              

      

      

      The
        Health Plan shall provide medically necessary community-based services for
        plan
        enrollees who have criminal justice system involvement as follows:

      

      a. Establish
        a linkage to pre-booking sites for assessment, screening or diversion related
        to
        mental health services;

      

      b. Provide
        immediate access (within 24 hours of release) for psychiatric services upon
        release from a jail or a juvenile
        detention facility to assure that prescribed medications are available for
        all
        health plan enrollees; and

      

      c. Establish
        a linkage to post-booking sites for discharge planning and assuring that
        prior
        health plan Enrollees receive necessary services upon release from the facility.
        Health plan Enrollees must be linked to services and receive routine care
        within
        seven (7) days from the date they are released.

      

      

      d. Provide
        outreach to homeless and other populations of plan enrollees at risk of criminal
        justice system involvement, as well as those plan enrollees currently involved
        in this system, to assure that services are accessible and provided when
        necessary. This activity should be oriented toward preventative measures
        to
        assess mental health needs and provide services that can potentially prevent
        the
        need for future inpatient services or possible deeper involvement in the
        criminal justice system.

      

      e. The
        health plan shall develop a cooperative agreement with corrections facilities
        to
        enable the health plan to anticipate Enrollees who were health plan Enrollees
        prior to incarceration who will be released from these institutions. The
        cooperative agreement must address arrangement for persons who are to be
        released, but for whom re-Enrollment may not take effect immediately. All
        Enrollees who were health plan Enrollees prior to incarceration and Medicaid
        Recipients who are likely to enroll in the health plan upon return to the
        community must receive a community mental health service within twenty-four
        (24)
        hours of discharge from the corrections facility

      

      
        	 	
                9.

              	
                Treatment
                  and Coordination of Care for Enrollees with Medically Complex
                  Conditions

              

      

      

      a. The
        Health Plan shall ensure that there are appropriate treatment resources
        available to address the treatment of complex conditions that reflect both
        mental health and physical health involvement. The following conditions must
        be
        addressed:

      

      	(1)  	
              Mental
                health disorders due to or involving a general medical condition,
                specifically -9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89,
                and
                310.1; and

            

      

      
        	
              	 (2)	
                Eating
                  disorders - ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
                  307.52

              

      

      

      b. The
        Health Plan shall provide medically necessary community mental health services
        to enrollees who exhibit the above diagnoses and shall develop a plan of
        care
        that includes all appropriate collateral providers necessary to address the
        complex medical issues involved. Clinical care criteria shall address modalities
        of treatment that are effective for each diagnosis. The Health Plan’s provider
        network must include appropriate treatment resources necessary for effective
        treatment of each diagnosis within the required access time
        periods.

      

      
        	 	
                10.

              	
                Monitoring
                  of Enrollees Admitted to Children’s Residential Treatment (Levels I - IV)
                  Programs 

              

      

      

      a. The
        Health Plan shall maintain contact with children who are disenrolled from
        the
        plan due to placement in a residential treatment facility (Statewide Inpatient
        Psychiatric Program (SIPP), Therapeutic Group Care Services (TGCS), or
        Behavioral Health Overlay Services (BHOS)). The health plan shall participate
        in
        discharge planning, assist the enrollee and their caregiver to locate
        community-based services, and notify Medicaid when the enrollee is discharged
        from the facility. The Health Plan’s contract manager or designee shall
        re-enroll the enrollee in the plan upon notification of discharge into the
        community.

      

      b. Children
        placed in SIPP, TGCS, or BHOS facilities will be disenrolled from the Health
        Plan and then covered under Medicaid Fee-for-Service for mental health services.
        The Medicaid contract manager or designee will be responsible for the
        disenrollment process. The Department of Juvenile Justice, residential
        providers, and/or the assigned Mental Health Targeted Case Management providers
        will be responsible for notifying Medicaid of all admissions and discharges.
        A
        specific agreement regarding the disenrollment and re-enrollment process
        will be
        developed between the Agency, residential providers, and the
        departments.

      

      c.
        Upon
        notification of the Enrollee's discharge from the facility the health plan
        shall
        notify the Choice Counselor/Enrollment Broker for re-Enrollment into the
        health
        plan , if it is within 6 months (180 days) from the
        disenrollment.

      

      
        	 	
                11.

              	
                Coordination
                  of Children’s Services

              

      

      

      a.
        The
        delivery and coordination of children’s mental health services shall be provided
        for all children who exhibit the symptoms and behaviors of an emotional
        disturbance. The delivery of services must address the needs of any child
        served
        in an SED or EH school program. Developmentally appropriate early childhood
        mental health services must be available to children age birth to 5 years
        old
        and their families.

      

      b.
        Services
        for all children shall be delivered within a strengths-based, culturally
        competent service design. The service design shall recognize and ensure that
        services are family-driven and include the participation of family, significant
        others, informal support systems, school personnel, and any state entities
        or
        other service providers involved in the child’s life.

      

      c.
        For
        all
        children receiving services under the plan, the vendor shall work with the
        parents, guardians, or other responsible parties to monitor the results of
        services and determine whether progress is occurring. Active monitoring of
        the
        child’s status shall occur to detect potential risk situations and emerging
        needs or problems. Services shall be conducted in a manner that maximizes
        the
        participation of all involved parties, such as providing services at alternative
        sites or times.

      

      d.
        When
        the
        court mandates a parental mental health assessment, and the parent is a plan
        enrollee, the vendor must complete an assessment of the parent’s mental health
        status and the effects on the child. Time frames for completion of this service
        shall be determined by the mandates issued by the courts.

      

      12.  Evaluation
        and Treatment Services for Enrolled Children/Adolescents 

      

      a. The
        health plan shall provide all Medically Necessary evaluation and treatment
        services for Children/Adolescents referred to the health plan by DCF, DJJ
        and by
        schools (elementary, middle, and secondary schools).

      

      b. The
        health plan shall provide Medically Necessary Children/Adolescent mental
        health
        services in such a way as to minimize disruption of services available to
        high-risk populations served by DCF. The health plan shall promptly evaluate,
        provide psychological testing, and deliver mental health services to
        Children/Adolescents (including delinquent and dependent Children/Adolescent)
        referred by DCF in accordance with Medical Necessity. As well, the health
        plan
        shall adhere to the minimum staffing, availability and access standards
        described in this Contract.

      

      c.
        The
        health plan shall provide court ordered evaluation and treatment required
        for
        Children/Adolescents who are Enrollees.55

      

      d.
        The
        health plan must participate in all DCF or school staffings that may result
        in
        the provision of mental health services to an enrolled
        Child/Adolescent.

      

      e.
        The
        plan shall refer Children/Adolescents to DCF when residential treatment is
        Medically Necessary. The health plan shall not be responsible for providing
        any
        residential treatment for Children/Adolescents. The DCF, Substance Abuse
        and
        Mental Health ("SAMH") or DJJ District office shall coordinate the placement
        of
        the Enrolled Child/Adolescent with the health plan.

      

      f.
         The
        health plan's Case Management of Children/Adolescents shall include
        those persons, schools, programs, networks and agencies that figure importantly
        in the Child's/Adolescent's life.

      

      g.
         The
        health plan shall make determinations about care based on a comprehensive
        evaluation, consultation with those persons, schools, programs, networks
        and
        agencies that figure importantly in the Child's/Adolescent's life, and
        appropriate protocols for admission and retention.

      

      h.
        The
        health plan shall monitor services for adequacy in conformity with the
        cooperative agreement between the health plan and the facility.

      

      
        	 	
                C.

              	
                Psychiatric
                  Evaluations for Enrollees Applying for Nursing Home
                  Admission 

              

      

      

      The
        Health Plan shall, upon request from the Substance Abuse and Mental Health
        (SAMH) Offices, promptly arrange for and authorize psychiatric evaluations
        for
        enrollees who are applying for admission to a nursing facility pursuant to
        OBRA
        1987, and who, on the basis of a screening conducted by Comprehensive Assessment
        and Review for Long Term Care (CARES) workers, are thought to need mental
        health
        treatment. The examination shall be adequate to determine the need for
“specialized treatment” under the Act. Evaluations must be completed within five
        working days from the time the request from the DCF SAMH Program Office is
        received. State regulations have been interpreted by the state to permit
        any of
        the “mental health professionals” listed in Section 394.455, Florida Statutes,
        to make the observations preparatory to the evaluation, although a psychiatrist
        must sign such evaluations. The Health Plan will not be responsible for resident
        reviews or for providing services as a result of a Pre-Admission Screening
        and
        Resident Review (PASRR) evaluation.

      

      
        	 	
                D.

              	
                Assessment
                  and Treatment of Mental Health Residents Who Reside in Assisted
                  Living
                  Facilities (ALF) that hold a Limited Mental Health
                  License

              

      

      

      
        	 	 	
                The
                  Health Plan must develop and implement a plan to ensure compliance
                  with
                  Section 394.4574, F.S., related to services provided to residents
                  of
                  licensed assisted living facilities that hold a limited mental
                  health
                  license. A cooperative agreement, as defined in 400.402, F.S.,
                  must be
                  developed with the ALF if an enrollee is a resident of the ALF.
                  The Health
                  Plan must ensure that appropriate assessment services are provided
                  to plan
                  enrollees and that medically necessary mental health care services
                  are
                  available to all enrollees who reside in this type of
                  setting.

              

      

      

      
        	 	 	
                A
                  community living support plan, as defined in Section I, Definitions
                  and
                  Acronyms, must be developed for each enrollee who is a resident
                  of an ALF,
                  and it must be updated annually. The Health Plan case manager is
                  responsible for ensuring that the community living support plan
                  is
                  implemented as written.

              

      

      

      
        	 	
                E.

              	
                Individuals
                  with Special Health Care Needs:

              

      

      

      The
        plan
        shall implement mechanisms for identifying, assessing and ensuring the existence
        of an Individualized Treatment Plan for individuals with special health care
        needs as defined in Section I, Definitions and Acronyms. Mechanisms shall
        include evaluation of risk assessments, claims data, and CPT/ICD-9 codes.
        Additionally, the plan shall implement a process for receiving and considering
        provider and enrollee input.

      

      In
        accordance with this contract and 42 CFR 438.208(c)(3), an Individualized
        Treatment Plan for an enrollee determined to need a course of treatment or
        regular care monitoring must be:

      

      	·  	
              Developed
                by the enrollee's direct service mental health care professional
                with
                enrollee participation and in consultation with any specialists caring
                for
                the enrollee; 

            

      

      	·  	
              Approved
                by the plan in a timely manner if this approval is required;
                and

            

      

      	·  	
              Developed
                in accordance with any applicable Agency quality assurance and utilization
                review standards.

            

      

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

      

      F. Crisis
        Support/Emergency Services 

      

      The
        health plan shall operate, as part of its Crisis Support/Emergency Services,
        a
        crisis emergency hotline available to all Enrollees twenty-four (24) hours
        a
        day, seven (7) days a week.

      

      
        	 	
                G.

              	
                Provision
                  of Behavioral Health Services When Not Covered by the Health
                  Plan

              

      

      

      1. If
        the
        Health Plan determines that an Enrollee is in need of behavioral health services
        that are not covered under the Contract, the Health Plan shall refer the
        Enrollee to the appropriate provider. The Health Plan may request the assistance
        of the Agency’s local field office or the local DCF District ADM Office for
        referral to the appropriate service setting.

      

      2. Long
        term
        care institutional services in a nursing facility, an institution for persons
        with developmental disabilities, specialized therapeutic foster care, children's
        residential treatment services or State Hospital services are not covered
        by the
        Health Plan. For Enrollees requiring those services, the Health Plan shall
        consult the Medicaid Field Office and/or the DCF District ADM Office to identify
        appropriate methods of assessment and referral.

      

      3. The
        Health Plan is responsible for transition and referral of the Enrollee to
        appropriate providers. The Health Plan shall request Disenrollment of all
        Enrollees receiving the services described in this Section VI.B.8., Provision
        of
        Behavioral Health Care Services When Not Covered by the Health
        Plan.

      

      
        	 	
                H.

              	
                Behavioral
                  Health Services Care Coordination and Management
                  

              

      

      

      The
        Health Plan shall be responsible for the coordination and management of
        Behavioral Health Services and continuity of care for all Enrollees. At a
        minimum, the Health Plan shall provide the following services to its
        Enrollees:

      

      1. Minimize
        disruption to the Enrollee as a result of any change in behavioral health
        care
        providers or behavioral health care case managers that occur as a result
        of this
        Contract. For new Enrollees who had been receiving Behavioral Health Services,
        the Health Plan shall continue to authorize all valid claims for services
        until
        the Health Plan has: 

      

      
        	 	
                a.

              	
                Reviewed
                  the Enrollee's treatment plan;

              

      

      

      
        	 	
                b.

              	
                Developed
                  an appropriate written transition plan;
                  and

              

      

      

      c. Implemented
        the written transition plan.

      

      2. If
        the
        previous behavioral health care provider is unable to allow the Health Plan
        access to the Enrollee's Medical Records because the Enrollee refuses to
        release
        his/her records, then the Health Plan shall provide:

      

      
        	 	
                .a

              	
                Up
                  to four (4) sessions of individual or group
                  therapy;

              

      

      

      
        	 	
                .b

              	
                One
                  (1) psychiatric medical session;

              

      

      

      
        	 	
                .c

              	
                Two
                  (2) one-hour intensive therapeutic on-site;
                  or

              

      

      

      
        	 	
                .d

              	
                Six
                  (6) days of day treatment services.

              

      

      

      3.. Document
        all Emergency Behavioral Health Services received by an Enrollee, along with
        any
        follow-up services, in the Enrollee's behavioral health Medical Records.
        The
        Health Plan shall also assure the PCP receives the information about the
        Emergency Behavioral Health Services for filing in the PCP's Medical
        Record.

      

      4. Document
        all referral services in the Enrollees’ behavioral health Medical
        Records.

      

      5. Monitor
        Enrollees admitted to State mental health institutions by participating in
        discharge planning and community placement of Enrollees who are discharged
        within sixty (60) days of losing their Health Plan enrollment due to State
        institutionalization. The Agency shall sanction the Health Plan, as described
        in
        Section XIII, Sanctions, for any inappropriate over-utilization of State
        mental
        Hospital services for its Enrollees.

      

      6. Coordinate
        Hospital and institutional discharge planning for psychiatric admissions
        and
        substance abuse detoxification to ensure inclusion of appropriate post-discharge
        care. 

      

      
        	 	
                a.

              	
                Enrollees
                  admitted to an acute care facility (inpatient Hospital or crisis
                  stabilization unit) shall receive appropriate services upon discharge
                  from
                  the acute care facility.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall have follow-up services available to Enrollees
                  within
                  twenty-four (24) hours of discharge from an acute care facility,
                  provided
                  the acute care facility notified the Health Plan that it had provided
                  services to the Enrollee.

              

      

      

      
        	 	
                c

              	
                The
                  Health Plan shall continue the medication prescribed by a State
                  mental
                  health facility to the Enrollee for at least ninety (90) days after
                  the
                  State mental health facility discharges the Enrollee, unless the
                  Health
                  Plan's prescribing psychiatrist, in consultation and agreement
                  with the
                  State mental health facility's prescribing physician, determines
                  that the
                  medications: 

              

      

      

      (1) Are
        not
        Medically Necessary; or

      

      (2) Are
        potentially harmful to the Enrollee.

      

      7. Provide
        appropriate referral of the Enrollee for non-covered services to the appropriate
        service setting. The Health Plan shall request referral assistance, as needed,
        from the Medicaid Field Office. The Health Plan is encouraged to use the
        Florida
        Supplement to the American Society of Addictions Medicine Patient Placement
        Criteria for coordination and treatment of substance abuse related disorders
        with substance abuse providers. The Health Plan is encouraged to use the
        Florida
        Supplement to the American Society of Addictions Medicine Placement Criteria
        for
        coordination and treatment of substance-related disorders with substance
        abuse
        Providers. The Health Plan shall provide coordination of care with
        community-based substance abuse agencies as part of its policies and procedures
        developed for continuity of care for Enrollees who are diagnosed with mental
        illness and substance abuse or dependency.

      

      8. Provide
        court ordered mental health evaluations for Enrollees. The Health Plan shall
        also provide expert behavioral health testimony for Enrollees.

      

      9. Provide
        appropriate screening, assessment, and crisis intervention in support for
        Enrollees who are in the care and custody of the State. See Specifications
        listed in the Medicaid Community Mental Health Services Coverage &
Limitations Handbook.

      

      10. Upon
        a
        request from an ALF, the Health Plan shall provide procedures for the ALF
        to
        follow should an emergent condition arise with an Enrollee that resides at
        the
        ALF. (See Section 409.912, F.S.)

      

      11. The
        Health Plan shall participate in the SAMH planning process in each DCF district.
        (See Section 4098.912, F.S.)

      

      The
        Health Plan shall design and implement a Drug Utilization Review ("DUR")
        program. Once the Health Plan's pharmacy utilization indicates that an Enrollee
        is receiving an antipsychotic medication from a PCP or prescribing
        non-psychiatrist physician, the Health Plan shall request a consultation
        with
        the PCP or prescribing non-psychiatrist physician. Once the Health Plan's
        pharmacy utilization indicates that an Enrollee, who is being treated by
        a
        Behavioral Health Care Provider, receives medication for certain physical
        conditions (such as hypertension, diabetes, neurological disorders, cardiac
        problems, or any other serious medical condition) the Health Plan shall schedule
        a consultation with the PCP or prescribing physician to discuss coordination
        of
        care and concerns related to drug interactions. The Health Plan shall ensure
        coordination with the PCP or prescribing physician with regards to drug
        utilization and potential contraindications.

      

      
        	 	
                I.

              	
                Discharge
                  Planning

              

      

      

      Discharge
        Planning is the evaluation of an Enrollee's medical care needs, including
        mental
        health service needs, substance abuse service needs, or both, in order to
        arrange for appropriate care after discharge from one level of care to another
        level of care. The Health Plan shall:

      

      1. Monitor
        all Enrollee discharge plans from behavioral health inpatient admissions
        to
        ensure that they incorporate the Enrollees’ needs for continuity in existing
        behavioral health therapeutic relationships.

      

      2. Ensure
        that Enrollees' family members, guardians, outpatient individual practitioners
        and other identified supports are given the opportunity to participate in
        Enrollee treatment to the maximum extent practicable and appropriate, including
        behavioral health treatment team meetings and developing the discharge plan.
        For
        adult Enrollees, family members and other identified supports may be involved
        in
        the development of the Discharge Plan only if the Enrollee consents to their
        involvement.

      

      3. Designate
        staff members who are responsible for identifying Enrollees who remain in
        the
        Hospital for non-clinical reasons (i.e., absence of appropriate treatment
        setting availability, high demand for appropriate treatment setting, high-risk
        Enrollees and Enrollees with multiple agency involvement).

      

      4. Develop
        and implement a plan that monitors and ensures that clinically indicated
        Behavioral Health Services are offered and available to Enrollees within
        twenty-four (24) hours of discharge from an inpatient setting.

      

      5. Ensure
        that a behavioral health program clinician provides medication management
        to
        Enrollees requiring medication monitoring within twenty-four (24) hours of
        discharge from a behavioral health program inpatient setting. The Health
        Plan
        shall ensure that the behavioral health program clinician is duly qualified
        and
        licensed to provide medication management.

      

      6. Upon
        the
        admission of an Enrollee, the Health Plan shall make its best efforts to
        ensure
        the Enrollee’s smooth transition to the next service or to the community; and
        shall require that Behavioral Health Care Providers:

      

      
        	 	
                (a)

              	
                Assign
                  a case manager to oversee the care given to the
                  Enrollee;

              

      

      

      
        	 	
                (b)

              	
                Develop
                  an individualized discharge plan, in collaboration with the Enrollee
                  where
                  appropriate, for the next service or program or the Enrollee's
                  discharge,
                  anticipating the Enrollee's movement along a continuum of services;
                  and

              

      

      

      
        	 	
                (c)

              	
                Make
                  best efforts to ensure a smooth transition to the next service
                  or
                  community;

              

      

      

      
        	 	
                (d)

              	
                Document
                  all significant efforts related to these activities, including
                  the
                  Enrollee's active participation in discharge
                  planning.

              

      

      

      
        	 	
                J.

              	
                Transition
                  Plan 

              

      

      

      A
        transition plan is a detailed description of the process of transferring
        Enrollees from providers to the Health Plan's Behavioral Health Care Provider
        network to ensure optimal continuity of care. The transition plan shall include,
        but not be limited to, a timeline for transferring Enrollees, description
        of
        provider medical record transfers, scheduling of appointments, propose
        prescription drug protocols and claims approval for existing providers during
        the transition period. The Health Plan shall document its efforts relating
        to
        the transition plan.

      

      1. The
        Health Plan shall minimize the disruption of treatment by an Enrollee's current
        behavioral health care provider by arranging for Enrollee use of services
        outside of the Health Plan's network. For Enrollees who have received Behavioral
        Health Services for at least six (6) months from a behavioral health care
        provider, whether the provider is in the Health Plan’s network or not, the
        Health Plan shall continue to authorize all valid claims until the Health
        Plan
        reviews the Enrollee's treatment plan and implements an appropriate written
        transition plan.

      

      2. During
        the first three (3) months that the Enrollee receives Behavioral Health Services
        under this Contract, the Health Plan shall not deny requests for Behavioral
        Health Services outside the network under the following conditions:

      

      
        	 	
                (1)

              	
                The
                  Enrollee is a patient at a community behavioral health center and
                  the
                  center has discussed the Enrollee's care with the Health
                  Plan.

              

      

      

      
        	 	
                (2)

              	
                If,
                  following contact with the Health Plan, there is no Behavioral
                  Health Care
                  Provider readily available and the Enrollee's condition would not
                  permit a
                  delay in treatment.

              

      

      

      3. If
        the
        previous treating Provider is unable to allow the Health Plan access to the
        Enrollee's Medical Records because the Enrollee refuses to release the records,
        then the Health Plan shall approve the provider’s claims for:

      

      
        	 	
                (a)

              	
                Four
                  (4) sessions of outpatient behavioral health counseling or
                  therapy;

              

      

      

      
        	 	
                (b)

              	
                One
                  (1) outpatient psychiatric physician session;

              

      

      

      
        	 	
                (c)

              	
                Two
                  (2) one-hour intensive therapeutic on-site sessions;
                  or

              

      

      

      
        	 	
                (d)

              	
                Six
                  (6) days of day treatment services.

              

      

      

      

      4. Any
        disputes related to coverage of services necessary for the transition of
        Enrollees from their current behavioral health care provider to a Behavioral
        Health Care Provider shall follow the process set forth in Section IX, Grievance
        System, of this Contract.

      

      5. The
        Health Plan shall approve claims from providers for authorized out-of-plan
        non-emergency services, provided such claims are submitted within twelve
        (12)
        months of the date of service. The Plan must process such claims within the
        time
        period specified in section 641.3155, F.S.

      

      
        	 	
                K.

              	
                Functional
                  Assessments 

              

      

      

      1. The
        Health Plan shall ensure that all Behavioral Health Care Providers administer
        functional assessments using the Functional Assessment Rating Scales (FARS)
        for
        all Enrollees over the age of eighteen (18) and Child Functional Assessment
        Rating Scale (CFARS) for all Enrollees age eighteen (18) and under.

      

      2. The
        Health Plan shall ensure that all Behavioral Health Care Providers administer
        and maintain the FARS and CFARS according to the FARS and CFARS manuals to
        all
        Enrollees receiving Behavioral Health Services and upon termination of providing
        such services. 

      

      3. The
        results of the FARS and CFARS assessments shall be maintained in each Enrollee's
        medical record, including a chart trending the results of the functional
        assessments.

      

      4. The
        Health Plan shall submit the FARS/CFARS reports as required in Section XI,
        Reporting Requirements.

      

      
        	 	
                L.

              	
                Outreach
                  Program

              

      

      

      The
        Health Plan shall have an outreach program designed to encourage Enrollees
        to
        seek Behavioral Health Services through the Health Plan when the Health Plan,
        or
        Providers, perceive a need for Behavioral Health Services. In addition, the
        outreach program, at a minimum, shall provide for the following:

      

      1. Outreach
        program Enrollee communications that are written at the fourth (4th) grade
        reading level;

      

      2. Outreach
        program communications that are written the primary language spoken by the
        Enrollee;

      

      3. A
        program
        designed to assist PCP's in the identification and management, including
        referral and other resources, to aid in the treatment of:

      

      
        	 	
                (a)

              	
                Enrollees
                  with severe and persistent mental illness;

              

      

      

      
        	 	
                (b)

              	
                Children/Adolescents
                  with severe emotional disturbances;
                  and

              

      

      

      
        	 	
                (c)

              	
                Enrollees
                  with clinical depression.

              

      

      

      4. A
        program
        to identify and manage Enrollees who are homeless.

      

      
        	 	
                M.

              	
                Behavioral
                  Health Subcontracts

              

      

      

      If
        the
        Health Plan subcontracts with a Managed Behavioral Health Organization ("MBHO")
        for the provision of Behavioral Health Services stipulated in this Section,
        the
        MBHO must be accredited by at least one (1) of the recognized national
        accreditation organizations. 

      

      1. The
        Health Plan shall submit to the Agency the staff psychiatrist subcontract,
        if
        any, and the model Provider contracts for each Behavioral Health Services
        specialist type or facility.

      

      2. All
        Provider contracts and subcontracts must adhere to the requirements set forth
        in
        this Contract, including Section XVI.Q., Terms and Conditions, Subcontracts,
        in
        this Contract.

      

      
        	 	
                N.

              	
                Optional
                  Services

              

      

      

      The
        Health Plan is encouraged to provide additional services that will enhance
        the
        Health Plan’s Covered Services for Enrollees. To the degree possible, the Health
        Plan should use existing community resources. Below is a list of possible
        optional services that could be provided with the savings achieved or as
        downward substitutions. This list is not intended to be all-inclusive and
        the
        Health Plan is encouraged to use creativity in developing new and innovative
        services to expand the array of services and meet the needs of
        recipients.

      

      1.
         Respite
        Care Services

      

      2.
         Prevention
        Services in the Community

      

      3.
         Supportive
        Living Services

      

      4.
         Supported
        Employment Services

      

      5.
         Foster
        Homes for Adults

      

      6.
         Parental
        Education Programs

       

      7.
Drop-In
        Centers and other consumer operated programs (beyond the elements provided
        under
        the Opportunities for Recovery and Reintegration component)

       

      8.
         Intensive
        Therapeutic On-Site Services for Adults

      

      9.
         Home
        and
        Community Based Rehabilitation Services for Adults

       

      
        10. 
          Any
          other new and innovative interventions or services designed to benefit
          enrollees
          receiving Mental Health services

      

      
        	 	
                 

              	
                 

              

      

      

      
        	 	
                O.
                  

              	
                Community
                  Coordination and
                  Collaboration

              

      

      

      The
        provider must be or become a vital part of the community services and support
        system. They must actively participate with and support community programs
        and
        coalitions that promote school readiness, that assist persons to return to
        work
        and provide for prevention programs. The provider must have linkages with
        numerous community programs that will assist enrollees in obtaining housing,
        economic assistance and other supports.

      

      
        	 	
                P.

              	
                Behavioral
                  Health Managed Care Local Advisory
                  Group

              

      

      

      1. There
        will be an advisory group for the Health Plan that convenes quarterly and
        reports to the Agency on advocacy and programmatic concerns. The local advisory
        group is responsible for providing technical and policy advice to the Agency
        regarding the Health Plan’s provision of services. The local advisory group does
        not have access to Enrollee Medical Records.

      

      2. The
        role
        of the local advisory group is to report to the Agency information related
        to
        practical and real events that occur related to the activities of Medicaid
        Health Plans. Concerns about services, program changes, Quality of care,
        difficulties, advocacy issues, and reports about positive outcomes are presented
        by members of the advisory group and are addressed by the agency as part
        of the
        ongoing monitoring of the Health Plan contracts. The Agency presents information
        about actions taken related to issues presented by the group. If the group
        determines that it is appropriate, the advisory group members also vote to
        present their issues to the Agency in writing.

      

      3. The
        group
        may request information to be presented at each meeting that will keep the
        group
        up-to-date regarding the contract and activities of each Health Plan. Minutes
        of
        the meetings are kept and distributed to all members and attendees. The voting
        membership of the group is updated periodically. This is a public meeting
        and
        may be attended by anyone in the community.

       

      4. The
        local
        advisory group is coordinated by Agency area staff (who are not part of the
        voting membership) and consists of providers, consumer representatives, advocacy
        groups, and other relevant groups as identified by the Agency, which represent
        the counties within the service area. Such relevant groups include the Agency’s
        Medicaid Office, including Health Plan representatives; SAMH and Family Safety
        representatives; representatives from any community based care Providers
        contracted with DCF; the Florida Drop-In Center Association; the Human Rights
        Advocacy Committee; the Alliance for the Mentally Ill; the Florida Consumer
        Action Council; and the Substance Abuse and Mental Health Planning Council.
        In
        addition, the Health Plan provides representation to the local advisory group.
        The advisory group elects a chairperson and vice-chairperson from the voting
        membership, who facilitates the meetings and prepares any written correspondence
        on behalf of the group.

      

      5. The
        Health Plan’s responsibility related to the advisory group is as
        follows:

      

      	·  	
              Assure
                representation at all scheduled meetings;

            

      

      	·  	
              Provide
                information requested by advisory group
                members;

            

      

      	·  	
              Follow
                up on identified issues of concern related to the provision of services
                or
                administration of the Health Plan; and

            

      

      	·  	
              Share
                pertinent information about Quality improvement findings and outreach
                activities with the group.

            

      

      

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      Section
        VII

      Provider
        Network

      

      
        	A.	
                 General
                  Provisions

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall have sufficient facilities, service locations,
                  service
                  sites and personnel to provide the Covered Services described in
                  Section V
                  and Behavioral Health Care described in Section VI.
                  

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall provide the Agency with adequate assurances that
                  the
                  Health Plan has the capacity to provide Covered Services to all
                  Enrollees
                  up to the maximum enrollment level in each county, including assurances
                  that the Health Plan: 

              

      

      

      a. Offers
        an
        appropriate range of services and accessible preventive and primary care
        services such that the Health Plan can meet the needs of the maximum enrollment
        level in each county, and

      

      b. Maintains
        a sufficient number, mix and geographic distribution of Providers, including
        Providers who are accepting new Medicaid patients as specified in Section
        1932(b)(7) of the Social Security Act, as enacted by Section 4704(a) of the
        Balanced Budget Act of 1997.

      

      
        	 	
                3.

              	
                When
                  designing the Provider network, the Health Plan shall take the
                  following
                  into consideration as required by 42 CFR
                  438.206:

              

      

      

      a. The
        anticipated number of Enrollees;

      

      b. The
        expected utilization of services, taking into consideration the characteristics
        and health care needs of specific Medicaid populations represented;

      

      c. The
        numbers and types (in terms of training, experience, and specialization)
        of
        providers required to furnish the Covered Services;

      

      d. The
        numbers of network providers who are not accepting new Enrollees; 

      

      e. The
        geographic location of providers and Enrollees, considering distance, travel
        time, the means of transportation ordinarily used by Enrollees and whether
        the
        location provides physical access for Medicaid enrollees with disabilities;
        and

      

      f. There
        is
        to be no discrimination against particular providers that serve high-risk
        populations or specialize in conditions that require costly
        treatments.

      

      
        	 	
                4.

              	
                Health
                  Maintenance Organizations and other licensed managed care organizations
                  shall enroll all network providers with the Agency’s Fiscal Agent, no
                  later than November 30, 2006, using the Agency’s streamlined Provider
                  Enrollment process. All Capitated PSNs shall use the streamlined
                  Provider
                  Enrollment process to enroll network providers prior to contract
                  execution.

              

      

      

      
        	 	
                5.

              	
                Each
                  Provider shall maintain Hospital privileges if Hospital privileges
                  are
                  required for the delivery of Covered Services. The Health Plan
                  may use
                  admitting panels to comply with this
                  requirement.

              

      

      

      
        	 	
                6.

              	
                If
                  the Health Plan is unable to provide Medically Necessary services
                  to an
                  Enrollee, the Health Plan must cover these services by using providers
                  and
                  services that are not providers in the Health Plan's network, in
                  an
                  adequate and timely manner, for as long as the Health Plan is unable
                  to
                  provide the Medically Necessary services within the Health Plan's
                  network.

              

      

      

      
        	 	
                7.

              	
                The
                  Health Plan shall allow each Enrollee to choose his or her Providers
                  to
                  the extent possible and
                  appropriate.

              

      

      

      
        	 	
                8.

              	
                The
                  Health Plan shall require each Provider to have a unique Florida
                  Medicaid
                  Provider number, in accordance with the requirement of Section
                  X, C. jj.,
                  of this Contract. By May 2007, the Health Plan shall require each
                  Provider
                  to have a National Provider Identifier (NPI) in accordance with
                  section
                  1173(b) of the Social Security Act, as enacted by section
                  4707(a) of the Balanced Budget Act of
                  1997.

              

      

      

      
        	 	
                9.

              	
                The
                  Health Plan shall provide the Agency with documentation of compliance
                  with
                  access requirements: 

              

      

      

      a. Upon
        the
        effective date of the Contract; and

      

      b. At
        any
        time there has been a significant change in the Health Plan's operations
        that
        would affect adequate capacity and services, including, but not limited to,
        the
        following:

      

      
        	 	
                (1)

              	
                Changes
                  in Health Plan services or Service Area;
                  and

              

      

      

      
        	 	
                (2)

              	
                Enrollment
                  of a new population in the Health
                  Plan.

              

      

      

      
        	 	
                10.

              	
                The
                  Health Plan shall have procedures to inform Potential Enrollees
                  and
                  Enrollees of any changes to service delivery and/or the Provider
                  network
                  including the following:

              

      

      

      a. Inform
        Potential Enrollees and Enrollees of any restrictions to access to Providers,
        including Providers who are not taking new patients, upon request and, for
        Enrollees, at least on a six (6) month basis.

      

      b. An
        explanation to all Potential Enrollees that an enrolled family may choose
        to
        have all family members served by the same PCP or they may choose different
        PCPs
        based on each family member’s needs.

      

      c. Inform
        Potential Enrollees and Enrollees of objections to providing counseling and
        referral services based on moral or religious grounds within ninety (90)
        days
        after adopting the policy with respect to any service.

      

      
        	 	
                11.

              	
                The
                  Health Plan shall have procedures to document when a decision is
                  made to
                  not include individual or groups of providers in its network and
                  must give
                  the affected providers written notice of the reason for its decision.
                  

              

      

      

      

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        	B.	
                Primary
                  Care Providers

              

      

       

      
        	 	
                1.

              	
                The
                  Health Plan shall enter into agreements with a sufficient number
                  of PCPs
                  to ensure adequate accessibility for Enrollees of all ages. The
                  Health
                  Plan shall select and approve its PCPs. The Health Plan shall ensure
                  its
                  approved PCPs agree to the following: 

              

      

      

      (a) The
        PCP’s
        agreement to accept the associated Case Management
        responsibilities.

      

      (b) The
        PCP’s
        agreement to provide or arrange for coverage of services, consultation or
        approval for referrals twenty four (24) hours per day, seven days per week
        by
        Medicaid enrolled providers who will accept Medicaid reimbursement. This
        coverage must consist of an answering service, call forwarding, provider
        call
        coverage or other customary means approved by the Agency. The chosen method
        of
        twenty four (24) hour coverage must connect the caller to someone who can
        render
        a clinical decision or reach the PCP for a clinical decision. The after hours
        coverage must be accessible using the medical office’s daytime telephone number.
        The PCP or covering medical professional must return the call within thirty
        (30)
        minutes of the initial contact.

      

      (c) The
        PCP’s
        agreement to arrange for coverage of primary care services during absences
        due
        to vacation, illness or other situations which require the PCP to
        be
        unable to provide services. Coverage must be provided by a Medicaid enrolled
        PCP. 

      

      
        	 	
                2.
                  

              	
                The
                  Health Plan shall provide the
                  following:

              

      

      

      a. At
        least
        one (1) FTE PCP per county including, but not limited to, the following
        specialties:

      

      
        	 	
                (1)

              	
                Family
                  Practice;

              

      

      

      
        	 	
                (2)

              	
                General
                  Practice;

              

      

      

      
        	 	
                (3)

              	
                Obstetrics
                  or Gynecology;

              

      

      

      
        	 	
                (4)

              	
                Pediatrics;
                  and

              

      

      

      
        	 	
                (5)

              	
                Internal
                  Medicine.

              

      

      

      b. At
        least
        one (1) FTE PCP per 1,500 Enrollees. The Health Plan may increase the ratio
        by
        750 Enrollees for each FTE ARNP or FTE PA affiliated with a PCP.

      

      c. The
        Health Plan shall allow pregnant Enrollees to choose the Health Plan’s
        obstetricians as their PCPs to the extent that the obstetrician is willing
        to
        participate as a PCP.

      

      
        	 	
                3.

              	
                At
                  least annually, the Health Plan shall review each PCPs average
                  wait times
                  to ensure services are in compliance with Section VII, D. Appointment
                  Waiting Times and Geographic Access
                  Standards.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan shall assign a pediatrician or other appropriate primary
                  care
                  physician to all pregnant Enrollees for the care of their newborn
                  babies
                  no later than the beginning of the last trimester of gestation.
                  If the
                  Health Plan was not aware that the Enrollee was pregnant until
                  she
                  presented for delivery, the Health Plan shall assign a pediatrician
                  or a
                  primary care physician to the newborn baby within one (1) Business
                  Day
                  after birth. The Health Plan shall advise all Enrollees of the
                  Enrollees’
                  responsibility to notify their Health Plan and their DCF public
                  assistance
                  specialists (case workers) of their pregnancies and the births
                  of their
                  babies.

              

      

      

      
        	C.	
                 Minimum
                  Standards

              

      

      

      
        	 	
                1.

              	
                Emergency
                  Services and Emergency Services Facilities

              

      

      

      The
        Health Plan shall ensure the availability of Emergency Services and Care
        twenty-four (24) hours a day, seven (7) days a week. 

      

      
        	 	
                2.

              	
                General
                  Acute Care Hospital 

              

      

      

      The
        Health Plan shall provide one
        (1)
        fully accredited general acute care Hospital bed
        per
        275 enrollees.
        The
        Agency may waive this accreditation requirement, in writing, for
        Rural
        areas.

      

      
        	 	
                3.

              	
                Birth
                  Delivery Facility 

              

      

      

      The
        Health Plan shall provide one (1) birth delivery facility, licensed under
        Chpater 383, F.S., or a Hospital with birth delivery facilities, licensed
        under
        Chapter 395, F.S. The birth delivery facility may be part of a Hospital or
        a
        freestanding facility.

      

      
        	 	
                4.

              	
                Birthing
                  Center

              

      

      

      The
        Health Plan shall provide a birthing center, licensed under Chapter 383,
        F.S.
        that is accessible to low risk Enrollees. 

      

      
        	 	
                5.

              	
                Regional
                  Perinatal Intensive Care Centers (RPICC)

              

      

      

      The
        Health Plan shall assure access for Enrollees in one (1) or more of Florida's
        Regional Perinatal Intensive Care Centers (RPICC), (see sections 383.15 through
        383.21, F.S.) or a Hospital licensed by the Agency for Neonatal Intensive
        Care
        Unit (NICU) Level III beds.

      

      
        	 	
                6.

              	
                Neonatal
                  Intensive Care Unit (NICU) 

              

      

      

      The
        Health Plan shall ensure that care for medically high risk perinatal Enrollees
        is provided in a facility with a NICU sufficient to meet the appropriate
        level
        of need for the Enrollee.

      

      
        	 	
                7.

              	
                Certified
                  Nurse Midwife Services

              

      

      

      The
        Health Plan shall ensure access to certified nurse midwife services or licensed
        midwife services for low risk Enrollees. 

      

      
        	 	
                8.

              	
                Pharmacy
                  

              

      

      

      If
        the
        Health Plan elects to use a more restrictive pharmacy network than the
        non-Medicaid Reform Fee-for-Service network, the Health Plan shall provide
        one
        (1) licensed pharmacy per 2,500 Enrollees. The Health Plan shall ensure that
        its
        contracted pharmacies comply with the Settlement Agreement to Hernandez,
        et. al.
        v. Medows (case number 02-20964 Civ-Gold/ Simonton) (HSA).

      

      
        	 	
                9.

              	
                Access
                  for Persons with Disabilities

              

      

      

      The
        Health Plan shall ensure that all facilities have access for persons with
        disabilities. 

      

      
        	 	
                10.

              	
                Health,
                  Cleanliness and Safety

              

      

      

      The
        Health Plan shall ensure adequate space, supplies, proper sanitation, and
        smoke-free facilities with proper fire and safety procedures in operation.
        

      

      
        	D.	
                 Appointment
                  Waiting Times and Geographic Access
                  Standards

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plans must assure that PCP services and referrals to Participating
                  Specialists are available on a timely basis, as
                  follows:

              

      

      

      a. Urgent
        Care — within one (1) day,

      

      b. Routine
        Sick Patient Care — within one (1) week, and

      

      c. Well
        Care
        Visit — within one (1) month.

      

      
        	 	
                2.

              	
                All
                  PCP's and Hospital services must be available within an average
                  of thirty
                  (30) minutes travel time from an Enrollee's residence. All Participating
                  Specialists and ancillary services must be within an average of
                  sixty (60)
                  minutes travel time from an Enrollee's residence. The Agency may
                  waive
                  this requirement, in writing, for Rural areas and where there are
                  no PCPs
                  or Hospitals within the thirty (30) minute average travel
                  time.

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan shall provide a designated emergency services facility
                  within
                  an average of thirty (30) minutes travel time from an Enrollee's
                  residence, that provides care on a twenty-four (24) hours a day,
                  seven (7)
                  days a week basis. Each designated emergency service facility shall
                  have
                  one (1) or more physicians and one (1) or more nurses on duty in
                  the
                  facility at all times. The Agency may waive the travel time requirement,
                  in writing, in Rural areas. 

              

      

      
        	 	 	 

      

      
        	 	
                4.

              	
                For
                  Rural areas, if the Health Plan is unable to enter into an agreement
                  with
                  specialty or ancillary service providers within the required sixty
                  (60)
                  minute average travel time, the Agency may waive, in writing, the
                  requirement.

              

      

      

      
        	 	
                5.

              	
                At
                  least one (1) pediatrician or one (1) CHD, FQHC or RHC within an
                  average
                  of thirty (30) minutes travel time from an Enrollee's residence,
                  provided
                  that this requirement remains consistent with the other minimum
                  time
                  requirements of this Contract. In order to meet this requirement,
                  the
                  pediatrician(s), CHD, FQHC, and/or RHC must provide access to care
                  on a
                  twenty-four (24) hours a day, seven days a week basis. The Agency
                  may
                  waive this requirement, in writing, for Rural areas and where there
                  are no
                  pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
                  average
                  travel time. 

              

      

      

      
        	E.	
                 Behavioral
                  Health Services

              

      

       

      
        	 	
                1.

              	
                The
                  Health Plan shall have at least one (1) certified adult psychiatrist
                  and
                  at least one (1) board certified child psychiatrist (or one (1)
                  child
                  psychiatrist who meets all education and training criteria for
                  Board
                  Certification) that are available within thirty (30) minutes average
                  travel time for Urban areas and sixty (60) minutes average travel
                  time for
                  Rural areas of all Enrollees. 

              

      

      

      
        	 	
                2.

              	
                For
                  Rural areas, if the Health Plan does not have a Provider with the
                  necessary experience, the Agency may waive, in writing, the requirements
                  in E.1 above.

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan shall ensure that outpatient staff includes at least
                  one (1)
                  FTE Direct Service Behavioral Health Provider per 1,500 Enrollees.
                  The
                  Agency expects the Health Plan’s staffing pattern for direct service
                  Providers to reflect the ethnic and racial composition of the
                  community.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan’s array of Direct Service Behavioral Health Providers for
                  adults and Children/Adolescents shall include Providers that are
                  licensed
                  or eligible for licensure, and demonstrate two (2) years of clinical
                  experience in the following specialty areas or with the following
                  populations:

              

      

      

      a. Adoption;

      

      b. Child
        protection or foster care;

      

      c. Dual
        diagnosis (mental illness and substance abuse);

      

      d. Dual
        diagnosis (mental illness and developmental disability);

      

      e. Developmental
        disabilities;

      

      f. Behavior
        analysis;

      

      g. Behavior
        management and alternative therapies for Children/Adolescents;

      

      h. Separation
        and loss;

      

      i. Victims
        and perpetrators of sexual abuse (Children/Adolescents and adults);

      

      j. Victims
        and perpetrators of violence and violent crimes (Children/Adolescents and
        adults);

      

      k. Court
        ordered mental health evaluations including assessment of parental mental
        health
        issues and parental competency as it relates to mental health; and

      

      l. Expert
        witness testimony.

      

      
        	 	
                5.

              	
                All
                  Direct Service Behavioral Health Providers and mental health targeted
                  case
                  managers serving the Children/Adolescent population shall be certified
                  by
                  DCF to administer CFARS (or other rating scale required by DCF
                  or the
                  Agency).

              

      

      

      
        	 	
                6.

              	
                Mental
                  health targeted case managers shall not be counted as Direct Service
                  Behavioral Health Providers.

              

      

      

      
        	 	
                7.

              	
                For
                  Case Management services, the Health Plan shall provide staff that
                  meets
                  the following minimum requirements:

              

      

      

      a.
         Have
        a
        baccalaureate degree from an accredited university, with major course work
        in
        the areas of psychology, social work, health education or a related human
        service field and, if working with Children/Adolescents, have a minimum of
        one-(1) year full time experience or equivalent experience, working with
        the
        target population. Prior experience is not required if working with the adult
        population; or

      

      b.
         Have
        a
        baccalaureate degree from an accredited university and if working with
        Children/Adolescents, have at least three (3) years full time or equivalent
        experience, working with the target population. If working with adults, the
        case
        manager must have two (2) years of experience. (Note: case managers who were
        certified by the Department prior to July 1, 1999, who do not meet the degree
        requirements, may provide Case Management services if they meet the other
        requirements; and

      

      c. Have
        completed a training program within six (6) months of employment. The training
        program must be prior approved by the Agency. The training must include a
        review
        of the local resources and a thorough presentation of the applicable State
        and
        federal statutes and promote the knowledge, skills, and competency of all
        case
        managers through the presentation of key core elements relevant to the target
        population. The case manager must also be able to demonstrate an understanding
        of the Health Plan’s Case Management policies and procedures.

      

      
        	 	
                8.
                  

              	
                Case
                  Management supervision must be provided by a person who has a master’s
                  degree in a human services field and three (3) years of professional
                  full
                  time experience serving this target population or a person with
                  a
                  bachelor’s degree and five (5) years of full time or equivalent Case
                  Management experience. For supervising case managers who work only
                  with
                  adults, two (2) years of full time experience is required. The
                  supervisors
                  must have had the approved Health Plan training in Case Management
                  or have
                  documentation that they have prior equivalent
                  training.

              

      

      

      
        	 	
                9.
                  

              	
                The
                  Health Plan shall have access to no less than one (1) fully accredited
                  psychiatric community Hospital bed per 2,000 Enrollees, as appropriate
                  for
                  both Children/Adolescents and adults. Specialty psychiatric Hospital
                  beds
                  may be used to count toward this requirement when psychiatric community
                  Hospital beds are not available within a particular community.
                  Additionally, the Health Plan shall have access to sufficient numbers
                  of
                  accredited Hospital beds on a medical/surgical unit to meet the
                  need for
                  medical detoxification treatment.

              

      

      

      
        	 	
                10.

              	
                The
                  Health Plan’s facilities must be licensed, as required by law and rule,
                  accessible to the handicapped, in compliance with federal Americans
                  with
                  Disabilities Act guidelines, and have adequate space, supplies,
                  good
                  sanitation, and fire, safety, and disaster preparedness and recovery
                  procedures in operation.

              

      

      

      
        	 	
                11.

              	
                The
                  Health Plan shall ensure that it has Providers that are qualified
                  to serve
                  Enrollees and experienced in serving severely emotionally disturbed
                  Children/Adolescents and severely and persistent mentally ill adults.
                  The
                  Health Plan shall maintain documentation of its Providers’ experience in
                  the Providers' credentialing file.

              

      

      

      
        	 	
                12.

              	
                The
                  Health Plan shall adhere to the staffing ratio of at least one
                  (1) FTE
                  Behavioral Health Care Case Manager for twenty (20) Children/Adolescents
                  and at least one (1) FTE Behavioral Health Care Case Manager per
                  forty
                  (40) adults. Direct Service Behavioral Health Care Providers shall
                  not
                  count as Behavioral Health Care Case
                  Managers.

              

      

      

      
        	 	
                13.

              	
                Prior
                  to commencement of Behavioral Health Services, the Health Plan
                  shall enter
                  into agreements for coordination of care and treatment of Enrollees,
                  jointly or sequentially served, with county community mental health
                  care
                  center(s) that are not a part of the Health Plan's Participating
                  Provider
                  network. The Health Plan shall enter into similar agreements with
                  agencies
                  funded pursuant to Chapter 394, F.S., 2004. The Agency shall approve
                  all
                  model agreements between the Health Plan and county community mental
                  health center(s)/agencies before the Health Plan enters into the
                  agreement. This requirement shall not apply if the Health Plan
                  provides
                  the Agency with documentation that shows the Health Plan has made
                  a good
                  faith effort to contract with county community mental health
                  center(s)/agencies, but could not reach an
                  agreement.

              

      

      

      
        	 	
                14.

              	
                The
                  Health Plan shall request current behavioral health care provider
                  information from all new Enrollees upon enrollment. The Health
                  Plan shall
                  solicit these behavioral health services providers to participate
                  in the
                  Health Plan's network. The Health Plan may request in writing that
                  the
                  Agency grant exemption to a Health Plan from soliciting a specific
                  behavioral health services provider on a case-by-case
                  basis.

              

      

      

      
        	 	
                15.

              	
                To
                  the maximum extent possible, the Health Plan shall contract for
                  the
                  provision of Behavioral Health Services with the State's community
                  mental
                  health centers designated by the Agency and
                  DCF.

              

      

      

      
        	F.	
                 Specialists
                  and Other Providers

              

      

      

      
        	 	
                1.

              	
                In
                  addition to the above requirements, the Health Plan shall assure
                  the
                  availability of the following specialists, as appropriate for both
                  adults
                  and pediatric members, on at least a referral basis. The Health
                  Plan shall
                  use Participating Specialists with pediatric expertise for
                  Children/Adolescents when the need for pediatric specialty care
                  is
                  significantly different from the need for adult specialty care
                  (for
                  example a pediatric cardiologist for Children/Adolescents with
                  congenital
                  heart defects).

              

      

      

      a. Allergist,

      

      b. Cardiologist,

      

      c. Endocrinologist,

      

      d. General
        Surgeon,

      

      e. Obstetrical/Gynecology
        (OB/GYN),

      

      f. Neurologist,

      

      g. Nephrologist,

      

      h. Orthopedist,

      

      i. Urologist,

      

      j. Dermatologist,

      

      k. Otolaryngologist,

      

      l. Pulmonologist,

      

      m. Chiropractic
        Physician,

      

      n. Podiatrist,

      

      o. Ophthalmologist,

      

      p. Optometrist,

      

      q. Neurosurgeon,

      

      r. Gastroenterologist,

      

      s. Oncologist,

      

      t. Radiologist,

      

      u. Pathologist,

      

      v. Anesthesiologist,

      

      w. Psychiatrist,

      

      x. Oral
        surgeon,

      

      y. Physical,
        respiratory, speech and occupational therapists, and

      

      z. Infectious
        disease specialist.

      

      
        	 	
                2.

              	
                If
                  the infectious disease specialist does not have expertise in HIV
                  and its
                  treatment and care, then the Health Plan must have another Provider
                  with
                  such expertise.

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan shall make a good faith effort to execute memoranda
                  of
                  agreement with the local CHDs to provide services which may include,
                  but
                  are not limited to, family planning services, services for the
                  treatment
                  of sexually transmitted diseases, other public health related diseases,
                  tuberculosis, immunizations, foster care emergency shelter medical
                  screenings, and services related to Healthy Start prenatal and
                  post natal
                  screenings. The Health Plan shall provide documentation of its
                  good faith
                  effort upon the Agency’s request.

              

      

      

      
        	 	
                4.

              	
                Notwithstanding
                  Section VIII.B.2, Certain Public Providers, of this Contract, the
                  Health
                  Plan shall pay, without prior authorization, at the contracted
                  rate or the
                  Medicaid Fee-for-Service rate, all valid claims initiated by any
                  CHD for
                  office visits, prescribed drugs, laboratory services directly related
                  to
                  DCF emergency shelter medical screening, and tuberculosis. The
                  Health Plan
                  need not reimburse the CHD until the CHD notifies the Plan and
                  provides
                  the Plan with copies of the appropriate medical records and provides
                  the
                  Enrollee's PCP with the results of any tests and associated office
                  visits.

              

      

      

      
        	 	
                5.

              	
                The
                  Health Plan shall make a good faith effort to execute a contract
                  with a
                  Federally Qualified Health Center (FQHC), and if applicable, a
                  Rural
                  Health Clinic (RHC). The Health Plan shall reimburse FQHCs and
                  RHCs at
                  rates comparable to those rates paid for similar services in the
                  FQHC's or
                  RHC's community. The Health Plan shall report to the Agency, on
                  a
                  quarterly basis, the payment rates and the payment amounts made
                  to FQHCs
                  and RHCs for contractual services provided by these
                  entities.

              

      

      

      
        	 	
                6.

              	
                The
                  Health Plan shall permit female Enrollees to have direct access
                  to a
                  women's health specialist within the network for Covered Services
                  necessary to provide women's routine and preventive health care
                  services.
                  This is in addition to an Enrollee's designated PCP, if that Provider
                  is
                  not a women's health specialist.

              

      

      

      G. Specialty
        Plan Provider Network

      

      A
        Health
        Plan that offers a Specialty Plan shall ensure its Provider network meets
        the
        following requirements:

      

      
        	 	
                1.

              	
                The
                  Provider network will be integrated and consist of PCPs and specialists
                  who are trained to provide services for a particular condition
                  or
                  population;

              

      

      

      
        	 	
                2.

              	
                If
                  the Specialty Plan has been developed for individuals with a particular
                  disease state, the network will contain a sufficient number of
                  board
                  certified specialists in the care and management of the disease.
                  Because
                  individuals have multiple diagnoses, there should be a sufficient
                  number
                  of specialists to manage different diagnoses as
                  well;

              

      

      

      
        	 	
                3.

              	
                A
                  defined network of facilities used for inpatient care shall be
                  included
                  with accredited tertiary hospitals and hospitals that have been
                  designated
                  for specific conditions, appropriate for the Specialty Plan population
                  (e.g., end stage renal disease centers, comprehensive hemophilia
                  centers;

              

      

      

      
        	 	
                4.

              	
                Specialty
                  pharmacies when appropriate; and

              

      

      

      
        	 	
                5.

              	
                A
                  range of community based care options as alternatives to hospitalization
                  and institutionalization.

              

      

      

      
        	H.	
                 Continuity
                  of Care

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall allow Enrollees in active treatment to continue
                  care
                  with a terminated treating provider when such care is Medically
                  Necessary,
                  through completion of treatment of a condition for which the Enrollee
                  was
                  receiving care at the time of the termination, until the Enrollee
                  selects
                  another treating Provider, or during the next Open Enrollment period.
                  None
                  of the above may exceed six (6) months after the termination of
                  the
                  Provider's contract.

              

      

      

      
        	 	
                2.

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

              

      

      

      
        	 	
                3.

              	
                Notwithstanding
                  the provisions in this subsection, a terminated provider may refuse
                  to
                  continue to provide care to an Enrollee who is abusive or
                  noncompliant.

              

      

      

      
        	 	
                4.

              	
                For
                  continued care under this subsection, the Health Plan and the terminated
                  provider shall continue to abide by the same terms and conditions
                  as
                  existed in the terminated contract.

              

      

      

      
        	 	
                5.

              	
                The
                  requirements set forth in this subsection shall not apply to providers
                  who
                  have been terminated from the Health Plan for
                  Cause.

              

      

      

      
        	 	
                6.

              	
                The
                  Health Plan shall develop and maintain policies and procedures
                  for the
                  above requirements. 

              

      

      

      
        	I.	
                Network
                  Changes

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall notify the Agency within seven (7) Business Days
                  of any
                  significant changes to the Health Plan network. A significant change
                  is
                  defined as:

              

      

      

      a. A
        decrease in the total number of PCPs by more than five percent
        (5%);

      

      b. A
        loss of
        all Participating Specialists in a specific specialty where another
        Participating Specialist in that specialty is not available within sixty
        (60)
        minutes;

      

      c. A
        loss of
        a Hospital in an area where another Health Plan Hospital of equal service
        ability is not available within thirty (30) minutes; or

      

      d. Other
        adverse changes to the composition of the network which impair or deny the
        Enrollee's adequate access to Providers.

      

      
        	 	
                2.

              	
                The
                  Health Plan shall have procedures to address changes in the Health
                  Plan
                  network that negatively affect the ability of Enrollees to access
                  services, including access to a culturally diverse Provider network.
                  Significant changes in network composition that negatively impact
                  Enrollee
                  access to services may be grounds for Contract termination or Agency
                  determined sanctions.

              

      

      

      
        	 	
                3.

              	
                If
                  a PCP ceases participation in the Health Plan network, the Health
                  Plan
                  shall send written notice to the Enrollees who have chosen the
                  Provider as
                  their PCP. This notice shall be issued no less than ninety (90)
                  Calendar
                  Days prior to the effective date of the termination and no more
                  than ten
                  (10) Calendar Days after receipt or issuance of the termination
                  notice.
                  

              

      

      

      a. If
        an
        Enrollee is in a Prior Authorized ongoing course of treatment with any other
        Provider who becomes unavailable to continue to provide services, the Health
        Plan shall notify the Enrollee in writing within ten (10) Calendar Days from
        the
        date the Health Plan becomes aware of such unavailability.

      

      b. These
        requirements to provide notice prior to the effective dates of termination
        shall
        be waived in instances where a Provider becomes physically unable to care
        for
        Enrollees due to illness, a Provider dies, the Provider moves from the Service
        Area and fails to notify the Health Plan, or when a Provider fails
        credentialing. Under these circumstances, notice shall be issued immediately
        upon the Health Plan becoming aware of the circumstances.

      

      

      REMAINDER
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      Section
        VIII

      Quality
        Management

      

      	A.  	
              Quality
                Improvement

            

       

      	1.  	
              General
                Requirements

            

      

      a. The
        Health Plan shall have an ongoing Quality Improvement Program (QIP) that
        objectively and systematically monitors and evaluates the quality and
        appropriateness of care and services rendered, thereby promoting Quality
        of care
        and Quality patient outcomes in service performance to its
        Enrollees.

      

      b. The
        Health Plan’s written policies and procedures shall address components of
        effective health care management including, but not limited to anticipation,
        identification, monitoring, measurement, evaluation of Enrollee’s health care
        needs, and effective action to promote Quality of care. 

      

      c. The
        Health Plan shall define and implement improvements in processes that enhance
        clinical efficiency, provide effective utilization, and focus on improved
        outcome management achieving the highest level of success. 

      

      d. The
        Health Plan and its QIP shall demonstrate in its care management, specific
        interventions to better manage the care and promote healthier Enrollee outcomes.
        

      

      e. The
        Health Plan shall cooperate with the Agency and the External Quality Review
        Organization (EQRO). The Agency will set methodology and standards for QI
        (spell
        out first time) with advice from the EQRO.

      

      f. Prior
        to
        implementation, the Agency and/or the EQRO shall review the Health Plan
        QIP.

      

      g. The
        Health Plan must submit its QIP to the Agency no later than the execution
        date
        of the Contract. The QIP must be approved, in writing, by the Agency no later
        than three (3) months following the execution of this Contract. 

      

      
        	 	
                2.
                  

              	
                Specific
                  Required Components of the
                  QIP

              

      

      

      a. The
        Health Plan’s governing body shall oversee and evaluate the QIP. The role of the
        Health Plan’s governing body shall include providing strategic direction to the
        QIP, as well as ensuring the QIP is incorporated into the operations throughout
        the Health Plan.

      

      b. The
        Health Plan shall have a QIP Committee. The Chairman of the Committee shall
        be
        the Health Plan Medical Director. Appropriate Health Plan staff representing
        the
        various departments of the organization shall have membership on the Committee.
        The Committee shall meet on a regular periodic basis. Its responsibilities
        shall
        include the following:

      

      (1) Development
        and implementation of a written QI plan, which incorporates the strategic
        direction provided by the governing body.

      

      (2) The
        QI
        plan shall reflect a coordinated strategy to implement the QIP including
        planning, decision making, intervention, and assessment of results.

      

      (3) The
        QI
        plan shall include a description of the Health Plan staff assigned to the
        QIP;
        their specific training regarding Medicaid; how they are organized; and their
        responsibilities.

      

      (4) The
        QI
        plan shall describe the role of its Providers in giving input to the QIP,
        whether that is by membership on the Committee, its Sub-Committees, or other
        means.

      

      (5) The
        Health Plan is encouraged to include an advocate representative on the QIP
        Committee.

      

      (6) The
        Health Plan shall submit its written QI plan to the Agency for written approval
        within thirty (30) days of the execution of the Contract.

      

      c. Direct
        and review QI activities, including, but not limited to:

      

      (1) Assure
        that QIP activities take place throughout the Health Plan;

      

      (2) Review
        and suggest new and/or improved QI activities;

      

      (3) Direct
        task forces/committees to review areas of concern in the provision of health
        care services to Enrollees;

      

      (4) Designate
        evaluation and study design procedures;

      

      (5) Report
        findings to appropriate executive authority, staff, and departments within
        the
        Health Plan; and 

      

      (6) Direct
        and analyze periodic reviews of Enrollees' service utilization
        patterns.

       

      d. Maintain
        minutes of all Committee and Sub-Committee meetings.

      

      
        	 	
                3.

              	
                Health
                  Plan QI Activities

              

      

      

      The
        Health Plan shall monitor and evaluate the quality and appropriateness of
        care
        and service delivery (or the failure to provide care or deliver services)
        to
        Enrollees through performance improvement projects (PIPs), medical record
        audits, performance measures, surveys, and related activities. 

      

      a. PIPs

      

      The
        Health Plan shall perform no less than six (6) Agency approved performance
        improvement projects.

      

      (1) Each
        PIP
        must include a statistically significant sample of Enrollees.

      

      (2) At
        least
        one (1) of the PIPs must focus on Language and Culture, Clinical Health Care
        Disparities, or Culturally and Linguistically Appropriate Services.

      

      (3) At
        least
        two (2) of the PIPs must relate to Behavioral Health Services.

      

      (4) All
        PIPs
        by the Health Plan must achieve, through ongoing measurements and intervention,
        significant improvement to the Quality of care and service delivery, sustained
        over time, in both clinical care and non-clinical care areas that are expected
        to have a favorable effect on health outcomes and Enrollee
        satisfaction.

      

      (5) The
        PIPs
        must be completed in a reasonable time period so as to allow the Health Plan
        to
        evaluate the information drawn from them and to use the results of the analysis
        to improve Quality of care and service delivery every year.

      

      (6) Within
        three months of the execution of this Contract, the Health Plan shall submit,
        in
        writing, a description of each of the PIPs to the Agency for approval. The
        detailed description shall include: 

      

      	i.  	
              An
                overview explaining how and why the project was selected, as well
                as its
                relevance to the Health Plan Enrollees and
                Providers;

            

      

      	ii.  	
              The
                study question;

            

      

      	iii.  	
              The
                study population;

            

      

      	iv.  	
              The
                quantifiable measures to be used, including a goal or
                benchmark;

            

      

      	v.  	
              Baseline
                methodology;

            

      

      	vi.  	
              Data
                sources;

            

      

      	vii.  	
              Data
                collection methodology;

            

      

      	viii.  	
              Data
                collection cycle;

            

      

      	ix.  	
              Data
                analysis cycle;

            

      

      	x.  	
              Results
                with quantifiable measures;

            

      

      	xi.  	
              Analysis
                with time period and the measures
                covered;

            

      

      	xii.  	
              Analysis
                and identification of opportunities for improvement;
                and

            

      

      	xiii.  	
              An
                explanation of all interventions to be
                taken.

            

      

      b. Behavioral
        Health QI Requirements

      

      (1) 
        The
        Health Plan's QIP shall include a Behavioral Health component in order to
        monitor and assure that the Health Plan's Behavioral Health Services are
        sufficient in quantity, of acceptable Quality and meet the needs of the
        Enrollees. 

      

      (2) Treatment
        plans must:

      

      	i.  	
              Identify
                reasonable and appropriate objectives;

            

      

      	ii.  	
              Provide
                necessary services to meet the identified objectives;
                and

            

      

      	iii.  	
              Include
                retrospective reviews that confirm that the care provided, and its
                outcomes, were consistent with the approved treatment plans and
                appropriate for the Enrollees' needs.

            

      

      (3) In
        determining if Behavioral Health Services are acceptable according to current
        treatment standards, the Health Plan shall:

      

      	i.  	
              Perform
                a quarterly review of a random selection of ten percent (10%) or
                fifty
                (50) medical records, whichever is more, of Enrollees who received
                Behavioral Health Services during the previous quarter;
                and

            

      

      	ii.  	
              Elements
                of these reviews shall include, but not be limited to:
                

            

      

      
        	 	
                (a)

              	
                Management
                  of specific diagnoses;

              

      

      

      
        	 	
                (b)

              	
                Appropriateness
                  and timeliness of care;

              

      

      

      
        	 	
                (c)

              	
                Comprehensiveness
                  of and compliance with the plan of
                  care;

              

      

      

      
        	 	
                (d)

              	
                Evidence
                  of special screening for high risk Enrollees and/or conditions;
                  and

              

      

      

      
        	 	
                (e)

              	
                Evidence
                  of appropriate coordination of
                  care.

              

      

      

      (4) In
        areas
        in which there is not an established local advisory group, the Health Plan
        is
        responsible for the development of local advisory group meetings within sixty
        (60) days of the effective date of the Contract.

      

      (5) In
        areas
        where there is more than one (1) Health Plan authorized to provide Behavioral
        Health Services, the Health Plans shall work together in establishing an
        area
        local advisory group.

      

      (6) Composition
        of local advisory groups shall follow Section X. Administration and Management,
        I., Health Plan Local Advisory Group.

      

      (7) The
        Health Plan shall send representation to the local advisory group’s meetings
        that convene quarterly and report to the Agency on the Behavioral Health
        advocacy and programmatic concerns.

      

      (8) Local
        advisory groups shall provide technical and policy advice to the Agency
        regarding Behavioral Health Services.

      

      c. Performance
        Measures (PMs) 

      

      The
        Health Plan shall collect data on patient outcome PMs, as defined by the
        Health
        Plan Employee Data and Information Set (HEDIS) or otherwise defined by the
        Agency and report the results of the measures to the Agency annually. The
        Agency
        may add or remove reporting requirements with 30-days advance notice. At
        a
        minimum, the following PMs shall be measured by the Health Plan:

      

      (1) Breast
        Cancer Screening;

      

      (2) Cervical
        Cancer Screening;

      

      (3) Colorectal
        Cancer Screening;

      

      (4) Well
        Child Visits in the First 15 Months of Life;

      

      (5) Well
        Child Visits in the Third, Fourth, Fifth and Sixth Years of Life;

      

      (6) Adolescent
        Well Care Visits;

      

      (7) Childhood
        Immunization Status; 

      

      (8) Adolescent
        Immunization Status;

      

      (9) Preventive
        and Total Dental Visits for Children/Adolescents Between Three Years and
        Eleven
        Years and for Children/Adolescents Between Twelve Years and Twenty Years
        of
        Age;

      

      (10) Average
        number of days spent in the community by all Enrollees receiving Behavioral
        Health intensive case management services;

      

      (11) Number
        of
        enrollees admitted to the State Mental Hospital;

      

      (12) Amount
        of
        time between discharge from the State Mental Hospital and first date of service
        received from the Provider; and

      

      (13) Number
        of
        Enrollees who receive a psychiatric evaluation within required time frames
        prior
        to admission to a nursing facility.

      

      (14) Agency-specified
        data on the five Disease Management programs for chronic conditions specified
        in
        subsection B.6.a. of this Section.

      

      d. Consumer
        Assessment of Health Plans Survey (CAHPS)

      

      At
        the
        end of the first (1st) year under this Contract, the Agency shall conduct
        an
        annual Consumer Assessment of Health Plans Survey. The CAHPS survey shall
        be
        done on an annual basis thereafter. The Vendor shall a corrective action
        plan to
        address the results of the CAHPS Survey within two (2) months of the request
        from the Agency. 

      

      e. Provider
        Satisfaction Survey

      

      The
        Health Plan shall submit a Provider satisfaction survey plan, including the
        questions to be asked, to the Agency for written approval by the end of the
        eighth (8th) month of this Contract. The Health Plan shall conduct the survey
        at
        the end of the first (1st) year of this Contract. The results of the Provider
        satisfaction survey shall be reported to the Agency within four (4) months
        of
        the beginning of the second year of this Contract. 

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      f. Medical
        Record Review

      

      (1) If
        the
        Health Plan is not accredited, or if the Health Plan is accredited by an
        entity,
        that does not review the Medical Records of the Health Plan's PCPs, then
        the
        Health Plan shall conduct reviews of Enrollees’ Medical Records to ensure that
        PCPs provide high Quality health care that is documented according to
        established standards. 

      

      (2) The
        standards, which must include all Medical Record documentation requirements
        addressed in this Contract, must be distributed to all Providers. 

      

      (3) The
        Health Plan must conduct these reviews at all PCP sites that serve fifty
        (50) or
        more Enrollees. 

      

      (4) Practice
        sites include both individual offices and large group facilities. 

      

      (5) The
        Health Plan must review each practice site at least one (1) time during each
        two
        (2) year period. 

      

      
        	 	
                (6)

              	
                The
                  Health Plan must review a reasonable number of records at each
                  site to
                  determine compliance. Five (5) to ten (10) records per site is
                  a
                  generally-accepted target, though additional reviews must be completed
                  for
                  large group practices or when additional data is necessary in specific
                  instances. 

              

      

      

      
        	 	
                (7)

              	
                The
                  Health Plan shall report the results of all Medical Record reviews
                  to the
                  Agency within thirty (30) Calendar Days of the
                  review.

              

      

      

      
        	 	
                (8)

              	
                The
                  Health Plan must submit to the Agency for written approval and
                  maintain a
                  written strategy for conducting Medical Record reviews. The strategy
                  must
                  include, at a minimum, the following:

              

      

      

      i. Designated
        staff to perform this duty; 

      

      ii. The
        method of case selection; 

      

      iii. The
        anticipated number of reviews by practice site; 

      

      iv. The
        tool
        that the Health Plan will use to review each site; and

      

      v. How
        the
        Health Plan will link the information compiled during the review to other
        Health
        Plan functions (e.g., QI, credentialing, Peer Review, etc.).

      

      g. Peer
        Review

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall have a Peer Review process which:
                  

              

      

      

      i. Reviews
        a
        Provider's practice methods and patterns, morbidity/mortality rates, and
        all
        Grievances filed against the Provider relating to medical
        treatment.

      

      ii. Evaluates
        the appropriateness of care rendered by Providers.

      

      iii. Implements
        corrective action(s) when the Health Plan deems it necessary to do
        so.

      

      iv. Develops
        policy recommendations to maintain or enhance the Quality of care provided
        to
        Enrollees.

      

      v. Conducts
        reviews which include the appropriateness of diagnosis and subsequent treatment,
        maintenance of a Provider's Medical Records, adherence to standards generally
        accepted by a Provider's peers and the process and outcome of a Provider's
        care.

      

      vi. Appoints
        a Peer Review Committee, as a Sub-Committee to the QIP Committee, to review
        provider performance when appropriate. The Medical Director or his/her designee
        shall chair the Peer Review Committee, and its membership shall be drawn
        from
        the Provider Network and include peers of the Provider being
        reviewed.

      

      vii. Receive
        and review all written and oral allegations of inappropriate or aberrant
        service
        by a Provider.

      

      viii. Educate
        Enrollees and Health Plan staff about the Peer Review process, so that Enrollees
        and the Health Plan staff can notify the Peer Review authority of situations
        or
        problems relating to Providers.

      

      h. Credentialing
        and Recredentialing 

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall be responsible the credentialing and recredentialing
                  of
                  its Provider network. Hospital ancillary Providers are not required
                  to be
                  independently credentialed if those Providers only provide services
                  to the
                  Health Plan Enrollees through the
                  Hospital.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall establish and verify credentialing and recredentialing
                  criteria for all professional Providers that, at a minimum, meet
                  the
                  Agency's Medicaid participation standards. The Agency’s criterion
                  includes:

              

      

      

      i. A
        completed Medicaid Agreement with a copy of each Provider's current medical
        license sent to the Agency’s Fiscal Agent and verification that the Provider is
        an approved Medicaid provider. The Provider’s active licensure shall suffice in
        lieu of verification of education, training, and professional liability coverage
        requirements.

      

      ii. No
        receipt of revocation or suspension of the Provider's State License by the
        Division of Medical Quality Assurance, Department of Health.

      

      iii. No
        ongoing investigation(s) by Medicaid Program Integrity, Medicaid Fraud and
        Control Unit, Medicare, Medical Quality Assurance, or other governmental
        entities.

      

      
        	 	
                (3)

              	
                The
                  Health Plan's credentialing files must document the education,
                  experience,
                  prior training and ongoing service training for each staff member
                  or
                  Provider rendering Behavioral Health
                  Services.

              

      

      

      
        	 	
                (4)

              	
                The
                  following additional requirements apply to physicians and must
                  ensure
                  compliance with 42 CFR 438.214:

              

      

      

      i. Good
        standing of privileges at the Hospital designated as the primary admitting
        facility by the PCP or if the Provider does not have admitting privileges,
        good
        standing of privileges at the Hospital by another physician with whom the
        PCP
        has entered into an arrangement for Hospital coverage.

      

      ii. Valid
        Drug Enforcement Administration (DEA) certificates, where
        applicable.

      

      iii. Attestation
        that the total active patient load (all populations with Medicaid
        Fee-for-Service (FFS), CMS Network, Health Maintenance Organization (HMO),
        Health Plan, Medicare or commercial coverage) is no more than 3,000 patients
        per
        PCP. An active patient is, one that is, seen by the Provider a minimum of
        three
        (3) times per year.

      

      iv. Passage
        of a criminal background check, within the previous twelve (12) months from
        the
        date of the Enrollment application, by the Provider, any officer, director,
        agent managing employee, affiliated person, or any partner or shareholder
        having
        an ownership interest of five percent (5%) or greater in the Provider. (If
        the
        Provider is a corporation, partnership, or other business entity.)

      

      v. A
        good
        standing report on a credentialing site visit survey.

      

      vi. Attestation
        to the correctness/completeness of the Provider's application.

      

      vii. Statement
        regarding any history of loss or limitation of privileges or disciplinary
        activity.

      

      viii. Current
        curriculum vitae, which includes at least five (5) years of work
        history.

      

      
        	 	
                4.

              	
                Agency
                  Oversight

              

      

      

      a. The
        Agency shall evaluate the Health Plan’s QIP and PMs at least one (1) time per
        year at dates to be determined by the Agency, or as otherwise specified by
        this
        Contract.

      

      b. The
        Health Plan, in conjunction with the Agency, shall participate in workgroups
        to
        design additional QI strategies and to learn to use the best practice methods
        for enhancing the Quality of health care provided to Enrollees.

      

      c. If
        the
        PIPs, CAHPS, the PMs, the annual Medical Record audit or the EQRO indicate
        that
        the Health Plan's performance is not acceptable, then the Agency may restrict
        the Health Plan’s Enrollment activities including, but not limited to,
        termination of Mandatory Assignments.

      

      d. If
        the
        Agency determines that the Health Plan’s performance is not acceptable, the
        Agency shall require the Health Plan to submit a corrective action plan (CAP).
        f
        the Health Plan fails to provide a CAP within the time specified by the Agency,
        the Agency shall sanction the Health Plan, in accordance with the provisions
        of
        Section XIV, Sanctions, and may immediately terminate all Enrollment activities
        and Mandatory Assignments. When considering whether to impose a limitation
        on
        Enrollment activities or Mandatory Assignment, the Agency may take into account
        the Health Plan’s cumulative performance on all QI activities.

      

      

      e. Annual
        Medical Record Audit

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall furnish specific data requested by the Agency
                  in order
                  to conduct the Medical Record
                  audit.

              

      

      

      
        	 	
                (2)

              	
                If
                  the Medical Record audit indicates that Quality of care is not
                  acceptable,
                  pursuant to contractual requirements, the Agency shall sanction
                  the Health
                  Plan, in accordance with the provisions of Section XIV, Sanctions,
                  and may
                  immediately terminate all Enrollment activities and Mandatory Assignments,
                  until the Health Plan attains an acceptable level of Quality of
                  care as
                  determined by the Agency.

              

      

      

      f. Independent
        Medical Record Review by an EQRO

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall provide all information requested by the EQRO
                  and/or the
                  Agency, including, but not limited to quality outcomes concerning
                  timeliness of, and Enrollee access to, Covered
                  Services.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall cooperate with the EQRO during the Medical Record
                  review, which will be done at least one (1) time per year.
                  

              

      

      

      
        	 	
                (3)

              	
                If
                  the EQRO indicates that the Quality of care is not within acceptable
                  limits set forth in this Contract, the Agency shall sanction the
                  Health
                  Plan, in accordance with the provisions of Section XIV, Sanctions
                  and may
                  immediately terminate all Enrollment activities and Mandatory Assignments
                  until the Health Plan attains a satisfactory level of Quality of
                  care as
                  determined by the EQRO.

              

      

      

      

      	B.  	
              Utilization
                Management (UM)

            

       

      

      
        	 	
                1.

              	
                General
                  Requirements

              

      

      

      The
        UM
        program shall be consistent with 42 CFR 456 and include, but not be limited
        to:

      

      a. Procedures
        for identifying patterns of over-utilization and under-utilization by Enrollees
        and for addressing potential problems identified as a result of these
        analyses.

      

      b. The
        Health Plan shall report Fraud and Abuse information identified through the
        Utilization Management program to the Agency’s contract manager, MPI and MFCU as
        described in Section X, and referenced in 42 C.F.R. 455.1(a)(1).

      

      c. A
        procedure for Enrollees to obtain a second medical opinion and that the Health
        Plan shall be responsible for authorizing claims for such services in accordance
        with section 641.51, F.S.

      

      d. Service
        Authorization protocols for Prior Authorization and denial of services; the
        process used to evaluate prior and con-current authorization; mechanisms
        to
        ensure consistent application of review criteria for authorization decisions;
        consultation with the requesting Provider when appropriate, Hospital discharge
        planning, physician profiling; and a retrospective review of both inpatient
        and
        ambulatory claims, meeting the predefined criteria below. The Health Plan
        shall
        be responsible for ensuring the consistent application of review criteria
        for
        authorization decisions and consulting with the requesting Provider when
        appropriate.

      

      
        	 	
                (1)

              	
                The
                  Health Plan must have written approval from the Agency for its
                  Service
                  Authorization protocols and for any changes to the original protocols.
                  

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan's Service Authorization systems shall provide the
                  authorization number and effective dates for authorization to
                  Participating Providers and non-participating
                  Providers.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan's Service Authorization systems shall provide written
                  confirmation of all denials of authorization to providers. (See
                  42 C.F.R.
                  438.210(c)).

              

      

      

      i. The
        Health Plan may request to be notified, but shall not deny claims payment
        based
        solely on lack of notification, for the following:

      

      
        	 	
                (a)

              	
                Inpatient
                  emergency admissions (within ten (10)
                  days);

              

      

      

      
        	 	
                (b)

              	
                Obstetrical
                  care (at first visit);

              

      

      

      
        	 	
                (c)

              	
                Obstetrical
                  admissions exceeding forty-eight (48) hours for vaginal delivery
                  and
                  ninety-six (96) hours for caesarean section;
                  and

              

      

      

      
        	 	
                (d)

              	
                Transplants.

              

      

      

      ii. The
        Health Plan shall ensure that all decisions to deny a Service Authorization
        request, or limit a service in amount, duration, or scope that is less than
        requested, are made by Health Care Professionals who have the appropriate
        clinical expertise in treating the Enrollee’s condition or disease. (See 42
        C.F.R. 438.210(b)(3))

      

      
        	 	
                (4)

              	
                Only
                  a licensed psychiatrist may authorize a denial for an initial or
                  concurrent authorization of any request for Behavioral Health Services.
                  The psychiatrist's review shall be part of the UM process and not
                  part of
                  the clinical review, which may be requested by a Provider or the
                  Enrollee,
                  after the issuance of a denial.

              

      

      

      
        	 	
                (5)

              	
                The
                  Health Plan shall provide post authorization to County Health Departments
                  (CHD) for the provision of emergency shelter medical screenings
                  provided
                  for clients of DCF.

              

      

      

      
        	 	
                (6)

              	
                Health
                  Plans with automated authorization systems may not require paper
                  authorization as a condition of receiving
                  treatment.

              

      

      

      
        	 	
                2.

              	
                Certain
                  Public Providers 

              

      

      

      a. The
        Health Plan shall authorize all claims, from a CHD, a migrant health center
        funded under Section 329 of the Public Health Services Act or a community
        health
        center funded under Section 330 of the Public Health Services Act, without
        Prior
        Authorization for the following:

      
        	 	
                (1)

              	
                The
                  diagnosis and treatment of sexually transmitted diseases and other
                  communicable diseases, such as tuberculosis and human immunodeficiency
                  syndrome;

              

      

      

      
        	 	
                (2)

              	
                The
                  provision of immunizations;

              

      

      

      
        	 	
                (3)

              	
                Family
                  planning services and related
                  pharmaceuticals;

              

      

      

      
        	 	
                (4)

              	
                School
                  health services listed in (1), (2) and (3) above, and for services
                  rendered on an urgent basis by such Providers;
                  and,

              

      

      

      
        	 	
                (5)

              	
                In
                  the event that a vaccine-preventable disease emergency is declared,
                  the
                  Health Plan shall authorize claims from the County Health Department
                  for
                  the cost of the administration of
                  vaccines.

              

      

      

      b. The
        providers specified in B.2.a. above, shall attempt to contact the Health
        Plan
        before providing health care services to Enrollees. Such providers shall
        provide
        the Health Plan with the results of the office visit, including test results,
        and shall be reimbursed by the Health Plan at the rate negotiated between
        the
        Health Plan and the public provider or the Medicaid Fee-for-Service
        rate.

      

      c. The
        Health Plan shall not deny claims for services delivered by the providers
        specified in B.2.a. above solely based on the period between the date of
        service
        and the date of clean claim submission, unless that period exceeds 365 Calendar
        Days.

      

      
        	 	
                3.

              	
                Notice
                  of Action

              

      

      

      a. The
        Health Plan shall notify the Enrollee, in writing, using language at, or
        below
        the fourth grade reading level, of any Action taken by the Health Plan to
        deny a
        Service Authorization request, or limit a service in amount, duration, or
        scope
        that is less than requested. (See 42 C.F.R. 438.404(a) and (c) and 42 C.F.R.
        438.10(c) and (d))

       

      b. The
        Health Plan must provide notice to the Enrollee as set forth below: (See
        42
        C.F.R. 438.404(a) and (c) and 42 C.F.R. 438.210(b) and (c)) 

      

      
        	 	
                (1)

              	
                The
                  Action the Health Plan has taken or intends to
                  take.

              

      

      

      
        	 	
                (2)

              	
                The
                  reasons for the Action, customized for the circumstances of the
                  Enrollee.

              

      

      

      
        	 	
                (3)

              	
                The
                  Enrollee’s or the Provider's (with written permission of the Enrollee)
                  right to file an Appeal.

              

      

      

      
        	 	
                (4)

              	
                The
                  procedures for filing an Appeal.

              

      

      

      
        	 	
                (5)

              	
                The
                  circumstances under which expedited resolution is available and
                  how to
                  request it.

              

      

      

      
        	 	
                (6)

              	
                Enrollee
                  rights to request that Benefits continue pending the resolution
                  of the
                  Appeal, how to request that Benefits be continued, and the circumstances
                  under which the Enrollee may be required to pay the costs of these
                  services.

              

      

      

      c. The
        Health Plan must provide the notice of Action within the following time
        frames:

      

      
        	 	
                (1)

              	
                At
                  least ten (10) Calendar Days before the date of the Action or fifteen
                  (15)
                  Calendar Days if the notice is sent by Surface Mail (five [5] Calendar
                  Days if the Health Plan suspects Fraud on the part of the Enrollee.
                  (See
                  42 C.F.R. 431.211, 42 C.F.R. 431.213 and 42 C.F.R. 431.214)
                  

              

      

      

      
        	 	
                (2)

              	
                For
                  denial of the claim, at the time of any Action affecting the
                  claim.

              

      

      

      
        	 	
                (3)

              	
                For
                  standard Service Authorization decisions that deny or limit services,
                  as
                  quickly as the Enrollee’s health condition requires, but no later than
                  fourteen (14) Calendar Days following receipt of the request for
                  service.
                  (See 42 C.F.R. 438.201(d)(1))

              

      

      

      
        	 	
                (4)

              	
                If
                  the Health Plan extends the time frame for notification, it
                  must:

              

      

      1.  

      i. Give
        the
        Enrollee written notice of the reason for the extension and inform the Enrollee
        of the right to file a Grievance if the Enrollee disagrees with the Health
        Plan’s decision to extend the time frame.

      

      ii. Carry
        out
        its determination as quickly as the Enrollee's health condition requires,
        but in
        no case later than the date upon which the fourteen (14) Calendar Day extension
        period expires. (See 42 C.F.R. 438.210(d)(1))

      2.  

      
        	 	
                (5)

              	
                If
                  the Health Plan fails to reach a decision within the time frames
                  described
                  above, the failure on the part of the Health Plan shall be considered
                  a
                  denial and is an Action adverse to the Enrollee. (See 42 C.F.R.
                  438.210(d))

              

      

      

      
        	 	
                (6)

              	
                For
                  expedited Service Authorization decisions, within the three (3)
                  Business
                  Days (with the possibility of a fourteen (14) Calendar Day extension)
                  (See
                  42 C.F.R. 438.210(d)(2))

              

      

      

      
        	 	
                (7)

              	
                The
                  Health Plan shall provide timely approval or denial of authorization
                  of
                  out-of-network use through the assignment of a Prior Authorization
                  number,
                  which refers to and documents the approval. The Health Plan shall
                  provide
                  written follow-up documentation of the approval or the denial to
                  the
                  out-of-network provider within five (5) Business Days from the
                  request for
                  approval.

              

      

      

      
        	 	
                (8)

              	
                The
                  Health Plan shall determine when exceptional referrals to out-of-network
                  specially qualified providers are needed to address the unique
                  medical
                  needs of an Enrollee (e.g., when an Enrollee’s medical condition requires
                  testing by a geneticist). The Health Plan shall develop and maintain
                  policies and procedures for such
                  referrals.

              

      

      

      
        	 	
                4.

              	
                Care
                  Management

              

      

      

      The
        Health Plan shall be responsible for the management of medical care and
        continuity of care for all Enrollees. The Health Plan shall maintain written
        Case Management and continuity of care protocols that include the following
        minimum functions:

      

      a. Appropriate
        referral and scheduling assistance of Enrollees needing specialty health
        care/Transportation services, including those identified through Child Health
        Check-Up Program (CHCUP) Screenings.

      

      b. Determination
        of the need for Non-Covered Services and referral of the Enrollee for assessment
        and referral to the appropriate service setting (to include referral to WIC
        and
        Healthy Start) utilizing assistance as needed by the area Medicaid
        office.

      

      c. Case
        Management follow-up services for children, who the Health Plan identifies
        through blood Screenings as having abnormal levels of lead.

      

      d. Coordinated
        Hospital/institutional discharge planning that includes post-discharge care,
        including skilled, short-term, skilled nursing facility care, as
        appropriate.

      

      e. A
        mechanism for direct access to specialists for Enrollees identified as having
        special health care needs, as is appropriate for their condition and identified
        needs.

      

      f. The
        Health Plan shall have an outreach program and other strategies for identifying
        every pregnant Enrollee. This shall include case management, claims analysis,
        and use of health risk assessment, etc. The Health Plan shall require its
        participating Providers to notify the Health Plans of any Medicaid Enrollee
        who
        is identified as being pregnant. 

      

      g. Documentation
        of referral services in Enrollees’ medical records, including results.

      

      h. Monitoring
        of Enrollees with ongoing medical conditions and coordination of services
        for
        high utilizers such that the following functions are addressed as appropriate:
        acting as a liaison between the Enrollee and Providers, ensuring the Enrollee
        is
        receiving routine medical care, ensuring that the Enrollee has adequate support
        at home, assisting Enrollees who are unable to access necessary care due
        to
        their medical or emotional conditions or who do not have adequate community
        resources to comply with their care, and assisting the Enrollee in developing
        community resources to manage the member’s medical condition. 

      

      i. Documentation
        of emergency care encounters in Enrollees’ records with appropriate medically
        indicated follow-up. 

      

      j. Coordination
        of hospital/institutional discharge planning that includes post-discharge
        care,
        including skilled short-term rehabilitation, and skilled nursing facility
        care,
        as appropriate. 

      

      k. Share
        with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its
        identification and assessment of any enrollee with special health care needs
        so
        that those activities need not be duplicated.

      

      l. Ensure
        that in the process of coordinating care, each Enrollee's privacy is protected
        consistent with the confidentiality requirements in 45 CFR parts 160 and
        164. 45
        CFR Part 164 specifically describes the requirements regarding the privacy
        of
        individually identifiable health information. 

      

      
        	 	
                5.

              	
                New
                  Enrollee Procedures

              

      

      

      a. The
        Health Plan shall not delay Service Authorization if written documentation
        is
        not available in a timely manner.

      

      b. The
        Health Plan shall contact each new Enrollee at least two (2) times, if
        necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment
        to
        schedule the Enrollee's initial appointment with the PCP for the purpose
        of
        obtaining a health risk assessment and/or CHCUP Screening. For this subsection,
        "contact" is defined as mailing a notice to, or telephoning, an Enrollee
        at the
        most recent address or telephone number available.

      

      c. The
        Health Plan shall urge Enrollees to see their PCPs within 180 Calendar Days
        of
        Enrollment.

      

      d. The
        Health Plan shall contact each new Enrollee within thirty (30) Calendar Days
        of
        Enrollment to request that the Enrollee authorize the release of his or her
        Medical Records (including those related to Behavioral Health Services) to
        the
        Health Plan, or the Health Plan's health services subcontractor, from those
        providers who treated the Enrollee prior to the Enrollee's Enrollment with
        the
        Health Plan. Also, the Health Plan shall request or assist the Enrollee's
        new
        PCP by requesting the Enrollee's Medical Records from the previous
        providers.

      

      e. The
        Health Plan shall use the Enrollee's health risk assessments and/or released
        Medical Records to identify Enrollee's who have not received CHCUP Screenings
        in
        accordance with the Agency approved periodicity schedule.

      

      f. The
        Health Plan shall contact, up to two (2) times if necessary, any Enrollee
        more
        than two (2) months behind in the Agency approved periodicity Screening schedule
        to urge those Enrollees, or their legal representatives, to make an appointment
        with the Enrollees' PCPs for a Screening visit.

      

      g. Within
        thirty (30) Calendar Days of Enrollment, the Health Plan shall notify Enrollees
        of, and ensures the availability of, a Screening for all Enrollees known
        to be
        pregnant or who advise the Health Plan that they may be pregnant. The Health
        Plan shall refer Enrollees who are, or may be, pregnant to the appropriate
        Provider stating that the Enrollee can obtain appropriate prenatal
        care.

      

      h. The
        Health Plan shall honor any written documentation of Prior Authorization
        of
        ongoing Covered Services for a period of thirty (30) Business Days after
        the
        effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's
        treatment plan for the following types of Enrollees:

      

      
        	 	
                (1)

              	
                Enrollees
                  who voluntarily enrolled; and

              

      

      

      
        	 	
                (2)

              	
                Those
                  Enrollees who were automatically reenrolled after regaining Medicaid
                  eligibility.

              

      

      

      i. For
        Mandatory Assignment Enrollees, the Health Plan shall honor any written
        documentation of Prior Authorization of ongoing services for a period of
        one (1)
        month after the effective date of Enrollment or until the Mandatory Assignment
        Enrollee's PCP reviews the Enrollee's treatment plan, whichever comes
        first.

      

      j. For
        all
        Enrollees, written documentation of Prior Authorization of ongoing services
        includes the following, provided that the services were prearranged prior
        to
        Enrollment with the Health Plan:

      

      
        	 	
                (1)

              	
                Prior
                  existing orders;

              

      

      

      
        	 	
                (2)

              	
                Provider
                  appointments, e.g. dental appointments, surgeries, etc.;
                  and

              

      

      

      
        	 	
                (3)

              	
                Prescriptions
                  (including prescriptions at non-participating
                  pharmacies).

              

      

      

      k. The
        Health Plan shall not delay Service Authorization if written documentation
        is
        not available in a timely manner. The Health Plan is not required to approve
        claims for which it has received no written documentation. 

      

      l. The
        Health Plan shall not deny claims submitted by an out-of-network provider
        solely
        based on the period between the date of service and the date of clean claim
        submission, unless that period exceeds 365 days.

      

      m. The
        Enrollee's guardian, next of kin or legally authorized responsible person
        is
        permitted to act on the Enrollee's behalf in matters relating to the Enrollee's
        Enrollment, plan of care, and/or provision of services, if the
        Enrollee: 

      

      
        	 	
                (1)

              	
                Was
                  adjudicated incompetent in accordance with the law;
                  

              

      

      

      
        	 	
                (2)

              	
                Is
                  found by his or her Provider to be medically incapable of understanding
                  his or her rights; or

              

      

      

      
        	 	
                (3)

              	
                Exhibits
                  a significant communication
                  barrier.

              

      

      

      n. The
        Health Plan shall take immediate action to address any identified urgent
        medical
        needs. "Urgent medical needs" means any sudden or unforeseen situation which
        requires immediate action to prevent hospitalization or nursing home placement.
        Examples include hospitalization of spouse or caregiver or increased impairment
        of in Enrollee living alone who suddenly cannot manage basic needs without
        immediate help, hospitalization or nursing home placement.

      

      
        	 	
                6.

              	
                Disease
                  Management

              

      

      

      a. The
        Health Plan shall develop and implement disease management programs for
        Enrollees living with chronic conditions. The disease management initiatives
        shall include, but are not limited to asthma, HIV/AIDS, diabetes, congestive
        heart failure, and hypertension. The Health Plan may develop and implement
        additional disease management programs for its Enrollees.

      

      b. The
        disease management programs shall include the following components:

      

      
        	 	
                (1)

              	
                Provider
                  and Enrollee profiling;

              

      

      

      
        	 	
                (2)

              	
                Specialized
                  disease-specific physician care;

              

      

      

      
        	 	
                (3)

              	
                Intensive
                  care management;

              

      

      

      
        	 	
                (4)

              	
                Provider
                  education;

              

      

      

      
        	 	
                (5)

              	
                Enrollee
                  education; 

              

      

      

      
        	 	
                (6)

              	
                Clinical
                  practice guidelines;

              

      

      

      
        	 	
                (7)

              	
                Severity
                  and risk assessments of the Enrollee
                  population;

              

      

      

      
        	 	
                (8)

              	
                Screening
                  to verify the Enrollee’s initial diagnosis, any complications and the
                  severity of the Enrollee’s illness;
                  and

              

      

      

      
        	 	
                (9)

              	
                Interventions
                  designed to improve compliance and prevent acute events, which
                  may
                  include:

              

      

      

      i. Implementation
        of standard clinical guidelines for recommended treatments for each disease
        process; and

      ii. Enrollee
        and Provider education focusing on self-management by the Enrollee.

      

      c. The
        Health Plan must develop and use a plan of treatment for chronic disease
        follow-up care that is tailored to the individual Enrollee. The purpose of
        the
        plan of treatment is to assure appropriate ongoing treatment reflecting the
        highest standards of medical care designed to minimize further deterioration
        and
        complications. The plan of treatment shall be on file for each Enrollee with
        a
        chronic disease and shall contain sufficient information to explain the progress
        of treatment.

      

      d. As
        indicated below, the Health Plan must conduct Agency-specified patient
        satisfaction surveys for each of the five chronic conditions specified in
        subsection a. above, for a statistically valid sample of the respective Enrollee
        population identified with each chronic conditions.  These patient
        satisfaction surveys must be completed on a quarterly-rotational basis so
        that
        the Health Plans submit the respective patient satisfaction surveys results
        by
        the 15th of the month following the quarter being reported. The Agency may
        use
        the results of these surveys in Health Plan comparison information provided
        by
        the Choice Counselor/Enrollment Broker to Potential Enrollees.

      

      i. 
        If the
        Health Plan implements Disease Management programs for other chronic conditions
        in addition to the five chronic conditions specified in subsection B.6.a.
        above,
        it may request approval from the Agency to replace no more than two of the
        required patient satisfaction surveys with patient satisfaction surveys on
        other
        Health Plan-implemented Disease Management programs for chronic
        conditions.

      

      ii. For
        the
        first (1st) Contract Year, the Health Plan must begin conducting the first
        patient satisfaction surveys by January 1, 2007, with a completion date no
        later
        than August 31, 2007. The Health Plan can choose how it divides the patient
        satisfaction surveys during the first (1st) Contract Year. For example, the
        Health Plan can conduct three (3) of the patient satisfaction surveys during
        the
        quarter beginning January 1, 2007 and the last two (2) patient satisfaction
        surveys during the quarter beginning April 1, 2007. 

      

      iii. For
        the
        second (2nd)
        and
        third (3rd)
        Contract Years, the Health Plan shall commence conducting patient satisfaction
        surveys on September 1, 2008 and September 1, 2009, respectively, with
        completion of the patient satisfaction surveys by August 31, 2009 and August
        31,
        2010, respectively. As
        with
        the first Contract Year, the Health Plan may choose which patient satisfaction
        surveys to conduct each quarter. For example, the Health Plan may choose
        to
        conduct 1 patient satisfaction survey for the first three quarters of the
        second
        Contract Year and two in the last quarter for a total of five. In the third
        Contract Year, the health Plan may choose to conduct one patient satisfaction
        survey in the first, third and fourth quarters of the Contract Year, and
        two
        during the second quarter of the third Contract Year.

      iv. By
        October 1, 2006, the Health Plan must submit its sampling methodology and
        patient satisfaction survey schedule for each of the Disease Management chronic
        conditions for the first Contract Year to the Agency for review and
        approval.  If the Health Plan is requesting to replace any of the required
        patient satisfaction surveys with patient satisfaction surveys on other Health
        Plan-implemented Disease Management programs, then it must submit its request
        with the October 1, 2006, sampling methodology and scheduling submittal. 
For each Contract Year thereafter, the Health Plan must submit to the Agency
        its
        sampling methodology, patient satisfaction survey schedule, and all requests
        for
        survey replacement by the April 1 prior to the beginning of the next Contract
        Year.

      

      v. The
        Health Plan shall submit patient satisfaction survey results must be submitted
        in the format and with the information prescribed by the Agency.

      

      
        	 	
                7.

              	
                Incentive
                  Programs 

              

      

      

      a. The
        Health Plan may offer incentives for Enrollees to receive preventive care
        services. The incentives shall not duplicate those included in the Enhanced
        Benefits Program. The Health Plan shall receive written approval from the
        Agency
        before offering any incentives. The Health Plan shall make all incentives
        available to all Enrollees. The Health Plan shall not use incentives to direct
        individuals to select a particular Provider. 

      

      b. The
        Health Plan may inform Enrollees, once they are enrolled, about the specific
        incentives available.

      

      c. The
        Health Plan shall not include the provision of gambling, alcohol, tobacco
        or
        drugs in any of the Health Plan's incentives.

      

      d. The
        Health Plan's incentives shall have some health or child development related
        function (e.g., clothing, food, books, safety devices, infant care items,
        magazine subscriptions to publications which devote at least ten percent
        (10%)
        of their copy to health related subjects, membership in clubs advocating
        educational advancement and healthy lifestyles, etc.). Incentive dollar values
        shall be in proportion to the importance of the health service to be utilized
        (e.g., a T-shirt for attending one (1) prenatal class, but a car seat for
        completion of a series of classes).

      

      e. Incentives
        shall be limited to a dollar value of ten dollars ($10), except in the case
        of
        incentives for the completion of a series of services, health education classes
        or other educational activities, in which case the incentive shall be limited
        to
        a dollar value of fifty dollars ($50). The Agency will allow a special exception
        to the dollar value relating to infant car seats, strollers, and cloth baby
        carriers, or slings.

      

      f. The
        Health Plan shall not include in the dollar limits on incentives any money
        spent
        on the transportation of Enrollees to services or child care provided during
        the
        provision of services.

      

      g. The
        Health Plan may offer an Agency approved program for pregnant women in order
        to
        encourage the commencement of prenatal care visits in the first (1st) trimester
        of pregnancy. The Health Plan's prenatal and postpartum care Incentive Program
        must be aimed promoting early intervention and prenatal care to decrease
        infant
        mortality and low birth weight and to enhance healthy birth outcomes. The
        prenatal and postpartum incentives may include the provision of maternity
        and
        health related items and education as an incentive.

      

      h. The
        Health Plan's request for approval of all incentives shall contain a detailed
        description of the incentive and its mission.

      

      
        	 	
                8.

              	
                Practice
                  Guidelines

              

      

      

      a. The
        Health Plan shall adopt practice guidelines that meet the following
        requirements:

      

      
        	 	
                (1)

              	
                Are
                  based on valid and reliable clinical evidence or a consensus of
                  Health
                  Care Professionals in a particular
                  field;

              

      

      

      
        	 	
                (2)

              	
                Consider
                  the needs of the Enrollees;

              

      

      

      
        	 	
                (3)

              	
                Are
                  adopted in consultation with Providers;
                  and

              

      

      

      
        	 	
                (4)

              	
                Are
                  reviewed and updated periodically, as appropriate. ( See 42 CFR
                  438.236(b))

              

      

      

      b. The
        Health Plan shall disseminate any revised practice guidelines to all affected
        Providers and, upon request, to Enrollees and Potential Enrollees.

      

      c. The
        Health Plan shall ensure consistency with regard to all decisions relating
        to
        UM, Enrollee education, Covered Services and other areas to which the practice
        guidelines apply.

      

      9.
         Changes
        to Utilization Management Components 

      

      The
        Health Plan shall provide no less than thirty (30) Calendar Days written
        notice
        before making any changes to the administration and/or management procedures
        and/or authorization, denial or review procedures, including any delegations,
        as
        described in this section.

      

      
        	 	
                10.
                  

              	
                Out-of-Plan
                  Use of Non-Emergency
                  Services

              

      

      

      Unless
        otherwise specified in this Contract, where an Enrollee utilizes services
        available under the Health Plan other than emergency services from a
        non-contract provider, the Health Plan shall not be liable for the cost of
        such
        utilization unless the Health Plan referred the Enrollee to the non-contract
        provider or authorized such out-of-plan utilization. The Health Plan shall
        provide timely approval or denial of authorization of out-of-plan use through
        the assignment of a prior authorization number, which refers to and documents
        the approval. A Health Plan may not require paper authorization as a condition
        of receiving treatment if the plan has an automated authorization system.
        Written follow up documentation of the approval must be provided to the
        out-of-plan provider within one (1) Business Day from the request for approval.
        The Enrollee shall be liable for the cost of such unauthorized use of
        contract-covered services from non-contract providers.

      

      In
        accordance with section 409.912, F.S., the Health Plan shall reimburse any
        hospital or physician that is outside the Health Plan’s authorized geographic
        service area for Health Plan authorized services provided by the hospital
        or
        physician to plan members at a rate negotiated with the hospital or physician
        for the provision of services or according to the lesser of the
        following:

      

      a. The
        usual
        and customary charge made to the general public by the hospital or physician;
        or

      

      b. The
        Florida Medicaid reimbursement rate established for the hospital or
        physician.

      

      The
        plan
        shall reimburse all out-of-plan providers pursuant to section 641.3155,
        F.S.

       

      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Section
        IX

      Grievance
        System

      

      
        	A.	
                 General
                  Requirements

              

      

      

      	1.  	
              The
                Health Plan must develop, implement, and maintain a Grievance System
                that
                complies with federal laws and regulations, including 42 CFR 431.200
                and
                438, Subpart F, “Grievance System.” 

            

      

      	2.  	
              The
                Grievance System must include an external grievance resolution process
                modeled after the subscriber assistance program panel, as created
                in
                section 408.7056, F.S., and referred to in this contract as the
                Beneficiary Assistance Program.

            

      

      	3.  	
              The
                Grievance System must include written policies and procedures that
                are
                approved in writing, by the Agency.

            

      

      	4.  	
              The
                Health Plan must give Enrollees reasonable assistance in completing
                forms
                and other procedural steps, including, but not limited to, providing
                interpreter services and toll-free numbers with TTY/TDD and interpreter
                capability. 

            

      

      	5.  	
              The
                Health Plan must acknowledge receipt of each Grievance and
                Appeal.

            

      

      	6.  	
              The
                Health Plan must ensure that decision makers about Grievances and
                Appeals
                were not involved in previous levels of review or decision making
                and are
                Health Care Professionals with appropriate clinical expertise in
                treating
                the Enrollee’s condition or disease when deciding any of the
                following:

            

      

      a. An
        Appeal
        of a denial based on lack of Medical Necessity;

      

      b. A
        Grievance regarding denial of expedited resolution of an Appeal; or

      

      c. A
        Grievance or Appeal involving clinical issues.

      

      	7.  	
              The
                Health Plan shall provide information regarding the Grievance System
                to
                Enrollees as described in Section IV., A., 2. and 3. The information
                shall
                include, but not be limited to:

            

      

      	a.  	
              Enrollee
                rights to file Grievances and Appeals and requirements and time frames
                for
                filing.

            

      

      	b.  	
              The
                availability of assistance in the filing
                process.

            

      

      	c.  	
              The
                address, toll-free telephone number, and the office hours of the
                Grievance
                coordinator.

            

      

      	d.  	
              The
                method for obtaining a Medicaid fair hearing, the rules that govern
                representation at the hearing, and the DCF address for pursuing a
                fair
                hearing, which is:

            

      

      Office
        of
        Public Assistance Appeals Hearings 

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        Florida 32399-0700

      

      	e.  	
              A
                description of the Beneficiary Assistance Program, the types of Grievances
                and Appeals that can be forwarded to the Beneficiary Assistance Program
                and directions for doing so. 

            

      

      	f.  	
              A
                statement assuring Enrollees that the Health Plan, its Providers
                or the
                Agency will not retaliate against an Enrollee for submitting a Grievance,
                an Appeal or a request for a Medicaid fair hearing.
                

            

      

      	g.  	
              Enrollee
                rights to request continuation of Benefits during an Appeal or Medicaid
                fair hearing process and, if the Health Plan’s Action is upheld in a
                hearing, the fact that the Enrollee may be liable for the cost of
                said
                Benefits.

            

      

      	h.  	
              Notice
                that the Health Plan must continue Enrollee Benefits
                if:

            

      

      
        	 	
                (1)

              	
                The
                  Appeal is filed timely, meaning on or before the later of the
                  following:

              

      

      

      	i.  	
              Within
                ten (10) Calendar Days of the date on the notice of Action (Fifteen
                (15)
                Calendar Days if the notice is sent via Surface Mail),
                and

            

      

      	ii.  	
              The
                intended effective date of the Health Plan’s proposed Action.
                

            

      

      
        	 	
                (2)

              	
                The
                  Appeal involves the termination, suspension, or reduction of a
                  previously
                  authorized course of treatment.

              

      

      

      
        	 	
                (3)

              	
                The
                  services were ordered by an authorized
                  provider.

              

      

      

      
        	 	
                (4)

              	
                The
                  authorization period has not
                  expired.

              

      

      

      
        	 	
                (5)

              	
                The
                  Enrollee requests extension of
                  Benefits.

              

      

      

      	i.  	
              The
                Health Plan must provide information about the Grievance System and
                its
                respective policies, procedures, and timeframes, to all Providers
                and
                subcontractors at the time they enter into a subcontract/Provider
                contract. The Health Plan must clearly specify all procedural steps
                in the
                Provider manual, including the address, telephone number, and office
                hours
                of the Grievance coordinator.

            

      

      	8.  	
              The
                Health Plan must maintain records of Grievances and Appeals for tracking
                and trending for QI and to fulfill reporting requirements as described
                in
                Section XII., Reporting Requirements.

            

      

      
        	B.	
                 Grievance
                  Process

              

      

      

      	1.  	
              Filing
                a Grievance

            

      

      	a.  	
              A
                Grievance is any expression of dissatisfaction by an Enrollee, about
                any
                matter other than an Action. A Provider, acting on behalf of the
                Enrollee
                and with the Enrollee’s written consent, may also file a
                Grievance.

            

      

      	b.  	
              A
                Grievance may be filed orally.

            

      

      	2.  	
              Grievance
                Resolution

            

      

      	a.  	
              The
                Health Plan must resolve each Grievance and provide the Enrollee
                with a
                notice of the Grievance disposition within ninety (90) days of its
                receipt.

            

      

      	b.  	
              The
                Grievance must be resolved more expeditiously, within twenty four
                (24)
                hours, if the Enrollee’s health condition requires, as found in
                s409.91211(3)(q), F.S.

            

      

      	c.  	
              The
                notice of disposition must be in writing and include the results
                and the
                date of Grievance resolution. 

            

      

      	d.  	
              The
                Health Plan must provide the Agency with a copy of the notice of
                disposition upon request.

            

      

      	e.  	
              The
                Health Plan must ensure that punitive action is not taken against
                a
                Provider who files a Grievance on an Enrollee’s behalf or supports an
                Enrollee’s Grievance as required in s. 409.9122(12),
                F.S.

            

      

      	3.  	
              Submission
                to the Beneficiary Assistance
                Program

            

      

      a. The
        original Grievance must be filed with the Health Plan in writing.

      

      b. The
        submission of the Grievance to the Beneficiary Assistance Program must be
        done
        within one (1) year of the date of the occurrence which initiated the
        Grievance.

      

      c. The
        Grievance may be filed if it concerns:

      

      
        	 	
                (1)

              	
                The
                  quality of health care services; or

              

      

      

      
        	 	
                (2)

              	
                Matters
                  pertaining to the contractual relationship between an Enrollee
                  and the
                  Health Plan.

              

      

      

      
        	C.	
                 
                  Appeal Process

              

      

      

      	1.  	
              Filing
                an Appeal

            

      

      a. An
        Enrollee may request a review of a Health Plan Action by filing an
        Appeal.

      

      b. An
        Enrollee may file an Appeal, and a Provider, acting on behalf of the Enrollee
        and with the Enrollee’s written consent, may file an Appeal. The Appeal
        procedure must be the same for all Enrollees.

      

      c. The
        Appeal must be filed within thirty (30) days of the date of the notice of
        Action. If the Health Plan fails to issue a written notice of Action, the
        Enrollee or Provider may file an Appeal within one (1) year of the
        Action.

      

      d. The
        Enrollee or Provider may file an Appeal either orally or in writing and must
        follow an oral filing with a written, signed Appeal. For oral filings, time
        frames for resolution begin on the date the Health Plan receives the oral
        filing.

      

      	2.  	
              Resolution
                of Appeals

            

      

      The
        Health Plan must:

      

      a. Ensure
        that oral inquiries seeking to appeal an Action are treated as Appeals and
        acknowledge receipt of those inquiries, as well as written Appeals, in writing,
        unless the Enrollee or the Provider requests expedited resolution.

      

      b. Provide
        a
        reasonable opportunity for the Enrollee/Provider to present evidence, and
        allegations of fact or law, in person as well as in writing.

       

      c. Allow
        the
        Enrollee and their representative the opportunity, before and during the
        Appeals
        process, to examine the Enrollee’s case file, including Medical Records and any
        other documents and records.

      

      d. Consider
        the Enrollee representative, or estate representative of a deceased Enrollee
        as
        parties to the Appeal.

      

      e. Resolve
        each Appeal and provide notice within forty-five (45) days from the day the
        Health Plan receives the Appeal. 

      

      f. Resolve
        the Appeal more expeditiously if the Enrollee’s health condition
        requires.

      

      g. The
        Health Plan may extend the resolution time frames by up to fourteen (14)
        Calendar Days if the Enrollee requests the extension or the Health Plan
        documents that there is need for additional information and that the delay
        is in
        the Enrollee’s interest. If the extension is not requested by the Enrollee, the
        Health Plan must give the Enrollee written notice of the reason for the
        delay.

      

      h. Continue
        the Enrollee's Benefits if:

      

      
        	 	
                (1)

              	
                The
                  Appeal is filed timely, meaning on or before the later of the
                  following:

              

      

      

      i. Within
        ten (10) Calendar Days of the date on the notice of Action or fifteen (15)
        Calendar Days if sent by Surface Mail, or

      

      ii. The
        intended effective date of the Health Plan’s proposed Action.

      

      
        	 	
                (2)

              	
                The
                  Appeal involves the termination, suspension, or reduction of a
                  previously
                  authorized course of treatment.

              

      

      

      
        	 	
                (3)

              	
                The
                  services were ordered by an authorized
                  provider.

              

      

      

      
        	 	
                (4)

              	
                The
                  Authorization period has not
                  expired.

              

      

      

      
        	 	
                (5)

              	
                The
                  Enrollee requests extension of
                  Benefits.

              

      

      

      i. If
        the
        Health Plan continues or reinstates Enrollee Benefits while the Appeal is
        pending, the Benefits must be continued until one of following
        occurs:

      

      
        	 	
                (1)

              	
                The
                  Enrollee withdraws the Appeal.

              

      

      

      
        	 	
                (2)

              	
                Ten
                  (10) Calendar Days (Fifteen (15) Calendar Days if the notice is
                  sent via
                  Surface Mail) pass from the date of the Health Plan’s adverse decision,
                  and the Enrollee has not requested a Medicaid fair hearing with
                  continuation of Benefits. 

              

      

      

      
        	 	
                (3)

              	
                A
                  Medicaid fair hearing decision adverse to the Enrollee is made.
                  

              

      

      

      
        	 	
                (4)

              	
                The
                  authorization expires or authorized service limits are
                  met.

              

      

      

      

      j. Provide
        written notice of disposition that includes the results and date of Appeal
        resolution, and for decisions not wholly in the Enrollee’s favor, also
        includes:

      

      
        	 	
                (1)

              	
                Notice
                  of the Enrollee’s right to request a Medicaid fair
                  hearing.

              

      

      

      
        	 	
                (2)

              	
                Information
                  about how to request a Medicaid fair hearing, including the DCF
                  address
                  for pursuing a Medicaid fair hearing, which
                  is:

              

      

      

      Office
        of
        Public Assistance Appeals Hearings

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        Florida 32399

      

      
        	 	
                (3)

              	
                Notice
                  of the right to continue to receive Benefits pending a Medicaid
                  fair
                  hearing.

              

      

      

      
        	 	
                (4)

              	
                Information
                  about how to request the continuation of
                  Benefits.

              

      

      

      
        	 	
                (5)

              	
                Notice
                  that if the Health Plan’s action is upheld in a Medicaid fair hearing, the
                  Enrollee may be liable for the cost of any continued
                  Benefits.

              

      

      

      k. Provide
        the Agency with a copy of the written notice of disposition upon
        request.

      

      l. Ensure
        that punitive action is not taken against a Provider who files an Appeal
        on an
        Enrollee’s behalf or supports an Enrollee’s Appeal.

      

      	3.  	
              Post
                Appeal Resolution

            

      

      a. If
        the
        final resolution of the Appeal in a fair hearing is adverse to the Enrollee,
        the
        Agency may recover the cost of the services furnished while the Appeal was
        pending, to the extent that they were furnished solely because of the
        requirements of this section.

      

      b. The
        Health Plan must authorize or provide the disputed services promptly, and
        as
        expeditiously as the Enrollee's health condition requires, if the services
        were
        not furnished while the Appeal was pending and the disposition reverses a
        decision to deny, limit, or delay services.

      

      c. The
        Health Plan must pay for disputed services, in accordance with State policy
        and
        regulations, if the services were furnished while the Appeal was pending
        and the
        disposition reverses a decision to deny, limit, or delay services.

       

      	4.  	
              Expedited
                Process

            

      

      a. The
        Health Plan must establish and maintain an expedited review process for
        Grievances and Appeals when the Health Plan determines (if requested by the
        Enrollee) or the Provider indicates (in making the request on the Enrollee's
        behalf or supporting the Enrollee's request) that taking the time for a standard
        resolution could seriously jeopardize the Enrollee's life or health or ability
        to attain, maintain, or regain maximum function.

       

      b. The
        Enrollee or Provider may file an expedited Appeal either orally or in writing.
        No additional Enrollee follow-up is required.

      

      The
        Health Plan must:

      

      
        	 	
                (1)

              	
                Inform
                  the Enrollee of the limited time available for the Enrollee to
                  present
                  evidence and allegations of fact or law, in person and/or in
                  writing.

              

      

      

      
        	 	
                (2)

              	
                Resolve
                  each expedited Appeal and provide notice, as expeditiously as the
                  Enrollee’s health condition requires, not to exceed seventy-two (72) hours
                  after the Health Plan receives the Appeal.

              

      

      

      
        	 	
                (3)

              	
                Provide
                  written notice of disposition that includes the results and date
                  of
                  expedited Appeal resolution, and for decisions not wholly in the
                  Enrollee’s favor, that includes:

              

      

      

      i. Notice
        of
        the Enrollee’s right to request a Medicaid fair hearing.

      

      ii. Information
        about how to request a Medicaid fair hearing, including the DCF address for
        pursuing a fair hearing, which is:

      

      Office
        of
        Public Assistance Appeals Hearings

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        Florida 32399-0700

      

      iii.
         Notice
        of
        the right to continue to receive Benefits pending a hearing.

      

      iv. Information
        about how to request the continuation of Benefits.

      

      v. Notice
        that if the Health Plan’s action is upheld in a hearing, the Enrollee may be
        liable for the cost of any continued Benefits.

      

      c. If
        the
        Health Plan denies a request for expedited resolution of an Appeal, the Health
        Plan must:

      

      
        	 	
                (1)

              	
                Transfer
                  the Appeal to the standard time frame of no longer than forty-five
                  (45)
                  days from the day the Health Plan receives the Appeal with a possible
                  fourteen (14) day extension.

              

      

      

      
        	 	
                (2)

              	
                Make
                  reasonable efforts to provide prompt oral notice of the
                  denial.

              

      

      

      
        	 	
                (3)

              	
                Provide
                  written notice of the denial within two (2) Calendar
                  Days.

              

      

      

      
        	 	
                (4)

              	
                Fulfill
                  all general Health Plan duties listed
                  above.

              

      

      

      	5.  	
              Submission
                to the Beneficiary Assistance
                Program

            

      

      a. The
        submission of the Appeal to the Beneficiary Assistance Program must be done
        within one (1) year of the date of the occurrence that initiated the
        Appeal.

      

      b. An
        Enrollee may submit an Appeal to the Beneficiary Assistance Program if it
        concerns: 

      

      
        	 	
                (1)

              	
                The
                  availability of health care services or the coverage of Benefits,
                  or an
                  adverse determination about Benefits made pursuant to UM;
                  or

              

      

      

      
        	 	
                (2)

              	
                Claims
                  payment, handling, or reimbursement for
                  Benefits.

              

      

      

      c. If
        the
        Enrollee has taken the Appeal to a Medicaid fair hearing, the Enrollee cannot
        submit the Appeal to the Beneficiary Assistance Program. 

      

      
        	D.	
                 Medicaid
                  Fair Hearing System

              

      

      

      	1.  	
              Request
                for a Medicaid Fair Hearing

            

       

      a. An
        Enrollee may request a Medicaid fair hearing either upon receipt of a notice
        of
        Action from the Health Plan or upon receiving an adverse decision from the
        Health Plan, after filing an Appeal with the Health Plan.

      

      b. A
        Provider, acting on behalf of the Enrollee and with the Enrollee’s written
        consent, may request a Medicaid fair hearing under the same circumstances
        as the
        Enrollee. 

      

      c. Parties
        to the Medicaid fair hearing include the Health Plan, as well as the Enrollee
        and his or her representative or the representative of a deceased Enrollee’s
        estate.

      

      d. The
        Enrollee or Provider may request a Medicaid fair hearing within ninety (90)
        Calendar Days of the date of the notice of Action from the Health Plan regarding
        an Enrollee Appeal. 

      

      e. The
        Enrollee or Provider may request a Medicaid fair hearing by contacting DCF
        at:

      

      The
        Office of Public Assistance Appeals Hearings

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        Florida 32399-0700

      

      	2.  	
              Health
                Plan Responsibilities

            

      

      The
        Health Plan must:

      

      a. Continue
        the Enrollee's Benefits while the Medicaid fair hearing is pending
        if:

      

      
        	 	
                (1)

              	
                The
                  Medicaid fair hearing is filed timely, meaning on or before the
                  later of
                  the following:

              

      

      

      i. Within
        ten (10) Calendar Days of the date on the notice of Action (Fifteen (15)
        Calendar Days if the notice is sent via Surface Mail); or

      

      ii. The
        intended effective date of the Health Plan’s proposed Action.

      

      
        	 	
                (2)

              	
                The
                  Medicaid fair hearing involves the termination, suspension, or
                  reduction
                  of a previously authorized course of
                  treatment.

              

      

      

      
        	 	
                (3)

              	
                The
                  services were ordered by an authorized
                  provider.

              

      

      

      
        	 	
                (4)

              	
                The
                  authorization period has not
                  expired.

              

      

      

      
        	 	
                (5)

              	
                The
                  Enrollee requests extension of
                  Benefits.

              

      

      

      b. Ensure
        that punitive action is not taken against a Provider who requests a Medicaid
        fair hearing on the Enrollee’s behalf or supports an Enrollee’s request for a
        Medicaid fair hearing.

      

      c. If
        the
        Health Plan continues or reinstates Enrollee Benefits while the Medicaid
        fair
        hearing is pending, the Benefits must be continued until one of following
        occurs:

      

      
        	 	
                (1)

              	
                The
                  Enrollee withdraws the request for a Medicaid fair
                  hearing.

              

      

      

      
        	 	
                (2)

              	
                Ten
                  (10) Calendar Days pass from the date of the Health Plan’s adverse
                  decision and the Enrollee has not requested a Medicaid fair hearing
                  with
                  continuation of Benefits until a Medicaid fair hearing decision
                  is
                  reached. (Fifteen (15) Calendar Days if the notice is sent via
                  Surface
                  Mail)

              

      

      

      
        	 	
                (3)

              	
                A
                  Medicaid fair hearing decision adverse to the Enrollee is
                  made.

              

      

      

      
        	 	
                (4)

              	
                The
                  authorization expires or authorized service limits are
                  met.

              

      

      

      	3.  	
              Post
                Medicaid Fair Hearing Decision

            

      

      a. If
        the
        final resolution of the Medicaid fair hearing is adverse to the Enrollee,
        the
        Health Plan may recover the cost of the services furnished while the Medicaid
        fair hearing was pending, to the extent that they were furnished solely because
        of the requirements of this section.

      

      b. The
        Health Plan must authorize or provide the disputed services promptly, and
        as
        expeditiously as the Enrollee's health condition requires, if the services
        were
        not furnished while the Medicaid fair hearing was pending and the Medicaid
        fair
        hearing officer reverses a decision to deny, limit, or delay
        services.

      

      c. The
        Health Plan must pay for disputed services, in accordance with State policy
        and
        regulations, if the services were furnished while the Medicaid fair hearing
        was
        pending and the Medicaid fair hearing officer reverses a decision to deny,
        limit, or delay services.

      

      

      

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      Section
        X

      Administration
        and Management

      

      
        	A.	
                General
                  Provisions

              

      

      

      1. The
        Health Plan’s governing body shall set forth policy and has overall
        responsibility for the organization of the Health Plan. The Health Plan shall
        be
        responsible for the administration and management of all aspects of this
        Contract, including all Subcontracts, employees, agents and services performed
        by anyone acting for or on behalf of the Health Plan. The Health Plan shall
        have
        a centralized executive administration, which shall serve as the contact
        point
        for the Agency, except as otherwise specified in the Contract.

      2. The
        Health Plan shall be responsible for the administration and management of
        all
        aspects of this Contract, such as, but not limited to, the delivery of services,
        provider network, provider education, and claims resolution and assistance.
        

      

      
        	 	
                3.

              	
                The
                  Health Plan must provide that compensation to individuals or entities
                  that
                  conduct utilization management activities is not structured so
                  as to
                  provide incentives for the individual or entity to deny, limit,
                  or
                  discontinue medically necessary services to any
                  Enrollee.

              

      

      

      
        	B.	
                Staffing

              

      

      

      1. Minimum
        Staffing Requirements

      

      a. Contract
        Manager:
        The
        Health Plan shall designate a contract manager to work directly with the
        Agency.
        The contract manager shall be a full-time employee of the Health Plan with
        the
        authority to revise processes or procedures and assign additional resources
        as
        needed to maximize the efficiency and effectiveness of services required
        under
        the Contract. The Health Plan shall meet in person or by telephone at the
        request of Agency representatives, but at least monthly, to discuss the status
        of the Contract, Health Plan performance, benefits to the State, necessary
        revisions, reviews, reports and planning. Formal summary reports shall be
        developed and presented to the Agency, or its Agent, as specified.

      

      b. Full-Time
        Administrator:
        The
        Health Plan shall have a full-time administrator specifically identified
        to
        administer the day-to-day business activities of this Contract. The Health
        Plan
        may designate the same person as the Contract Manager, the Full-time
        Administrator, or the Medical Director, but such person cannot be designated
        to
        any other position in this section, including in other lines of business
        within
        the Health Plan, unless otherwise approved by the Agency.

      

      c. Medical
        and Professional Support Staff:
        The
        Health Plan shall have medical and professional support staff sufficient
        to
        conduct daily business in an orderly manner, including having Enrollee services
        staff directly available during business hours for Enrollee services
        consultation, as determined through management and medical reviews. The Health
        Plan shall maintain sufficient medical staff, available twenty-four (24)
        hours
        per day, seven (7) days per week, to handle Emergency Services and Care
        inquiries. The Health Plan shall maintain sufficient medical staff during
        non-business hours, unless the Health Plan's computer system automatically
        approves all Emergency Services and care claims relating to Screening and
        treatment.

      

      d. Medical
        Director:
        The
        Health Plan shall have a full-time licensed physician to serve as medical
        director to oversee and be responsible for the proper provision of Covered
        Services to Enrollees, the Quality Management Program, and the Grievance
        System.
        The medical director shall be licensed in accordance with chapter 458 or
        459,
        F.S. The medical director cannot be designated to serve in any other
        non-administrative position. 

      

      e. Medical
        Records Review Coordinator:
        A
        designated person, qualified by training and experience, to ensure compliance
        with the Medical Records requirements as described in this Contract. The
        medical
        records review coordinator shall maintain Medical Record standards and conduct
        Medical Record reviews according to the terms of this Contract. 

      

      f. Data
        Processing and Data Reporting Coordinator:
        The
        Health Plan shall have a person trained and experienced in data processing,
        data
        reporting, and claims resolution, as required to ensure that computer system
        reports that that the Health Plan provides to the Agency and its Agent are
        accurate, and that computer systems operate in an accurate and timely
        manner.

      

      g. Marketing
        Oversight Coordinator:
        If the
        Health Plan engages in Marketing, the Health Plan shall have a designated
        person, qualified by training and experience, to assure the Health Plan adheres
        to the marketing requirements of this Contract.

      

      h. QI
        and
        UM Professional:
        The
        Health Plan shall have a designated person, qualified by training and experience
        in QI and UM and who holds the appropriate clinical certification and/or
        license.

      

      i. Grievance
        System Coordinator:
        The
        Health Plan shall have a designated person, qualified by training and
        experience, to process and resolve Appeals and Grievances and to be responsible
        for the Grievance System.

      

      j. Compliance
        Officer:
        The
        Health Plan shall have a designated person qualified by training and experience,
        to oversee a Fraud and Abuse program to prevent and detect potential Fraud
        and
        Abuse activities pursuant to State and federal rules and
        regulations.

      

      k. Case
        Management Staff:
        The
        Health Plan shall have sufficient Case Management staff, qualified by training,
        experience and certification/licensure to conduct the Health Plan's Case
        Management functions.

      

      l. Claims/Encounter
        Manager:
        The
        Health Plan shall have a designated person qualified by training and experience
        to oversee claims and encounter submittal and processing and to ensure the
        accuracy, timeliness and completeness of processing payment and
        reporting.

      

      2. Behavioral
        Health Staff Requirements 

      

      a. The
        Health Plan must name a staff member to maintain oversight responsibility
        for
        Behavioral Health Services and to act as a liaison to the Agency. 

      

      b. The
        Health Plan's Medical Director shall appoint a board certified, or board
        eligible, licensed psychiatrist (staff psychiatrist) to oversee the provision
        of
        Behavioral Health Services to Enrollees. The Health Plan may delegate this
        duty,
        by way of a written subcontract, to a third party.

      

      c. The
        Agency shall review and approve the Health Plan's Behavioral Health Services
        staff and any subcontracted Behavioral Health Care Providers in order to
        determine the Health Plan's compliance with all licensure
        requirements.

      

      
        	C.	
                 Provider
                  Contracts Requirements

              

      

      

      1. The
        Health Plan shall comply with all Agency procedures for Provider Contract
        review
        and approval submission. 

      

      a. All
        Provider Contracts must comply with 42 CFR 438.230. 

      

      b. All
        Providers must be eligible for participation in the Medicaid program. Any
        provider of service who has been involuntarily terminated from the Florida
        Medicaid program, other than those terminated for inactivity, is not considered
        to be an eligible Medicaid provider.

      

      c.
         The
        Health Plan shall not employ or contract with individuals on the State or
        federal exclusions list.

      

      d. No
        Provider Contract which the Health Plan enters into with respect to performance
        under the Contract shall in any way relieve the Health Plan of any
        responsibility for the provision of services duties under this Contract.
        The
        Health Plan shall assure that all services and tasks related to the Provider
        Contract are performed in accordance with the terms of this Contract. The
        Health
        Plan shall identify in its Provider Contracts any aspect of service that
        may be
        subcontracted by the Provider.

      

      e. All
        model
        Provider Contracts and amendments must be submitted by the Health Plan to
        the
        Agency for approval and the Health Plan must receive approval by the Agency
        prior to use.

      

      2. All
        Provider Contracts and amendments executed by the Health Plan must be in
        writing, signed, and dated by the Health Plan and the Provider. All model
        and
        executed Provider Contracts and amendments shall meet the following
        requirements:

      

      a. Prohibit
        the Provider from seeking payment from the Enrollee for any Covered Services
        provided to the Enrollee within the terms of the Contract;

      

      b. Require
        the Provider to look solely to the Agency or its Agent for compensation for
        services rendered, with the exception of nominal cost sharing, pursuant to
        the
        Florida State Medicaid Plan and the Florida Coverages and Limitations Handbooks,
        

      

      c. If
        there
        is a Health Plan physician incentive plan, include a statement that the Health
        Plan shall make no specific payment directly or indirectly under a physician
        incentive plan to a Provider as an inducement to reduce or limit Medically
        Necessary services to an Enrollee, and that all incentive plans shall not
        contain provisions which provide incentives, monetary or otherwise, for the
        withholding of Medically Necessary care;

      

      d. Specify
        that any contracts, agreements, or subcontracts entered into by the Provider
        for
        the purposes of carrying out any aspect of this contract must include assurances
        that the individuals who are signing the contract, agreement or subcontract
        are
        so authorized and that it includes all the requirements of this
        Contract;

      

      e. Require
        the Provider to cooperate with the Health Plan's peer review, grievance,
        QIP and
        UM activities, and provide for monitoring and oversight, including monitoring
        of
        services rendered to Enrollees, by the Health Plan (or its subcontractor)
        and
        for the Provider to provide assurance that all licensed Providers are
        Credentialed in accordance with the Health Plan’s and the Agency’s Credentialing
        requirements as found in Section VIII.A.3.h Credentialing and Recredentialing,
        of this Contract, if the Health Plan has delegated the Credentialing to a
        Subcontractor;

      

      f. Include
        provisions for the immediate transfer to another PCP or Health Plan if the
        Enrollee's health or safety is in jeopardy;

      

      g. Not
        prohibit a Provider from discussing treatment or non-treatment options with
        Enrollees that may not reflect the Health Plan's position or may not be covered
        by the Health Plan;

      

      h. Not
        prohibit a Provider from acting within the lawful scope of practice, from
        advising or advocating on behalf of an Enrollee for the Enrollee's health
        status, medical care, or treatment or non-treatment options, including any
        alternative treatments that might be self-administered;

      

      i. Not
        prohibit a Provider from advocating on behalf of the Enrollee in any Grievance
        System or UM process, or individual authorization process to obtain necessary
        health care services;

      

      j. Require
        Providers to meet appointment waiting time standards pursuant to this
        Contract;

      

      k. Provide
        for continuity of treatment in the event a Provider's agreement terminates
        during the course of an Enrollee's treatment by that Provider;

      

      l. Prohibit
        discrimination with respect to participation, reimbursement, or indemnification
        of any Provider who is acting within the scope of his or her license or
        certification under applicable State law, solely on the basis of such license
        or
        certification. This provision should not be construed as a willing Provider
        law,
        as it does not prohibit the Health Plan from limiting provider participation
        to
        the extent necessary to meet the needs of the Enrollees. This provision does
        not
        interfere with measures established by the Health Plan that are designed
        to
        maintain quality and control costs;

      

      m. Prohibit
        discrimination against Providers serving high-risk populations or those that
        specialize in conditions requiring costly treatments;

      

      n. Require
        an adequate record system be maintained for recording services, charges,
        dates
        and all other commonly accepted information elements for services rendered
        to
        the Health Plan.

      

      o. Require
        that records be maintained for a period not less than five (5) years from
        the
        close of the Contract and retained further if the records are under review
        or
        audit until the review or audit is complete. (Prior approval for the disposition
        of records must be requested and approved by the Health Plan if the Provider
        Contract is continuous.)

      

      p. Specify
        that DHHS, the Agency, including MPI and MFCU, shall have the right to inspect,
        evaluate, and audit all of the following related to the contract:

      

      i. Pertinent
        books, 

      

      ii. Financial
        records, 

      

      iii. Medical
        Records, and

      

      iv. Documents,
        papers, and records of any Provider involving transactions, financial or
        otherwise, related to this Contract;

      

      q. Specify
        Covered Services and populations to be served under the contract;

      

      r. Require
        that Providers comply with the Health Plan's cultural competency
        plan;

      

      s. Require
        that any marketing materials related to this Contract that are distributed
        by
        the Provider be submitted to the Agency for written approval before
        use;

      

      t. Provide
        for submission of all reports and clinical information required by the Health
        Plan, including Child Health Check-Up reporting (if applicable);

      

      u. Prohibit
        Providers from making referrals for designated health services to health
        care
        entities with which the Provider or a member of the Provider's family has
        a
        financial relationship; 

      

      v. Require
        Providers of transitioning Enrollees to cooperate in all respects with providers
        of other Health Plans to assure maximum health outcomes for
        Enrollees;

      

      w. Require
        Providers to submit notice of withdrawal from the network at least ninety
        (90)
        Calendar Days prior to the effective date of such withdrawal;

      

      x. Require
        that all Providers agreeing to participate in the network as PCPs fully accept
        and agree to perform the Case Management responsibilities and duties associated
        with the PCP designation;

      

      y. Require
        all Providers to notify the Health Plan in the event of a lapse in general
        liability or medical malpractice insurance, or if assets fall below the amount
        necessary for licensure under Florida Statute; 

      

      z. Require
        Providers to offer hours of operation that are no less than the hours of
        operation offered to commercial enrollees or comparable to non-Reform Medicaid
        FFS Recipients if the Provider serves only Medicaid Recipients.

      

      aa. Require
        safeguarding of information about Enrollees according to 42 CFR, Part
        438.224.

      

      bb. Require
        compliance with HIPAA privacy and security provisions.

      

      cc. Require
        an exculpatory clause, which survives Subcontract termination including breach
        of Subcontract due to insolvency, that assures that Medicaid Recipients or
        the
        Agency may not be held liable for any debts of the Subcontractor. 

      

      dd. Contain
        a
        clause indemnifying, defending and holding the Agency and the Health Plan
        Enrollees harmless from and against all claims, damages, causes of action,
        costs
        or expense, including court costs and reasonable attorney fees to the extent
        proximately caused by any negligent act or other wrongful conduct arising
        from
        the Provider Contract: 

      

      
        	 	
                i.

              	
                This
                  clause must survive the termination of the Provider Contract, including
                  breach due to Insolvency, and 

              

      

      

      
        	 	
                ii.

              	
                The
                  Agency may waive this requirement for itself, but not Health Plan
                  Enrollees, for damages in excess of the statutory cap on damages
                  for
                  public entities if the Provider is a public health entity with
                  statutory
                  immunity (all such waivers must be approved in writing by the
                  Agency);

              

      

      

      	ee.  	
              Require
                that the Provider secure and maintain during the life of the Provider
                Contract worker's compensation insurance (complying with the Florida's
                Worker's Compensation Law) for all of its employees connected with
                the
                work under this Contract unless such employees are covered by the
                protection afforded by the Health Plan;

            

      

      	ff.  	
              Make
                provisions for a waiver of those terms of the Provider Contract,
                which, as
                they pertain to Medicaid Recipients, are in conflict with the
                specifications of this Contract; 

            

      

      	gg.  	
              Contain
                no provision that in any way prohibits or restricts the Provider
                from
                entering into a commercial contract with any other plan (pursuant
                to s.
                641.315, F.S.);

            

      

      	hh.  	
              Contain
                no provision requiring the Provider to contract for more than one
                Health
                Plan product or otherwise be excluded (pursuant to s. 641.315, F.S.);
                

            

      

      	ii.  	
              Contain
                no provision that prohibits the Provider from providing inpatient
                services
                in a contracted hospital to an Enrollee if such services are determined
                to
                be medically necessary and covered services under this
                Contract;.

            

      

      	jj.  	
              Require
                all Providers to apply for a National Provider Identification number
                (NPI)
                within ninety (90) days of final execution of this Contract or within
                ninety (90) days of final execution of the Provider contract, whichever
                is
                later. Providers can obtain their NPIs through the National Plan
                and
                Provider Enumerator System located at: .
                Additionally, the Provider contract shall require the Provider to
                submit
                all NPIs for its physicians and other health care providers to the
                Health
                Plan within fifteen (15) Business Days of receipt. The Health Plan
                shall
                report the Providers’ NPIs as part of its Provider Network Report, in a
                manner to be determined by the Agency, and in its Provider Directory,
                to
                the Agency or its Choice Counselor/Enrollment Broker, as set forth
                in
                Section XII, Reporting Requirements.

            

      

      a. The
        Health Plan need not obtain an NPI from the following Providers:

      

      (1) Individuals
        or organizations that furnish atypical or nontraditional services that are
        only
        indirectly related to the provision of health care (examples include taxis,
        home
        and vehicle modifications, insect control, habilitation and respite services);
        and

      

      (2) Individuals
        ore businesses that only bill or receive payment for, but do not furnish,
        health
        care services or supplies (examples include billing services, repricers and
        value-added networks).

      

      	kk.  	
              Require
                Providers to cooperate fully in any investigation by the Agency,
                Medicaid
                Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU), or
                any
                subsequent legal action that may result from such an
                investigation.

            

      

      

      
        	D.	
                 Provider
                  Termination 

              

      

      

      1. The
        Health Plan shall comply with all State and federal laws regarding Provider
        termination. In its Provider contracts, the Health Plan shall:

      

      a. Specify
        that in addition to any other right to terminate the Provider contract, and
        not
        withstanding any other provision of this Contract, the Agency or the Health
        Plan
        may request immediate termination of a Provider contract if, as determined
        by
        the Agency, a Provider fails to abide by the terms and conditions of the
        Provider contract, or in the sole discretion of the Agency, the Provider
        fails
        to come into compliance with the Provider contract within fifteen (15) Calendar
        Days after receipt of notice from the Health Plan specifying such failure
        and
        requesting such Provider abide by the terms and conditions thereof;
        and

      

      b. Specify
        that any Provider whose participation is terminated pursuant to the Provider
        contract for any reason shall utilize the applicable appeals procedures outlined
        in the Provider contract. No additional or separate right of appeal to the
        Agency or the Health Plan is created as a result of the Health Plan's act
        of
        terminating, or decision to terminate any Provider under this Contract.
        Notwithstanding the termination of the Provider contract with respect to
        any
        particular Provider, this Contract shall remain in full force and effect
        with
        respect to all other Providers; and

      

      2. The
        Health Plan shall notify the Agency at least ninety (90) Calendar Days prior
        to
        the effective date of the suspension, termination, or withdrawal of a Provider
        from participation in the Health Plan network. If the termination was for
        "Cause" the Health Plan shall provide to the Agency the reasons for termination;
        and

      

      3. The
        Health Plan shall notify Enrollees in accordance with the provisions of this
        Contract;
        and

      

      4. The
        Health Plan shall provide sixty (60) Calendar Days’ advance written notice to
        the Provider before canceling, without cause, the contract with the Provider,
        except in a case in which a patient's health is subject to imminent danger
        or a
        physician's ability to practice medicine is effectively impaired by an action
        by
        the Board of Medicine or other governmental Agency, in which case notification
        shall be provided to the Agency immediately. A copy of the notice shall be
        submitted simultaneously to the Agency.

      

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        	E.	
                 Provider
                  Services

              

      

      

      
        	 	
                1.

              	
                General
                  Provisions

              

      

      

      a. The
        Health Plan shall provide sufficient information to all Providers in order
        to
        operate in full compliance with this Contract and all applicable federal
        and
        State laws and regulations. 

      

      b. The
        Health Plan shall monitor Provider knowledge and understanding of Provider
        requirements, and take corrective actions to ensure compliance with such
        requirements.

      

      c. The
        Health Plan shall submit to the Agency for written approval all materials
        and
        information to be distributed and/or made available to Providers.

      

      
        	 	
                2.

              	
                Provider
                  Handbooks

              

      

      

      The
        Health Plan shall develop and issue a Provider handbook to all Providers
        at the
        time the Provider contract is signed. The Health Plan may choose not to
        distribute the Provider handbook via Surface Mail, provided it submits a
        written
        notification to all Providers that explains how to obtain the Provider handbook
        from the Health Plan’s Web site. This notification shall also detail how the
        Provider can request a hard-copy from the Health Plan at no charge to the
        Provider. All Provider handbooks and bulletins shall be in compliance with
        State
        and federal laws. The Provider handbook shall serve as a source of information
        regarding Health Plan Covered Services, policies and procedures, statutes,
        regulations, telephone access and special requirements to ensure all Contract
        requirements are met. At a minimum, the Provider handbook shall include the
        following information:

      

      a. Description
        of the program;

      

      b. Covered
        Services;

      

      c. Emergency
        Service responsibilities;

      

      d. Child
        Health Check-Up program services and standards;

      

      e. Policies
        and procedures that cover the Provider complaint system. This information
        shall
        include, but not be limited to, specific instructions regarding how to contact
        the Health Plan’s Provider services to file a Provider complaint and which
        individual(s) has the authority to review a Provider complaint;

      

      f. Information
        about the Grievance System, the timeframes and requirements, the availability
        of
        assistance in filing, the toll-free numbers and the Enrollee’s right to request
        continuation of Benefits while utilizing the Grievance System;

      

      g. Medical
        Necessity standards and practice guidelines; 

      

      h. Practice
        protocols, including guidelines pertaining to the treatment of chronic and
        complex conditions;

      

      i. PCP
        responsibilities;

      

      j. Other
        Provider or Subcontractor responsibilities;

      

      k. Prior
        Authorization and referral procedures;

      

      l. Medical
        Records standards;

      

      m. Claims
        submission protocols and standards, including instructions and all information
        necessary for a clean or complete claim;

      

      n. Notice
        that the amount paid to Providers by the Agency shall be the Medicaid fee
        schedule amount less any applicable co-payments;

      

      o. Notice
        that Provider complaints regarding claims payment should be sent to the Health
        Plan;

      

      p. The
        Health Plan’s cultural competency plan; 

      

      q. Enrollee
        rights and responsibilities; and

      

      r. The
        Health Plan shall disseminate bulletins as needed to incorporate any needed
        changes to the Provider handbook.

      

      
        	 	
                3.

              	
                Education
                  and Training

              

      

      

      a. The
        Health Plan shall provide training to all Providers and their staff regarding
        the requirements of this Contract and special needs of Enrollees. The Health
        Plan shall conduct initial training within thirty (30) Calendar Days of placing
        a newly Contracted Provider on active status. The Health Plan shall also
        conduct
        ongoing training as deemed necessary by the Health Plan or the Agency in
        order
        to ensure compliance with program standards and this Contract.

      

      b. The
        Health Plan shall submit the Provider training manual and training schedule
        to
        the Agency for written approval. 

      

      
        	 	
                4.

              	
                Provider
                  Relations

              

      

      

      The
        Health Plan shall establish and maintain a formal Provider relations function
        to
        timely and adequately respond to inquiries, questions and concerns from network
        Providers. The Health Plan shall implement policies addressing the compliance
        of
        Providers with the requirements of this Contract, institute a mechanism for
        Provider dispute resolution and execute a formal system of terminating Providers
        from the Health Plan’s network.

      

      
        	 	
                5.

              	
                Toll-free
                  Provider Telephone Help
                  Line

              

      

      

      a. The
        Health Plan shall operate a toll-free telephone help line to respond to Provider
        questions, comments and inquiries. 

      

      b. The
        Health Plan shall develop telephone help line policies and procedures that
        address staffing, personnel, hours of operation, access and response standards,
        monitoring of calls via recording or other means, and compliance with standards.
        

      

      c. The
        Health Plan shall submit these telephone help line policies and procedures,
        including performance standards, to the Agency for written approval.

      

      d. The
        Health Plan’s call center systems shall have the capability to track call
        management metrics identified in Section IV.6., Enrollee Services and Marketing,
        Toll-free Enrollee Help Line.

      

      e. The
        telephone help line shall be staffed twenty-four (24) hours a day, seven
        (7)
        days a week to respond to Prior Authorization requests. This telephone help
        line
        shall have staff to respond to Provider questions in all other areas, including
        the Provider complaint system, Provider responsibilities, etc., between the
        hours of 7:00 am and 7:00 pm EST or EDT as appropriate, Monday through Friday,
        excluding State holidays.

      

      f. The
        Health Plan shall develop performance standards and monitor telephone help
        line
        performance by recording calls and employing other monitoring activities.
        All
        performance standards shall be submitted to the Agency for approval.

      

      g. The
        Health Plan shall ensure that after regular business hours the Provider services
        line (not the Prior Authorization line) is answered by an automated system
        with
        the capability to provide callers with information about operating hours
        and
        instructions about how to verify Enrollment for an Enrollee with an Emergency
        or
        Urgent Medical Condition. The requirement that the Health Plan shall provide
        information to providers about how to verify Enrollment for an Enrollee with
        an
        Emergency or Urgent Medical Condition shall not be construed to mean that
        the
        provider must obtain verification before providing Emergency Services and
        Care.

      

      
        	 	
                6.

              	
                Provider
                  Complaint System 

              

      

      

      a. The
        Health Plan shall establish a Provider complaint system that permits a Provider
        to dispute the Health Plan’s policies, procedures, or any aspect of a Health
        Plan’s administrative functions, including proposed Actions. 

      

      b. The
        Health Plan shall submit its Provider complaint system policies and procedures
        to the Agency for written approval.

       

      

      c. The
        Health Plan shall include its Provider complaint system policies and procedures
        in its Provider handbook as described above.

      

      d. The
        Health Plan shall also distribute the Provider complaint system policies
        and
        procedures to out of network providers upon written or oral request. The
        Health
        Plan may distribute a summary of these policies and procedures, if the summary
        includes information about how the provider may access the full policies
        and
        procedures on the Health Plan’s Web site. This summary shall also detail how the
        provider can request a hard-copy from the Health Plan at no charge to the
        provider.

      

      e. As
        a part
        of the Provider complaint system, the Health Plan shall:

      

      
        	
                (1)

              	
                Allow
                  providers forty-five (45) Calendar Days to file a written
                  complaint;

              

      

      

      
        	
                (2)

              	
                Have
                  dedicated staff for providers to contact via telephone, electronic
                  mail,
                  or in person, to ask questions, file a Provider complaint and resolve
                  problems;

              

      

      

      
        	
                (3)

              	
                Identify
                  a staff person specifically designated to receive and process provider
                  complaints; 

              

      

      

      
        	
                (4)

              	
                Thoroughly
                  investigate each provider complaint using applicable statutory,
                  regulatory, Contractual and Provider contract provisions, collecting
                  all
                  pertinent facts from all parties and applying the Health Plan’s written
                  policies and procedures; and

              

      

      

      
        	
                (5)

              	
                Ensure
                  that Health Plan executives with the authority to require corrective
                  action are involved in the provider complaint
                  process.

              

      

      

      f. In
        the
        event the outcome of the review of the provider complaint is adverse to the
        provider, the Health Plan shall provide a written notice of adverse action
        to
        the provider. 

      

      
        	F.	
                 Medical
                  Records Requirements

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall maintain Medical Records for each Enrollee in
                  accordance
                  with this section. Medical Records shall include the Quality, quantity,
                  appropriateness, and timeliness of services performed under this
                  Contract.

              

      

      

      a. The
        Health Plan must include/follow the Medical Record standards set forth below
        for
        each Enrollee's Medical Records, as appropriate:

      

      (1) The
        Enrollee’s identifying information, including name, Enrollee identification
        number, date of birth, sex and legal guardianship (if any).

      

      (2) Each
        record must be legible and maintained in detail.

      

      (3) A
        summary
        of significant surgical procedures, past and current diagnoses or problems,
        allergies, untoward reactions to drugs and current medications.

      

      (4) All
        entries must be dated and signed by the appropriate party.

      

      (5) All
        entries must indicate the chief complaint or purpose of the visit, the
        objective, diagnoses, medical findings or impression of the
        provider.

      

      (6) All
        entries must indicate studies ordered (e.g., laboratory, x-ray, EKG) and
        referral reports.

      

      (7) All
        entries must indicate therapies administered and prescribed.

      

      (8) All
        entries must include the name and profession of the provider rendering services
        (e.g., MD, DO, OD), including the signature or initials of the
        provider.

      

      (9) All
        entries must include the disposition, recommendations, instructions to the
        Enrollee, evidence of whether there was follow-up and outcome of
        services.

      

      (10) All
        records must contain an immunization history.

      

      (11) All
        records must contain information relating to the Enrollee’s use of tobacco
        products and alcohol/substance abuse.

      

      (12) All
        records must contain summaries of all Emergency Services and Care and Hospital
        discharges with appropriate medically indicated follow up.

      

      (13) Documentation
        of referral services in Enrollees' Medical Records.

      

      (14) All
        services provided by providers. Such services must include, but not necessarily
        be limited to, family planning services, preventive services and services
        for
        the treatment of sexually transmitted diseases.

      

      (15) All
        records must reflect the primary language spoken by the Enrollee and any
        translation needs of the Enrollee.

      

      (16) All
        records must identify Enrollees needing communication assistance in the delivery
        of health care services.

      

      (17) All
        records must contain documentation that the Enrollee was provided written
        information concerning the Enrollee’s rights regarding advance directives
        (written instructions for living will or power of attorney) and whether or
        not
        the Enrollee has executed an advance directive. Neither the Health Plan,
        nor any
        of its Providers shall, as a condition of treatment, require the Enrollee
        to
        execute or waive an advance directive. The Health Plan must maintain written
        policies and procedures for advance directives.

      

      b. Confidentiality
        of Medical Records

      

      (1) The
        Health Plan shall have a policy to ensure the confidentiality of Medical
        Records
        in accordance with 42 CFR, Part 431, Subpart F. This policy shall also include
        confidentiality of a minor’s consultation, examination, and treatment for a
        sexually transmissible disease in accordance with section 384.30(2),
        F.S.

      

      (2) The
        Health Plan shall have a policy to ensure compliance with the Privacy and
        Security provisions of the Health Insurance Portability and Accountability
        Act
        (HIPAA).

      

      
        	 	
                2.

              	
                The
                  Health Plan shall maintain a behavioral health Medical Record for
                  each
                  Enrollee. Each Enrollee's behavioral health Medical Record shall
                  include:

              

      

      

      a. Documentation
        sufficient to disclose the Quality, quantity, appropriateness and timeliness
        of
        Behavioral Health Services performed;

      

      b. Must
        be
        legible and maintained in detail consistent with the clinical and professional
        practice which facilitates effective internal and external purity, medical
        audit
        and adequate follow-up treatment; and

      

      c. For
        each
        service provided, clear identification as to

      

      
        	 	
                (1)

              	
                The
                  physician or other service provider;

              

      

      

      
        	 	
                (2)

              	
                Date
                  of service;

              

      

      

      
        	 	
                (3)

              	
                The
                  units of service provided; and

              

      

      

      
        	 	
                (4)

              	
                The
                  type of service provided.

              

      

      

      
        	G.
                	
                 Claims
                  Payment

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall reimburse providers for the delivery of authorized
                  services pursuant to section 641.3155 F.S. including, but not limited
                  to:

              

      

      

      a. Claims
        are considered received on the date the claims are received by the Health
        Plan
        at its designated claims receipt location.

      

      b. The
        provider must mail or electronically transfer (submit) the claim to the Health
        Plan within six (6) months of:

      

      
        	 	
                (1)

              	
                The
                  date of service or discharge from an inpatient setting;
                  or

              

      

      

      
        	 	
                (2)

              	
                The
                  provider has been furnished with the correct name and address of
                  the
                  Enrollee’s Health Plan.

              

      

      

      c. When
        the
        Health Plan is the secondary payor, the provider must submit the claim to
        the
        Health Plan within ninety (90) days of the final determination of the primary
        payor.

      

      
        	 	
                2.

              	
                The
                  Health Plan shall reimburse providers for Medicare deductibles
                  and
                  co-insurance payments for Medicare dually eligible members according
                  to
                  the lesser of the following:

              

      

      

      a. The
        rate
        negotiated with the provider; or

      

      b. The
        reimbursement amount as stipulated in section 409.908 F.S.

      

      
        	 	
                3.

              	
                In
                  accordance with section 409.912 F.S., the Health Plan shall reimburse
                  any
                  Hospital or physician that is outside the Health Plan’s authorized
                  geographic service area for Health Plan authorized services provided
                  by
                  the Hospital or physician to
                  Enrollees:

              

      

      

      a. At
        a rate
        negotiated with the Hospital or physician; or

      

      b. The
        lesser of the following:

      

      
        	 	
                (1)

              	
                The
                  usual and customary charge made to the general public by the Hospital
                  or
                  physician; or

              

      

      

      
        	 	
                (2)

              	
                The
                  Florida Medicaid reimbursement rate established for the Hospital
                  or
                  physician.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan shall have a process for handling and addressing the
                  resolution of provider complaints concerning claims issues. The
                  process
                  shall be in compliance with 641 .3155
                  F.S.

              

      

      

      
        	 	
                5.

              	
                The
                  Health Plan shall have claims processing and payment performance
                  metrics
                  including those for quality, accuracy and timeliness and include
                  a process
                  for measurement and monitoring, and for the development and implementation
                  of interventions for improvement. These metrics must be approved
                  in
                  writing by the Agency.

              

      

      

      
        	 	
                6.

              	
                Pursuant
                  to 42CFR447.45, the Health Plan shall have a claims processing
                  and payment
                  system, such that:

              

      

      

      a. Ninety
        percent (90%) of clean claims are paid within thirty (30) days from receipt
        at
        the Health Plan;

      

      b. Ninety-nine
        percent (99%) of clean claims are paid within ninety (90) days of receipt
        a the
        Health Plan; and

      

      c. All
        clean
        claims are paid within twelve (12) months of receipt by the Health
        Plan.

      

      
        	H.	
                 Encounter
                  Data 

              

      

      

      The
        Agency is developing a Medicaid Encounter Data System (MEDS) to collect all
        encounter data from health plans reimbursed on a capitated basis. Encounter
        data
        collection will be required from all Florida capitated health plans for all
        health care services rendered to its members. 

      

      The
        information required to support encounter reporting and submission will be
        defined by the Agency in the MEDS Companion Guide and MEDS Operations Manual.
        Other information contained within the MEDS Companion Guide and MEDS Operations
        Manual will be Managed Care Organization testing requirements for SFY 06-07
        and
        thereafter. The Companion Guide and Operations Manual will be distributed
        to
        Health Plans in a manner that makes them easily accessible. 

      

      Upon
        the
        request of the Agency, Health Plans shall be prepared to submit encounter
        data
        to the Agency or its designee. Health Plans shall have a comprehensive automated
        and integrated Encounter Data System that is capable of meeting the requirements
        listed below:

      

      	1.  	
              All
                encounters shall be submitted in the standard HIPAA transaction formats,
                namely the ANSI X12N 837 Transaction formats (P - Professional, I
                -
                Institutional, and D - Dental), and the National Council for Prescription
                Drug Programs NCPDP format (for Pharmacy
                services).

            

      

      	2.  	
              Health
                Plans shall collect and submit to the Agency or its designee, enrollee
                service level encounter data for all covered services. Health Plans
                will
                be held responsible for errors or noncompliance resulting from their
                own
                actions or the actions of an agent authorized to act on their
                behalf.

            

      

      	3.  	
              Health
                Plans shall have the capability to convert all information that enters
                their claims systems via hard copy paper claims to encounter data
                to be
                submitted in the appropriate HIPAA compliant
                formats.

            

      

      	4.  	
              Complete
                and accurate encounters shall be provided to the Agency. Health Plans
                will
                implement review procedures to validate encounter data submitted
                by
                providers. The historical encounter data submission shall be retained
                for
                a period not less than five years following generally accepted retention
                guidelines.

            

      

      	5.  	
              Health
                Plans shall require each Provider to have a unique Florida Medicaid
                Provider number, in accordance with the requirement of Section X,
                C. jj.
                of this Contract.

            

      

      	6.  	
              Health
                Plans will designate sufficient IT and staffing resources to perform
                these
                encounter functions as determined by generally accepted best industry
                practices. 

            

      

      
        	I.	
                Fraud
                  Prevention

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall establish functions and activities governing
                  program
                  integrity in order to reduce the incidence of Fraud and Abuse and
                  shall
                  comply with all State and federal program integrity requirements,
                  including the applicable provisions of chapters 358, 414, 641 and
                  932 in
                  Florida law and s. 409.912 (21) and (22). (See 42 CFR
                  438.608)

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall designate a compliance officer with sufficient
                  experience in health care, who shall have the responsibility and
                  authority
                  for carrying out the provisions of the Fraud and Abuse policies
                  and
                  procedures. The Health Plan shall have adequate staffing and resources
                  to
                  investigate unusual incidents and develop and implement corrective
                  action
                  plans to assist the Health Plan in preventing and detecting potential
                  Fraud and Abuse activities.

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan shall have internal controls and policies and procedures
                  in
                  place that are designed to prevent, detect and report known or
                  suspected
                  Fraud and Abuse activities.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan shall submit its Fraud and Abuse policies and procedures
                  to
                  the Bureau of Managed Health Care for written approval before
                  implementation. At a minimum, the policies and procedures
                  shall:

              

      

      

      a. Ensure
        that all officers, directors, managers and employees know and understand
        the
        provision of the Health Plan's Fraud and Abuse policies and
        procedures;

      

      b. Include
        procedures designed to prevent and detect potential or suspected abuse and
        fraud
        in the administration and delivery of services under this Contract. The Health
        Plan is responsible for reporting suspected fraud and abuse by participating
        and
        non-participating providers, as well as enrollees, when detected. 

      

      c. Incorporate
        a description of the specific controls in place for prevention and detection
        of
        potential or suspected Fraud and Abuse, including, but not limited
        to:

      

      
        	 	
                (1)

              	
                Claims
                  edits;

              

      

      

      
        	 	
                (2)

              	
                Post-processing
                  review of claims;

              

      

      

      
        	 	
                (3)

              	
                Provider
                  profiling and credentialing, including a review process for claims
                  that
                  shall include Providers and nonparticipating
                  providers:

              

      

      

      i. Who
        consistently demonstrate a pattern of submitting falsified encounter or service
        reports;

      

      ii. Who
        consistently demonstrate a pattern of overstated reports or up-coded levels
        of
        service;

      

      iii. Who
        alter, falsify or destroy clinical record documentation;

      

      iv. Who
        make
        false statements relating to credentials;

      

      v. Who
        misrepresent medical information to justify Enrollee referrals;

      

      vi. Who
        fail
        to render Medically Necessary Covered Services that they are obligated to
        provide according to their Provider contracts; and

      

      vii. Who
        charge Enrollees for Covered Services.

      

      
        	 	
                (4)

              	
                Prior
                  Authorization;

              

      

      

      
        	 	
                (5)

              	
                Utilization
                  Management;

              

      

      

      
        	 	
                (6)

              	
                Relevant
                  Subcontract and Provider contract provisions;
                  and

              

      

      
        	 	
                (7)

              	
                Pertinent
                  provisions from the Provider handbook and the Enrollee
                  handbook.

              

      

      

      d. Contain
        provisions for the confidential reporting of Health Plan violations to the
        Health Plan's analyst with the Bureau of Managed Health Care, MPI and
        MFCU;

      

      e. Include
        provisions for the investigation and follow-up of any reports;

      

      f. Ensure
        that the identities of individuals reporting acts of Fraud and Abuse are
        protected;

      

      g. Require
        all instances of provider or Enrollee Fraud and Abuse under State and/or
        federal
        law be reported to the Health Plan's analyst with the Bureau of Managed Health
        Care and MPI. The Health Plan shall not cease an investigation or resolve
        the
        suspicion, knowledge or action without first informing the Agency and MPI.
        Additionally, any final resolution must include a written statement that
        provides notice to the provider or enrollee that the resolution in no way
        binds
        the State of Florida nor precludes the State of Florida from taking further
        action for the circumstances that brought rise to the matter;

      

      h. The
        Health Plan and all providers, upon request, and as required by State and/or
        federal law, shall:

      

      
        	 	
                (1)

              	
                Make
                  available to the Agency, MPI and/or MFCU any and all administrative,
                  contractual, financial and Medical Records relating to the delivery
                  of
                  items or services for which Medicaid monies are expended;
                  and

              

      

      

      
        	 	
                (2)

              	
                Allow
                  access to the Agency, MPI and/or MFCU to any place of business
                  and all
                  Medical Records, as required by State and/or federal law. The Agency,
                  MPI
                  and MFCU shall have access during normal business hours, except
                  under
                  special circumstances when the Agency, MPI and MFCU shall have
                  after hour
                  admission. The Agency, MPI and/or MFCU shall determine the need
                  for
                  special circumstances.

              

      

      

      i. The
        Health Plan shall cooperate fully in any investigation by the Agency, MPI,
        MFCU
        or any subsequent legal action that may result from such an
        investigation.

      

      j. The
        Health Plan shall ensure that the Health Plan does not retaliate against
        any
        individual who reports violations of the Health Plan's Fraud and Abuse policies
        and procedures or suspected Fraud and Abuse.

      

      k. The
        Health Plan shall provide for the use of the List of Excluded Individuals
        and
        Entities (LEIE), or its equivalent, to identify excluded parties during the
        process of an engaging the services of new Providers to ensure that the
        Providers are not in a nonpayment status or sanctioned from participation
        in
        federal health care programs. The Health Plan shall not engage the services
        of a
        provider if that provider is in nonpayment status or salute from participation
        in federal health care programs under sections 1128 and/or 1128A of the Social
        Security Act. The Health Plan shall not employ or contract the services of
        excluded Providers and must terminate the Provider contract immediately between
        the Health Plan and a Provider that becomes an excluded provider.

      

      
        	 	
                5.

              	
                The
                  Health Plan shall comply with all reporting requirements set forth
                  in
                  Section XII., Reporting
                  Requirements.

              

      

      

      
        	 	
                6.

              	
                The
                  Health Plan shall meet with the Agency periodically, at the Agency’s
                  request, to discuss fraud, abuse, neglect and overpayment issues.
                  For
                  purpose of this section, the Health Plan Compliance Officer shall
                  be the
                  point of contact for the Health Plan and the Agency’s Medicaid Fraud and
                  Abuse Liaison shall be the point of contact for the
                  Agency.

              

      

      

      

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      Section
        XI

      Information
        Management and Systems 

      

      

      
        	A.	
                 General
                  Provisions

              

      

      

      	1.  	
              Systems
                Functions.
                The Health Plan shall have Information management processes and
                Information Systems (hereafter referred to as Systems) that enable
                it to
                meet Agency and federal reporting requirements and other Contract
                requirements and that are in compliance with this Contract and all
                applicable State and federal laws, rules and regulations including
                HIPAA.

            

      

      	2.  	
              Systems
                Capacity.
                The Health Plan’s Systems shall possess capacity sufficient to handle the
                workload projected for the begin date of operations and will be scaleable
                and flexible so they can be adapted as needed, within negotiated
                timeframes, in response to changes in Contract requirements, increases
                in
                enrollment estimates, etc. 

            

      

      	3.  	
              E-Mail
                System.
                The Health Plan shall provide a continuously available electronic
                mail
                communication link (E-mail system) with the Agency. This system shall
                be:
                available from the workstations of the designated Health Plan contacts;
                and capable of attaching and sending documents created using software
                products other than Health Plan’s systems, including the Agency’s
                currently installed version of Microsoft Office and any subsequent
                upgrades as adopted.

            

      

      	4.  	
              Participation
                in Information Systems Work Groups/Committees.
                The Health Plan shall meet as requested by the Agency to coordinate
                activities and develop cohesive systems strategies across vendors
                and
                agencies that actively participate in the reform initiative.
                

            

      

      	5.  	
              Connectivity
                to the Agency/State Network and Systems.
                The Health Plan shall be responsible for establishing connectivity
                to the
                Agency’s/the State’s wide area data communications network, and the
                relevant information systems attached to this network, in accordance
                to
                all applicable Agency and/or State policies, standards and guidelines.
                

            

      

      
        	B.	
                 Data
                  and Document Management
                  Requirements

              

      

      

      1. Adherence
        to Data and Document Management Standards 

      

      	a.  	
              Health
                Plan Systems shall conform to the standard transaction code sets
                specified
                in Section XI.I. 

            

      

      	b.  	
              The
                Health Plan’s Systems shall conform to HIPAA standards for data and
                document management that are currently under development within one
                hundred twenty (120) Calendar Days of the standard’s effective date or, if
                earlier, the date stipulated by CMS or the
                Agency.

            

      

      	c.  	
              The
                Health Plan shall partner with the Agency in the management of standard
                transaction code sets specific to the Agency. Furthermore, the Health
                Plan
                shall partner with the Agency in the development and implementation
                planning of future standard code sets not specific to HIPAA or other
                federal efforts and shall conform to these standards as stipulated
                in the
                plan to implement the standards. 

            

      

      	2.  	
              Data
                Model and Accessibility.
                Health Plan Systems shall be Structured Query Language (SQL) and/or
                Open
                Database Connectivity (ODBC) compliant; alternatively, Health Plan
                Systems
                shall employ a relational data model in the architecture of its databases
                in addition to a relational database management system (RDBMS) to
                operate
                and maintain them. 

            

      

      	3.  	
              Data
                and Document Relationships.
                The Health Plan shall house indexed images of documents used by Enrollees
                and providers to transact with the Health Plan in the appropriate
                database(s) and document management systems so as to maintain the
                logical
                relationships between certain documents and certain data.
                

            

      

      	4.  	
              Information
                Retention.
                Information in Health Plan systems shall be maintained in electronic
                form
                for three years in live Systems and, for audit and reporting purposes,
                for
                seven years in live and/or archival
                Systems.

            

      

      	5.  	
              Information
                Ownership.
                All Information, whether data or documents, and reports that contain
                or
                make references to said Information, involving or arising out of
                this
                Contract is owned by the Agency. The Health Plan is expressly prohibited
                from sharing or publishing the Agency information and reports without
                the
                prior written consent of the Agency. In the event of a dispute regarding
                the sharing or publishing of information and reports, the Agency’s
                decision on this matter shall be final and not subject to change.
                

            

      

      
        	C.	
                 System
                  and Data Integration
                  Requirements

              

      

       

      1. Adherence
        to Standards for Data Exchange 

      

      	a.  	
              Health
                Plan Systems shall be able to transmit, receive and process data
                in
                HIPAA-compliant formats that are in use as of the Contract Execution
                Date;
                these formats are detailed in Section
                XI.J.

            

      

      	b.  	
              Health
                Plan Systems shall be able to transmit, receive and process data
                in the
                Agency-specific formats and/or methods that are in use on the Contract
                Execution Date, as specified in Section
                XI.J.

            

      

      	c.  	
              Health
                Plan Systems shall conform to future federal and/or Agency specific
                standards for data exchange within one hundred twenty (120) Calendar
                Days
                of the standard’s effective date or, if earlier, the date stipulated by
                CMS or the Agency. The Health Plan shall partner with the Agency
                in the
                management of current and future data exchange formats and methods
                and in
                the development and implementation planning of future data exchange
                methods not specific to HIPAA or other Federal effort. Furthermore,
                the
                Health Plan shall conform to these standards as stipulated in the
                plan to
                implement such standards.

            

      

      2. HIPAA
        Compliance Checker.
        

      

      All
        HIPAA-conforming exchanges of data between the Agency and the Health Plan
        shall
        be subjected to the highest level of compliance as measured using an
        industry-standard HIPAA compliance checker application.

      

      3. Data
        and Report Validity and Completeness. 

      

      The
        Health Plan shall institute processes to ensure the validity and completeness
        of
        the data, including reports, it submits to the Agency. At its discretion,
        the
        Agency will conduct general data validity and completeness audits using
        industry-accepted statistical sampling methods. Data elements that will be
        audited include but are not limited to: Enrollee ID, date of service, assigned
        Medicaid Provider ID, category and sub category (if applicable) of service,
        diagnosis codes, procedure codes, revenue codes, date of claim processing,
        and
        (if and when applicable) date of claim payment. Control totals shall also
        be
        reviewed and verified.

      

      4. State/Agency
        Website/Portal Integration. 

      

      Where
        deemed that the Health Plan’s Web presence will be incorporated to any degree to
        the Agency’s or the State’s Web presence (also known as Portal), the Health Plan
        shall conform to any applicable Agency or State standard for Website structure,
        coding and presentation. 

      

      5. Connectivity
        to and Compatibility/Interoperability with Agency Systems and IT Infrastructure.
        

      

      The
        Health Plan shall be responsible for establishing connectivity to the
        Agency’s/State’s wide area data communications network, and the relevant
        information systems attached to this network, in accordance with all applicable
        Agency and/or State policies, standards and guidelines.

      

      6. Functional
        Redundancy with FMMIS. 

      

      The
        Health Plan’s Systems shall be able to transmit and receive transaction data to
        and from FMMIS as required for the appropriate processing of claims and any
        other transaction that could be performed by either System. 

      

      7. Data
        Exchange in Support of the Agency’s Program Integrity and Compliance Functions.

      

      The
        Health Plan’s System(s) shall be capable of generating files in the prescribed
        formats for upload into Agency Systems used specifically for program integrity
        and compliance purposes.

      

      8. Address
        Standardization. 

      

      The
        Health Plan’s System(s) shall possess mailing address standardization
        functionality in accordance with US Postal Service conventions.

      

      9. Eligibility
        and Enrollment Data Exchange Requirements

      

      	a.  	
              The
                Health Plan shall receive, process and update enrollment files sent
                daily
                by the Agency or its Agent.

            

      

      	b.  	
              The
                Health Plan shall update its eligibility/Enrollment databases within
                twenty-four (24) hours of receipt of said files.
                

            

      

      	c.  	
              The
                Health Plan shall transmit to the Agency or its Agent, in a periodicity
                schedule, format and data exchange method to be determined by the
                Agency,
                specific data it may garner from an Enrollee including third party
                liability data.

            

      

      	d.  	
              The
                Health Plan shall be capable of uniquely identifying a distinct Medicaid
                Recipient across multiple Systems within its Span of
                Control.

            

      

      
        	D.	
                 
                  Systems Availability, Performance and Problem Management
                  Requirements

              

      

       

      	1.  	
              Availability
                of Critical Systems Functions. 

            

      

      The
        Health Plan will ensure that critical systems functions available to Health
        Plan
        Enrollees and Providers - functions that if unavailable would have an immediate
        detrimental impact on enrollees and providers - are available twenty-four
        (24)
        hours a day, seven (7) days a week, except during periods of scheduled System
        Unavailability agreed upon by the Agency and the Health Plan. Unavailability
        caused by events outside of a Health Plan’s Span of Control is outside of the
        scope of this requirement. 

      

      	2.  	
              Availability
                of Data Exchange Functions. 

            

      

      The
        Health Plan shall ensure that the systems and processes within its Span of
        Control associated with its data exchanges with the Agency and/or its Agent(s)
        are available and operational according to specifications and the data exchange
        schedule. 

      

      	3.  	
              Availability
                of Other Systems Functions.
                

            

      

      The
        Health Plan shall ensure that at a minimum all other System functions and
        Information are available to the applicable System users between the hours
        of
        7:00 a.m. and 7:00 p.m., EST or EDT as appropriate, Monday through Friday.
        

      

      	4.  	
              Problem
                Notification. 

            

      

      	a.  	
              Upon
                discovery of any problem within its Span of Control that may jeopardize
                or
                is jeopardizing the availability and performance of all Systems functions
                and the availability of information in said Systems, including any
                problems impacting scheduled exchanges of data between the Health
                Plan and
                the Agency and/or its Agent(s), the Health Plan shall notify the
                applicable Agency staff via phone, fax and/or electronic mail within
                fifteen (15) minutes of such discovery. In its notification the Health
                Plan shall explain in detail the impact to critical path processes
                such as
                enrollment management and claims submission
                processes.

            

      

      	b.  	
              The
                Health Plan shall provide to appropriate Agency staff information
                on
                System Unavailability events, as well as status updates on problem
                resolution. At a minimum these up-dates shall be provided on an hourly
                basis and made available via electronic mail and/or telephone.
                

            

      

      

      	5.  	
              Recovery
                from Unscheduled System Unavailability.
                

            

      

      Unscheduled
        System unavailability caused by the failure of systems and telecommunications
        technologies within the Health Plan’s Span of Control will be resolved, and the
        restoration of services implemented, within forty-eight (48) hours of the
        official declaration of System Unavailability.

       

      	6.  	
              Exceptions
                to System Availability Requirement.
                

            

      

      The
        Health Plan shall not be responsible for the availability and performance
        of
        systems and IT infrastructure technologies outside of the Health Plan’s span of
        control. 

      

      	7.  	
              Corrective
                Action Plan.
                

            

      

      Full
        written documentation that includes a Corrective Action Plan, that describes
        how
        problems with critical Systems functions will be prevented from occurring
        again,
        shall be delivered within five (5) Business Days of the problem’s
        occurrence.

      

      	8.  	
              Business
                Continuity-Disaster Recovery (BC-DR) Plan
                

            

      

      	a.  	
              Regardless
                of the architecture of its Systems, the Health Plan shall develop
                and be
                continually ready to invoke a business continuity and disaster recovery
                (BC-DR) plan that is reviewed and prior-approved by the Agency.
                

            

      

      	b.  	
              At
                a minimum the Health Plan’s BC-DR plan shall address the following
                scenarios: (1) the central computer installation and resident software
                are
                destroyed or damaged, (2) System interruption or failure resulting
                from
                network, operating hardware, software, or operational errors that
                compromises the integrity of transactions that are active in a live
                system
                at the time of the outage, (3) System interruption or failure resulting
                from network, operating hardware, software or operational errors
                that
                compromises the integrity of data maintained in a live or archival
                system,
                (4) System interruption or failure resulting from network, operating
                hardware, software or operational errors that does not compromise
                the
                integrity of transactions or data maintained in a live or archival
                system
                but does prevent access to the System, i.e. causes unscheduled System
                Unavailability.

            

      	c.  	
              The
                Health Plan shall periodically, but no less than annually, perform
                comprehensive tests of its BC-DR plan through simulated disasters
                and
                lower level failures in order to demonstrate to the Agency that it
                can
                restore System functions per the standards outlined elsewhere in
                this
                Section of the Contract.

            

      

      	d.  	
              In
                the event that the Health Plan fails to demonstrate in the tests
                of its
                BC-DR plan that it can restore system functions per the standards
                outlined
                in this Contract, the Health Plan shall be required to submit to
                the
                Agency a corrective action plan in accordance with Section XIV (Sanctions)
                of this Contract that describes how the failure will be resolved.
                The
                corrective action plan shall be delivered within ten (10) Business
                Days of
                the conclusion of the test.

            

       

      
        	E.	
                 
                  System Testing and Change Management Requirements 

              

      

      

      	1.  	
              Notification
                and Discussion of Potential System Changes.
                

            

      

      The
        Health Plan shall notify the applicable Agency staff person of the following
        changes to Systems within its Span of Control within at least ninety (90)
        Calendar Days of the projected date of the change; if so directed by the
        Agency,
        the Health Plan shall discuss the proposed change with the applicable Agency
        staff: (1) software release updates of core transaction Systems: claims
        processing, eligibility and Enrollment processing, service authorization
        management, Provider enrollment and data management; (2) conversions of core
        transaction management Systems. 

      

      	2.  	
              Response
                to Agency Reports of Systems Problems not Resulting in System
                Unavailability.
                

            

      

      The
        Health Plan shall respond to Agency reports of System problems not resulting
        in
        System Unavailability according to the following timeframes: 

      

      	a.  	
              Within
                seven (7) Calendar Days of receipt the Health Plan shall respond
                in
                writing to notices of system problems. 

            

      

      	b.  	
              Within
                twenty (20) Calendar Days, the correction will be made or a Requirements
                Analysis and Specifications document will be due.
                

            

      

      	c.  	
              The
                Health Plan will correct the deficiency by an effective date to be
                determined by the Agency. 

            

      

      	3.  	
              Valid
                Window for Certain System Changes.
                

            

      

      Unless
        otherwise agreed to in advance by the Agency as part of the activities described
        in this Contract Section, scheduled System Unavailability to perform System
        maintenance, repair and/or upgrade activities shall not take place during
        hours
        that could compromise or prevent critical business operations. 

      

      	4.  	
              Testing

            

      

      	a.  	
              The
                Health Plan shall work with the Agency pertaining to any testing
                initiative as required by the Agency. 

            

      

      	b.  	
              The
                Health Plan shall provide sufficient system access to allow the Agency
                and/or independent testing of the Health Plan’s systems during and
                subsequent to readiness review. 

            

      

      

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        	F.	
                 Information
                  Systems Documentation Requirements 

              

      

      

      	1.  	
              Types
                of Documentation.
                

            

      

      The
        Health Plan shall develop, prepare, print, maintain, produce, and distribute
        distinct System Process and Procedure Manuals, User Manuals and Quick/Reference
        Guides, and any updates thereafter, for the Agency and other applicable Agency
        staff.

      

      	2.  	
              Content
                of System Process and Procedure Manuals.
                

            

      

      The
        Health Plan shall ensure that written System Process and Procedure Manuals
        document and describe all manual and automated system procedures for its
        information management processes and information systems. 

      

      	3.  	
              Content
                of System User Manuals.
                

            

      

      The
        System User Manuals shall contain information about, and instructions for,
        using
        applicable System functions and accessing applicable system data. 

      

      	4.  	
              Changes
                to Manuals. 

            

      

      	a.  	
              When
                a System change is subject to Agency sign off, the Health Plan shall
                draft
                revisions to the appropriate manuals prior to Agency sign off of
                the
                change. 

            

      

      	b.  	
              Updates
                to the electronic version of these manuals shall occur in real time;
                updates to the printed version of these manuals shall occur within
                ten
                (10) Business Days of the update taking
                effect.

            

      

      	5.  	
              Availability
                of/Access to Documentation.
                

            

      

      All
        of
        the aforementioned manuals and reference guides shall be available in printed
        form and/or on-line. If so prescribed, the manuals will be published in
        accordance to the appropriate Agency and/or State standard. 

      

      
        	G.	
                 
                  Reporting Requirements - Specific to Information Management and
                  Systems
                  Functions and Capabilities - and Technological Capabilities 

              

      

      

      	1.  	
              Reporting
                Requirements.
                

            

      

      The
        Health Plan shall submit a monthly Systems
        Availability and Performance Report
        to the
        Agency as described in Section XII (Reporting) of this Contract. 

      

      	2.  	
              Reporting
                Capabilities.
                

            

      

      The
        Health Plan shall provide systems-based capabilities to access to authorized
        Agency personnel, on a secure and read-only basis, to data that can be used
        in
        ad hoc reports.

      

      
        	H.	
                 Other
                  Requirements

              

      

      

      Community
        Health Record/Electronic Medical Record and
        Related Efforts 

      

      	a.  	
              At
                such time that the Agency requires, the Health Plan shall participate
                and
                cooperate with the Agency to implement, within a reasonable timeframe,
                a
                secure, Web-accessible Community Health Records for
                Enrollees.

            

      

      	b.  	
              The
                design of the vehicle(s) for accessing the Community Health Record,
                the
                health record format and design shall comply with all HIPAA and related
                regulations.

            

      

      	c.  	
              The
                Health Plan shall also cooperate with the Agency in the continuing
                development of the state’s health care data site (FloridaHealthStat).
                

            

      

      
        	I.	
                 Compliance
                  with Standard Coding
                  Schemes

              

      

      

      	1.  	
              Compliance
                with HIPAA-Based Code Sets. 

            

      

      A
        Health
        Plan System that is required to or otherwise contains the applicable data
        type
        shall conform to the following HIPAA-based standard code sets; the processes
        through which the data are generated should conform to the same standards
        as
        needed: 

      

      	a.  	
              Logical
                Observation Identifier Names and Codes
                (LOINC)

            

      

      	b.  	
              Health
                Care Financing Administration Common Procedural Coding System
                (HCPCS)

            

      

      	c.  	
              Home
                Infusion EDI Coalition (HEIC) Product Codes

            

      

      	d.  	
              National
                Drug Code (NDC)

            

      

      	e.  	
              National
                Council for Prescription Drug Programs
                (NCPDP)

            

      

      	f.  	
              International
                Classification of Diseases (ICD-9)

            

      

      	g.  	
              Diagnosis
                Related Group (DRG)

            

      

      	h.  	
              Claim
                Adjustment Reason Codes

            

      

      	i.  	
              Remittance
                Remarks Codes

            

      

      	2.  	
              Compliance
                with Other Code Sets. 

            

      

      A
        Health
        Plan System that is required to or otherwise contains the applicable data
        type
        shall conform to the following non-HIPAA-based standard code sets:

      

      
        	 	
                a.
                  

              	
                As
                  described in all AHCA Medicaid Reimbursement Handbooks, for all
                  "Covered
                  Entities", as defined under the HIPAA, and which submit transactions
                  in
                  paper format (non-electronic
                  format).

              

      

      

      
        	 	
                b.

              	
                As
                  described in all AHCA Medicaid Reimbursement Handbooks for all
                  "Non-covered Entities", as defined under the
                  HIPAA.

              

      

       

      

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        	J.	
                 Data
                  Exchange and Formats and Methods Applicable to Health
                  Plans 

              

      

      

      	1.  	
              HIPAA-Based
                Formatting Standards. 

            

      

      Health
        Plan Systems shall conform to the following HIPAA-compliant standards for
        information exchange effective the first day of operations in the applicable
        service region:

      

      Batch
        transaction types

      - ASC
        X12N
        834 Enrollment and Audit Transaction

      - ASC
        X12N
        835 Claims Payment Remittance Advice Transaction

      - ASC
        X12N
        837I Institutional Claim/Encounter Transaction 

      - ASC
        X12N
        837P Professional Claim/Encounter Transaction

      - ASC
        X12N
        837D Dental Claim/Encounter Transaction

      - NCPDP
        1.1 Pharmacy
        Claim/Encounter Transaction

       

      

      Online
        transaction types

      - ASC
        X12N
        270/271 Eligibility/Benefit Inquiry/Response

      - ASC
        X12N
        276 Claims Status Inquiry 

      - ASC
        X12N
        277 Claims Status Response 

      - ASC
        X12N
        278/279 Utilization Review Inquiry/Response 

      - NCPDP
        5.1 Pharmacy
        Claim/Encounter Transaction

      

      	2.  	
              Methods
                for Data Exchange. 

            

      

      The
        Health Plans and the Agency and/or its Agent(s) shall made predominant use
        of
        Secure File Transfer Protocol (SFTP) and Electronic Data Interchange (EDI)
        in
        their exchanges of data. 

      

      	3.  	
              Agency-Based
                Formatting Standards and Methods. 

            

      

      Health
        Plan Systems shall exchange the following data with the Agency and/or its
        Agent(s) in a format to be jointly agreed upon by the Health Plan and the
        Agency: 

      

      	a.  	
              Provider
                network data

            

      

      	b.  	
              Case
                management fees

            

      

      	c.  	
              Administrative
                payments 

            

      

      

      

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      Section
        XII

      Reporting
        Requirements

      

      
        	A.	
                 Health
                  Plan Reporting
                  Requirements

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall comply with all Reporting Requirements set forth
                  by the
                  Agency in this Contract.

              

      

      

      
        	 	
                a.

              	
                The
                  Health Plan is responsible for assuring the accuracy, completeness,
                  and
                  timely submission of each report.

              

      

       

      
        	 	
                b.

              	
                The
                  Health Plan’s chief executive officer (CEO), chief financial officer
                  (CFO), or an individual who reports to the CEO or CFO and who has
                  delegated authority to certify the Health Plan’s reports, must attest,
                  based on his/her best knowledge, information, and belief, that
                  all data
                  submitted in conjunction with the reports and all documents requested
                  by
                  the Agency are accurate, truthful, and complete. (42 C.F.R. 438.606(a)
                  and
                  (b))

              

      

       

      
        	 	
                c.

              	
                The
                  Health Plan must submit its certification at the same time it submits
                  the
                  certified data reports. (42 C.F.R.
                  438.606(c))

              

      

      

      
        	 	
                d.

              	
                Before
                  October 1 of each year, the Health Plan shall deliver to the Agency
                  a
                  certification by an Agency-approved independent auditor that the
                  Performance Measure data reported for the previous calendar year
                  have been
                  fairly and accurately presented.

              

      

      

      
        	 	
                e.

              	
                Deadlines
                  for report submission referred to in this Contract specify the
                  actual time
                  of receipt at the Agency, not the date the file was postmarked
                  or
                  transmitted. 

              

      

      

      
        	 	
                f.

              	
                If
                  a reporting due date falls on a weekend, the report shall be due
                  to the
                  Agency on the following Monday. 

              

      

      

      
        	 	
                g.

              	
                All
                  reports to be filed on a quarterly basis shall be filed on a calendar
                  year
                  quarter.

              

      

      

      
        	 	
                2.

              	
                The
                  Agency shall furnish the Health Plan with the appropriate reporting
                  formats, instructions, submission timetables, and technical assistance,
                  as
                  required.

              

      

      

      
        	 	
                3.

              	
                The
                  Agency reserves the right to modify the Reporting Requirements,
                  with a
                  ninety (90) Calendar Day notice to allow the Health Plan to complete
                  implementation, unless otherwise required by law.
                  

              

      

      

      
        	 	
                4.

              	
                The
                  Agency shall provide the Health Plan with written notification
                  of any
                  modifications to the Reporting Requirements.

              

      

      

      5. The
        Reporting Requirements specifications are outlined in detail below.

      

      
        	 	
                6.

              	
                If
                  the Health Plan fails to submit the required reports accurately
                  and within
                  the timeframes specified below, the Agency shall fine or otherwise
                  sanction the Health Plan in accordance with Section XIV,
                  Sanctions.

              

      

      

      	7.  	
              The
                Health Plan must use the following naming convention for all submitted
                reports. Unless otherwise noted, each report will have an 8-digit
                file
                name, constructed as follows:

            

      

      
        	
                Digit
                  1

              	
                Report
                  Identifier

              	
                Indicates
                  the report type. Use G for grievance report; 

              
	
                Digits
                  2, 3, and 4

                 

              	
                Plan
                  Identifier

                 

              	
                Indicates
                  the specific Health Plan submitting the data by the use of three
                  (3)
                  unique alpha digits. Comports to the Health Plan identifier used
                  in
                  exchanging data with the enrollment broker.

              
	
                Digits
                  5 and 6

              	
                Year

              	
                Indicates
                  the year. For example, reports submitted in 2006 should indicate
                  06.

              
	
                Digits
                  7 and 8

              	
                Time
                  Period

                 

              	
                For
                  reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For
                  reports
                  submitted monthly, use the appropriate month, such as 01, 02, 03,
                  etc.

              

      

      

      8. These
        files can be: 

      

      a. Mailed
        to
        the following address:

      

      Agency
        for Health Care Administration

      Bureau
        of
        Managed Health Care

      2727
        Mahan Drive, MS #26

      Tallahassee,
        FL 32308

      

      or

      

      b. Transmitted
        electronically to the Agency at the following address:

      

      MMCDATA@ahca.myflorida.com

      

      

      
        	 	
                9.

              	
                For
                  financial reporting, the Health Plan shall complete the spreadsheets
                  and
                  mail the diskette or compact disk to the address indicated above
                  or
                  transmit it electronically to the Agency at the email address noted
                  above.
                  Additionally, the Health Plan must also send financial reports
                  to the
                  following e-mail address:

              

      

      

      MMCDATA@ahca.myflorida.com

      

      

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      Table
        1

      Summary
        of Reporting Requirements

      

      
        	
                Health
                  Plan Reports Required by AHCA

              
	
                Report
                  Name

              	
                Level
                  of Analysis

              	
                Frequency

              	
                Submission
                  Media

              
	
                834
                  Transaction

                Enrollment/Disenrollment

              	
                Location
                  Level

              	
                Monthly

              	
                File
                  Transfer Protocol (FTP) to the Agency or its Agent via a secure
                  Internet
                  site

              
	
                Grievance
                  System Reporting

                Table
                  2

              	
                Individual
                  Level

              	
                Quarterly,
                  within 45 Calendar Days of end of reporting quarter

              	
                Electronic
                  mail or diskette

              
	
                Provider
                  Network Report

                Table
                  3

              	
                Location
                  Level

              	
                At
                  least monthly

              	
                FTP
                  to Choice Counselor vendor

              
	
                Marketing
                  Representative Report

                Table
                  4

              	
                Health
                  Plan Level

              	
                Monthly

              	
                Electronic
                  mail

              
	
                Enhanced
                  Benefit Report

                Table
                  5

              	
                Enrollee
                  Level

              	
                Monthly

              	
                Electronic
                  Mail

              
	
                Catastrophic
                  Costs Report

                Table
                  6

              	
                Enrollee
                  Level

              	
                Monthly,
                  as needed

              	
                Electronic
                  Mail

              
	
                Critical
                  Incidents

              	
                Enrollee
                  Level

              	
                Daily
                  , as needed

              	
                Electronic
                  Mail

              
	
                Results
                  of the HSA Survey

              	
                Health
                  Plan Level

              	
                Biannually,
                  on February 1 and August 1

              	
                Electronic
                  mail or diskette

              
	
                Performance
                  Measures

              	
                Health
                  Plan Level

              	
                Annually,
                  for previous calendar year, due October 1

              	
                Electronic
                  mail, CD ROM or diskette submission

              
	
                Financial
                  Reporting

              	
                Health
                  Plan Level

              	
                Quarterly,
                  within 45 Calendar Days of end of reporting quarter

              	
                Diskette

              
	
                Audited
                  Financial Report

              	
                Health
                  Plan Level

              	
                Annually,
                  within 90 Calendar Days of end of Health Plan Fiscal Year

              	
                Electronic
                  mail or diskette

              
	
                Suspected
                  Fraud Reporting

              	
                Individual
                  Level

              	
                As
                  described in 

                Section
                  X, H.

              	
                Electronic
                  Mail

              
	
                Denials
                  of Authorization

                Tables
                  7 and 7A

              	
                Enrollee
                  Level

              	
                Monthly
                  within 14 Calendar Days of the end of the month being
                  reported

              	
                Electronic
                  mail or diskette

              
	
                Systems
                  Availability and Performance Report

                Table
                  8

              	
                Health
                  Plan Level

              	
                Monthly,
                  within fifteen (15) Calendar Days of the end of the reporting
                  month

              	
                Electronic
                  Mail

              
	
                Claims
                  Inventory Summary Reports

                Tables
                  9, 9a, 9b and 9c

              	
                Health
                  Plan Level

              	
                Quarterly,
                  within forty five (45) Calendar Days of the end of the reporting
                  quarter

              	
                Electronic
                  Mail

              
	
                Child
                  Health Check Up Reports

                Tables
                  10 and 10a

              	
                Health
                  Plan Level

              	
                Annually
                  for previous federal fiscal year (Oct.-Sept.) due by January 15.
                  Audited
                  report due by Oct. 1

              	
                Electronic
                  Mail

              
	
                Pharmacy
                  Encounter Data

              	
                Health
                  Plan Level

              	
                Quarterly,
                  within 30 days of the end of the quarter

              	
                Electronic
                  Mail

              
	
                Health
                  Plan Benefit Package

                Table
                  11

              	
                Health
                  Plan Level

              	
                Annual
                  re-certification by 

                June
                  30

              	
                Electronic
                  Mail

              
	
                Transportation
                  Services

              	
                Health
                  Plan Level

              	 	 
	
                Behavioral
                  Health Specific Reporting

              
	
                Enrollee
                  Satisfaction Survey Summary 

                Table
                  12

              	
                Health
                  Plan Level

              	
                Semi-annually,
                  due sixty (60) days after the end of the six months being reported.
                  

              	
                Hard
                  Copy

              
	
                Stakeholders
                  Satisfaction Survey Summary 

                Table
                  13

              	
                Health
                  Plan Level

              	
                Semi-annually,
                  due sixty (60) days after the end of the six months being reported.
                  

              	
                Hard
                  Copy

              
	
                Grievance
                  System Report

                Table
                  2 

              	
                Individual
                  Level

              	
                Quarterly,
                  within 45 days of end of reporting quarter

              	
                Via
                  AHCA secure RTP site

              
	
                Critical
                  Incident

                Summary
                  

                Table
                  14

              	
                Health
                  Plan Level

              	
                Monthly
                  — Due on the 15th of the month- Contains previous calendar month’s
                  data

              	
                Via
                  AHCA secure FTP site

              
	
                Critical
                  Incidents 

                Table
                  14a

              	
                Individual

              	
                Immediately
                  upon occurrence

              	
                Via
                  AHCA secure FTP site

              
	
                Required
                  Staff/Providers 

                Table
                  15

              	
                Health
                  Plan Level

              	
                Quarterly
                  — Due forty-five (45) after the end of the quarter being reported
                  -
                  Contains data for the entire quarter

              	
                Via
                  AHCA secure FTP site.

              
	
                FARS/CFARS
                  

                Table
                  16

              	 	
                Biannually,
                  due no later than forty-five (45) days after the reporting
                  period.

              	
                Via
                  AHCA secure FTP site

              
	
                Encounter
                  Data 

                Table
                  17

              	
                Individual
                  Level

              	
                Quarterly
                  - Due forty five (45) days after the end of the quarter being
                  reported.

              	
                Via
                  AHCA secure FTP site

              
	
                Minority
                  Reporting

              	
                Health
                  Plan Level

              	
                Monthly
                  - Due 15 days after the end of the month being reported

              	
                Electronic
                  Mail 

              

      

      

      

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        	B.	
                 Enrollment/Disenrollment
                  Reports:

              

      

      

      
        	 	
                1.

              	
                The
                  Agency or its Agent will report Enrollment/Disenrollment information
                  to
                  the PSN.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall review the Enrollment/Disenrollment reports for
                  accuracy
                  and will notify the Agency within three (3) Business Days of any
                  discrepancies. Failure to notify the Agency of any discrepancies
                  within
                  three (3) Business Days shall lead
                  to fines and other sanctions as detailed in Section XIV,
                  Sanctions.

              

      

      

      
        	 	
                3.

              	
                The
                  Enrollment/Disenrollment Reports will use HIPAA-compliant standard
                  transactions. The Agency or its Agent will use the X12N 834 transaction
                  for all Enrollee maintenance and reporting. The PSN must be capable
                  of
                  receiving and processing X12N 834 transactions.

              

      

      

      During
        the transition period from proprietary to standard formats, the PSN shall
        cooperatively participate with the Agency in the transition process, including
        formal testing when asked to do so by the Agency. 

      

      
        	C.	
                 Grievance
                  System

              

      

       

      
        	 	
                1.

              	
                The
                  Health Plan shall submit the Grievance System report to the Agency
                  for
                  Health Care Administration via the Agency’s secure FTP server or
                  on a diskette or CD.

              

      

      

      
        	 	
                2.

              	
                The
                  report is due forty-five (45) Calendar Days following the end of
                  the
                  reported quarter. 

              

      

      

      	3.  	
              The
                Health
                Plan must
                submit the Grievance System report each quarter. If no new Grievances
                or
                Appeals have been filed with the Health
                Plan,
                or if the status of an unresolved Appeal has not changed to 'Resolved,'
                please submit one (1) record only. This record must contain the PLAN_ID
                field only, with the first 7-digits of the 9-digit Medicaid provider
                number. 

            

      

      
        	 	
                4.

              	
                The
                  report shall contain information about Grievances and Appeals concerning
                  both medical and behavioral health
                  issues.

              

      

       

      

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      Table
        2

      Structure
        for Grievance/Appeal Reporting File

      

      
        	
                Field
                  Name

              	
                 

                Length

              	
                 

                Start
                  Column

              	
                 

                End
                  Column

              	
                 

                Description

              
	
                 

                PLAN_ID

              	
                9

              	
                1

              	
                9

              	
                 

                The
                  nine digit Medicaid provider number.

              
	
                 

                RECIP_ID

                 

              	
                 

                9

                 

              	
                 

                10

                 

              	
                 

                18

                 

              	
                 

                The
                  recipient’s 9 digit Medicaid ID number

                 

              
	
                 

                LAST_NAME

                 

              	
                 

                20

                 

              	
                 

                19

                 

              	
                 

                38

                 

              	
                 

                The
                  recipient’s last name

                 

              
	
                 

                FIRST_NAME

                 

              	
                 

                10

                 

              	
                 

                39

                 

              	
                 

                48

                 

              	
                 

                The
                  recipient’s first name

                 

              
	
                 

                MID_INIT

                 

              	
                 

                1

                 

              	
                 

                49

                 

              	
                 

                49

                 

              	
                 

                The
                  recipient’s middle initial

                 

              
	
                 

                GRV_DATE

                 

              	
                 

                10

                 

              	
                 

                50

                 

              	
                 

                59

                 

              	
                 

                The
                  date of the grievance (MM/DD/CCYY)

                 

              
	
                 

                GRV_TYPE

                 

              	
                 

                2

                 

              	
                 

                60

                 

              	
                 

                61

                 

              	
                1. Quality
                  of Care

                2. Access
                  to Care

                3. Emergency
                  Services

                4. Not
                  Medically Necessary

                5. Pre-Existing
                  Condition

                6. Excluded
                  Benefit

                7. Billing
                  Dispute

                8. Contract
                  Interpretation

                 

              	
                1.
                  Enrollment/Disenrollment

                2.
                  Termination of Contract

                3.
                  Services after termination

                4.
                  Unauthorized out of plan svcs

                5.
                  Unauthorized in-plan svcs

                6.
                  Benefits available in plan

                7.
                  Experimental/ Investigational

                8.
                  Other

                 

              
	
                 

                APP_DATE

                 

              	
                 

                10

                 

              	
                 

                62

                 

              	
                 

                71

                 

              	
                 

                The
                  date of the appeal (MM/DD/CCYY)

                 

              
	
                 

                APP_ACTION

                 

              	
                 

                1

                 

              	
                 

                72

                 

              	
                 

                72

                 

              	
                 

                The
                  type of action (42 CFR 438.400):

                 

              
	 	 	 	 	
                1. The
                  denial or limited authorization of a requested service, including
                  the type
                  or level of service.

                2. The
                  reduction, suspension, or termination of a previously authorized
                  service.

                3. The
                  denial, in whole or in part, of payment for a service.

                4. The
                  failure to provide services in a timely manner, as defined by the
                  state.

                5. The
                  failure of the plan to act within the time frames provided in Sec.
                  438.408(b).

                6. For
                  a resident of a rural area with only one managed care entity, the
                  denial
                  of a Medicaid enrollee’s request to exercise his or her right, under Sec.
                  438.52(b)(2)(ii), to obtain services outside the network.

                 

              
	
                 

                DISP_DATE

                 

              	
                 

                10

                 

              	
                 

                73

                 

              	
                 

                82

                 

              	
                 

                The
                  date of the Disposition (MM/DD/CCYY)

                 

              
	
                 

                DISP_TYPE

                 

              	
                 

                2

                 

              	
                 

                83

                 

              	
                 

                84

                 

              	
                 

                The
                  Disposition of the Appeal / Grievance:

                 

              
	 	 	 	 	
                1. Referral
                  made to specialist

                2. PCP
                  Appointment made

                3. Bill
                  Paid

                4. Procedure
                  scheduled

                5. Reassigned
                  PCP

                6. Reassigned
                  Center

                7. Disenrolled
                  Self

                8. Disenrolled
                  by plan

                 

              	
                1. In
                  HMO QA Review

                2. In
                  HMO Grievance System

                3. Referred
                  to Area Office

                4. Member
                  sent OLC form

                5. Lost
                  contact with member

                6. Hospitalized
                  / Institutionalized

                7. Confirmed
                  original decision

                8. Reinstated
                  in HMO

                9. Other

              
	
                 

                DISP_STAT

                 

              	
                 

                1

                 

              	
                 

                85

                 

              	
                 

                85

                 

              	
                 

                R
                  =
                  Resolved

                 

              	
                 

                U
                  =
                  Unresolved

                 

              
	 	 	 	 	
                Note:
                  Any grievance or appeal first reported as unresolved must be reported
                  again when resolved. Grievances and appeals that are resolved in
                  the
                  quarter prior to reporting should be reported for the first time
                  as
                  resolved.

              
	
                 

                EXPED_REQ

                 

              	
                 

                1

                 

              	
                 

                86

                 

              	
                 

                86

                 

              	
                Indicate
                  whether the appeal was an expedited request

                Y
                  =Yes N = No Note: This field is required for all reported
                  appeals.

              
	
                 

                FILE_TYPE

                 

              	
                 

                2

                 

              	
                 

                87

                 

              	
                 

                88

                 

              	
                Indicate
                  whether the report is related to Grievance or Appeal and a behavioral
                  health service respectively

                G
                  =
                  Grievance Report GB = Grievance Behavioral Report

                A
                  =
                  Appeal Report AB = Appeal Behavioral Report

              
	
                 

                ORIGINATOR

                 

              	
                 

                1

                 

              	
                 

                89

                 

              	
                 

                89

                 

              	
                1
                  =
                  An enrollee

                2
                  =
                  A provider, acting on behalf of the enrollee and with the enrollee’s
                  written consent

              

      

      

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        	D.	
                 Provider
                  Reporting

              

      

      

      
        	 	
                1.

              	
                The
                  Health
                  Plan shall
                  submit its provider directory as described in Section IV, A.5,
                  Provider
                  Directory, of this Contract, to the Agency or its Choice
                  Counselor/Enrollment Broker at least on a monthly basis via FTP.
                  

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall ensure that the Provider Network Report as described
                  in
                  Table 3 of this Section is an electronic representation of the
                  Health
                  Plan’s complete network of Providers, not a listing of entities for
                  whom
                  the Health Plan has paid claims.

              

      

      

      
        	 	
                3.

              	
                The
                  Provider Network Report shall be in an ASCII flat file and must
                  be a
                  complete refresh of the Health Plan’s Provider information. Plans will
                  receive final instructions regarding file naming, Plan Code (see
                  layout
                  below), file transfers, file submission frequency and schedule
                  and other
                  issues prior to implementation.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan shall submit the Provider Network Report on the Monday
                  preceding the second to the last Saturday of each month. If the
                  Monday
                  deadline falls on a holiday, the PSN shall submit the file on the
                  Friday
                  before the holiday. The Health Plan may choose to submit the Provider
                  Network Report a second time each month, on the third Business
                  Day before
                  the end of the month. This reporting schedule is subject to change
                  upon
                  notice from the Agency.

              

      

      

      

      NOTE:
        The following reporting material is proprietary information of ACS Inc. and
        may
        not be used, duplicated, or altered without the written permission of Corporate
        Management.

      

      

      

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                    Field
                      Name

                  	
                    Field
                      Length

                  	
                    Required
                      Field

                  	
                    Field
                      Format

                  	
                    Justification

                  	
                    Comments

                  
	
                    Plan
                      Code

                  	
                    9

                  	
                    X

                  	
                    alpha

                  	
                    Left
                      with leading zeros

                  	
                    This
                      is the 9 digit Medicaid Provider ID number specific to the
                      county of HMO/
                      operation.

                  
	
                    Provider
                      Type 

                  	
                    1

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    Identifies
                      the provider’s general area of service with an alpha character, as
                      follows:

                    P
                      =
                      Primary Care Provider (PCP)

                    I
                      =
                      Individual Practitioner other than a PCP

                    B
                      =
                      Birthing Center

                    T
                      =
                      Therapy

                    G
                      =
                      Group Practice (includes FQHCs and RHCs)

                    H
                      =
                      Hospital

                    C
                      =
                      Crisis Stabilization Unit

                    D
                      =
                      Dentist

                    R
                      =
                      Pharmacy

                    A
                      =
                      Ancillary Provider (DME providers, Home Health Care 

                    Agencies,
                      etc.)

                  
	
                    Plan
                      Provider Number

                  	
                    15

                  	
                    X

                  	
                    alpha

                  	
                    Left
                      with leading zeros

                  	
                    Unique
                      number assigned to the provider by the plan.

                  
	
                    Group
                      Affiliation 

                  	
                    15

                  	
                    Required
                      for all groups and providers who are members of a group

                  	
                    alpha

                  	
                    Left
                      with leading zeros

                  	
                    The
                      unique provider number assigned by the HMO/ to the group practice.
                      This
                      field is required for all providers who are members of a group,
                      such as
                      PCPs and specialists. The group affiliation number must be
                      the same for
                      all providers who are members of that group. A record is also
                      required for
                      each group practice being reported. For groups, this identification
                      number
                      must be the same as the plan provider number.

                  
	
                    SSN
                      or FEIN 

                  	
                    9

                  	
                    X

                  	
                    alpha

                  	
                    Left
                      with leading zeros

                  	
                    Social
                      Security Number of Federal Identification Number for the individual
                      provider or the group practice.

                  
	
                    Provider
                      last name

                  	
                    30

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    The
                      last name of the provider, or the first 30 characters of the
                      name of the
                      group. (Please do not include courtesy titles such as Dr.,
                      Mr., Ms., since
                      this titles can interfere with electronic searches of the data.)
                      This
                      field should also be used to note hospital name. UPPER CASE
                      ONLY
                      PLEASE.

                  
	
                    Provider
                      first name

                  	
                    30

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    The
                      first name of the provider, or the continuation of the name
                      of the group.
                      Please do not include provider middle name in this field. Middle
                      name
                      field has been added at the end of the file for this purpose.
                      UPPER CASE
                      ONLY PLEASE.

                  
	
                    Address
                      line 1

                  	
                    30

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    Physical
                      location of the provider or practice. Do not use P.O. Box or
                      mailing
                      address is different from practice location. UPPER CASE ONLY
                      PLEASE.
                      

                  
	
                    Address
                      line 2

                  	
                    30

                  	 	
                    alpha

                  	
                    Left

                  	 
	
                    City
                      

                  	
                    30

                  	
                    X

                  	
                    alpha

                  	
                    Left

                    Left

                  	
                    Physical
                      city location of the provider or practice. UPPER CASE ONLY
                      PLEASE

                  
	
                    Zip
                      Code

                  	
                    9

                  	
                    X

                  	
                    numeric

                  	
                    Left
                      with trailing zeros

                  	
                    Physical
                      zip code location of the provider or practice. Accuracy is
                      important,
                      since address information is one of the standard items used
                      to search for
                      providers that are located in close proximity to the member.
                      

                  
	
                    Phone
                      area code

                  	
                    3

                  	 	
                    numeric

                  	
                    Left

                  	 
	
                    Phone
                      number

                  	
                    7

                  	 	
                    numeric

                  	
                    Left

                  	
                    Please
                      note that the format does not allow for use of a
                      hyphen.

                  
	
                    Phone
                      extension

                  	
                    4

                  	 	
                    numeric

                  	
                    Left

                  	 
	
                    Sex

                  	
                    1

                  	 	
                    alpha

                  	
                    Left

                  	
                    The
                      gender of the provider. Valid values: M = male; F = Female;
                      U =
                      Unknown

                  
	
                    PCP
                      Indicator 

                  	
                    1

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    Used
                      to indicate if an individual provider is a primary care physician,
                      or for
                      the , a medical home. Valid values: P = Yes, the provider is
                      a PCP/medical
                      home; N = No, the provider is not a PCP/medical home. This
                      field should
                      not be used to note group providers as PCPs, since members
                      must be
                      assigned to specific providers, not group practices. 

                  
	
                    Provider
                      Limitation 

                  	
                    1

                  	
                    Required
                      if PCP Indicator = P 

                  	
                    alpha

                  	
                    Left

                  	
                    X
                      =
                      Accepting new patients

                    N
                      =
                      Not accepting new patients but remaining a contracted network
                      provider

                    L
                      =
                      Not accepting new patients; leaving the network (Please note
                      the “L”
                      designation at the earliest opportunity)

                    P
                      =
                      Only accepting current patients

                    C
                      =
                      Accepting children only

                    A
                      =
                      Accepting adults only

                    R
                      =
                      Refer member to HMO/ member services

                    F
                      =
                      Only accepting female patients

                    S
                      =
                      Only serving children through CMS (MediPass/PSN only)

                  
	
                    HMO//MediPass
                      Indicator 

                  	
                    1

                  	
                    X

                  	
                    alpha

                  	
                    Left

                  	
                    H
                      =
                      HMO/

                    This
                      field must be completed with this designation for each record
                      submitted by
                      the HMO/.

                  
	
                    Evening
                      hours 

                  	
                    1

                  	 	
                    alpha

                  	
                    Left

                  	
                    Y
                      =
                      Yes; N = No

                  
	
                    Saturday
                      hours

                  	
                    1

                  	 	
                    alpha

                  	
                    Left

                  	
                    Y
                      =
                      Yes; N = No

                  
	
                    Age
                      restrictions

                  	
                    20

                  	 	
                    alpha

                  	
                    Left

                  	
                    Populate
                      this field with free-form text, to identify any age restriction
                      the
                      provider may have on their practice.

                  
	
                    Primary
                      Specialty 

                  	
                    3

                  	
                    Required
                      if Provider Type = P or I

                  	
                    numeric

                  	
                    Left
                      with leading zeros

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                     

                  	
                    Insert
                      the 3 digit code that most closely describes

                    001
                      Adolescent Medicine

                    002
                      Allergy

                    003
                      Anesthesiology

                    004
                      Cardiovascular Medicine

                    005
                      Dermatology

                    006
                      Diabetes

                    007
                      Emergency Medicine

                    008
                      Endocrinology

                    009
                      Family Practice

                    010
                      Gastroenterology

                    011
                      General Practice

                    012
                      Preventative Medicine

                    013
                      Geriatrics

                    014
                      Gynecology

                    015
                      Hematology

                    016
                      Immunology

                    017
                      Infectious Diseases

                    018
                      Internal Medicine

                    019
                      Neonatal/Perinatal

                    020
                      Neoplastic Diseases

                    021
                      Nephrology

                    022
                      Neurology

                    023
                      Neurology/Children

                    024
                      Neuropathology

                    025
                      Nutrition

                    026
                      Obstetrics

                    027
                      OB-GYN

                    028
                      Occupational Medicine

                    029
                      Oncology

                    030
                      Ophthalmology

                    031
                      Otolaryngology

                    032
                      Pathology

                    033
                      Pathology, Clinical

                    034
                      Pathology, Forensic

                    035
                      Pediatrics

                    036
                      Pediatric Allergy

                    037
                      Pediatric Cardiology

                    038
                      Pediatric Oncology &Hematology

                    039
                      Pediatric Nephrology

                    040
                      Pharmacology

                    041
                      Physical Medicine and Rehab

                    042
                      Psychiatry 

                    043
                      Psychiatry, Child

                    044
                      Psychoanalysis

                    045
                      Public Health

                    046
                      Pulmonary Diseases

                    047
                      Radiology

                    048
                      Radiology, Diagnostic

                    049
                      Radiology, Pediatric

                    050
                      Radiology, Therapeutic

                    051
                      Rheumatology

                    052
                      Surgery, Abdominal

                    053
                      Surgery, Cardiovascular

                    054
                      Surgery, Colon / Rectal

                    055
                      Surgery, General

                    056
                      Surgery, Hand

                    057
                      Surgery, Neurological

                    058
                      Surgery, Orthopedic

                    059
                      Surgery, Pediatric

                    060
                      Surgery, Plastic

                    061
                      Surgery, Thoracic

                    062
                      Surgery, Traumatic

                    063
                      Surgery, Urological

                    064
                      Other Physician Specialty

                    065
                      Maternal/Fetal

                    066
                      Assessment Practitioner

                    067
                      Therapeutic Practitioner

                    068
                      Consumer Directed Care

                    069
                      Medical
                      Oxygen Retailer 

                    070
                      Adult Dentures Only

                    071
                      General Dentistry

                    072
                      Oral Surgeon (Dentist)

                    073
                      Pedodontist

                    074
                      Other Dentist

                    075
                      Adult Primary Care Nurse Practitioner

                    076
                      Clinical Nurse Spec

                    077
                      College Health Nurse Practitioner

                    078
                      Diabetic Nurse Practitioner

                    079
                      Brain
                      & Spinal Injury Medicine 

                    080
                      Family/Emergency Nurse Practitioner

                    081
                      Family Planning Nurse Practitioner

                    082
                      Geriatric Nurse Practitioner

                    083
                      Maternal/Child Family Planning Nurse Practitioner

                    084
                      Reg. Nurse Anesthetist

                    085
                      Certified Registered Nurse Midwife

                    086
                      OB/GYN Nurse Practitioner

                    087
                      Pediatric Neonatal 

                    088
                      Orthodontist

                    089
                      Assisted Living for the Elderly

                    090
                      Occupational Therapist

                    091
                      Physical Therapist

                    092
                      Speech Therapist

                    093
                      Respiratory Therapist

                     

                     

                    100
                      Chiropractor

                    101
                      Optometrist

                    102
                      Podiatrist

                    103
                      Urologist

                    104
                      Hospitalist

                    BH1
                      Psychology, Adult

                    BH2
                      Psychology, Child

                    BH3
                      Mental Health Counselor

                    BH4
                      Community Mental Health Center

                    BH5
                      Clubhouse (TBD)

                  
	
                    Specialty
                      2 

                  	
                    3

                  	 	
                    numeric

                  	
                    Left
                      with leading

                  	
                    Use
                      codes listed above.

                  
	
                    Specialty
                      3 

                  	
                    3

                  	 	
                    numeric

                  	
                    Left
                      with leading

                  	
                    Use
                      codes listed above.

                  
	
                    Language
                      1 

                  	
                    2

                  	 	
                    numeric

                  	
                    Left
                      with leading

                  	
                    01
                      = English

                    02
                      = Spanish

                    03
                      = Haitian Creole

                    04
                      = Vietnamese

                    05
                      = Cambodian

                    06
                      = Russian

                    07
                      = Laotian

                    08
                      = Polish

                    09
                      = French

                    10
                      = Other

                  
	
                    Language
                      2 

                  	
                    2

                  	 	
                    numeric

                  	 	
                    Use
                      codes listed above.

                  
	
                    Language
                      3 

                  	
                    2

                  	 	
                    numeric

                  	 	
                    Use
                      codes listed above.

                  
	
                    Hospital
                      Affiliation 1 

                  	
                    9

                  	 	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    Hospital
                      with which the provider is affiliated. Use the AHCA ID for
                      accurate
                      identification, 

                  
	
                    Hospital
                      Affiliation 2

                  	
                    9

                  	 	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    as
                      above

                  
	
                    Hospital
                      Affiliation 3

                  	
                    9

                  	 	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    as
                      above

                  
	
                    Hospital
                      Affiliation 4

                  	
                    9

                  	 	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    as
                      above

                  
	
                    Hospital
                      Affiliation 5

                  	
                    9

                  	 	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    as
                      above

                  
	
                    Wheel
                      Chair Access 

                  	
                    1

                  	 	
                    alpha

                  	 	
                    Indicates
                      if the provider’s office is wheelchair accessible. Use Y = Yes or N =
                      No.

                  
	
                    #
                      of HMO/ Members

                  	
                    4

                  	
                    X

                  	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    Information
                      must be provided for PCPs only. Indicates the total number
                      of patients who
                      are enrolled in submitting plan. For providers who practice
                      at multiple
                      locations, the number of HMO/ members specific to each physical
                      location
                      must be specified.

                  
	
                    Active
                      Patient Load

                  	
                    4

                  	
                    X

                  	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    Total
                      Active Patient Load, as defined in contract

                  
	
                    Professional
                      License Number

                  	
                    10

                  	
                    X

                  	
                    alpha/
                      numeric

                  	 	
                    Must
                      be included for all health care professionals. License number
                      is formatted
                      with up to 3 alpha characters followed by up to 7 numeric digits.
                      

                  
	
                    AHCA
                      Hospital ID1 
                      AHCA provided the list of AHCA IDs for hospitals to plans on
                      8-26-05.
                      

                  	
                    8

                  	
                    Required
                      if Provider Type = “H”

                  	
                    numeric

                  	
                    Left
                      with leading zeros

                  	
                    The
                      number assigned by the Agency to uniquely identify each specific
                      hospital
                      by physical location. Any out of state hospital for which an
                      AHCA ID is
                      not included should be designated with the pseudo-number
                      99999999.

                  
	
                    County
                      Health Department (CHD) Indicator

                  	
                    1

                  	
                    X

                  	
                    alpha

                  	 	
                    Used
                      to designate whether the individual or group provider is associated
                      only
                      with a county health department. Y = Yes; N = No. This field
                      must be
                      completed for all PCP and specialty providers.

                  
	
                    Filler

                  	
                    47

                  	
                    X

                  	 	 	 

          

          

            
              
                

              

            

          

        

        
          
            1 
              AHCA
              provided the list of AHCA IDs for hospitals to plans on 8-26-05.

          

        

      

       

      
 

      
        
          
            
              

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              

            

          

        

      

      

      

      
        	E.	
                Marketing
                  Representative Report

              

      

      

      The
        Health Plan shall register each marketing representative with the Agency
        as
        outlined in Section IV, Enrollee Services and Marketing. The file will be
        submitted within five days of the reporting month to the Agency at the following
        e-mail address: petrieg@ahca.myflorida.com.
        The
        Agency-supplied spreadsheet template must be used. This template contains
        the
        following data elements:

      

       

      Table
        4

      

      Required
        Information for Marketing Representative Report Template

      

      
        	
                Plan
                  Information

              	
                Marketing
                  Representative Information

              
	
                Plan
                  Name

              	
                Last
                  Name

              
	
                Address

              	
                First
                  Name

              
	
                Contact
                  Person

              	
                DOI
                  License Number

              
	
                Phone

              	
                Address

              
	
                Fax

              	
                City

              

      

      

       

       

      
        	F.	
                 
                  Enhanced Benefits Report

              

      

       

       

      Table
        5

      Placeholder

      

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        	G.	
                 
                  Catastrophic Component Threshold and Benefit Maximum
                  Report

              

      

       

      Health
        Plans that choose to cover the comprehensive component shall submit this
        report
        for each Enrollee, whose costs for Covered Services reach $25,000 in a Contract
        Year. The report shall be in the format shown in Table 6 below. The report
        shall
        be submitted monthly from the time the Enrollee’s costs reach $25,000 through
        the end of the Contract Year.

      

      Health
        Plans that choose to cover the comprehensive and catastrophic component shall
        submit this report for each Enrollee, whose costs for Covered Services reach
        $450,000 in a Contract Year. The report shall be in the format shown in Table
        6
        below. The report shall be submitted monthly from the time the Enrollee’s costs
        reach $450,000 through the end of the Contract Year.

      

      

      Table
        6

      

      

      
        	
                $25,000
                  or $450,000 Thresholds Reached/Report to AHCA

                 

              
	
                RECIP

              	
                DOS

              	
                DOP

              	
                UNIT/DAY

              	
                AMOUNT

              	
                APPCD

              	
                TRPROV

              	
                TRTYPE

              	
                DIAG1

              	
                DIAG2

              	
                DIAG3

              	
                DIAG4

              	
                DIAG5

              	
                PROCD

              	
                MOD1

              	
                MOD
                  2

              	
                NDC

              	
                DRUGQTY

              	
                P2PROV

              	
                P2TYPE

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              

      

      

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        	H.	
                 
                  Critical Incidents

              

      

      

      The
        Health Plan shall report all serious Enrollee injuries occurring through
        health
        care services within 15 days of the Health Plan receiving information about
        the
        injury. The Health Plan will use the Florida Agency for Health Care
        Administration, Division of Health Quality Assurance’s Code 15 Report for
        Florida Ambulatory Surgical Centers, Hospitals and HMOs to document the
        incident. The Code 15 Report shall be sent to the Health Plan’s analyst in the
        Bureau of Managed Health Care. The Code 15 Report can be found at
        www.ahca.myflorida/MCHQ/Health_Facility_Regulation/Risk/reporting.

      

      
        	I.	
                 Hernandez
                  Settlement Agreement (HAS)
                  Report

              

      

      

      If
        the
        Health Plan has authorization requirements for prescribed drug services,
        the
        Health Plan shall file reports biannually to the Bureau of Managed Health
        Care,
        to include the following:

      

      1. The
        results of the HSA survey with:

      (a) The
        total
        number of pharmacy locations surveyed;

      (b) The
        HSA
        areas surveyed;

      
        	 	
                (c)

              	
                Those
                  HSA areas in which the pharmacy locations were delinquent;
                  and

              

      

      
        	 	
                (d)

              	
                The
                  process by which the Health Plan selected the pharmacy
                  locations.

              

      

      

      2. A
        copy of
        the Hernandez Ombudsman Log.

      

      
        	J.	
                 
                  Performance Measure Report

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall report the performance measures described in
                  Section
                  VIII, A.3.c.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall calculate the performance measures based on the
                  calendar
                  year (January 1 through December 31), unless otherwise
                  specified.

              

      

      

      
        	 	
                3.

              	
                The
                  performance measure report is due by October 1 after the measurement
                  year.

              

      

      

      
        	K.	
                 Financial
                  Reporting

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall complete the spreadsheet supplied by the
                  Agency.

              

      

      

      
        	 	
                2.

              	
                Audited
                  financial reports — The Health Plan shall submit to the Agency annual
                  audited financial statements and four (4) quarterly unaudited financial
                  statements.

              

      

      

      
        	 	
                a.

              	
                The
                  audited financial statements are due no later than three (3) calendar
                  months after the end of the Health Plan’s fiscal
                  year.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall submit the quarterly unaudited financial statements
                  no
                  later than forty-five (45) days after each calendar quarter and
                  shall use
                  generally accepted accounting principles in preparing the unaudited
                  quarterly financial statements, which shall include, but not be
                  limited
                  to, the following:

              

      

      

      (1) A
        Balance
        Sheet;

      

      (2) A
        Statement of Revenues and Expenses;

      

      	(2)  	
              A
                Statement of Cash Flows; and 

            

      

      (4) Footnotes.

      

      
        	 	
                c.

              	
                The
                  Health Plan shall submit the annual and quarterly financial statements
                  using, an Agency-supplied template, by electronic transmission
                  to the
                  following e-mail address:

              

      

      

      MMCFIN@AHCA.MYFLORIDA.COM

      

      
        	 	
                d.

              	
                The
                  Health Plan shall submit annual and quarterly financial statements
                  that
                  are specific to the operations of the Health Plan rather than to
                  a parent
                  or umbrella organization.

              

      

      

      
        	L.	
                 Suspected
                  Fraud Reporting

              

      

      

      
        	 	
                1.

              	
                Provider
                  Fraud and Abuse

              

      

      

      Upon
        detection of a potential or suspected fraudulent claim submitted by a provider,
        the Health Plan shall file a report with the Agency, MPI and MFCU..
        The
        report shall contain at a minimum:

      

      
        	 	
                a.

              	
                The
                  name of the provider;

              

      

      

      
        	 	
                b.

              	
                The
                  assigned Medicaid provider number and the tax identification
                  number;

              

      

      

      
        	 	
                c

              	
                A
                  description of the suspected fraudulent act;
                  and

              

      

      

      
        	 	
                d.

              	
                The
                  narrative report must be sent to the Health Plan’s analyst at the Bureau
                  of Managed Health Care, MPI and
                  MFCU.

              

      

      

      2. Enrollee
        Fraud

      

      
        	 	
                a.

              	
                Upon
                  detection of all instances of fraudulent claims or acts by an Enrollee,
                  the Health Plan shall file a report with the Agency and MPI.
                  

              

      

      

      
        	 	
                b.

              	
                The
                  report shall contain, at a minimum:

              

      

      

      (1) The
        name
        of the Enrollee,

      

      (2) The
        Enrollee’s Health Plan identification number,

      

      (3) The
        Enrollee’s Medicaid identification number,

      

      (4) A
        description of the suspected fraudulent act, and

      

      
        	 	
                (5)

              	
                The
                  narrative report must be sent to the Health Plan’s analyst at the Bureau
                  of Managed Health Care and MPI.

              

      

      

      
        	 	
                3.

              	
                Failure
                  to report instances of suspected Fraud and Abuse is a violation
                  of law and
                  subject to the penalties provided by
                  law.

              

      

      

      
        	M.	
                 
                  Denials of Authorization Reporting Requirements 

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall report, on a monthly basis, denials of authorization
                  for
                  services in the following
                  categories:

              

      

      

      a. Inpatient
        care (pre-certification and concurrent denials);

      

      b. Specialty
        care; and

      

      c. Ancillary
        Services.

      

      	3.  	
              The
                Health Plan shall report all Denials of Authorization in accordance
                with
                the format set forth in Table 7 and 7-A,
                below.

            

      

       

      Table
        7

      Denials
        of Authorization Report

      

      
        	 	
                Inpatient

                Pre-Certification

              	
                Inpatient

                Concurrent

              	
                Specialty
                  Care

              	
                Ancillary
                  Services

              
	 	 	 	 	 
	
                Enrollee
                  ID #

              	 	 	 	 
	
                Service
                  Requested

              	 	 	 	 
	
                Date
                  of Request

              	 	 	 	 
	
                Date
                  of Denial

              	 	 	 	 
	
                Denial
                  Reason

              	 	 	 	 
	
                Denial
                  Appealed Yes/No

              	 	 	 	 

      

      

      

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      Table
        7-A

      Summary
        of Authorization Denials

      

      
        	 	
                Inpatient
                  Pre-Certification

              	
                Inpatient
                  Con-Current

              	
                Specialty
                  Care

              	
                Ancillary
                  Services

              
	
                 

                Total
                  Authorizations Requested

              	 	 	 	 
	
                 

                Total
                  Authorizations Denied

              	 	 	 	 
	
                 

                Average
                  Number of Calendar Days Between Request and Denial

              	 	 	 	 
	
                 

                Longest
                  Number of Calendar Days Between Request and Denial

              	 	 	 	 
	
                 

                Total
                  Number of Denials Appealed

              	 	 	 	 

      

      

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        	N.	
                 
                  Systems Availability and Performance
                  Report

              

      

      

      The
        Systems Availability and Performance Report should be formatted as shown
        in
        Table 8, below. The Health Plan shall provide average uptime, downtime and
        unscheduled downtime, i.e. outage and data by system (application/operating
        environment cohort) in tabular form.

      

      

      Table
        8

      

      Systems
        Availability and Performance Report

      

      
        	
                System
                  Availability and Performance Report

              
	
                System

              	
                 

              	
                Total
                  Up Time

              	
                Total
                  Down Time

              	
                Total
                  UNSCHEDULED Down Time ("Outage Time")

              	
                 

              
	
                Measurement
                  Period

              	
                Up
                  Time During Period

              	
                Up
                  Time During Period

              	
                During
                  Period

              	
                Notes/Comments

              
	
                 system
                  1

              	 	 	 	 	 	 
	
                system2

              	 	 	 	 	
                 

              	
                 

              
	
                system3

              	 	 	 	 	
                 

              	
                 

              
	
                system4

              	 	 	 	 	
                 

              	
                 

              
	
                system5

              	 	 	 	 	 	 
	
                system6

              	 	 	 	 	
                 

              	
                 

              
	
                system7

              	 	 	 	 	
                 

              	
                 

              
	
                system8

              	 	 	 	 	
                 

              	
                 

              
	
                system9

              	 	 	 	 	
                 

              	
                 

              
	
                system10

              	 	 	 	 	
                 

              	
                 

              

      

      

      

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        	O.	
                 
                  Claims Inventory Summary
                  Report

              

      

      

      The
        Health Plan shall file an Aging Claims Summary Report quarterly, noting paid,
        denied and unpaid claims by provider type. The Health Plan will submit this
        report using the CLAIMS
        AGING TEMPLATE.xls
        file
        supplied by the Agency and presented in Tables 10, 10a, 10b and 10c. This
        file
        is an Excel spreadsheet and may be submitted to the following email address:
        mmcclms@ahca.myflorida.com.

      

      Table
        9

      

      Total
        Claims Aging By Provider Type

       

      
        NOTE:
          List
          ALL
          claims including those contained in the beginning inventory on this
          page.

      
        	
                00/00/00

              	 	
                 

              	
              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      

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      Table
        9a

      

      Paid
        Claims Aging by Provider Type Report

      

      
        	
                00/00/00

              	 	
                 

              	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      

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      Table
        9b

      Denied
        Claims Aging By Provider Type

      

      
        	
                00/00/00

              	 	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      

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      Table
        9c

      

      Unpaid
        Claims Aging by Provider Type Report

      

      

      
        	
                 

              	
                00/00/00

              	
                 

              	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              

      

      

      

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      Table
        9d

      

      Claims
        Inventory by Provider Type

      

      

      
        	
                00/00/00

              	 	
                Inventory

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                (Ending
                  Inventory from Previous quarter) 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                Beginning
                  

              	
                Claims

              	
                 

              	
                 

              	
                Ending
                  

              
	
                PROVIDER

              	
                Inventory

              	
                Received

              	
                Claims
                  Paid

              	
                Claims
                  Denied

              	
                Inventory

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                SPECIALTY

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                OTHER

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              

      

      

      

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        	P.	
                 
                  Child Health Check-Up
                  Reports

              

      

      

      The
        Agency will supply the Excel spreadsheets necessary to create these
        reports.

      

      CMS
        416
        Report

      

      
        	 	
                1.

              	
                The
                  Child Health Check Up, CMS 416 Report shall be submitted annually
                  and in
                  the formats as presented in Tables 10. The reporting period is
                  the federal
                  fiscal year. The report is due on January 1, following the reporting
                  period. Before October 1 following each reporting period, the Health
                  Plan
                  shall deliver to the Agency a certification by an Agency approved
                  independent auditor that the Child Health Check-Up data has been
                  fairly
                  and accurately presented. This filing requires a copy of the audited
                  reports and a copy of the auditors' letter of
                  opinion.

              

      

      

      
        	 	
                2.

              	
                For
                  each of the following line items, report total counts by the age
                  groups
                  indicated. In cases where calculations are necessary, perform separate
                  calculations for the total column and each age group. Report age
                  based
                  upon the child's age as of September 30 of the federal fiscal
                  year.

              

      

      

      Medicaid
        Provider ID Number:
        Enter
        the plan's seven digit Medicaid Provider ID number, i.e., 015----

      

      Plan
        Name:
        Enter
        the name of the Health Plan.

      

      Fiscal
        Year:
        Entered
        is the federal fiscal year being reported. Given

      

      Line
        1 - Total Individuals Eligible for Child Health Check-Up
        (CHCUP):  Enter
        the
        total unduplicated number of all Enrollees under the age of 21, distributed
        by
        age and by basis of Medicaid Eligibility category.
        Unduplicated
        means
        that an Enrollee is reported
        only once,
        although
        he or she may have had more than one period of Eligibility during the year.
        All
        Enrollees under age 21 (except MediKids Enrollees) are considered eligible
        for
        CHCUP services, regardless of whether they have been informed about the
        availability of CHCUP services or whether they accept CHCUP services at the
        time
        of informing. Do
        not count Enrollees in the MediKids populations.

      

      Line
        2a - State Periodicity Schedules
        -
        Given.

      

      Line
        2b - Number of Years in Age Group
        -
        Given.

      

      Line
        2c - Annualized State Periodicity Schedule
        -
        Given.

      

      Line
        3a - Total Months Eligibility
        - Enter
        the total months of Eligibility for the Enrollees in each age group in Line
        1
        during the reporting year.

      Line
        3b - Average Period of Eligibility
        -
        Pre-calculated by dividing the total months of Eligibility by Line 1, then
        by
        dividing that number by 12. This number represents the portion of the year
        that
        Enrollees remain Medicaid Eligible during the reporting year, regardless
        of
        whether Eligibility was maintained continuously.

      

      Line
        4 - Expected Number of Screenings per Eligible
        Multiply
        -
        Pre-calculated by multiplying Line 2c by Line 3b. This number reflects the
        expected number of initial or periodic screenings per Child/Adolescent per
        year
        based on the number required by the State-specific periodicity schedule and
        the
        average period of Eligibility.

      

      Line
        5 - Expected Number of Screenings
        -
        Pre-calculated by multiplying Line 4 by Line 1. This reflects the total number
        of initial or periodic screenings expected to be provided to the Enrollees
        in
        Line 1.

      

      Line
        6 - Total Screenings Received
        - Enter
        the total number of initial or periodic screens furnished to Enrollees. Use
        the
        CPT codes listed below or any Health Plan-specific CHCUP codes developed
        for
        these screens. Use of these proxy codes is for reporting purposes
        only.

      

      
        	 	
                3.

              	
                Health
                  Plans must continue to ensure that all five age-appropriate elements
                  of an
                  CHCUP screen, as defined by law, are provided to CHCUP eligible
                  Enrollees

              

      

      

      
        	 	
                4.

              	
                This
                  number should not
                  reflect sick visits or episodic visits provided to children unless
                  an
                  initial or periodic screen was also performed during the visit.
                  However,
                  it may reflect a screen outside of the normal state periodicity
                  schedule
                  that is used as a "catch-up" CHCUP screening. (A catch-up CHCUP
                  screening
                  is defined as a complete
                  screening that is provided to bring a child up-to-date with the
                  State's
                  screening periodicity schedule.) Use data reflecting date
                  of service
                  within the fiscal year for such screening services or other documentation
                  of such services. Do
                  not count MediKids Enrollees, who have had a
                  check-up.
                  The
                  CPT-4 codes to be used to document the receipt of an initial or
                  periodic
                  screen are as follows:

              

      

      

      Codes
        for Preventive Medicine Services

      

      99381
        New
        Patient Under One Year

      99382
        New
        Patient Ages 1 - 4 Years

      99383
        New
        Patient Ages 5 - 11 Years

      99384
        New
        Patient Ages 12 - 17 Years

      99385EP
        New
        Patient Ages 18 - 39 Years 

      99391
        Established Patient Under One Year

      99392
        Established Patient Ages 1 - 4 Years

      99393
        Established Patient Ages 5 - 11 Years

      99394
        Established Patient Ages 12 - 17 Years

      99395EP
        Established Patient Ages 18 - 39 Years

      99431
        Newborn
        Care - History and Examination

      99432
        Normal
        Newborn Care 

      99435
        Newborn
        Care (history and examination)

      

      Codes
        For Evaluation and Management Services (must
        be used in conjunction withV codes V20-V20.2 and/or V70.0 and/or
        V70.3-V70.9)

      

      99201-99205
        New
        Patient

      99211-99215
        Established
        Patient

      

      Line
        7 - Screening Ratio
        -
        Pre-calculated by dividing the actual number of initial and periodic screening
        services received (Line 6) by the expected number of initial and periodic
        screening services (Line 5). This ratio indicates the extent to which CHCUP
        eligible Enrollees receive the number of initial and periodic screening services
        required by the State's periodicity schedule, adjusted by the proportion
        of the
        year for which they are Medicaid Eligible. This
        ratio should not be over 100%. Any data submitted which exceeds 100% will
        be
        reflected as 100% on the final report.

      

      Line
        8 - Total Eligibles Who Should Receive at Least One Initial or Periodic
        Screen
        - The
        number of Enrollees who should receive at least one initial or periodic screen
        is dependent on the State's periodicity schedule. The following calculations
        were used:

      

      
        	 	 	
                a.

              	
                If
                  the number entered in Line 4 is greater than 1, the number 1 is
                  used. If
                  the number in Line 4 is less than or equal to 1, the number in
                  Line 4 is
                  used. This eliminates situations where more than one visit is expected
                  in
                  any age group in a year.

              

      

      

      
        	 	 	
                b.

              	
                The
                  number from calculation 1 is multiplied by the number in Line 1
                  and
                  entered on Line 8.

              

      

      

      Line
        9 - Total Eligibles Receiving at Least One Initial or Periodic
        Screen
        - Enter
        the unduplicated count of Enrollees who received at least one
        documented initial or periodic screen during the year. Refer to codes in
        Line 6
        and count
        Enrollees where you have received a claim. Do
        not count MediKids Enrollees who have had a check-up.

      

      Line
        10 - Participant Ratio
        -
        Pre-Calculated by dividing Line 9 by Line 8. This ratio indicates the extent
        to
        which Enrollees are receiving any initial and periodic screening services
        during
        the year. NOTE:
        The
        Health Plan shall adopt annual participation goals to achieve at least a
        eighty
        percent (80%) CHCUP participation rate pursuant to Section 5360, Annual
        Participation Goals, of the State Medicaid Manual.

      

      Line
        11 - Total Eligibles Referred for Corrective
        Treatment
        - Enter
        the unduplicated
        number
        of Enrollees who, as a result of at least one health problem identified during
        an initial or periodic screening service, including
        vision and hearing screenings,
        were
        scheduled for another appointment with the screening provider or referred
        to
        another provider for further needed diagnostic or treatment services. This
        element does not include correction of health problems during the course
        of a
        screening examination. This element is required. The new federally required
        referral codes should be provided in Line 11.

      

      

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                For
                  reporting on the CMS-416 only count the referral codes "T" and
                  "V". 
                  

              
	
                U

              	
                Complete
                  Normal

              
	
                Indicator
                  is used when there are no referrals made.

              
	
                2

              	
                Abnormal,
                  Treatment Initiated

              	
                 

              
	
                Indicator
                  is used when a child is currently under treatment for referred
                  diagnostic
                  or corrective health problem.

              
	
                T

              	
                Abnormal,
                  Recipient Referred

              
	
                Indicator
                  is used for referrals to another provider for diagnostic or corrective
                  treatments or scheduled for another appointment with check-up provider
                  for
                  diagnostic or corrective treatment for at least one health problem
                  identified during an initial or 

              
	
                V

              	
                Patient
                  Refused Referral

              
	
                Indicator
                  is used when the patient refused a referral.

              

      

      

      

      
        	 	
                5.

              	
                For
                  purposes of reporting information on dental services, unduplicated
                  means that each child is counted once for each
                  line of data
                  requested. Example: a child would be counted once on Line 12a for
                  receiving any dental service and would be counted again for Line
                  12b
                  and/or 12c if the child received a preventive and/or treatment
                  dental
                  service. These numbers should reflect services received in managed
                  care.
                  Lines 12b and 12c do not
                  equal total services reflected on Line
                  12a.

              

      

      

      Line
        12a - Total Eligibles Receiving Any Dental
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving any
        dental
        services as defined by CDT Codes D0100 - D9999.

      

      Line
        12b - Total Eligibles Receiving Preventive Dental
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving a preventive dental service as defined
        by CDT
        Codes D1000 - D1999.

      

      Line
        12c - Total Eligibles Receiving Dental Treatment
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving treatment services as defined by CDT Codes
        D2000 - D9999.

      

      Line
        13 - Total Eligibles Enrolled in Managed Care
        - This
        number is reported for informational purposes only. This number represents
        all
        Enrollees eligible for CHCUP services, who were Enrolled at any time during
        the
        reporting year. These Enrollees should be included in the total number of
        unduplicated eligibles on Line 1 and the number of initial or periodic
        screenings provided to these Enrollees should be included in Lines 6 and
        8 for
        purposes of determining the State's screening and participation rates. The
        number of Enrollees referred for corrective treatment and receiving dental
        services should be reflected in Lines 11 and 12, respectively. Do
        not count
        MediKids Enrollees.

      

      
        	 	
                6.

              	
                To
                  report the number of screening blood lead tests do the following:
                  Count
                  the number of times CPT code 83655 ("lead") or any State-specific
                  (local)
                  codes used for a blood lead test reported with any ICD-9-CM except
                  with
                  diagnosis codes 984 (.0 - .9) ("Toxic Effects of Lead and Its Compounds"),
                  E861.5 ("Accidental Poisoning by Petroleum Products, Other Solvents
                  and
                  Their Vapors NEC: Lead Paints"), and E866.0 (Accidental Poisoning
                  by Other
                  Unspecified Solid and Liquid Substances: Lead and Its Compounds
                  and
                  Fumes"). These specific ICD-9-CM diagnosis codes are used to identify
                  people who are lead poisoned. Blood lead tests done in these individuals
                  should not be counted as a screening blood lead test. This
                  is a federally mandated test for ages 12 months, 24 months and
                  between the
                  ages of 36 - 72 months
                  who have not been previously screened for lead
                  poisoning.

              

      

      

      

      Line
        14 - Total Number of Screening Blood Lead Tests
        - Enter
        the total number of screening blood lead tests furnished to eligible Enrollees.
        Blood lead tests done on Enrollees who have been diagnosed or treated for
        lead
        poisoning should not be counted. Do not make entries in the shaded
        columns.

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

      Table
        10

      

      Child
        Health Check Up Report 

      

      
        	
                 

              	
                Enter
                  Data in Blue Colored Out-Lined Cells Only

              	
                CHILD
                  HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]

              
	 	
                Seven
                  Digit Medicaid Provider Number :

              	
                 

              	
                This
                  report is due to the Agency no later than January
                  15.

              
	 	
                Plan
                  Name :

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                Federal
                  Fiscal Year :

              	
                October
                  1, 2004 - September 30, 2005

              	
                 

              	
                 

              	
                The
                  Audited Report is due October 1.

              
	
                 

              	
                Age
                  Groups

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                Less
                  than 1 Year

              	
                1-2
                  Years *

              	
                3-5
                  Years

              	
                6-9
                  Years

              	
                10-14
                  Years

              	
                15-18
                  Years

              	
                19-20
                  Years

              	
                Total
                  All Years

              
	
                1.

              	
                Total
                  Individuals Eligible for CHCUP (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                2a.

              	
                State
                  Periodicity Schedule

              	
                6

              	
                4

              	
                3

              	
                2

              	
                5

              	
                4

              	
                2

              	
                26

              
	
                2b.

              	
                Number
                  of Years in Age Group

              	
                1

              	
                2

              	
                3

              	
                4

              	
                5

              	
                4

              	
                2

              	
                21

              
	
                2c.

              	
                Annualized
                  State Periodicity Schedule

              	
                6.00

              	
                2.00

              	
                1.00

              	
                0.50

              	
                1.00

              	
                1.00

              	
                1.00

              	
                1.24

              
	
                3a.

              	
                Total
                  Months of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                3b.

              	
                Average
                  Period of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.

              	
                Expected
                  Number of screenings per Eligible

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                5.

              	
                Expected
                  Number of screenings

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.

              	
                Total
                  Screens Received

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              

      

      

      

      
        	
                7.

              	
                Screening
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                8.

              	
                Total
                  Eligible who should receive at least one Initial or periodic
                  screening

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                #VALUE!

              
	
                9.

              	
                Total
                  Eligibles receiving at least one Initial or periodic screen
                  (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                10.

              	
                Participation
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                11.

              	
                Total
                  eligibles referred for corrective treatment (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12a.

              	
                Total
                  Eligibles receiving any dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0
                  

              
	
                12b.

              	
                Total
                  Eligibles receiving preventative dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0
                  

              
	
                12c.

              	
                Total
                  Eligibles receiving dental treatment services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                0
                  

              
	
                13.

              	
                Total
                  Eligibles Enrolled in Plan

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                14.

              	
                Total
                  number of Screening Blood Lead Tests

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	 	
                *
                  Includes 12-month visit

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      
        
          
            
 

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

      Florida
        Sixty Percent Ratio

      

      
        	 	
                1.

              	
                The
                  Child Health Check Up, CMS 416 Report shall be submitted annually
                  and in
                  the formats as presented in Tables 10 and 10a. The reporting period
                  is the
                  federal fiscal year. The report is due on January 1, following
                  the
                  reporting period. Before October 1 following each reporting period,
                  the
                  Health Plan shall deliver to the Agency a certification by an Agency
                  approved independent auditor that the Child Health Check-Up data
                  has been
                  fairly and accurately presented. This filing requires a copy of
                  the
                  audited reports and a copy of the auditors' letter of
                  opinion.

              

      

      

      
        	 	
                2.

              	
                For
                  each of the following line items, report total counts by the age
                  groups
                  indicated. In cases where calculations are necessary, formulas
                  have been
                  inserted to pre-calculate the field. Report age based
                  upon the child's age as of September 30 of the Federal fiscal
                  year.

              

      

      

      Medicaid
        Provider ID Number:
        Enter
        the Health Plan's basic seven digit Medicaid Provider ID number, i.e.,
        015----

      

      Plan
        Name:
        Enter
        the name of the Health Plan.

      

      Fiscal
        Year:
        Entered
        is the federal fiscal year being reported.

      

      Line
        1 - Total Individuals Eligible for Child Health Check-Up
        (CHCUP):
        Enter
        the total unduplicated number of all Enrollees under the age of 21 Enrolled
        continuously
        for 8 months,
        distributed by age and by basis of Medicaid Eligibility.
        Unduplicated
        means
        that an Enrollee is reported
        only once
        although
        he or she may have had more than one period of Eligibility during the year.
        All
        Enrollees under age 21 (except MediKids Enrollees) are considered eligible
        for
        CHCUP services, regardless of whether they have been informed about the
        availability of CHCUP services or whether they accept CHCUP services at the
        time
        of informing. Do
        not count MediKids Enrollees.

      

      Line
        2a - State Periodicity Schedules
        -
        Given.

      

      Line
        2b - Number of Years in Age Group
        -
        Given.

      

      Line
        2c - Annualized State Periodicity Schedule
        -
        Given.

      

      Line
        3a - Total Months Eligibility
        - Enter
        the total months of eligibility for the Enrollees in each age group in Line
        1
        during the reporting year.

      

      Line
        3b - Average Period Eligibility
        -
        Calculated by dividing the total months of eligibility by Line 1, then by
        dividing that number by 12. This number represents the portion of the year
        that
        Enrollees remain Medicaid Eligible during the reporting year, regardless
        of
        whether Eligibility was maintained continuously.

      

      Line
        4 - Expected Number of Screenings per Eligible
        Multiply
        -
        Calculated by multiplying Line 2c by Line 3b. This number reflects the expected
        number of initial or periodic screenings per Child/Adolescent per year based
        on
        the number required by the State-specific periodicity schedule and the average
        period of Eligibility.

      

      Line
        5 - Expected Number of Screenings
        -
        Calculated by multiplying Line 4 by Line 1. This reflects the total number
        of
        initial or periodic screenings expected to be provided to the Enrollees in
        Line
        1.

      

      Line
        6 - Total Screenings Received
        - Enter
        the total number of initial or periodic screens furnished to Enrollees. Use
        the
        CPT codes listed below or any Health Plan-specific CHCUP codes developed
        for
        these screens. Use
        of these proxy codes is for reporting purposes only.

      

      
        	 	
                3.

              	
                Health
                  Plans must continue to ensure that all five age-appropriate elements
                  of an
                  CHCUP screen, as defined by law, are provided to CHCUP eligible
                  Enrollees.

              

      

      

      
        	 	
                4.

              	
                This
                  number should not
                  reflect sick visits or episodic visits provided to Children/Adolescents
                  unless an initial or periodic screen was also performed during
                  the visit.
                  However, it may reflect a screen outside of the normal State periodicity
                  schedule that is used as a "catch-up" CHCUP screening. (A catch-up CHCUP
                  screening is defined as a complete
                  screening that is provided to bring a Child/Adolescent up-to-date
                  with the
                  State's screening periodicity schedule.) Use data reflecting date
                  of service
                  within the fiscal year for such screening services or other documentation
                  of such services. Do
                  not
                  count MediKids Enrollees, who have had a check-up. The
                  CPT-4 codes to be used to document the receipt of an initial or
                  periodic
                  screen are as follows:

              

      

      

      Codes
        for Preventive Medicine Services

      

      99381
        New
        Patient Under One Year

      99382
        New
        Patient Ages 1 - 4 Years

      99383
        New
        Patient Ages 5 - 11 Years

      99384
        New
        Patient Ages 12 - 17 Years

      99385EP
        New
        Patient Ages 18 - 39 Years

      99391
        Established Patient Under One Year

      99392
        Established Patient Ages 1 - 4 Years

      99393
        Established Patient Ages 5 - 11 Years

      99394
        Established Patient Ages 12 - 17 Years

      99395EP
        Established Patient Ages 18 - 39 Years

      99431
        Newborn
        Care - History and Examination

      99432
        Normal
        Newborn Care 

      99435
        Newborn
        Care (history and examination)

      

      Codes
        for Evaluation and Management
        (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
        V70.3-V70.9)

      

      99201-99205
        New
        Patient

      99211-99215
        Established
        Patient

      

      Line
        7 - Screening Ratio
        -
        Calculated by dividing the actual number of initial and periodic screening
        services received (Line 6) by the expected number of initial and periodic
        screening services (Line 5). This ratio indicates the extent to which CHCUP
        eligible Enrollees receive the number of initial and periodic screening services
        required by the State's periodicity schedule, adjusted by the proportion
        of the
        year for which they are Medicaid eligible. This
        ratio should not
        be over 100%. Any data submitted which exceeds 100% will be reflected as
        100% on
        the final report. The goal ratio is 60% or higher under State
        requirements.

      

      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

      Table
        10a

      Child
        Health Check Up Report

       

      
        COMPLETE
          THIS 60% TEMPLATE TO MEET THE 60% SCREENING RATIO PURSUANT TO SECTION 409.912,
          FLORIDA STATUTES AND SECTIONS 10.8.1 AND 60.0, 2004-2006 MEDICAID HMO
          CONTRACT

         

         

        
          	 Enter
                  Data in Blue Colored Out-Lined Cells ONLY - This report reflects
                  only
                  those eligibles that have at least 8 months of continuous enrollment
                  -
                  State
                  Required	 FL
                  60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP) - 8
                  MONTHS
                  CONTINUOUS ENROLLMENT

        

      

      

      
        	
                 

              
	
                 

              	
                 

              
	 	
                Seven
                  Digit Medicaid Provider ID Number :

              	
                 

              	
                The
                  unaudited report is due to the Agency no later than January
                  15.
                  The audited report is due October 1.

              
	 	
                Plan
                  Name :

              	
                 

              	
                F.S.
                  409.912 & Section 10.8.1, Medicaid HMO Contract

              
	
                 

              	
                Federal
                  Fiscal Year :

              	
                October
                  1, 2004 - September 30, 2005

              	
                REQUIRED
                  FILING

              
	
                 

              	
                Age
                  Groups

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                Less
                  than 1 Year

              	
                1-2
                  Years *

              	
                3-5
                  Years

              	
                6-9
                  Years

              	
                10-14
                  Years

              	
                15-18
                  Years

              	
                19-20
                  Years

              	
                Total
                  All Years

              
	
                1.

              	
                Total
                  Individuals Eligible for CHCUP with 8 months continuous enrollment
                  (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                2a.

              	
                State
                  Periodicity Schedule

              	
                6

              	
                4

              	
                3

              	
                2

              	
                5

              	
                4

              	
                2

              	
                26

              
	
                2b.

              	
                Number
                  of Years in Age Group

              	
                1

              	
                2

              	
                3

              	
                4

              	
                5

              	
                4

              	
                2

              	
                21

              
	
                2c.

              	
                Annualized
                  State Periodicity Schedule

              	
                6.00

              	
                2.00

              	
                1.00

              	
                0.50

              	
                1.00

              	
                1.00

              	
                1.00

              	
                1.24

              
	
                3a.

              	
                Total
                  Months of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                3b.

              	
                Average
                  Period of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.

              	
                Expected
                  Number of screenings per Eligible

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	 

                5.

              	 

                Expected
                  Number of screenings

              	 	 	 	 	 	 	 	 
	 

                6.

              	 

                Total
                  Screens Received

              	 	 	 	 	 	 	 	 
	 

                7.

              	 

                Screening
                  Ratio - F.S. 409.912 & Section 10.8.1, Medicaid HMO
                  Contract

              	 	 	 	 	 	 	 	 

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

      Q.  Pharmacy
        Encounter Data

       

      Health
        Plans shall submit pharmacy encounter data on an ongoing quarterly payment
        schedule. For example, all claims paid during 04/01/06 and 06/30/06 is due
        to
        the Agency by 07/31/06. The following should be used when submitting the
        data:

      

      	1.  	
              Any
                claims paid during the payment period should be submitted within
                30 days
                after the end of the quarter.

            

      	2.  	
              Only
                the final adjudication of claims should be
                submitted.

            

      	3.  	
              The
                File Naming Convention is: [health plan abbreviation]_[current date]_[file
                type]_[Production]_[file#]_[total # of files].format. For example:
                ABC_07312006_Rx_Production_1_7.txt

            

      	4.  	
              The
                files must be accompanied by a field layout and the records must
                have
                carriage-returns and line-feeds for record/file
                separation.

            

      	5.  	
              All
                Medicaid pharmacy data should be submitted via CD to Bureau of Health
                Systems Development and shall be timely, accurate, complete, and
                certified. Each submission requires a concurrent certification
                letter.

            

      	6.  	
              The
                minimal data requirements include the Plan ID, Transaction Reference
                number (claim identifier), NDC code, Date of Service (CCYYMMDD),
                Medicaid
                ID as assigned by the state, and Process/payment date
                (CCYYMMDD).

            

      	7.  	
              The
                format is expected to change to NCPDP as the Agency is developing
                the
                companion guide and the Plans shall conform to this change upon
                notification.

            

       

      R.
        Health Plan Benefit Package

      The
        Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package
        (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency
        standards for the population or populations which will be covered by the
        CBP.
        The Health Plan shall submit its CBP for recertification of actuarial
        equivalency and sufficiency standards on an annual basis. 

      

      The
        Grid
        displays the services to be covered and the areas that are customized by
        the
        Prepaid Health Plan, whether that is co-pays, or the amount, duration or
        scope
        of the services. The shaded areas indicate that no changes to the services
        in
        that part of the Grid can be changed from the Medicaid fee-for-service coverage
        limits.

      

      If
        the
        Health Plan submits a Benefit Grid with any input cells left blank, that
        indicates the coverage level of the respective benefit is at the fee-for-service
        coverage limits.

      

      If
        the
        CBP includes expanded services, beginning with #10 of the Grid, the Prepaid
        Health Plan must submit additional information with the Grid including projected
        PMPM costs for the target population, as well as the actuarial rationale
        for
        them. This rationale shall include utilization and unit cost expectations
        for
        services provided in the benefit.

      

      The
        Health Plan shall submit its CBP for recertification of actuarial equivalency
        and sufficiency standards no later than June 30th
        of each
        year. 

      

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

       

      Health
        Plan:________________________________

      Target
        Population:___________________________

       

       

      All
        Listed Services must be covered for Children and Pregnant Adults
        if medically necessary with no co-pay

      

        
          	 	
                  Covered
                    Service Category

                	
                  AHCA
                    Standard for Adult Coverage

                	
                  Day/Visit
                    Limit

                	
                  Limit
                    Period

                  (Annual/Monthly)

                	
                  Dollar
                    Limit

                	
                  Limit
                    Period

                  (Annual/Monthly)

                	
                  Copay
                    Amount

                	
                  Copay
                    Application

                
	
                  1

                	
                  Hospital
                    Inpatient

                	 	
                  45
                    days

                	 	 	 	 	 	 
	 	
                  Behavioral
                    Health

                	 	 	 	 	 	 	
                  day
                    or admit

                
	 	
                  Physical
                    Health

                	 	 	 	 	 	 	
                  day
                    or admit

                
	 	
                   

                	 	 	 	 	 	 	 	 
	
                  2

                	
                  Transplant
                    Services

                	 	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                   

                	 	 	 	 	 	 	 	 
	
                  3

                	
                  Outpatient Services

                	 	 	 	 	 	 	 	 
	 	
                  Emergency
                    Room

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Medical/Drug
                    Therapies (Chemo, Dialysis)

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Ambulatory
                    Surgery - ASC

                	
                  all
                    mecially nec.

                	 	 	 	 	 	 
	 	
                  Hospital
                    Outpatient Surgery

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	
                  Independent
                    Lab / Portable X-ray

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  day

                
	 	
                  Hospital
                    Outpatient Services NOS

                	
                  sufficiency
                    tested

                	 	 	 	 	 	
                  visit

                
	 	
                  Outpatient
                    Therapy (PT/RT)

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	
                  Outpatient
                    Therapy (OT/ST)

                	
                  not
                    applicable

                	 	 	 	 	 	 
	 	
                   

                	 	 	 	 	 	 	 	 
	
                  4

                	
                  Maternity
                    and Family Planning Services

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Inpatient
                    Hospital

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Birthing
                    Centers

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Physician
                    Care

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Family
                    Planning

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Pharmacy

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                  5

                	
                  Physician
                    and Phys Extender Services (non maternity)

                	 	 	 	 	 	 	 
	 	
                  EPSDT

                	
                  not
                    applicable

                	 	 	 	 	 	 
	 	
                  Primary
                    Care Physician

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	
                  Specialty
                    Physician

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	
                  ARNP
                    / Physician Assistant

                	
                   all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	
                  Clinic
                    (FQHC, RHC)

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	
                  Clinic
                    (CHD)

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Other

                	
                   all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	 	 	 	 	 	 	 	 	 
	
                  6

                	
                  Other
                    Outpatient Professional Services

                	 	 	 	 	 	 	 
	 	
                  Home
                    Health Services

                	
                  sufficiency
                    tested

                	 	 	 	 	 	
                  visit

                
	 	
                  Chiropractor

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	
                  Podiatrist

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	
                  Dental
                    Services

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	
                  Vision
                    Services

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	
                  Hearing
                    Services

                	
                  coverage

                	 	 	 	 	 	
                  visit

                
	 	 	 	
                   

                	 	 	 	 	 	 
	
                  7

                	
                  Outpatient
                    Mental Health

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  visit

                
	 	 	 	 	 	 	 	 	 	 
	
                  8

                	
                  Outpatient
                    Pharmacy

                	
                  sufficiency
                    tested

                	 	 	 	 	 	 
	 	
                  Generic
                    Pharmacy

                	 	 	 	 	 	 	 
	 	
                  Brand
                    Pharmacy

                	 	 	 	 	 	 	 
	 	
                   

                	 	 	 	 	 	 	 	 
	
                  9

                	
                  Other
                    Services

                	 	 	 	 	 	 	 
	 	
                  Ambulance

                	
                  all
                    medically nec

                	 	 	 	 	 	 
	 	
                  Non-emergent
                    Transportation

                	
                  all
                    medically nec

                	 	 	 	 	 	
                  trip

                
	 	
                  Durable
                    Medical Equipment

                	
                   sufficiency
                    tested

                	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	 	
                  Additional
                    Services (if applicable)*

                	
                  Projected
                    PMPM

                	 	 	 	 	 	 
	
                  10

                	 	 	 	 	 	 	 	 	 
	
                  11

                	 	 	 	 	 	 	 	 	 
	
                  12

                	 	 	 	 	 	 	 	 	 
	
                  13

                	 	 	 	 	 	 	 	 	 
	
                  14

                	 	 	 	 	 	 	 	 	 
	 	
                  *
                    Attach benefit description and supporting documentation.

                	 	 	 	 	 

        

      

       

       

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        S. 
          Transportation Services

      

      1. The
        Health Plan shall report the following encounter data on a quarterly
        basis:

      

      
        	a.  	
                A
                  call log broken down by month that includes the following
                  information:

              

      

      

      
        	i.  	
                Number
                  of calls received;

              

      

      
        	ii.  	
                Average
                  time required to answer a call;

              

      

      
        	iii.  	
                Number
                  of abandoned calls;

              

      

      
        	iv.  	
                Percentage
                  of calls that are abandoned;

              

      

      
        	v.  	
                Average
                  abandonment time; and

              

      

      
        	vi.  	
                Average
                  call time.

              

      

      

      
        	b.  	
                A
                  listing of the total number of reservations of Transportation Services
                  by
                  month, level of service and percentage of level of service utilized,
                  to
                  include, but not be limited to, the
                  following:

              

      

      

      
        	i.  	
                Ambulatory
                  transportation;

              

      

      
        	ii.  	
                Long
                  haul ambulatory transportation;

              

      

      
        	iii.  	
                Wheelchair
                  transportation;

              

      

      
        	iv.  	
                Stretcher
                  transportation;

              

      

      
        	v.  	
                Ambulatory
                  multiload transportation;

              

      

      
        	vi.  	
                Wheelchair
                  multiload transportation;

              

      

      
        	vii.  	
                Mass
                  transit pending transportation;

              

      

      
        	viii.  	
                Mass
                  transit transportation;

              

      

      
        	ix.  	
                Mass
                  transit transportation (Enrollee has pass);
                  and

              

      

      
        	x.  	
                Mass
                  transit transportation (sent pass to
                  Enrollee).

              

      

      

      

      
        	c.  	
                A
                  listing of the total number of authorized uses of Transportation
                  Services,
                  by month, level of service and percentage of level of service utilized,
                  to
                  include, but not be limited to, the
                  following:

              

      

      

      
        	i.  	
                Ambulatory
                  transportation;

              

      

      
        	ii.  	
                Long
                  haul ambulatory transportation;

              

      

      
        	iii.  	
                Wheelchair
                  transportation;

              

      

      
        	iv.  	
                Stretcher
                  transportation;

              

      

      
        	v.  	
                Ambulatory
                  multiload transportation;

              

      

      
        	vi.  	
                Wheelchair
                  multiload transportation;

              

      

      
        	vii.  	
                Mass
                  transit pending transportation;

              

      

      
        	viii.  	
                Mass
                  transit transportation;

              

      

      
        	ix.  	
                Mass
                  transit transportation (Enrollee has pass);
                  and

              

      

      
        	x.  	
                Mass
                  transit transportation (sent pass to
                  Enrollee).

              

      

      

      
        	d.  	
                A
                  listing of the total number of canceled trips, by month, level
                  of service
                  and percentage of level of service utilized, to include, but not
                  be
                  limited to, the following:

              

      

      

      
        	i.  	
                Ambulatory
                  transportation;

              

      

      
        	ii.  	
                Long
                  haul ambulatory transportation;

              

      

      
        	iii.  	
                Wheelchair
                  transportation;

              

      

      
        	iv.  	
                Stretcher
                  transportation;

              

      

      
        	v.  	
                Ambulatory
                  multiload transportation;

              

      

      
        	vi.  	
                Wheelchair
                  multiload transportation;

              

      

      
        	vii.  	
                Mass
                  transit pending transportation;

              

      

      
        	viii.  	
                Mass
                  transit transportation;

              

      

      
        	ix.  	
                Mass
                  transit transportation (Enrollee has pass);
                  and

              

      

      
        	x.  	
                Mass
                  transit transportation (sent pass to
                  Enrollee).

              

      

      

      
        	e.  	
                A
                  listing of the total number of denied Transportation Services,
                  by month,
                  and a detailed description of why the Plan denied the Transportation
                  Service request.

              

      

      

      
        	f.  	
                A
                  listing of the total number of authorized trips, by facility type,
                  for
                  each month and level of service.

              

      

      

      
        	g.  	
                A
                  listing of the total number of Transportation Service claims and
                  payments,
                  by facility type, for each month and level of
                  service.

              

      

      

      
        	2.  	
                Establish
                  a performance measure to evaluate the safety of the Transportation
                  Services provided by Participating Transportation Providers. The
                  Plan
                  shall report the results of the evaluation to the Agency on August
                  15th of
                  each year;

              

      

      

      
        	3.  	
                Establish
                  a performance measure to evaluate the reliability of the vehicles
                  utilized
                  by Participating Transportation Providers. The Plan shall report
                  the
                  results of the evaluation to the Agency on August 15th of each
                  year;
                  and

              

      

      

      
        	4.  	
                Establish
                  a performance measure to evaluate the quality of service provided
                  by a
                  Participating Transportation Provider. The Plan shall report the
                  results
                  of the evaluation to the Agency on August 15th of each
                  year.

              

      

      

      
        	5.  	
                Certification
                  - Each Health Plan/Participating Transportation Provider shall
                  submit an
                  annual safety and security certification in accordance with 14-90.10,
                  F.A.C., 2004 and shall submit to any and all Safety and Security
                  Inspections and Reviews in accordance with 14-90.12, F.A.C.,
                  2004.

              

      

      

      
        	6.  	
                The
                  Plan shall report the following by August 15th
                  of
                  each year:

              

      

      

      
        	a.  	
                The
                  estimated number of one-way passenger trips to be provided in the
                  following categories:

              

      

      

      
        	i.  	
                Ambulatory
                  transportation;

              

      

      
        	ii.  	
                Long
                  haul ambulatory transportation;

              

      

      
        	iii.  	
                Wheelchair
                  transportation;

              

      

      
        	iv.  	
                Stretcher
                  transportation;

              

      

      
        	v.  	
                Ambulatory
                  multiload transportation;

              

      

      
        	vi.  	
                Wheelchair
                  multiload transportation;

              

      

      
        	vii.  	
                Mass
                  transit pending transportation;

              

      

      
        	viii.  	
                Mass
                  transit transportation;

              

      

      
        	ix.  	
                Mass
                  transit transportation (Enrollee has pass);
                  and

              

      

      
        	x.  	
                Mass
                  transit transportation (sent pass to
                  Enrollee).

              

      

      

      
        	b.  	
                The
                  actual amount of funds expended and the total number of trips provided
                  during the previous fiscal year;
                  and

              

      

       

      
        	c.  	
                The
                  operating financial statistics for the previous fiscal
                  year.

              

      

      

      

      

      

      

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T. Enrollee
        Satisfaction Survey Summary

      
        	 	
                a.

              	
                In
                  all
                  areas in which the Health Plan provides Behavioral Health
                  Services,
                  the Health Plan shall conduct a Behavioral Health Services Enrollee
                  Satisfaction Survey in both English and
                  Spanish.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall report the Enrollee Satisfaction Survey Summary
                  to the
                  Agency in accordance with the requirements set forth in Table 9,
                  Enrollee
                  Satisfaction Survey Summary, below.

              

      

      

      Table
        12

      

      Enrollee
        Satisfaction Survey Summary

      

      
        	
                Number
                  of surveys distributed

              	 
	
                Number
                  of surveys completed

              	 
	
                Method
                  used 

              	 
	
                
                  Number
                    of Responses for each item on the survey

                

                 

              

      

      

      
        	
                Item
                  Numbers

              	
                Agree

              	
                Disagree

              	
                No
                  Response

              
	
                1

              	 	 	 
	
                2

              	 	 	 
	
                3

              	 	 	 
	
                4

              	 	 	 
	
                5

              	 	 	 
	
                6

              	 	 	 
	
                7

              	 	 	 
	
                8

              	 	 	 
	
                9

              	 	 	 
	
                10

              	 	 	 
	 	 	 	 
	
                 

                Significant
                  findings or results that will be addressed: 

                 

              
	 
	 
	 
	 
	 

      

      

      

      

      
        
          
            
              

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              

            

          

        

      

      
U.  Stakeholders’
        Satisfaction Survey Summary

      
 

      
        	 	
                a.

              	
                The
                  Health Plan shall submit to the Agency the results of a Stakeholders’
                  Satisfaction Survey Summary. 

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall report the results from the survey in accordance
                  with
                  Table 10, Stakeholders’ Satisfaction Survey Summary,
                  below.

              

      

      

      Table
        13

      

      Stakeholders
        Satisfaction Survey Summary

      

      
        	
                Types
                  of Stakeholders Surveyed

              	
                DCF

                Counselors

              	
                Community
                  Based Care Providers

              	
                Foster
                  Parents

              	
                Consumer
                  Advocacy Groups

              	
                Parents
                  of SED Children

              	
                Out-of-Plan
                  Providers (specify)

              	
                Others

              
	
                 

                Number
                  of Surveys Distributed

                 

              	 	 	 	 	 	 	 
	
                 

                Number
                  of surveys completed in each type

                 

              	 	 	 	 	 	 	 
	
                 

                Method
                  used for distribution

                 

              	 	 	 	 	 	 	 

      

      

      

      
        	
                Summary
                  of Responses:

                 

                 

              
	
                Significant
                  findings or results that will be addressed:

                 

                 

              

      

      

       

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        V.
          Behavioral Health Services Grievance and Appeals Reporting
          Requirements

      

      

      See
        C.
        Grievance System of this section, Section XII.

      

      W. 
Critical
        Incident Reporting

       

      
        	 	
                a.

              	
                For
                  Providers and providers under contract with DCF, the State’s operating
                  procedures for incident reporting and client risk protection establishes
                  departmental procedures and guidelines for reporting information
                  related
                  to the incidents specified in this Section. See CF Operating Procedure
                  No.
                  215-6, November 1, 1998.

              

      

      

      
        	 	
                b.

              	
                The
                  critical incident reporting requirements set forth in this section
                  do not
                  replace the abuse, neglect and exploitation reporting system established
                  by the State. Additionally, the Health Plan must report to the
                  Agency in
                  accordance with the format in Table 14, Critical Incidents Summary,
                  and
                  Table 14-A, Critical Incident Individual,
                  below.

              

      

      

      
        	 	
                c.

              	
                The
                  definitions of reportable critical incidents apply to the Health
                  Plan,
                  Providers (participating and non-participating) and any
                  subcontractees/delgatees providing services to
                  Enrollees.

              

      

      

      
        	 	
                d.

              	
                The
                  Health Plan shall report the following events immediately to the
                  Agency,
                  in accordance with the format set forth in Table 10-A, Critical
                  Incident
                  Individual, below:

              

      

      

      (1) Death
        of
        an Enrollee due to one (1) of the following:

      

      (a) Suicide;

      

      (b) Homicide;

      

      (c) Abuse;

      

      (d) Neglect;
        or

      

      
        	 	
                (e)

              	
                An
                  accident or other incident that occurs while the Enrollee is in
                  a facility
                  operated or contracted by the Health Plan or in an acute care
                  facility.

              

      

      

      
        	 	
                (2)

              	
                Enrollee
                  Injury or Illness - A medical condition that requires medical treatment
                  by
                  a licensed health care professional and which is sustained, or
                  allegedly
                  is sustained, due to an accident, act of abuse, neglect or other
                  incident
                  occurring while an Enrollee is in a Facility operated or contracted
                  by the
                  Health Plan or while the Enrollee is in an acute care
                  facility.

              

      

      

      
        	 	
                (3)

              	
                Sexual
                  Battery - An allegation of sexual battery, as determined by medical
                  evidence or law enforcement involvement, by:

              

      

      

      (a) An
        Enrollee on another Enrollee;

      

      
        	 	
                (b)

              	
                An
                  employee of the Health Plan, a provider or a subcontractee, an
                  Enrollee;
                  and/or 

              

      

      

      
        	 	
                (c)

              	
                An
                  Enrollee on an employee of the Health Plan, a provider or a
                  subcontractee.

              

      

      

      
        	 	
                e.

              	
                The
                  Health Plan shall immediately report to the Agency, in accordance
                  with the
                  format in Table 14-A, Critical Incident Individual, below, if one
                  (1) or
                  more of the following events occur:

              

      

      

      (1) Medication
        errors in an acute care setting; and/or

      

      
        	 	
                (2)

              	
                Medication
                  errors involving Children/Adolescents in the care or custody of
                  DCF.
                  

              

      

      

      
        	 	
                f.

              	
                The
                  Health Plan shall report monthly to the Agency, in accordance with
                  the
                  format in Table 14 Critical Incidents Summary, below, a summary
                  of all
                  critical incidents.

              

      

      

      
        	 	
                g.

              	
                In
                  addition to supplying a quarterly Critical Incidents Summary, the
                  Health
                  Plan shall also report Critical Incidents in the manner prescribed
                  by the
                  appropriate district’s DCF Alcohol, Drug Abuse Mental Health office, using
                  the appropriate DCF reporting forms and
                  procedures.

              

      

      

       

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      Table
        14

      

      Critical
        Incidents Summary

      

      
        	
                Incident
                  Type

              	
                # of
                  Events

              
	
                Enrollee
                  Death - Suicide

              	 
	
                Enrollee
                  Death - Homicide

              	 
	
                Enrollee
                  Death - Abuse/Neglect

              	 
	
                Enrollee
                  Death - other

              	 
	
                Enrollee
                  Injury or Illness

              	 
	
                Sexual
                  Battery

              	 
	
                Medication
                  Errors - acute care

              	 
	
                Medication
                  Errors - children

              	 
	
                Enrollee
                  Suicide Attempt

              	 
	
                Altercations
                  requiring Medical Interventions

              	 
	
                Enrollee
                  Escape

              	 
	
                Enrollee
                  Elopement

              	 
	
                Other
                  reportable incidents

              	 
	
                Total

              	 

      

      

      

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      Table
        14-A

      

      Critical
        Incident Individual

      

      
        	
                 

                Enrollee
                  Medicaid ID#:

              	 
	
                 

                Date
                  of Incident:

              	 
	
                 

                Location
                  of Incident:

              	 
	
                 

                Critical
                  Incident Type:

              	 
	
                 

                Details
                  of Incident: (Include
                  enrollee’s age, gender, diagnosis, current medication, source of
                  information, all reported details about the event, action taken
                  by Health
                  Plan or provider, and any other pertinent information)

              	 
	
                 

                Follow
                  up planned or required: (Include
                  information related to any Health Plan or provider protocol that
                  applies
                  to event.)

              	 
	
                 

                Assigned
                  provider:

              	 
	
                 

                Report
                  submitted by:

              	 
	
                 

                Date
                  of submission:

              	 

      

      

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        X. 
          Required Staff/Providers

      

      

      The
        Health Plan shall submit contracted and subcontracted staffing information
        by
        position, name and FTE for all direct service positions on a quarterly basis
        in
        accordance with the format of Table 15 below.

      

      

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      Table
        15

      Required
        Staff/Providers

      

      
        	 	 	
                Non-Clinical
                  Specialties

              	
                Therapeutic
                  Specialty Areas With 2 Years Clinical
                  Experience

              
	
                Positions

              	
                Total

              	
                Bi-Lingual

              	
                Expert
                  Witness

              	
                Court
                  Ordered Evals

              	
                Adoption/

                Attachment
                  Issues

              	
                Post
                  Traumatic Stress Syndrome

              	
                Dual
                  Diagnosis (Mental Disorder/ Substance Abuse)

              	
                Gender/
                  Sexual Issues

              	
                Geriatrics/
                  Aging Issues

              	
                Separation,
                  Grief & Loss

              	
                Easting
                  Disorders

              	
                Adolescent/
                  Children’s Issues

              	
                Sexual
                  / Physical Abuse 

                —Child

              	
                Sexual
                  Physical Abuse 

                —
                  Adult

              	
                Domestic
                  Violence

                —
                  Child

              	
                Domestic
                  Violence 

                —
                  Adult

              
	
                Adult
                  Psychiatrists

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Child
                  Psychiatrists

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Other
                  Physicians

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Psychiatric
                  ARNPs

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Psychologists

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Master
                  Level Clinicians (LCSW, LMFT, LMHC, MFCC)_

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Bachelor
                  Level

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                RN

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Unduplicated
                  Totals

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

      

      

       

      
        
          
            
              

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              

            

          

        

      

      
Y.  FARS/CFARS

       

      The
        reports shall be submitted in accordance with the format of Table 16 and
        16-A
        below.

      

      

      
        	
                Table
                  16

                FARS/CFARS
                  Reporting

              
	
                 

                O***YY06.txt
                  (January through June, due August 15) OR

                 

              
	
                 

                O***YY12.txt
                  (July through December, due February 15)

                 

              
	
                Data
                  Element Name

              	
                 

                Length

              	
                 

                Start
                  Column

              	
                End
                  Column

              	
                 

                Description

              
	
                 

                Recipient
                  ID

              	
                 

                9

              	
                 

                1

              	
                 

                9

              	
                 

                9-Digit
                  Medicaid ID Number of plan member

              
	
                 

                Recipient
                  DOB

              	
                 

                10

              	
                 

                10

              	
                 

                19

              	
                 

                Plan
                  member’s date of birth (MM/DD/CCYY)

              
	
                 

                Provider
                  ID

              	
                 

                9

              	
                 

                20

              	
                 

                28

              	
                 

                9-Digit
                  Medicaid HMO ID Number

              
	
                 

                Assessment
                  Type

              	
                 

                1

              	
                 

                29

              	
                 

                29

              	
                 

                Designate
                  the type of functional assessment that was done using “F: for FARS or “C”
                  for CFARS

              
	
                 

                Initial
                  Date

              	
                 

                10

              	
                 

                30

              	
                 

                39

              	
                 

                Date
                  of initial assessment (MM/DD/CCYY)

              
	
                 

                Initial
                  Score

              	
                 

                2

              	
                 

                40

              	
                 

                41

              	
                 

                Initial
                  overall assessment score

              
	
                 

                6
                  Month Date

              	
                 

                10

              	
                 

                42

              	
                 

                51

              	
                 

                Date
                  of 6 month assessment, if applicable** (MM/DD/CCYY)

              
	
                 

                6
                  Month Score

              	
                 

                2

              	
                 

                52

              	
                 

                53

              	
                 

                6
                  month overall assessment score, if applicable**

              
	
                 

                Discharge
                  Date

              	
                 

                10

              	
                 

                54

              	
                 

                63

              	
                 

                Date
                  of Discharge (MM/DD/CCYY)

              
	
                 

                Discharge
                  Score

              	
                 

                2

              	
                 

                64

              	
                 

                65

              	
                 

                Overall
                  assessment score at discharge

              
	 	 	 	 	 
	
                 

                **
                  Note: Discharge date may occur prior to the 6 month
                  assessment.

                 

              

      

      

      

      

      Placeholder
        for Table 16-A, Summary FARS/CFARS Outcomes and Trending
        Report

       

      

      
        
          
            
              

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              

            

          

        

      

      
Z.
Behavioral
        Health Encounter Report

      
The
        Behavioral Health encounter data shall be reported in the format given in
        Table
        17, below. The following should be used when completing the report.

      

      1. Diagnostic
        Criteria

      All
        provider claims are restricted to claims for beneficiaries with an ICD-9CM
        diagnosis code of 290 through 290.43; 293 through 298.9; 300 through 301.9;
        302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3, 315.31, 315.5,
        315.8,
        and 315.9.

      

      2. Provider
        and Coding Criteria

      a. General
        Hospital Services - Provider Type 01, Claim Input Indicator “I”

      Use
        Revenue Codes 0114, 0124, 0134, 0144, 0154, or 0204 on the UB-92 or
        837-I

      

      
        	 	
                b.

              	
                Hospital
                  Outpatient Services - Provider Type 01, Claim Input Indicator
                  “O”

              

      

      Use
        Revenue Center Codes 0450, 0513, 0901, 0914, or 0918
        on
        the UB-92 or 837-I

      

      3. Community
        Mental Health Services

      

      Provider
        Type - 05, Community Alcohol, Drug and Mental Health, or 

      Provider
        Type - 07, Mental Health Practitioner

      Both
        are
        Claim Input Indicator “J”

      

      Use
        Procedure code H0001; H000lHN; H0001H0; H0001TS; H0031; H0031 HO; H003lHN;
        H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP;
        H2010HO;
        H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
        H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
        Tl023HE; or T1023HF 

      

      
        	 	
                4.

              	
                Physician
                  Services - Provider Type 25 (MD) or 26 (DO) with a specialty code
                  of
                  "42"Psychiatrist, "43”Child Psychiatrist, or "44"
                  Psychoanalysis

              

      

      

      All
        claims submitted by these specialists apply

      

      
        	 	
                5.

              	
                Advanced
                  Nurse Practitioner Provider Type 30 (ARNP) with a specialty Code
                  of “76” -
                  Clinical Nurse Specialist.

              

      

      

      All
        claims submitted by these specialists apply

      

      6. Case
        Management Agency - Provider Type 91 

      

      Procedure
        code T1017 (Targeted Case Management for Adults); T1017HA (Targeted Case
        Management for Children (birth through 17); and T1017HK (Intensive Team Targeted
        Case Management, Adults 18 an over).

      

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      Table
        17

      Behavioral
        Health Encounter Data

      

        
          	
                  Field
                    Name

                	
                  Field
                    Length

                	
                  Comments

                
	
                  Medicaid
                    ID

                	
                  9

                	
                  First
                    9 digits of the Enrollee ID number 

                
	
                  Plan
                    ID

                	
                  9

                	
                  9
                    digit Medicaid ID of the Health Plan in which Enrollee was Enrolled
                    on the
                    first date of service

                
	
                  Service
                    Type

                	
                  1

                	
                  I Hospital
                    Inpatient

                  C CSU

                  O Hospital
                    Outpatient

                  P Physician
                    (MD or DO)

                  A Advanced
                    Nurse Practitioner, ARNP

                  H Comm.
                    Mental Health, Mental Health Practitioner

                  T Targeted
                    Case Management

                  L Locally
                    Defined or Optional Service

                
	
                  First
                    Date of Service

                	
                  8

                	
                  For
                    Inpatient and CSU encounters, this equals the admit date. Use
                    YYYYMMDD
                    format.

                
	
                  Revenue
                    Code

                	
                  4

                	
                  Use
                    only for Hospital Inpatient and Hospital Outpatient
                    Encounters

                
	
                  Procedure
                    Code

                	
                  5

                	
                  5
                    digit CPT or HCPCS Procedure Code (For Inpatient Claims only,
                    use the
                    ICD9-CM Procedure Code.) 

                
	
                  Procedure
                    Modifier 1

                	
                  2

                	 
	
                  Procedure
                    Modifier 2

                	
                  2

                	 
	
                  Units
                    of Service

                	
                  3

                	
                  For
                    Inpatient and CSU encounters, report the number of covered days.
                    For all
                    other encounters, use the units of service referenced in the
                    appropriate
                    Medicaid Coverage and Limitations Handbook.

                
	
                  Diagnosis

                	
                  6

                	
                  Primary
                    Diagnosis Code

                
	
                  Provider
                    Type

                	
                  1

                	
                  1 M.D.

                  2 D.O.

                  3 A.R.N.P.

                  4 P.A.

                  5 Community
                    Mental Health Center

                  6 Licensed
                    Psychologist, LCSW, LMFT, LMHC

                  7 Other

                
	
                  Provider
                    ID Type

                	
                  1

                	
                  Type
                    of unique identifier for the direct service provider:

                  A
                    =
                    AHCA ID 

                  M
                    =
                    Medicaid Provider ID

                  L
                    =
                    Professional License Number

                
	
                  Provider
                    ID

                	
                  9

                	
                  Unique
                    identifier for the direct service provider

                
	
                  Amount
                    Paid

                	
                  10

                	
                  Costs
                    associated with the claim. Format with an explicit decimal point
                    and 2
                    decimal places but no explicit commas. Optional.

                
	
                  Run
                    Date

                	
                  8

                	
                  The
                    date the file was prepared. Use YYYYMMDD format

                
	
                  Claim
                    Reference Number

                	
                  25

                	
                  The
                    Health Plan’s internal unique claim record
                    identifier

                

        

      

      
        
          
            
              

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              

            

          

        

      

      

      

      AA. Minority
        Participation Report

      

      The
        Agency for Health Care Administration encourages the Vendor to use Minority
        and
        Certified Minority businesses as subcontractors when procuring commodities
        or
        services to meet the requirement of this Contract.

      

      The
        Agency requires information regarding the Vendor’s use of minority owned
        businesses as subcontractors under this contract. This information will be
        used
        for assessment and evaluation of the Agency’s Minority Business Utilization
        Plan. During the term of the contract, it will be necessary to provide this
        information monthly by the 15th
        of each
        subsequent month. A minority owned business is defined as any business
        enterprise owned and operated by the following ethnic groups: African
        American (Certified Minority Code H or Non-Certified Minority Code N), Hispanic
        American (Certified Minority Code I or Non-Certified Minority O), Asian American
        (Certified Minority Code J or Non-Certified Minority Code P), Native American
        (Certified Minority Code K or Non-Certified Minority Code Q), or American
        Woman
        (Certified Minority Code M or Non-Certified Minority Code R). This
        requirement can be waived by the agency if the plan demonstrates that it
        is
        either at least 51 percent minority owned, at least 51 percent of its board
        of
        directors are a minority, at least 51 percent of its officers are a minority,
        or
        if the plan is not for profit corporation and at least 51 percent of the
        population it serves belong to a minority.

      

      The
        Vendor is required to provide the following information on company
        letterhead:

      

      1) Minority
        subvendor's company name and Minority Code (see above); 

      
        	 	
                2)

              	
                Services
                  subcontracted related to this
                  Contract;

              

      

      
        	 	
                3)

              	
                Dates
                  of services (beginning and ending);

              

      

      
        	 	
                4)
                  

              	
                Total
                  dollar amount paid to subvendor for services related to this Contract;
                  or

              

      

      
        	 	
                5)

              	
                A
                  statement that no minority subvendors were used during this
                  period.

              

      

      

      

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      Section
        XIII

      Method
        of Payment

      

      
        	
                A.

              	
                Payment
                  Overview. This
                  is a fixed price (unit cost) Contract. The Agency will manage this
                  fixed
                  price Contract for the delivery of Covered Services to Enrollees.
                  The
                  Agency or its Fiscal Agent shall make payment to the Health Plan
                  on a
                  monthly basis for the Health Plan’s satisfactory performance of its duties
                  and responsibilities as set forth in this Contract. To accommodate
                  payments, the Health Plan is enrolled as a Medicaid provider with
                  the
                  Fiscal Agent. Payments
                  made to the Health Plan resulting from this Contract include monthly
                  Capitation Rate payments for either a Comprehensive Component or
                  a
                  Comprehensive Component and Catastrophic Component, both of which
                  contain
                  risk adjustments, and were developed for particular Medicaid populations,
                  and may contain an adjustment to collect amounts for the Enhanced
                  Benefit
                  Accounts fund. The Agency may also pay Health Plans for obstetrical
                  delivery and transplant services through Kick Payments; for Covered
                  Services that are over the Catastrophic Component Threshold, if
                  the Health
                  Plan has contracted for the Comprehensive Component only; and for
                  Child
                  Health Check-Up (CHCUP) incentive payments, if any, as specified
                  below.
                  

              

      

      

      B. Capitation
        Rate Payments

      

       

      
        	1.  	
                The
                  Agency’s Capitation Rate payments shall meet the following
                  requirements:

              

      

       

      
        	a.  	
                Medicaid
                  Reform Capitation Rates will begin with the September 1, 2006 Capitation
                  Rate payments. 

              

      

      (1) For
        the
        first (1st)
        two (2)
        years of Medicaid Reform, the Health Plan’s Risk-Adjusted Capitation Rates (for
        the Children and Families and Aged and Disabled Enrollee population) will
        consist of two (2) components for the eligibility categories listed in Tables
        2
        and 3 in Attachment I. The two components are: a current Capitation Rate
        methodology component and a Risk-Adjusted Capitation Rate methodology component.
        

       

      (2) For
        SSI
        Medicare Part B Only Enrollees and SSI Medicare Parts A and B Enrollees,
        the
        Capitation Rates are based on the current Capitation Rate methodology for
        the
        age groups listed in Table 4 in Attachment I.

       

      (3) For
        Enrollees diagnosed with HIV/AIDS and for Children with Chronic Conditions,
        the
        Capitation Rates are fully Risk-Adjusted. 

       

      
        	 	
                (a)

              	
                The
                  Agency will pay the Health Plan the HIV/AIDS Capitation Rate only
                  for
                  those Enrollees who have been identified and verified as having
                  an
                  HIV/AIDS diagnosis. The HIV/AIDS Capitation Rate is provided in
                  the
                  Capitation Rate Table 5 in Attachment I.

              

      

       

      (i) The
        Agency will pay the HIV/AIDS Capitation Rate for those Enrollees who have
        been
        identified as having an HIV/AIDS diagnosis, regardless of whether or not
        the
        Health Plan is a Specialty Plan.

       

      (ii) Enrollees
        with an HIV/AIDS diagnosis may be identified by either the Agency or the
        Health
        Plan. For the Health Plan to identify that an Enrollee has an HIV/AIDS
        diagnosis, the Health Plan must have completed lab testing as interpreted
        by a
        licensed physician prior to reporting the Enrollee to the Agency as an
        identified Enrollee with an HIV/AIDS diagnosis. The Health Plan must provide
        the
        Agency with such Enrollee’s test results upon request.

       

      (iii) The
        Health Plan may submit Enrollees identified with an HIV/AIDS diagnosis to
        the
        Agency in a format and transmittal method approved by the Agency.

       

      (iv) The
        Agency shall not pay the HIV/AIDS Capitation Rate for any Enrollee who was
        not
        identified as HIV/AIDS prior to Enrollment processing for the month for which
        the capitation payment is made, nor shall the Agency make a retroactive
        capitation payment at the HIV/AIDS Capitation Rate if the Enrollee was
        identified as HIV/AIDS after Enrollment processing.

       

      
        	 	
                (b)

              	
                The
                  Agency will pay the Health Plan the Capitation Rate for Children
                  with
                  Chronic Conditions only if the Enrollee meets the requirements
                  for the
                  Children with Chronic Conditions and is enrolled in a Specialty
                  Plan for
                  for Children with Chronic Conditions based on the rates specified
                  in Table
                  6. 

              

      

       

       

      
        	b.  	
                For
                  each eligibility category indicated, and for each age group indicated,
                  the
                  Agency will make a capitation payment for Enrollees as provided
                  for in the
                  Capitation Rate tables in Attachment I and as described below.
                  

              

      

       

      (1) For
        Enrollees who are in the Children and Families and the Aged and Disabled
        eligibility categories, not identified as diagnosed with HIV/AIDS and not
        enrolled in a Specialty Plan as identified Children with Chronic Conditions,
        their Capitation Rates are provided in Capitation Rate Tables 2 and 3 of
        Attachment I. The columns in Capitation Rate Tables 2 and 3 of Attachment
        I are
        defined below: 

       

      
        	 	
                (a)

              	
                Age
                  ranges for the eligibility categories for which the Capitation
                  Rates are
                  calculated.

              

      

       

      
        	 	
                (b)

              	
                Contract
                  Year 2006-2007 Medicaid Reform rates under current Capitation Rate
                  methodology.

              

      

       

      
        	 	
                (c)

              	
                Percentage
                  of current methodology used for determining
                  rates.

              

      

       

      
        	 	
                (d)

              	
                Current
                  methodology capitation amount (component) based on the percentage
                  of
                  current methodology Capitation Rates
                  used.

              

      

       

      
        	 	
                (e)

              	
                Preliminary
                  base rate for Contract Year Risk-Adjusted methodology with Enhanced
                  Benefit adjustment. The Enhanced Benefit adjustment is a per Health
                  Plan
                  percentage amount that is deposited into the Enhanced Benefit Accounts
                  fund (see also subsection F.2. of this Attachment).
                  

              

      

       

      
        	 	
                (f)

              	
                Budget
                  neutrality factor: an actuarially-derived factor to ensure that
                  aggregate
                  costs do not increase or decrease.

              

      

       

      
        	 	
                (g)

              	
                Base
                  rates for Risk-Adjusted Methodology after Budget Neutrality: Capitation
                  amount based on the percentage of Risk-Adjusted methodology Capitation
                  Rates used multiplied by the budget neutrality factor
                  (f).

              

      

       

      
        	 	
                (h)

              	
                Percentage
                  of Risk-Adjusted methodology used for determining rates (the Agency’s
                  Risk-Adjusted Capitation Rate methodology is based on eligibility,
                  claims
                  and encounter data).

              

      

       

      
        	 	
                (i)

              	
                25%
                  of Risk Adjusted Methodology: The capitation amount based on the
                  percentage of Risk-Adjusted methodology (h) multiplied by the Base
                  Rates
                  column for Risk-Adjusted methodology after budget neutrality factor
                  (g).

              

      

       

      
        	i.  	
                The
                  Agency assigns the Health Plan a Risk-Adjusted Plan Factor which
                  designates the aggregated risk of the Health Plan’s enrolled population.
                  

              

      

       

      
        	ii.  	
                During
                  the first (1st)
                  two (2) Contract years, the Health Plan’s Risk-Adjusted Plan Factor will
                  not vary more than ten percent (10%) from the aggregate weighted
                  mean of
                  all Medicaid Reform Health Plans within the same Service Area for
                  the
                  respective eligibility categories. 

              

      

       

      
        	 	
                (j)

              	
                Final
                  Rate (with Enhanced Benefit Adjustment): The current methodology
                  capitation amount (d) added to the 25% of Risk-Adjusted methodology
                  amount
                  (i). The final rate provided in Attachment I is an estimate based
                  on a
                  Plan Factor of 1.0. Note: The actual final monthly Capitation Rate(s)
                  paid
                  to the Health Plan will be based on the Health Plan’s actual Plan Factor
                  and reduced by the actual percentage deducted to fund the Enhanced
                  Benefit
                  Accounts.

              

      

       

      (2) For
        Enrollees who in the SSI Medicare Part B Only and the SSI Medicare Parts
        A and B
        eligibility categories, and who are not identified as diagnosed with HIV/AIDS
        or
        enrolled in a Specialty Plan as identified Children with Chronic Conditions
        Enrollees, their Capitation Rates are provided in Table 4 of Attachment I.
        

       

      (3) For
        Enrollees who are identified as diagnosed with HIV/AIDS, their Capitation
        Rates
        are provided in Table 5 of Attachment I. 

       

      
        	 	
                (i)

              	
                HIV/AIDS
                  Specialty Plan Enrollees who are family members of Enrollees identified
                  as
                  diagnosed with HIV/AIDS, and who are not identified as diagnosed
                  with
                  HIV/AIDS, will receive a Capitation Rate based on their respective
                  eligibility categories in Capitation Rate Tables 2 or 3 in Attachment
                  I.
                  In developing the capitation rates for these family members, a
                  Plan Factor
                  of 1.0 will be assigned until the Agency determines that the Health
                  Plan
                  has enough of population of such Enrollees as to warrant its own
                  Plan
                  Factor.

                 

              

      

      (4) For
        Enrollees who are in the Children with Chronic Conditions Speciality Plan,
        their
        Capitation Rates are provided in Table 6 of Attachment I. Sibling Enrollees
        who
        are enrolled in the Children with Chronic Conditions Speciality Plan, and
        are
        not identified as Children with Chronic Conditions, will receive a Capitation
        Rate based on their respective eligibility categories in Capitation Rate
        Tables
        2 or 3 in Attachment I. In developing the capitation rates for these family
        members, a Plan Factor of 1.0 will be assigned until the Agency determines
        that
        the Health Plan has enough of population of such Enrollees as to warrant
        its own
        Plan Factor.

       

      
        	 	
                c.

              	
                The
                  Risk-Adjusted Capitation Rates paid by the Agency are either for
                  the
                  Comprehensive Component or Comprehensive Component and Catastrophic
                  Component as specified below. 

              

      

       

      
        	(1)  	
                Health
                  Plans are required to provide the Comprehensive Component and the
                  Catastrophic Component to Enrollees in the following
                  manner:

              

      

       

      
        	 	
                (a)

              	
                For
                  Contracts serving Broward County and/or Duval County, Health Plans
                  that
                  are not Capitated PSNs are required to provide both the Comprehensive
                  Component and Catastrophic Components. This means that the Health
                  Plan is
                  responsible for the cost of providing Covered Services up to the
                  Benefit
                  Maximum determined by the Agency for the Contract Year.
                  

              

      

       

      
        	 	
                (b)

              	
                For
                  Contracts serving Broward County and/or Duval County, Health Plans
                  that
                  are Capitated PSNs must provide the Comprehensive Component and
                  may choose
                  to provide the Catastrophic Component. The Capitated PSN’s choice will be
                  documented in Attachment I. 

              

      

       

      i. If
        the
        Capitated PSN has chosen to provide both the Comprehensive Component and
        the
        Catastrophic Component, the Health Plan is responsible for the cost of providing
        Covered Services up to the Benefit Maximum determined by the Agency for the
        Contract Year. 

       

      ii. If
        the
        Capitated PSN has chosen to provide the Comprehensive Component only, the
        Health
        Plan is responsible for the cost of providing Covered Services up to the
        Catastrophic Component Threshold by the Agency for the Contract Year. Such
        a
        Health Plan will receive reimbursement from the Agency for its costs beyond
        the
        Catastrophic Threshold up to the Benefit Maximum in accordance with Subsection
        D. 

       

      
        	 	
                (c)

              	
                For
                  Contracts serving Baker County, Clay County and/or Nassau County,
                  the
                  Health Plan is required to provide the Comprehensive Component
                  and may
                  choose to provide the Catastrophic Component to its Enrollees in
                  those
                  counties. 

              

      

       

      i. If
        by
        this Contract, as specified in Attachment I, the Health Plan has agreed to
        provide both the Comprehensive Component and the Catastrophic Component,
        then
        the Health Plan is responsible for the cost of providing the Enrollee with
        Covered Services up to the Benefit Maximum determined by the Agency for the
        Contract Year. 

       

      ii. If
        by
        this Contract, as specified in Attachment I, the Health Plan has agreed to
        provide the Comprehensive Component only, then the Health Plan is financially
        responsible for the provision of Covered Services up to the Catastrophic
        Component Threshold determined by the Agency for the Contract Year.

       

      (2) For
        purposes of calculating whether an Enrollee has met the Catastrophic Component
        Threshold and the Benefit Maximum, a Health Plan’s costs will be converted to
        the Medicaid Fee-for-Service payment levels as indicated in subsection D.
        below.
        For services covered by the Health Plan for which there is no Medicaid fee,
        the
        Agency will use the amount the Health Plan paid for the service. Upon the
        Agency’s request, the plan shall provide documentation to validate payment and
        services rendered. In addition, if the Health Plan receives payment from
        the
        Agency for Kick Payment services, the Kick Payment made by the Agency will
        be
        included toward the Catastrophic Component Threshold and toward the Benefit
        Maximum.

       

      (3) Health
        Plans will be paid Capitation Rates for the Comprehensive Component and the
        Catastrophic Component or for the Comprehensive Component only, in accordance
        with whether the Health Plan agreed, by this Contract, to provide both the
        Comprehensive Component and Catastrophic Component or to provide only the
        Comprehensive Component. 

       

      2. The
        Agency’s Capitation Rates are included as Attachment I,
        titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY
        CMS.”
        The
        Agency may use, or may amend and use these rates, only after certification
        by
        its actuary and approval by the Centers for Medicare and Medicaid Services.
        Inclusion of these rates is not intended to convey or imply any rights, duties
        or obligations of either party, nor is it intended to restrict, restrain
        or
        control the rights of either party that may have existed independently of
        this
        Section of the Contract. 

       

      

      
        	 	
                a.

              	
                By
                  signature on this Contract, the parties explicitly agree that this
                  Section
                  shall not independently convey any inherent rights, responsibilities
                  or
                  obligations of either party, relative to these rates, and shall
                  not itself
                  be the basis for any cause of administrative, legal or equitable
                  action
                  brought by either party. In the event that the rates certified
                  by the
                  actuary and approved by CMS are different from the rates included
                  in this
                  Contract, the Health Plan agrees to accept a reconciliation performed
                  by
                  the Agency to bring payments to the Health Plan in line with the
                  approved
                  rates. The Agency may amend and use the CMS-approved rates by notice
                  in a
                  Contract amendment to the Health Plan.

              

      

      

      
        	 	
                b.

              	
                Upon
                  receipt of CMS approval of the September 1, 2006 - August 31, 2007
                  Capitation Rates (remainder of the 2006-2007 Contract year), the
                  Agency
                  shall amend this Contract to reflect CMS-approved and actuarially
                  certified Capitation Rates effective September 1, 2006. The Health
                  Plan’s
                  Capitation Rates for this Contract period (September 1, 2006 -
                  August 31,
                  2007) will be weighted so that seventy-five percent (75%) is based
                  on
                  current Capitation Rate methodology and twenty-five percent (25%)
                  is based
                  on the Risk-Adjusted Capitation Rate
                  methodology.

              

      

      

      
        	 	
                c.

              	
                Upon
                  CMS approval of the September 1, 2007 - August 31, 2008 Capitation
                  Rates,
                  the Agency shall amend this Contract to reflect CMS-approved and
                  actuarially certified Capitation Rates effective September 1, 2007.
                  The
                  Health Plan’s Capitation Rates for the September 1, 2007 - August 31, 2008
                  Contract Year will be weighted so that fifty percent (50%) is based
                  on
                  current Capitation Rate methodology and fifty percent (50%) is
                  based on
                  the Risk-Adjusted Capitation Rate
                  methodology.

              

      

      

      
        	 	
                d.

              	
                Upon
                  CMS approval of the September 1, 2008 - August 31, 2009 Capitation
                  Rates,
                  the Agency shall amend this Contract to reflect CMS-approved and
                  actuarially certified Capitation Rates effective September 1, 2008.
                  The
                  Health Plan’s Capitation Rates shall be fully Risk-Adjusted for the
                  September 1, 2008 - August 31, 2009 Contract
                  Year.

              

      

      

      3. The
        Agency shall pay the applicable Capitation Rate for each Enrollee whose name
        appears on the ONGOING REPORT (FLMR 8200-R004) and the REINSTATEMENT
        REPORT
        (FLMR
        8200-R009) for each month, except that the Agency shall not pay for, and,
        in
        accordance with subsections F. and G. of this Attachment, shall recoup payment
        for, any part of the total Enrollment that exceeds the maximum authorized
        Enrollment level(s) expressed in this Contract in Attachment I. The total
        payment amount to the Health Plan shall depend on the number of Enrollees
        in
        each eligibility category and each rate group, and whether the Health Plan
        is
        providing the Comprehensive Component only or the Comprehensive Component
        and
        the Catastrophic Component, and at a rate that has been Risk-Adjusted pursuant
        to this Contract, or as adjusted pursuant to the Contract, where necessary
        in
        accordance with subsection F. of this Attachment. 

      

      
        	 	
                a.

              	
                The
                  Health Plan is obligated to provide services pursuant to the terms
                  of this
                  Contract for all Enrollees for whom the Health Plan has received
                  capitation payment or for whom the Agency has assured the Health
                  Plan that
                  the capitation payment is
                  forthcoming.

              

      

      

      
        	 	
                b.

              	
                To
                  ensure a seamless health care delivery system for the Enrollee,
                  if the
                  Health Plan contracts for the Comprehensive Component only, the
                  Health
                  Plan continues to be responsible for coordinating, managing, and
                  delivering all Enrollee care up to the Benefit Maximum regardless
                  of
                  whether the cost of the Enrollee’s Covered Services is above and beyond
                  the Catastrophic Component
                  Threshold.

              

      

      

      
        	 	
                c.

              	
                Regardless
                  of whether the Health Plan is at risk for the Comprehensive Component
                  only
                  or for both the Comprehensive Component and the Catastrophic Component,
                  the Health Plan continues to be responsible for the coordinating
                  and
                  managing all Enrollee care even if the cost of the Enrollee’s Covered
                  Services is above and beyond the Benefit Maximum.

              

      

      

      4. The
        Capitation Rates to be paid specific to the Health Plan shall be as indicated
        in
        the Payment Tables in Attachment I, and adjusted monthly based on the Health
        Plan’s Plan Factor in accordance with subsection B.1.b.(1)(g)(i) through (ii)
        of
        this Section. 

      

      5. Unless
        otherwise specified in this Contract, the
        Health Plan shall accept the capitation payment received each month as payment
        in full by the Agency for all services provided to Enrollees covered under
        this
        Contract and the administrative costs incurred by the Health Plan in providing
        or arranging for such services. Any and all costs incurred by the Health
        Plan in
        excess of the capitation payment shall be borne in total by the Health Plan.

      

      6. The
        Agency shall pay a retroactive Capitation Rate for each Newborn enrolled
        in the
        Health Plan for up to the first (1st)
        three
        (3) months of life provided the Newborn was enrolled through the Unborn
        Activation Process. 

      

      
        	 	
                a.

              	
                The
                  Health Plan shall use the Unborn Activation Process to enroll all
                  babies
                  born to pregnant Enrollees as specified in Section III, Eligibility
                  and
                  Enrollment, B.3.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan is responsible for payment of all Covered Services
                  provided to
                  Newborns enrolled through the Unborn Activation
                  Process.

              

      

      

      C. Kick
        Payments

      

      Beginning
        September 1, 2006, the Agency shall pay Health Plans one (1) Kick Payment
        for
        each covered transplant for the Health Plan’s Enrollees who are not dually
        eligible for Medicare, and for each obstetrical delivery performed for each
        obstetrical delivery performed for the Health Plan’s Enrollees. Kick Payments
        are not made for Enrollees dually eligible for Medicare. 

      

      1. The
        Agency shall pay Kick Payments in the amounts indicated for children and
        adults
        in Attachment I, Tables 7 and 8. 

      

      
        	 	
                a.

              	
                For
                  Health Plans under Contract to provide the Comprehensive Component
                  only,
                  Agency reimbursements to the Health Plan for Kick Payment services
                  will be
                  counted toward the Health Plan’s Catastrophic Component Threshold. Once
                  the Catastrophic Component Threshold has been met, the Agency will
                  continue to reimburse the Health Plan any Kick Payment services
                  delivered
                  by the Health Plan at the Kick Payment
                  amounts.

              

      

      

      
        	 	
                b.

              	
                For
                  purposes of Kick Payments, an obstetrical delivery includes all
                  births
                  resulting from the delivery; therefore, if an obstetrical delivery
                  results
                  in multiple births, the Agency will reimburse the Health Plan through
                  one
                  Kick Payment only. Obstetrical deliveries also include still births
                  as
                  specified in the Medicaid Physicians Services
                  Handbook.

              

      

      
        	 	
                c.

              	
                For
                  Health Plans under Contract as a Specialty Plan, Agency reimbursements
                  to
                  the Health Plans for Kick Payment services will be counted toward
                  the
                  Enrollee’s Benefit Maximum. 

              

      

      

      2. To
        receive a Kick Payment, the Health Plan must adhere to specific requirements
        listed in subsections 3. and 4. below and adhere to the following
        requirements:

      

      
        	 	
                a.

              	
                The
                  Health Plan must have provided the covered Kick Payment service
                  to the
                  recipient while he or she was enrolled in the Health Plan;
                  and

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan must submit any required documentation to the Agency
                  upon its
                  request in order to receive the Kick Payment applicable to the
                  Covered
                  Service provided.

              

      

      

      3. In
        addition to subsection 2. above, to receive a Kick Payment for covered
        transplants provided to an Enrollee without Medicare, the Health Plan must
        also
        comply with the following requirements: 

      

      
        	 	
                a.

              	
                For
                  each transplant provided, the Health Plan must submit an accurate
                  and
                  complete CMS-1500 Claim Form and (“CMS-1500”) Operative Report to the
                  Fiscal Agent within the required Medicaid Fee-for-Service claims
                  submittal
                  timeframes 

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan must list itself as both the Pay-to and the Treating
                  Provider
                  on the CMS-1500 Claim Form; and

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan must use the following list of transplant procedure
                  codes
                  relative to the type of transplant performed when completing Field
                  24 D on
                  the CMS-1500:

              

      

      

      
        	
                CPT
                  Code

              	
                Transplant
                  CPT Code Description

              
	
                32851

              	
                lung
                  single, without bypass

              
	
                32852

              	
                lung
                  single, with bypass

              
	
                32853

              	
                lung
                  double, without bypass

              
	
                32854

              	
                lung
                  double, with bypass

              
	
                33945

              	
                heart
                  transplant with or without recipient cardiectomy

              
	
                47135

              	
                liver,
                  allotransplation, orthotopic, partial or whole from cadaver or
                  living
                  donor

              
	
                47136

              	
                liver,
                  heterotopic, partial or whole from cadaver or living donor any
                  age

              

      

      

      4. In
        addition to subsection 2. above, to receive a Kick Payment for the covered
        obstetrical delivery provided to an Enrollee, the Health Plan must also comply
        with the following requirements:

      

      
        	 	
                a.

              	
                The
                  Health Plan must submit an accurate and complete CMS-1500 Claim
                  Form in
                  sufficient time to be received by the Fiscal Agent within six (6)
                  months
                  following the date of service
                  (delivery);

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan must list itself as both the Pay-to and the Treating
                  Provider
                  on the CMS-1500 Claim Form; and

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan must use the following list of delivery procedure codes
                  relative to the type of delivery performed when completing Field
                  24 D on
                  the CMS-1500:

              

      

      

      

      

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                CPT
                  Code

              	
                Obstetrical
                  Delivery CPT Code Description

              
	
                59409

              	
                Vaginal
                  delivery only

              
	
                59410

              	
                Vaginal
                  delivery including postpartum care

              
	
                59515

              	
                Cesarean
                  delivery including postpartum care

              
	
                59612

              	
                Vaginal
                  delivery only, after previous cesarean delivery

              
	
                59614

              	
                Vaginal
                  delivery only, after previous cesarean delivery including postpartum
                  care

              
	
                59622

                 

              	
                Cesarean
                  delivery only, following attempted vaginal delivery after previous
                  cesarean delivery including postpartum
                  care

              

      

      

      

      
        	
                D.

              	
                Claims
                  Payment for Health Plans Accepting Financial Risk for the Comprehensive
                  Component Only

              

      

      

      1. In
        order
        for Health Plans accepting financial risk for only the Comprehensive Component
        to receive reimbursement from the Agency for incurred expenditures for Covered
        Services for an Enrollee who has reached the annual Catastrophic Component
        Threshold, the Health Plan shall adhere to the following
        requirements:

      

      a.The
        Health Plan must notify the Agency in writing, in an Agency-specified format,
        when expenditures it has paid for an Enrollee’s Covered Services exceed $25,000
        prior to the end of a Contract Year. 

      

      b.For
        Enrollee’s whose Health Plan expenditures for Covered Services costs exceed
        $25,000, the Health Plan must update the Agency in writing, as specified
        in
        Section XII, and on a monthly basis, of the Health Plan’s additional
        expenditures for Covered Services for the Enrollee until the Enrollee has
        exceeded the Catastrophic Component Threshold or for the remainder of the
        Contract Year, whichever occurs first;

      

      c.Once
        the
        Agency has reviewed the Covered Services expenditure information provided
        by the
        Health Plan and has determined that a Health Plan’s expenditures for an Enrollee
        have exceeded the Catastrophic Component Threshold for the Medicaid Covered
        Services received based on Florida Medicaid’s fee schedules and as indicated in
        subsection B.1.c.(2) of this Attachment, and the Health Plan has received
        Agency
        notification that the Enrollee has met the Catastrophic Component Threshold,
        the
        Health Plan must submit the following in order to receive reimbursement for
        Covered Services provided: 

      

      (1)An
        accurate and fully-completed claim form in the Agency’s designated format and
        within the Medicaid FFS time frames for claims submission. The Health Plan
        must
        list itself as both the Pay to and Treating Provider.

      

      (2)Any
        specified data requested by the Agency regarding treating providers unknown
        to
        FMMIS.

      

      (3)Health
        Plan claims data, for an Agency-specified data set in an Agency-specified
        format
        and transmittal method, that documents that the Health Plan’s expenditures,
        after conversion to the appropriate Medicaid fee (as applicable) are an amount
        equal to the Catastrophic Component Threshold.

      

      2.For
        Health Plans providing the Comprehensive Component only, the Agency will
        be
        responsible for payment to the Health Plan for Medicaid Covered Services
        provided in excess of the Catastrophic Component Threshold up to the Enrollee’s
        Benefit Maximum.

      

      a.With
        the
        exception of Kick Payment services, such payment will be made at ninety-five
        percent (95%) of the Medicaid FFS payment rate, less co-payment or coinsurance
        required under the Medicaid fee schedule, for the respective Medicaid Covered
        Service provided and paid for by the Health Plan.

      

      b.For
        Kick
        Payment services provided by the Health Plan, the Agency’s payment to the Health
        Plan will be the Kick Payment amount specified in Attachment I, Tables 7
        and
        8.

      

      c.For
        Covered Services provided by the Health Plan for which there is not a Medicaid
        payment rate, the Agency will pay the actual amount the Health Plan paid
        to the
        Provider less five percent (5%).

      

      d.If
        the
        Health Plan submits claims to the Agency for Covered Services that are not
        in
        excess of the Catastrophic Component Threshold, or claims for Covered Services
        beyond the benefit maximum, and the Agency reimburses the plan for those
        claims,
        the Agency will recoup such reimbursement or the Health Plan will be responsible
        for repayment in accordance with the Payment Assessments and Errors subsections
        below.

      

      E. Child
        Health Check-UP (CHCUP) Incentive Payments

      

      Health
        Plans will be eligible to participate in the Child Health Check-Up (CHCUP)
        incentive program when the Health Plan has exceeded both the sixty percent
        (60%)
        State screening rate and the federal eighty percent (80%) participation and
        screening ratio goals as outlined in Section V, Covered Services, E.2. The
        Agency will determine which Health Plans will participate based upon the
        audited
        CHCUP reports submitted.

      

      
        	1.  	
                The
                  amount of the incentive payment shall be calculated as follows:
                  the ratio
                  of a qualified Health Plan’s screenings to the total of all Health Plans’
                  screenings will be multiplied by the total amount in the fund for
                  the
                  incentive payment. The ratios will be based on the Health Plans’ audited
                  CHCUP reports. The total amount in the fund will be determined
                  at the
                  discretion of the Agency. In no event shall the total monies allotted
                  to
                  the incentive program be in excess of the incentive payment fund.
                  

              

      

      

      2. Pursuant
        to 42 CFR 438.6, I(1)(iv) and (5)(iii), the payment to any one (1) Health
        Plan
        shall not be in excess of five percent (5%) of the capitation amount paid
        to all
        Health Plans for CHCUP services provided pursuant to this Contract

      

      

      

      
        
          
            
              

               

            

            
            

          

          
            
            

            
            

          

          
            
            

            
              

            

          

        

      

      

      

      F. Payment
        Assessments

      

      1. Choice
        Counseling/Enrollment and Disenrollment

      

      In
        accordance with s 409.912 (29), F.S., at such time as the Agency receives
        legislative direction to assess Health Plans for Enrollment and Disenrollment
        services costs,
        the Agency shall apply assessments, in quarterly installments each year,
        against
        the Health Plan’s next capitation payment to pay for the Enrollment and
        Disenrollment services costs of the Choice Counselor/Enrollment Broker as
        follows:

      

      
        	 	
                a.

              	
                July
                  1, for costs estimated for the Enrollment and Disenrollment services
                  rendered by the Choice Counselor/Enrollment Broker for July and
                  the
                  following two (2) months;

              

      

      

      
        	 	
                b.

              	
                October
                  1, for costs related to the Enrollment and Disenrollment services
                  rendered
                  by the Choice Counselor/Enrollment Broker for October and the
                  following two (2) months;

              

      

      

      
        	 	
                c.

              	
                January
                  1, for costs related to the Enrollment and Disenrollment services
                  rendered
                  by the Choice Counselor/Enrollment Broker for January and the
                  following two (2) months; and

              

      

      

      
        	 	
                d.

              	
                April
                  1, for costs related to maintaining the third party Enrollment
                  and
                  Disenrollment services contract for April and the following two
                  (2)
                  months.

              

      

      

      2. Rate
        Adjustments

      

      The
        Health Plan and the Agency acknowledge that the Capitation Rates paid under
        this
        Contract, as specified in Payment and Maximum Authorized Enrollment Levels
        of
        this Contract, are subject to approval by the federal government.

      

      
        	 	
                a.

              	
                Adjustments
                  to funds previously paid and to be paid may be required. Funds
                  previously
                  paid shall be adjusted when Capitation Rate calculations are determined
                  to
                  have been in error, or when capitation payments have been made
                  for
                  Medicaid Recipients who are determined to be ineligible for Health
                  Plan
                  Enrollment during the period for which the capitation payments
                  were made.
                  In such events, the Health Plan agrees to refund any overpayment
                  and the
                  Agency agrees to pay any
                  underpayment.

              

      

      

      
        	 	
                b.

              	
                If
                  the Agency receives legislative direction as specified in Section
                  XIII,
                  subsection F.1., Payment Assessments, Choice Counseling, respectively,
                  the
                  Agency shall annually, or more frequently, determine the actual
                  expenditures for Enrollment and Disenrollment services rendered
                  by the
                  Choice Counselor/Enrollment Broker. The Agency will compare Capitation
                  Rate assessments to the actual expenditures for such Enrollment
                  and
                  Disenrollment services. The following factors will enter into the
                  cost
                  settlement process:

              

      

      

      
        	 	
                (1)

              	
                If
                  the amount of Capitation Rate assessments are less than the actual
                  cost of
                  providing Enrollment and Disenrollment services rendered by the
                  Choice
                  Counselor/Enrollment Broker, the Health Plan shall pay the difference
                  to
                  the Agency within thirty (30) Calendar Days of
                  settlement.

              

      

      

      
        	 	
                (2)

              	
                If
                  the amount of capitation assessments exceeds the actual cost of
                  providing
                  Enrollment, and Disenrollment services, the Agency will pay the
                  difference
                  to the Health Plan within thirty (30) Calendar Days of the
                  settlement.

              

      

      

      
        	 	
                c.

              	
                As
                  the Agency adjusts the Plan Factor based on updated historical
                  data, the
                  Health Plan’s Capitation Rates will be adjusted according to the
                  methodology indicated in the Capitation Rate
                  tables.

              

      

      

      
        	 	
                d.

              	
                The
                  Agency may adjust the Health Plan’s Capitation Rates if the percentage
                  deducted for the Enhanced Benefit Accounts fund is modified due
                  to program
                  needs.

              

      

      

      G. Errors

      

      Health
        Plans are expected to carefully prepare all reports and monthly payment requests
        for submission to the Agency. 

      

      If
        after
        preparation and electronic submission, either the Health Plan or the Agency
        discover an error, including but not limited to errors resulting in incorrect
        Kick Payments, errors resulting in incorrect identification of Enrollees
        (including but not limited to specific identification of Enrollees with HIV/AIDS
        diagnoses), errors resulting in incorrect claims payments, and errors resulting
        in Capitation Rate payments above the Health Plan’s authorized Enrollment
        levels, the Health Plan has thirty (30) Calendar Days after its discovery
        of the
        error, or from its receipt of Agency notice of the error, to correct the
        error
        and re-submit accurate reports and/or invoices. Failure to respond within
        the
        thirty (30) Calendar Day period shall result in a loss of any money due the
        Health Plan for such errors and/or a sanction against the Health Plan pursuant
        to Section XIV of this Contract.

      

      H. Enrollment
        Levels

      

      The
        Health Plan is assigned an authorized maximum Enrollment level for each
        operational county. The authorized maximum Enrollment level is in effect
        on
        September 1, 2006, or upon Contract execution, whichever is later. 

      

      1. The
        Agency must approve in writing any increase in the Health Plan’s maximum
        Enrollment level for each operational county and subpopulation to be served,
        as
        applicable. Such approval shall not be unreasonably withheld, and shall be
        based
        on the Health Plan’s satisfactory performance of terms of the Contract and
        approval of the Health Plan’s administrative and service resources, as specified
        in this Contract, in support of each Enrollment level

      

      2. Authorized
        Enrollment Levels in Attachment I indicate the Health Plan’s maximum authorized
        Enrollment levels for each Medicaid Reform county and each applicable authorized
        eligibility category.

      

      

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      Section
        XIV

      Sanctions

      

      
        	
                A.

              	
                General
                  Provisions

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall comply with all requirements and performance
                  standards
                  set forth in this Contract. In the event the Agency identifies
                  a violation
                  of this Contract, or other non-compliance with this Contract, the
                  Health
                  Plan shall submit a corrective action plan (CAP) within three (3)
                  Calendar
                  Days of the date of receiving notification of the violation or
                  non-compliance from the Agency.

              

      

      

      
        	 	
                2.

              	
                Within
                  five (5) Business Days of receiving the CAP the Agency will either
                  approve
                  or disapprove the CAP. If disapproved, the Health Plan shall resubmit,
                  within ten (10) Business Days, a new CAP that addresses the concerns
                  identified by the Agency. 

              

      

      

      
        	 	
                3.

              	
                Upon
                  approval of the CAP, whether the initial CAP or the revised CAP,
                  the
                  Health Plan shall implement the CAP within the time frames specified
                  by
                  the Agency. 

              

      

      

      
        	 	
                4.

              	
                Except
                  where specified below, the Agency shall impose a monetary sanction
                  of $100
                  per day on the Health Plan for each Calendar Day that the approved
                  CAP is
                  not implemented to the satisfaction of the
                  Agency

              

      

      

      
        	
                B.

              	
                Specific
                  Sanctions

              

      

      

      
        	 	
                As
                  described in 42 CFR 438.700, the Agency may impose any of the following
                  sanctions against a Health Plan if it determines that a Health
                  Plan has
                  violated any provision of this Contract, or any applicable
                  statutes.

              

      

      

      
        	 	
                1.

              	
                Suspension
                  of the Health Plan’s Voluntary Enrollments and participation in the
                  Mandatory Assignment process for
                  Enrollment.

              

      

      

      
        	 	
                2.

              	
                Suspension
                  or revocation of payments to the Health Plan for Enrollees during
                  the
                  sanction period. 

              

      

      

      
        	 	
                3.

              	
                For
                  any nonwillful violation of the Contract, the Agency shall impose
                  a fine,
                  not to exceed $2,500 per Violation. In no event shall such fine
                  exceed an
                  aggregate amount of $10,000 for all nonwillful Violations arising
                  out of
                  the same action.

              

      

      

      
        	 	
                4.

              	
                With
                  respect to any knowing and willful violation of the Contract the
                  Agency
                  shall impose a fine upon the Health Plan in an amount not to exceed
                  $20,000 for each such violation. In no event shall such fine exceed
                  an
                  aggregate amount of $100,000 for all knowing and willful violations
                  arising out of the same action.

              

      

      

      
        	 	
                5.

              	
                If
                  the Health Plan fails to carry out substantive terms of the Contract
                  or
                  fails to meet applicable requirements in 42 CFR 438.700, the Agency
                  shall
                  terminate the Contract. After the Agency notifies the Health Plan
                  that it
                  intends to terminate the Contract, the Agency shall give the Health
                  Plan's
                  Enrollees written notice of the State's intent to terminate the
                  Contract
                  and allow the Enrollees to disenroll immediately without
                  Cause.

              

      

      

      
        	 	
                6.

              	
                The
                  Agency may impose intermediate sanctions in accordance with 42
                  CFR
                  438.702, including, but not limited
                  to:

              

      

      

      
        	 	
                a.

              	
                Civil
                  monetary penalties in the amounts specified in this
                  contract.

              

      

      

      
        	 	
                b.

              	
                Appointment
                  of temporary management for the Health Plan. Rules for temporary
                  management pursuant to 42 CFR 438.706 are as
                  follows:

              

      

      

      
        	 	
                (1)

              	
                The
                  State may impose temporary management only if it finds (through
                  on-site
                  survey, Enrollee Grievances, financial audits, or any other means)
                  that:

              

      

      

      
        	 	
                i.

              	
                There
                  is continued egregious behavior by the Health Plan, including but
                  not
                  limited to behavior that is described in 42 CFR
                  438.700;

              

      

      

      
        	 	
                ii.

              	
                There
                  is substantial risk to Enrollees'
                  health;

              

      

      

      
        	 	
                iii.

              	
                The
                  sanction is necessary to ensure the health of the Health Plan’s
                  Enrollees;

              

      

      

      
        	 	
                iv.

              	
                While
                  improvements are made to remedy the Health Plan’s violation(s) under 42
                  CFR 438.700; or

              

      

      

      
        	 	
                v.

              	
                Until
                  there is an orderly termination or reorganization of the Health
                  Plan.

              

      

      

      
        	 	
                (2)

              	
                The
                  State must impose temporary management (regardless of any other
                  sanction
                  that may be imposed) if it finds that the Health Plan has repeatedly
                  failed to meet substantive requirements in 42 CFR 438.706. The
                  State must
                  also grant Enrollees the right to terminate Enrollment without
                  Cause, as
                  described in 42 CFR 438.702(a)(3), and must notify the affected
                  Enrollees
                  of their right to terminate
                  Enrollment.

              

      

      

      
        	 	
                (3)

              	
                The
                  State shall not delay imposition of temporary management to provide
                  a
                  hearing before imposing this
                  sanction.

              

      

      

      
        	 	
                (4)

              	
                The
                  State shall not terminate temporary management until it determines
                  that
                  the Health Plan can ensure that the sanctioned behavior will not
                  recur.

              

      

      

      
        	 	
                c.

              	
                Granting
                  Enrollees the right to terminate Enrollment without Cause and notifying
                  affected Enrollees of their right to
                  disenroll.

              

      

      

      
        	 	
                d.

              	
                Suspension
                  or limitation of all new Enrollment, including Mandatory Enrollment,
                  after
                  the effective date of the sanction.

              

      

      

      
        	 	
                e.

              	
                Suspension
                  of payment for Enrollees after the effective date of the sanction
                  and
                  until CMS or the Agency is satisfied that the reason for imposition
                  of the
                  sanction no longer exists and is not likely to
                  recur.

              

      

      

      
        	 	
                f.

              	
                Before
                  imposing any intermediate sanctions, the State must give the Health
                  Plan
                  timely notice according to 42 CFR
                  438.710.

              

      

      

      
        	 	
                7.

              	
                If
                  the Health Plan’s CHCUP Screening compliance rate is below sixty percent
                  (60%), it must submit to the Agency, and implement, an Agency accepted
                  CAP. If the Health Plan does not meet the standard established
                  in the CAP
                  during the time period indicated in the plan, the Agency has the
                  authority
                  to impose sanctions in accordance with this
                  section.

              

      

      

      
        	 	
                8.

              	
                Unless
                  the duration of a sanction is specified, a sanction shall remain
                  in effect
                  until the Agency is satisfied that the basis for imposing the sanction
                  has
                  been corrected and is not likely to
                  recur.

              

      

      

      
        	 	
                9.

              	
                The
                  Agency reserves the right to withhold all or a portion of the Health
                  Plans
                  monthly administrative allocation for any amount owed pursuant
                  to this
                  section.

              

      

      

      

      

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      Section
        XV

      Financial
        Requirements

      

      
        	A.  	
                Insolvency
                  Protection 

              

      

       

      The
        Health Plan shall establish a restricted Insolvency protection account with
        a
        federally guaranteed financial institution licensed to do business in Florida
        in
        accordance with section 1903(m)(1) of the Social Security Act (amended by
        section 4706 of the Balanced Budget Act of 1997), and section 409.912, F.S.
        The
        Health Plan shall deposit into that account five percent of the capitation
        payments made by the Agency each month until a maximum total of two percent
        of
        the annualized total current contract amount is reached. No interest may
        be
        withdrawn from this account until the maximum contract amount is reached.
        This
        provision shall remain in effect as long as the Health Plan continues to
        contract with the Agency. The restricted Insolvency protection account may
        be
        drawn upon with the authorized signatures of two persons designated by the
        Health Plan and two representatives of the Agency. The signature card shall
        be
        resubmitted when a change in authorized personnel occurs. If the authorized
        persons remain the same, the Health Plan shall submit an attestation to this
        effect annually. A sample form (Multiple Signature Verification Agreement)
        is
        available from the Agency upon request. 
        All such
        agreements or other signature cards must be approved in advance by the
        Agency.

      

      1. In
        the
        event that a determination is made by the Agency that the Health Plan is
        Insolvent, as defined in Section I Definitions, of this Contract, the Agency
        may
        draw upon the amount solely with the two authorized signatures of
        representatives of the Agency and funds may be disbursed to meet financial
        obligations incurred by the Health Plan under this Contract. A statement
        of
        account balance shall be provided by the Health Plan within fifteen (15)
        Calendar Days of request of the Agency.

       

      2. If
        the
        Contract is terminated, expired, or not continued, the account balance shall
        be
        released by the Agency to the Health Plan upon receipt of proof of satisfaction
        of all outstanding obligations incurred under this Contract.

      

      3. In
        the
        event the Contract is terminated or not renewed and the Health Plan is
        Insolvent, the Agency may draw upon the Insolvency protection account to
        pay any
        outstanding debts the Health Plan owes the Agency including, but not limited
        to,
        overpayments made to the Health Plan, and fines imposed under the Contract
        or
        section 641.52, F.S., for which a final order has been issued. In addition,
        if
        the Contract is terminated or not renewed and the Health Plan is unable to
        pay
        all of its outstanding debts to health care providers, the Agency and the
        Health
        Plan agree to the court appointment of an impartial receiver for the purpose
        of
        administering and distributing the funds contained in the Insolvency protection
        account. Should a receiver be appointed, he shall give outstanding debts
        owed to
        the Agency priority over other claims.

      

      
        	B.  	
                Insolvency
                  Protection for a Capitated Provider Service Network
                  (PSN) 

              

      

       

      1. A
        capitated PSN is required to assume responsibility for comprehensive coverage
        and meet the following financial reserve requirements: 

      

      
        	a.  	
                The
                  capitated PSN shall maintain a minimum surplus in an amount that
                  is the
                  greater of $1 million or 1.5 percent of projected annual
                  premiums.

              

      

      

      
        	b.  	
                In
                  lieu of the requirements above, the Agency consider the following:
                  

              

      

      
        	i.  	
                If
                  the organization is a public entity, the Agency may take under
                  advisement
                  a statement from the public entity that a county supports the managed
                  care
                  plan with the county’s full faith and credit. In order to qualify for the
                  Agency’s consideration, the county must own, operate, manage, administer,
                  or oversee the managed care plan, either partly or wholly, through
                  a
                  county department or agency;

              

      

      
        	ii.  	
                The
                  state guarantees the solvency of the
                  organization;

              

      

      
        	iii.  	
                The
                  organization is a federally qualified health center or is controlled
                  by
                  one or more federally qualified health centers and meets the solvency
                  standards established by the state for such organization pursuant
                  to s.
                  409.912(4)(c), Florida Statutes; or

              

      

      
        	iv.  	
                The
                  entity meets the financial standards for federally approved
                  provider-sponsored organizations as defined in 42CFR ss. 422.380
                  -
                  422.390.

              

      

      

      2. Capitated
        PSNs have the option to assume responsibility for catastrophic coverage,
        but
        will be required to meet more stringent financial standards consistent with
        licensed HMOs in Chapter 641, F.S. and s. 409.912, F.S. At a minimum, the
        Capitated PSN shall at all times maintain a minimum surplus in an amount
        that is
        the greater $1,500,000, or 10 percent of total liabilities, or 2 percent
        of
        total contract amount. 

      

      
        	C.  	
                Surplus
                  Start Up Account 

              

      

       

      All
        new
        Health Plans, after initial Contract execution but prior to initial Enrollee
        enrollment, shall submit to the Agency, if a private entity, proof of working
        capital in the form of cash or liquid assets excluding revenues from Medicaid
        premium payments equal to at least the first three (3) months of operating
        expenses or $200,000, whichever is greater. This provision shall not apply
        to
        Health Plans that have been providing services to Enrollees for a period
        exceeding three (3) continuous months.

       

      
        	D.  	
                Surplus
                  Requirement 

              

      

       

      

      In
        accordance with section 409.912, F.S., the Health Plan shall maintain at
        all
        times in the form of cash, investments that mature in less than 180 Calendar
        Days allowable as admitted assets by the Department of Financial Services,
        and
        restricted funds of deposits controlled by the Agency (including the Health
        Plan’s Insolvency protection account) or the Department of Financial Services,
        a
        Surplus amount equal to one and one half (1 1⁄2) times the Health Plan’s monthly
        Medicaid prepaid revenues. In the event that the plan’s Surplus (as defined in
        Section I Definitions, of this Contract) falls below an amount equal to one
        and
        one half (1 1⁄2) times the Health Plan’s monthly Medicaid prepaid revenues, the
        Agency shall prohibit the Health Plan from engaging in Marketing and Request
        for
        Benefit Information activities, shall cease to process new Enrollments until
        the
        required balance is achieved, or may terminate the Health Plan’s Contract.

      

      
        	E.  	
                Interest

              

      

       

      

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

      

      
        	F.  	
                Inspection
                  and Audit of Financial
                  Records

              

      

       

      

      The
        state
        and DHHS may inspect and audit any financial records of the plan or its
        subcontractors. Pursuant to section 1903(m)(4)(A) of the Social Security
        Act and
        State Medicaid Manual 2087.6(A-B), non-federally qualified plans must report
        to
        the state, upon request, and to the Secretary and the Inspector General of
        DHHS,
        a description of certain transactions with parties of interest as defined
        in
        section 1318(b) of the Social Security Act.

      

      
        	G.  	
                Physician
                  Incentive Plans

              

      

       

      
        	 	
                1.

              	
                Physician
                  incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h),
                  42 CFR
                  422.208 and 42 CFR 422.210. Health Plans shall make no specific
                  payment
                  directly or indirectly under a physician incentive plan to a physician
                  or
                  physician group as an inducement to reduce or limit medically necessary
                  services furnished to an individual Enrollee. Incentive plans must
                  not
                  contain provisions which provide incentives, monetary or otherwise,
                  for
                  the withholding of medically necessary
                  care.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall disclose information on physician incentive plans
                  listed
                  in 42 CFR 417.479(h)(1) and 417.479(i) at the times indicated in
                  42 CFR
                  417.479(d)-(g). All such arrangements must be submitted to the
                  Agency for
                  approval, in writing, prior to use. If any other type of withhold
                  arrangement currently exists, it must be omitted from all
                  subcontracts.

              

      

      
        	
                 

                H.  

              	
                 

                Third
                  Party Resources 

              

      

       

      

      1. The
        Health Plan must specify whether it will assume full responsibility for third
        party collections in accordance with this section.

      

      2. The
        Health Plan shall be responsible for making every reasonable effort to determine
        the legal liability of third parties to pay for services rendered to members
        under this contract. The plan has the same rights to recovery of the full
        value
        of services as the Agency (See section 409.910, F.S. The following standards
        govern recovery.

      

      
        	 	
                a.

              	
                If
                  the Health Plan has determined that third party liability exists
                  for part
                  or all of the services provided directly by the Health Plan to
                  an
                  Enrollee, the Health Plan shall make reasonable efforts to recover
                  from
                  third party liable sources the value of services
                  rendered.

              

      

      

      
        	 	
                b.

              	
                If
                  the Health Plan has determined that third party liability exists
                  for part
                  or all of the services provided to an Enrollee by a Subcontractor
                  or
                  referral Provider, and the third party is reasonably expected to
                  make
                  payment within 120 Calendar Days, the Health Plan may pay the
                  Subcontractor or referral Provider only the amount, if any, by
                  which the
                  Subcontractor's allowable claim exceeds the amount of the anticipated
                  third party payment; or, the Health Plan may assume full responsibility
                  for third party collections for service provided through the Subcontractor
                  or referral Provider.

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan may not withhold payment for services provided to an
                  Enrollee
                  if third party liability or the amount of liability cannot be determined,
                  or if payment shall not be available within a reasonable time,
                  beyond 120
                  calendar days from the date of
                  receipt.

              

      

      

      
        	 	
                d.

              	
                When
                  both the Agency and the Health Plan have liens against the proceeds
                  of a
                  third party resource, the Agency shall prorate the amount due to
                  Medicaid
                  to satisfy such liens under section 409.910, F.S., between the
                  Agency and
                  the Health Plan. This prorated amount shall satisfy both liens
                  in
                  full.

              

      

      

      
        	 	
                e.

              	
                The
                  Agency may, at its sole discretion, offer to provide third party
                  recovery
                  services to the Health Plan. If the Health Plan elects to authorize
                  the
                  Agency to recover on its behalf, the Health Plan shall be required
                  to
                  provide the necessary data for recovery in the format prescribed
                  by the
                  Agency. All recoveries, less the Agency’s cost to recover shall be income
                  to the plan. The cost to recover shall be expressed as a percentage
                  of
                  recoveries and shall be fixed at the time the plan elects to authorize
                  the
                  Agency to recover on its behalf.

              

      

      

      
        	 	
                f.

              	
                All
                  funds recovered from third parties shall be treated as income for
                  the
                  Health Plan.

              

      

      

      
        	I.  	
                Fidelity
                  Bonds

              

      

       

      

      The
        Health Plan shall secure and maintain during the life of this Contract a
        blanket
        fidelity bond from a company doing business in the State of Florida on all
        personnel in its employment. The bond shall be issued in the amount of at
        least
        $250,000 per occurrence. Said bond shall protect the Agency from any losses
        sustained through any fraudulent or dishonest act or acts committed by any
        employees of the Health Plan and Subcontractors, if any. Proof of coverage
        must
        be submitted to the Agency’s contract manager within sixty (60) Calendar Days
        after execution of the Contract and prior to the delivery of health care.
        To be
        acceptable to the Agency for fidelity bonds, a surety company shall comply
        with
        the provisions of chapter 624, F.S. 

      

      

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      Section
        XVI

      Terms
        and Conditions

      

      
        	A.  	
                Agency
                  Contract Management

              

      

      

      
        	 	
                1.

              	
                The
                  Division of Medicaid within the Agency shall be responsible for
                  management
                  of the Contract. The Division of Medicaid shall make all statewide
                  policy
                  decision-making or contract interpretation. In addition, the Division
                  of
                  Medicaid shall be responsible for the interpretation of all federal
                  and
                  State laws, rules and regulations governing or in any way affecting
                  this
                  Contract. Management shall be conducted in good faith with the
                  best
                  interest of the State and the Medicaid Recipients it serves being
                  the
                  prime consideration. The Agency shall provide final interpretation
                  of
                  general Medicaid policy. When interpretations are required, the
                  Health
                  Plan shall submit written requests to the Agency’s contract
                  manager.

              

      

      

      
        	 	
                2.

              	
                The
                  terms of this Contract do not limit or waive the ability, authority
                  or
                  obligation of the Office of Inspector General, Bureau of Medicaid
                  Program
                  Integrity, its contractors, or other duly constituted government
                  units
                  (State or federal) to audit or investigate matters related to,
                  or arising
                  out of this Contract. 

              

      

      

      
        	 	
                3.

              	
                The
                  Contract shall only be amended as
                  follows:

              

      

      

      a. The
        parties cannot amend or alter the terms of this Contract without a written
        amendment.

      

      b. The
        Agency and the Health Plan understand that any such written amendment to
        amend
        or alter the terms of this Contract shall be executed by an officer of both
        parties, who is duly authorized to bind the Agency and the Health
        Plan.

      

      c. Only
        a
        person authorized by the Agency and a person authorized by the Health Plan
        may
        amend or alter the terms of this Contract. 

       

      
        	B.  	
                Applicable
                  Laws and Regulations

              

      

      

      The
        Health Plan agrees to comply with all applicable federal and State laws,
        rules
        and regulations including but not limited to: Title 42 Code of Federal
        Regulations (CFR) chapter IV, subchapter C; Title 45 CFR, Part 74, General
        Grants Administration Requirements; chapters 409 and 641, Florida Statutes;
        all
        applicable standards, orders, or regulations issued pursuant to the Clean
        Air
        Act of 1970 as amended (42 USC 1857, et seq.); Title VI of the Civil Rights
        Act
        of 1964 (42 USC 2000d) in regard to persons served; Title IX of the education
        amendments of 1972 (regarding education programs and activities); 42 CFR
        431,
        subpart F, section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C.
        in
        regard to the contractor safeguarding information about beneficiaries; Title
        VII
        of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
        applicants for employment; Rule 59G-8.100, F.A.C.; section 504 of the
        Rehabilitation Act of 1973, as amended, 29 USC. 794, which prohibits
        discrimination on the basis of handicap in programs and activities receiving
        or
        benefiting from federal financial assistance; the Age Discrimination Act
        of
        1975, as amended, 42 USC. 6101 et. seq., which prohibits discrimination on
        the
        basis of age in programs or activities receiving or benefiting from federal
        financial assistance; the Omnibus Budget Reconciliation Act of 1981, P.L.
        97-35,
        which prohibits discrimination on the basis of sex and religion in programs
        and
        activities receiving or benefiting from federal financial assistance; Medicare
        -
        Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget Reconciliation
        Acts; Americans with Disabilities Act (42 USC 12101, et seq.); the Newborns’ and
        Mothers’ Health Protection Act of 1996; and the Balanced Budget Act of 1997 and
        the Health Insurance Portability and Accountability Act of 1996. The Health
        Plan
        is subject to any changes in federal and state law, rules, or
        regulations.

      

      
        	C.  	
                Assignment

              

      

      

      
        	 	
                1.

              	
                Except
                  as provided below or with the prior written approval of the Agency,
                  which
                  approval shall not be unreasonably withheld, this Contract and
                  the monies
                  which may become due are not to be assigned, transferred, pledged
                  or
                  hypothecated in any way by the Health Plan, including by way of
                  an asset
                  or stock purchase of the Health Plan and shall not be subject to
                  execution, attachment or similar process by the Health
                  Plan.

              

      

      .

      a. As
        provided by section 409.912, F.S., when a merger or acquisition of a Health
        Plan
        has been approved by the Department of Financial Services pursuant to section
        628.4615, F.S., the Agency shall approve the assignment or transfer of the
        appropriate Contract upon the request of the surviving entity of the merger
        or
        acquisition if the Health Plan and the surviving entity have been in good
        standing with the Agency for the most recent 12 month period, unless the
        Agency
        determines that the assignment or transfer would be detrimental to the Medicaid
        Recipients or the Medicaid program. The entity requesting the assignment
        or
        transfer shall notify the Agency of the request ninety (90) days prior to
        the
        anticipated effective date.

      

      b. To
        be in
        good standing, a Health Plan or Plan must not have failed accreditation or
        committed any material violation of the requirements of section 641.52, F.S.,
        and must meet the Contract requirements.

      

      c. For
        the
        purposes of this section, a merger or acquisition means a change in controlling
        interest of an Entity, including an asset or stock purchase.

      

      
        	D.  	
                Attorney's
                  Fees

              

      

      

      In
        the
        event of a dispute, each party to the Contract shall be responsible for its
        own
        attorneys’ fees except as otherwise provided by law.

      

      
        	E.  	
                Conflict
                  of Interest

              

      

       

      The
        Contract is subject to the provisions of chapter 112, Florida Statutes. The
        Health Plan shall disclose the name of any officer, director, or agent who
        is an
        employee of the State of Florida, or any of its agencies. Further, the Health
        Plan shall disclose the name of any State employee who owns, directly or
        indirectly, an interest of five percent (5%) or more in the offerer's firm
        or
        any of its branches. The Health Plan covenants that it presently has no interest
        and shall not acquire any interest, direct or indirect, which would conflict
        in
        any manner or degree with the performance of the services hereunder. The
        Health
        Plan further covenants that in the performance of the Contract no person
        having
        any such known interest shall be employed. No official or employee of the
        Agency
        and no other public official of the State of Florida or the federal government
        who exercises any functions or responsibilities in the review or approval
        of the
        undertaking of carrying out the Contract shall, prior to completion of this
        Contract, voluntarily acquire any personal interest, direct or indirect,
        in this
        Contract or proposed Contract.

      

      

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        	F.  	
                Contract
                  Variation

              

      

       

       

      If
        any
        provision of the Contract (including items incorporated by reference) is
        declared or found to be illegal, unenforceable, or void, then both the Agency
        and the Health Plan shall be relieved of all obligations arising under such
        provisions. If the remainder of the Contract is capable of performance, it
        shall
        not be affected by such declaration or finding and shall be fully performed.
        In
        addition, if the laws or regulations governing this Contract should be amended
        or judicially interpreted as to render the fulfillment of the Contract
        impossible or economically infeasible, both the Agency and the Health Plan
        shall
        be discharged from further obligations created under the terms of the Contract.
        However, such declaration or finding shall not affect any rights or obligations
        of either party to the extent that such rights or obligations arise from
        acts
        performed or events occurring prior to the effective date of such declaration
        or
        finding.

      

      
        	G.  	
                Court
                  of Jurisdiction or Venue

              

      

       

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

      

      
        	H.  	
                Damages
                  for Failure to Meet Contract
                  Requirements

              

      

       

       

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

      

      
        	I.  	
                Disputes 

              

      

       

      The
        Health Plan may request in writing an interpretation of the Contract from
        the
        Contract manager. In the event the Health Plan disputes this interpretation,
        the
        Health Plan may request that the dispute be decided by the Division of Medicaid.
        The ability to dispute an interpretation does not apply to issues that are
        a
        matter of law or fact. Any disputes shall be decided by the Agency’s Division of
        Medicaid which shall reduce the decision to writing and serve a copy on the
        Health Plan. The written decision of the Agency’s Division of Medicaid shall be
        final and conclusive. The division will render its final decision based upon
        the
        written submission of the Health Plan and the Agency, unless, at the sole
        discretion of the Division director, the division allows an oral presentation
        by
        the Health Plan and the Agency. If such a presentation is allowed, the
        information presented will be considered in rendering the division’s decision.
        Should the Health Plan challenge an Agency decision through arbitration as
        provided below, the Agency action shall not be stayed except by order of
        an
        arbitrator. Thereafter, a Health Plan shall resolve any controversy or claim
        arising out of or relating to the Contract, or the breach thereof, by
        arbitration. Said arbitration shall be held in the City of Tallahassee, Florida,
        and administered by the American Arbitration Association in accordance with
        its
        applicable rules and the Florida Arbitration Code (chapter 682, F.S.). Judgment
        upon any award rendered by the arbitrator may be entered by the Circuit Court
        in
        and for the Second Judicial Circuit, Leon County, Florida. The chosen arbitrator
        must be a member of the Florida Bar actively engaged in the practice of law
        with
        expertise in the process of deciding disputes and interpreting contracts
        in the
        health care field. Any arbitration award shall be in writing and shall specify
        the factual and legal bases for the award. Either party may appeal a judgment
        entered pursuant to an arbitration award to the First District Court of Appeal.
        The parties shall bear their own costs and expenses relating to the preparation
        and presentation of a case in arbitration. The arbitrator shall award to
        the
        prevailing party all administrative fees and expenses of the arbitration,
        including the arbitrator’s fee. This Contract with numbered attachments
        represents the entire agreement between the Health Plan and the Agency with
        respect to the subject matter in it and supersedes all other contracts between
        the parties when it is duly signed and authorized by the Health Plan and
        the
        Agency. Correspondence and memoranda of understanding do not constitute part
        of
        this Contract. In the event of a conflict of language between the Contract
        and
        the attachments, the provisions of the Contract shall govern. However, the
        Agency reserves the right to clarify any contractual relationship in writing
        with the concurrence of the Health Plan and such clarification shall govern.
        Pending final determination of any dispute over an Agency decision, the Health
        Plan shall proceed diligently with the performance of the contract and in
        accordance with the Agency’s Division of Medicaid direction.

      

      
        	J.  	
                Force
                  Majeure

              

      

       

      

      The
        Agency shall not be liable for any excess cost to the Health Plan if the
        Agency's failure to perform the Contract arises out of causes beyond the
        control
        and without the result of fault or negligence on the part of the Agency.
        In all
        cases, the failure to perform must be beyond the control without the fault
        or
        negligence of the Agency. The Health Plan shall not be liable for performance
        of
        the duties and responsibilities of the Contract when its ability to perform
        is
        prevented by causes beyond its control. These acts must occur without the
        fault
        or negligence of the Health Plan. These include destruction to the facilities
        due to hurricanes, fires, war, riots, and other similar acts. Annually by
        May
        31, the Health Plan shall submit to the Agency for approval an emergency
        management plan specifying what actions the Health Plan shall conduct to
        ensure
        the ongoing provisions of health services in a disaster or man-made
        emergency.

      

      
        	K.  	
                Legal
                  Action Notification

              

      

       

      The
        Health Plan shall give the Agency by certified mail immediate written
        notification (no later than thirty (30) Calendar Days after service of process)
        of any action or suit filed or of any claim made against the Health Plan
        by any
        subcontractor, vendor, or other party which results in litigation related
        to
        this Contract for disputes or damages exceeding the amount of $50,000. In
        addition, the Health Plan shall immediately advise the Agency of the insolvency
        of a Subcontractor or of the filing of a petition in bankruptcy by or against
        a
        principal Subcontractor.

      

      
        	L.  	
                Licensing

              

      

       

      For
        the
        purposes of this Contract, a Health Plan includes health maintenance
        organizations authorized under chapter 641 of the Florida Statutes, exclusive
        provider organizations as defined in chapter 627 of the Florida Statutes,
        health
        insurers authorized under chapter 624 of the Florida Statutes, and Provider
        Service Networks as defined in Section 409.912, Florida Statutes. For purposes
        of this Contract, a PSN shall operate in accordance with section
        409.91211(3)(e), F.S., and is exempt from licensure under Chapter 641, F.S.,
        however, shall be responsible for meeting certain standards in Chapter 641,
        F.S.
        as required in this Contract. A
        Health
        Plan must be licensed under Chapter 641, Florida Statutes in order to offer
        a
        Specialty Plan for the population with HIV/AIDS.

      

      
        	M.  	
                Misuse
                  of Symbols, Emblems, or Names in Reference to
                  Medicaid

              

      

       

      No
        person
        or Health Plan may use, in connection with any item constituting an
        advertisement, solicitation, circular, book, pamphlet or other communication,
        or
        a broadcast, telecast, or other production, alone or with other words, letters,
        symbols or emblems the words “Medicaid,” or “Agency for Health Care
        Administration,” except as required in the Agency’s core contract, page two (2),
        unless prior written approval is obtained from the Agency. Specific written
        authorization from the Agency is required to reproduce, reprint, or distribute
        any Agency form, application, or publication for a fee. State and local
        governments are exempt from this prohibition. A disclaimer that accompanies
        the
        inappropriate use of program or Agency terms does not provide a defense.
        Each
        piece of mail or information constitutes a violation.

      

      
        	N.  	
                Offer
                  of Gratuities

              

      

       

      By
        signing this agreement, the Health Plan signifies that no member of or a
        delegate of Congress, nor any elected or appointed official or employee of
        the
        State of Florida, the General Accounting Office, Department of Health and
        Human
        Services, CMS, or any other federal Agency has or shall benefit financially
        or
        materially from this procurement. The Contract may be terminated by the Agency
        if it is determined that gratuities of any kind were offered to or received
        by
        any officials or employees from the offeror, his agent, or
        employees.

       

      
        	O.  	
                Subcontracts

              

      

       

      
        	 	
                1.

              	
                The
                  Health Plan is responsible for all work performed under this Contract,
                  but
                  may, with the written prior approval of the Agency, enter into
                  Subcontracts for the performance of work required under this Contract.
                  All
                  Subcontracts must comply with 42 CFR 438.230. All Subcontracts
                  and
                  amendments executed by the Health Plan shall meet the following
                  requirements. All Subcontractors must be eligible for participation
                  in the
                  Medicaid program; however, the Subcontractor is not required to
                  participate in the Medicaid program as a provider. The Agency encourages
                  use of minority business enterprise Subcontractors. See Section
                  X.C.,
                  Administration and Management, Provider Contracts, of this Contract,
                  for
                  provisions and requirements specific to Provider
                  contracts.

              

      

      

      
        	 	
                2.

              	
                No
                  Subcontract which the Health Plan enters into with respect to performance
                  under the Contract shall in any way relieve the Health Plan of
                  any
                  responsibility for the performance of duties under this Contract.
                  The
                  Health Plan shall assure that all tasks related to the Subcontract
                  are
                  performed in accordance with the terms of this Contract. The Health
                  Plan
                  shall identify in its Subcontracts any aspect of service that may
                  be
                  further subcontracted by the
                  Subcontractor.

              

      

      

      
        	 	
                3.

              	
                All
                  model and executed Subcontracts and amendments used by the Health
                  Plan
                  under this Contract must be in writing, signed, and dated by the
                  Health
                  Plan and the Subcontractor and meet the following
                  requirements:

              

      

      

      a. Identification
        of conditions and method of payment: 

      

      
        	 	
                i.

              	
                The
                  Health Plan agrees to make payment to all subcontractors in a timely
                  fashion. 

              

      

      

      
        	 	
                ii.

              	
                Provide
                  for prompt submission of information needed to make
                  payment.

              

      

      

      
        	 	
                iii.

              	
                Make
                  full disclosure of the method and amount of compensation or other
                  consideration to be received from the Health Plan.
                  

              

      

      

      
        	 	
                iv.

              	
                Require
                  an adequate record system be maintained for recording services,
                  charges,
                  dates and all other commonly accepted information elements for
                  services
                  rendered to the Health Plan.

              

      

      

      
        	 	
                v.

              	
                Specify
                  that the Health Plan shall assume responsibility for cost avoidance
                  measures for third party collections in accordance with Section
                  XV. F.,
                  Financial Requirements, Third Party Liability.

              

      

      

      b. Provisions
        for monitoring and inspections:

      

      
        	 	
                i.

              	
                Provide
                  that the Agency and DHHS may evaluate through inspection or other
                  means
                  the quality, appropriateness and timeliness of services
                  performed.

              

      

      

      
        	 	
                ii.

              	
                Provide
                  for inspections of any records pertinent to the contract by the
                  Agency and
                  DHHS.

              

      

      

      
        	 	
                iii.

              	
                Require
                  that records be maintained for a period not less than five (5)
                  years from
                  the close of the Contract and retained further if the records are
                  under
                  review or audit until the review or audit is complete. (Prior approval
                  for
                  the disposition of records must be requested and approved by the
                  Health
                  Plan if the Subcontract is
                  continuous.)

              

      

      

      
        	 	
                iv.

              	
                Provide
                  for monitoring and oversight by the Health Plan and the Subcontractor
                  to
                  provide assurance that all licensed medical professionals are Credentialed
                  in accordance with the Health Plan’s and the Agency’s Credentialing
                  requirements as found in Section VIII.A.3.h Credentialing and
                  Recredentialing, of this Contract, if the Health Plan has delegated
                  the
                  Credentialing to a Subcontractor.

              

      

      

      
        	 	
                v.

              	
                Provide
                  for monitoring of services rendered to Enrollees sponsored by the
                  Provider.

              

      

      

      c. Specification
        of functions of the Subcontractor:

      

      
        	 	
                i.

              	
                Identify
                  the population covered by the
                  Subcontract.

              

      

      

      
        	 	
                ii.

              	
                Provide
                  for submission of all reports and clinical information required
                  by the
                  Health Plan, including Child Health Check-Up reporting (if
                  applicable).

              

      

      

      
        	 	
                iii.

              	
                Provide
                  for the participation in any internal and external quality improvement,
                  utilization review, peer review, and grievance procedures established
                  by
                  the Health Plan.

              

      

      

      d. Protective
        clauses:

      

      
        	 	
                i.

              	
                Require
                  safeguarding of information about Enrollees according to 42 CFR,
                  Part
                  438.224.

              

      

      

      
        	 	
                ii.

              	
                Require
                  compliance with HIPAA privacy and security
                  provisions.

              

      

      

      
        	 	
                iii.

              	
                Require
                  an exculpatory clause, which survives Subcontract termination including
                  breach of Subcontract due to insolvency, that assures that Medicaid
                  Recipients or the Agency may not be held liable for any debts of
                  the
                  Subcontractor. 

              

      

      

      
        	 	
                iv.

              	
                If
                  there is a Health Plan physician incentive plan, include a statement
                  that
                  the Health Plan shall make no specific payment directly or indirectly
                  under a physician incentive plan to a Subcontractor as an inducement
                  to
                  reduce or limit Medically Necessary services to an Enrollee, and
                  that all
                  incentive plans shall not contain provisions which provide incentives,
                  monetary or otherwise, for the withholding of Medically Necessary
                  care;

              

      

      

      
        	 	
                4.

              	
                Contain
                  a clause indemnifying, defending and holding the Agency and the
                  Health
                  Plan Enrollees harmless from and against all claims, damages, causes
                  of
                  action, costs or expense, including court costs and reasonable
                  attorney
                  fees to the extent proximately caused by any negligent act or other
                  wrongful conduct arising from the Subcontract agreement. This clause
                  must
                  survive the termination of the Subcontract, including breach due
                  to
                  Insolvency. The Agency may waive this requirement for itself, but
                  not
                  Health Plan Enrollees, for damages in excess of the statutory cap
                  on
                  damages for public entities if the Subcontractor is a public health
                  entity
                  with statutory immunity. All such waivers must be approved in writing
                  by
                  the Agency.

              

      

      

      
        	 	
                5.

              	
                Require
                  that the Subcontractor secure and maintain during the life of the
                  Subcontract worker's compensation insurance for all of its employees
                  connected with the work under this Contract unless such employees
                  are
                  covered by the protection afforded by the Health Plan. Such insurance
                  shall comply with the Florida's Worker's Compensation
                  Law.

              

      

      

      
        	 	
                6.

              	
                Specify
                  that if the Subcontractor delegates or Subcontracts any functions
                  of the
                  Health Plan, that the Subcontract or delegation includes all the
                  requirements of this Contract.

              

      

      

      
        	 	
                7.

              	
                Make
                  provisions for a waiver of those terms of the Subcontract, which,
                  as they
                  pertain to Medicaid Recipients, are in conflict with the specifications
                  of
                  this Contract.

              

      

      

      
        	 	
                8.

              	
                Provide
                  for revoking delegation or imposing other sanctions if the Subcontractor's
                  performance is inadequate.

              

      

      

      
        	 	
                9.

              	
                The
                  Health Plan must provide that compensation to individuals or entities
                  that
                  conduct utilization management activities is not structured so
                  as to
                  provide incentives for the individual or entity to deny, limit,
                  or
                  discontinue medically necessary services to any
                  Enrollee.

              

      

      

      
        	P.  	
                Hospital
                  Subcontracts

              

      

       

      

      All
        hospital Subcontracts must meet the requirements outlined in Section XV.I.Q.,
        Terms and Conditions, Subcontracts, of this Contract. In addition such
        Subcontracts shall require that the hospitals notify the Health Plan of births
        where the mother is a Health Plan Enrollee. The Subcontract must also specify
        which entity (Health Plan or hospital) is responsible for completing form
        DCF-ES
        2039 and submitting it to the local DCF Economic Self-Sufficiency Services
        office. The Subcontract must also indicate that the plan’s name must be
        indicated as the referring Agency when the form DCF-ES 2039 is
        completed.

      

      
        	Q.  	
                Termination
                  Procedures

              

      

       

      

      
        	 	
                1.

              	
                In
                  conjunction with section III.B., Termination, on page eight (8)
                  of the
                  Agency's Standard Contract, termination procedures are required.
                  The
                  Health Plan agrees to extend the thirty (30) Calendar Days notice
                  found in
                  section III.B.1., Termination at Will, on page eight (8) of the
                  Agency's
                  Standard Contract to ninety (90) Calendar Days notice. The party
                  initiating the termination shall render written notice of termination
                  to
                  the other party by certified mail, return receipt requested, or
                  in person
                  with proof of delivery, or by facsimile letter followed by certified
                  mail,
                  return receipt requested. The notice of termination shall specify
                  the
                  nature of termination, the extent to which performance of work
                  under the
                  Contract is terminated, and the date on which such termination
                  shall
                  become effective. In accordance with 1932(e)(4), Social Security
                  Act, the
                  Agency shall provide the plan with an opportunity for a hearing
                  prior to
                  termination for cause. This does not preclude the Agency from terminating
                  without cause.

              

      

      

      
        	 	
                2.

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

              

      

      

      a. Stop
        work
        under the Contract, but not before the termination date.

      

      b. Cease
        enrollment of new Enrollees under the Contract.

      

      c. Terminate
        all Marketing activities and Subcontracts relating to Marketing.

      

      d. Assign
        to
        the State those Subcontracts as directed by the Agency's contracting officer
        including all the rights, title and interest of the Health Plan for performance
        of those Subcontracts.

      

      e. In
        the
        event the Agency has terminated this Contract in one or more Agency areas
        of the
        State, complete the performance of this Contract in all other areas in which
        the
        Health Plan has not been terminated.

      

      f. Take
        such
        action as may be necessary, or as the Agency's contracting officer may direct,
        for the protection of property related to the contract which is in the
        possession of the Health Plan and in which the Agency has been granted or
        may
        acquire an interest.

      

      g. Not
        accept any payment after the Contract ends unless the payment is for the
        time
        period covered under the Contract. Any payments due under the terms of this
        Contract may be withheld until the Agency receives from the Health Plan all
        written and properly executed documents as required by the written instructions
        of the Agency.

      

      h. At
        least
        sixty (60) Calendar Days prior to the termination effective date, provide
        written notification to all Enrollees of the following information: the date
        on
        which the Health Plan will no longer participate in the State’s Medicaid
        program; and instructions on contacting the Agency’s Choice Counselor/Enrollment
        Broker help line to obtain information on Enrollee’ enrollment options and to
        request a change in Health Plans.

      

      
        	R.  	
                Waiver

              

      

       

      

      No
        covenant, condition, duty, obligation, or undertaking contained in or made
        a
        part of the Contract shall be waived except by written agreement of the parties,
        and forbearance or indulgence in any other form or manner by either party
        in any
        regard whatsoever shall not constitute a waiver of the covenant, condition,
        duty, obligation, or undertaking to be kept, performed, or discharged by
        the
        party to which the same may apply. Until complete performance or satisfaction
        of
        all such covenants, conditions, duties, obligations, or undertakings, the
        other
        party shall have the right to invoke any remedy available under law or equity
        not withstanding any such forbearance or indulgence.

      

      
        	S.  	
                Withdrawing
                  Services from a County

              

      

       

      

      If
        the
        Health Plan intends to withdraw services from a county, it shall provide
        written
        notice to its members in that county at least sixty (60) Calendar Days prior
        to
        the last day of service. The notice shall contain the same information as
        required for a notice of termination according to Section XVI.S.2.h., Terms
        and
        Conditions, Termination Procedures, of this Contract. The Health Plan shall
        also
        provide written notice of the withdrawal to all Subcontractors in the
        county.

      

      
        
          
            

            
            

          

          
            
            

            
            

          

          
            
            

          

        

      

       

      
        	T.  	
                MyFloridaMarketPlace
                  Vendor Registration

              

      

       

      

      This
        Vendor is exempt under Rule 60A-1.030(3)d(ii), Florida Administrative Code,
        from
        being required to register in MyFloridaMarketPlace for this
        Contract.

      

      
        	U.  	
                MyFloridaMarketplace
                  Vendor Registration and Transaction Fee Exemption 

              

      

       

      

      The
        Vendor is exempted from paying the 1% transaction fee per 60A-1.032(1)(g)
        of the
        Florida Administrative Code for this Contract.

      

      
        	V.  	
                Ownership
                  and Management Disclosure 

              

      

       

      

      
        	 	
                1.

              	
                Federal
                  and State laws require full disclosure of ownership, management
                  and
                  control of Disclosing Entities. 

              

      

      

      a. Disclosure
        shall be made on forms prescribed by the Agency for the areas of ownership
        and
        control interest (42 CFR 455.104 Form CMS 1513), business transactions (42
        CFR
        455.105), public entity crimes (section 287.133(3)(a), F.S.), and disbarment
        and
        suspension (52 Fed. Reg., pages 20360-20369, and section 4707 of the Balanced
        Budget Act of 1997). The forms are available through the Agency and are to
        be
        submitted to the Agency with the initial application for a Medicaid HMO or
        Health Plan and then submitted on an annual basis. The Health Plan shall
        disclose any changes in management as soon as those occur. In addition, the
        Health Plan shall submit to the Agency full disclosure of ownership and control
        of Medicaid HMOs and Health Plans at least sixty (60) Calendar Days before
        any
        change in the Health Plan's ownership or control occurs.

      

      b. The
        following definitions apply to ownership disclosure:

      

      
        	 	
                (1)

              	
                A
                  person with an ownership interest or control interest means a person
                  or
                  corporation that:

              

      

      

      (a) Owns,
        indirectly or directly 5 percent (5%) or more of the Health Plan's capital
        or
        stock, or receives 5 percent (5%) or more of its profits;

      

      (b) Has
        an
        interest in any mortgage, deed of trust, note, or other obligation secured
        in
        whole or in part by the plan or by its property or assets and that interest
        is
        equal to or exceeds 5 percent (5%) of the total property or assets;
        or

      

      (c) Is
        an
        officer or director of the Health Plan if organized as a corporation, or
        is a
        partner in the plan if organized as a partnership.

      

      
        	 	
                (2)

              	
                The
                  percentage of direct ownership or control is calculated by multiplying
                  the
                  percent of interest which a person owns, by the percent of the
                  Health
                  Plan's assets used to secure the obligation. Thus, if a person
                  owns ten
                  percent (10%) of a note secured by sixty percent (60%) of the Health
                  Plan's assets, the person owns six percent (6%) of the Health
                  Plan.

              

      

      

      
        	 	
                (3)

              	
                The
                  percent of indirect ownership or control is calculated by multiplying
                  the
                  percentage of ownership in each organization. Thus, if a person
                  owns ten
                  percent (10%) of the stock in a corporation, which owns eighty
                  percent
                  (80%) of the Health Plan stock, the person owns 8 percent (8%)
                  of the
                  Health Plan.

              

      

      

      c. The
        following definitions apply to management disclosure:

      

      
        	 	
                (1)

              	
                Changes
                  in management are defined as any change in the management control
                  of the
                  Health Plan. Examples of such changes are those listed below or
                  equivalent
                  positions by another title.

              

      

      

      (a) Changes
        in the board of directors or officers of the Health Plan, medical director,
        chief executive officer, administrator, and chief financial
        officer.

      

      (b) Changes
        in the management of the Health Plan where the Health Plan has decided to
        contract out the operation of the Health Plan to a management corporation.
        The
        Health Plan shall disclose such changes in management control and provide
        a copy
        of the contract to the Agency for approval at least sixty (60) Calendar Days
        prior to the management contract start date.

      

      d. In
        accordance with section 409.912, F.S., the Health Plan shall annually conduct
        a
        background check with the Florida Department of Law Enforcement on all persons
        with five percent (5%) or more ownership interest in the Health Plan, or
        who
        have executive management responsibility for the Health Plan, or have the
        ability to exercise effective control of the Health Plan. The Health Plan
        shall
        submit information to the Agency for such persons who have a record of illegal
        conduct according to the background check. The Health Plan shall keep a record
        of all background checks to be available for Agency review upon
        request.

      

      
        	 	
                (1)

              	
                In
                  accordance with section 409.907, F.S., Health Plans with an initial
                  contract beginning on or after July 1, 1997, shall submit, prior
                  to
                  execution of a contract, complete sets of fingerprints of principals
                  of
                  the plan to the Agency for the purpose of conducting a criminal
                  history
                  record check.

              

      

      

      
        	 	
                (2)

              	
                Principals
                  of the Health Plan shall be as defined in section 409.907,
                  F.S.

              

      

      

      e. The
        Health Plan shall submit to the Agency, within five (5) Business Days, any
        information on any officer, director, agent, managing employee, or owner
        of
        stock or beneficial interest in excess of five percent (5%) of the Health
        Plan
        who has been found guilty of, regardless of adjudication, or who entered
        a plea
        of nolo contendere or guilty to, any of the offenses listed in section 435.03,
        F.S.

      

      f. In
        accordance with section 409.912, F.S., the Agency shall not contract with
        a
        Health Plan that has an officer, director, agent, managing employee, or owner
        of
        stock or beneficial interest in excess of five percent (5%) of the Health
        Plan,
        who has committed any of the above listed offenses. In order to avoid
        termination, the Health Plan must submit a corrective action plan, acceptable
        to
        the Agency, which ensures that such person is divested of all interest and/or
        control and has no role in the operation and management of the Health
        Plan.

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      

      

      
        	W.  	
                Minority
                  Recruitment and Retention
                  Plan

              

      

       

      

      The
        Health Plan shall implement and maintain a minority recruitment and retention
        plan in accordance with section 641.217, F.S. The Health Plan shall have
        policies and procedures for the implementation and maintenance of such a
        plan.
        The minority recruitment and retention plan may be company-wide for all product
        lines.

      

      
        	X.  	
                Independent
                  Provider

              

      

       

      

      It
        is
        expressly agreed that the Health Plan and any Subcontractors and agents,
        officers, and employees of the Health Plan or any Subcontractors, in the
        performance of this Contract shall act in an independent capacity and not
        as
        officers and employees of the Agency or the State of Florida. It is further
        expressly agreed that this Contract shall not be construed as a partnership
        or
        joint venture between the Health Plan or any Subcontractor and the Agency
        and
        the State of Florida.

      

      
        	Y.  	
                General
                  Insurance Requirements

              

      

       

      

      The
        Health Plan shall obtain and maintain the same adequate insurance coverage
        including general liability insurance, professional liability and malpractice
        insurance, fire and property insurance, and directors’ omission and error
        insurance. All insurance coverage must comply with the provisions set forth
        for
        HMOs in Rule 69O-191.069, F.A.C.; excepting that the reporting, administrative,
        and approval requirements shall be to the Agency rather than to the Department
        of Financial Services. All insurance policies must be written by insurers
        licensed to do business in the State of Florida and in good standing with
        the
        Department of Financial Services. All policy declaration pages must be submitted
        to the Agency annually. Each certificate of insurance shall provide for
        notification to the Agency in the event of termination of the
        policy.

      

      
        	Z.  	
                Worker's
                  Compensation Insurance

              

      

       

      

      The
        Health Plan shall secure and maintain during the life of the Contract, worker's
        compensation insurance for all of its employees connected with the work under
        this Contract. Such insurance shall comply with the Florida Worker's
        Compensation Law, chapter 440, F.S. Policy declaration pages must be submitted
        to the Agency annually.

      

      
        	AA.  	
                State
                  Ownership

              

      

       

      

      The
        Agency shall have the right to use, disclose, or duplicate all information
        and
        data developed, derived, documented, or furnished by the plan resulting from
        this contract. Nothing herein shall entitle the Agency to disclose to third
        parties data or information which would otherwise be protected from disclosure
        by State or federal law.

      

      
        	BB.  	
                Disaster
                  Plan

              

      

       

      The
        Health Plan shall submit a plan describing procedures guaranteeing the
        continuation of services during an emergency, including but not limited to
        localized acts of nature, accidents, and technological and/or attack-related
        emergencies.

      

      

      
        

        

        
          
            
              
              

              
              

            

            
              
              

              
                

              

            

            
              
              

              
                ATTACHMENT
                  III

              

            

          

        

        

        BUSINESS
          ASSOCIATE AGREEMENT

        

        The
          parties to this Attachment agree that the following provisions constitute
          a
          business associate agreement for purposes of complying with the requirements
          of
          the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
          This
          Attachment is applicable if the Vendor is a business associate within the
          meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.
          

        

        The
          Vendor certifies and agrees as to abide by the following:

        

        
          	1.  	
                  Definitions.
                    Unless specifically stated in this Attachment, the definition
                    of the terms
                    contained herein shall have the same meaning and effect as defined
                    in 45
                    C.F.R. 160 and 164.

                

        

        

        1.a.
          Protected
          Health Information.
          For
          purposes of this Attachment, protected health information shall have the
          same
          meaning and effect as defined in 45 C.F.R.
          160 and
164,
          limited to the information created, received, maintained or transmitted
          by the
          Vendor from, or on behalf of, the Agency. 

        

        1.b.
          Security
          Incident.
          For
          purposes of this Attachment, security incident shall mean any
          event
          resulting in computer systems, networks, or data being viewed, manipulated,
          damaged, destroyed or made inaccessible by an unauthorized activity. See
          National Institute of Standards and Technology (NIST) Special Publication
          800-61, "Computer Security Incident Handling Guide,” for more
          information.

        

        
          	2.  	
                  Use
                    and Disclosure of Protected Health Information.
                    The Vendor shall not use or disclose protected health information
                    other
                    than as permitted by this Contract or by federal and state law.
                    The Vendor
                    will use appropriate safeguards to prevent the use or disclosure
                    of
                    protected health information for any purpose not in conformity
                    with this
                    Contract and federal and state law. The Vendor will implement
                    administrative, physical, and technical safeguards that reasonably
                    and
                    appropriately protect the confidentiality, integrity, and availability
                    of
                    electronic protected health information the Vendor creates, receives,
                    maintains, or transmits on behalf of the Agency.
                    

                

        

        

        
          	
                  3.

                	
                  Use
                    and Disclosure of Information for Management, Administration,
                    and Legal
                    Responsibilities.
                    The Vendor is permitted to use and disclose protected health
                    information
                    received from the Agency for the proper management and administration
                    of
                    the Vendor or to carry out the legal responsibilities of the
                    Vendor, in
                    accordance with 45 C.F.R. 164.504(e)(4). Such disclosure is only
                    permissible where required by law, or where the
                    Vendor obtains reasonable assurances from the person to whom
                    the protected
                    health information is disclosed that: (1) the protected health
                    information
                    will be held confidentially, (2) the protected health information
                    will be
                    used or further disclosed only as required by law or for the
                    purposes for
                    which it was disclosed to the person, and (3) the person notifies
                    the
                    Vendor of any instance of which it is aware in which the confidentiality
                    of the protected health information has been
                    breached.

                

        

        

        
          	
                  4.

                	
                  Disclosure
                    to Third Parties.
                    The Vendor will not divulge, disclose, or communicate protected
                    health
                    information to any third party for any purpose not in conformity
                    with this
                    Contract without prior written approval from the Agency. The
                    Vendor shall
                    ensure that any agent, including a subcontractor, to whom it
                    provides
                    protected health information received from, or created or received
                    by the
                    Vendor on behalf of, the Agency agrees to the same terms, conditions,
                    and
                    restrictions that apply to the Vendor with respect to protected
                    health
                    information.

                

        

        

        5. Access
          to Information.
          The
          Vendor shall make protected health information available in accordance
          with
          federal and state law, including providing a right of access to persons
          who are
          the subjects of the protected health information in accordance with 45
          C.F.R.
          164.524. 

        

        6. Amendment
          and Incorporation of Amendments.
          The
          Vendor shall make protected health information available for amendment
          and to
          incorporate any amendments to the protected health information in accordance
          with 45 C.F.R. § 164.526.

        

        7. Accounting
          for Disclosures.
          The
          Vendor shall make protected health information available as required to
          provide
          an accounting of disclosures in accordance with 45 C.F.R. § 164.528. The Vendor
          shall document all disclosures of protected health information as needed
          for the
          Agency to respond to a request for an accounting of disclosures in accordance
          with 45 C.F.R. § 164.528.

        

        8. Access
          to Books and Records.
          The
          Vendor shall make its internal practices, books, and records relating to
          the use
          and disclosure of protected health information received from, or created
          or
          received by the Vendor on behalf of the Agency, available to the Secretary
          of
          the Department of Health and Human Services or the Secretary’s designee for
          purposes of determining compliance with the Department of Health and Human
          Services Privacy Regulations.

        

        9. Reporting.
          The
          Vendor shall make a good faith effort to identify any use or disclosure
          of
          protected health information not provided for in this Contract. The Vendor
          will
          report to the Agency, within ten (10) business days of discovery, any use
          or
          disclosure of protected health information not provided for in this Contract
          of
          which the Vendor is aware. The Vendor will report to the Agency, within
          twenty-four (24) hours of discovery, any security incident of which the
          Vendor
          is aware. A violation of this paragraph shall be a material violation of
          this
          Contract.

        

        10.
          Termination.
          Upon the
          Agency’s discovery of a material breach of this Attachment, the Agency shall
          have the right to terminate this Contract. 

        

        10.a.
          Effect
          of Termination.
          At the
          termination of this Contract, the Vendor shall return all protected health
          information that the Vendor still maintains in any form, including any
          copies or
          hybrid or merged databases made by the Vendor; or with prior written approval
          of
          the Agency, the protected health information may be destroyed by the Vendor
          after its use. If the protected health information is destroyed pursuant
          to the
          Agency’s prior written approval, the Vendor must provide a written confirmation
          of such destruction to the Agency. If return or destruction of the protected
          health information is determined not feasible by the Agency, the Vendor
          agrees
          to protect the protected health information and treat it as strictly
          confidential.

        

        

        

        The
          Vendor has caused this Attachment to be signed and delivered by its duly
          authorized representative, as of the date set forth below.

        

        Vendor
          Name:

         

         
/s/ 
Todd
          S.
          Farha           

        Signature

         

        6/26/06

        Date

          

        Todd
          S. Farha, President &
CEO          

        Name
          and
          Title of Authorized Signer

      

      
        
          
            
               

            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
               

            

          

        

      

      

        

        CERTIFICATION
          REGARDING

        DEBARMENT,
          SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

        CONTRACTS/SUBCONTRACTS

        

        This
          certification is required by the regulations implementing Executive Order
          12549,
          Debarment and Suspension, signed February 18, 1986. The guidelines were
          published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
          20360-20369).

        

        INSTRUCTIONS

        

        
          	
                  1.

                	
                  Each
                    Vendor whose contract/subcontract equals or exceeds $25,000 in
                    federal
                    monies must sign this certification prior to execution of each
                    contract/subcontract. Additionally, Vendors who audit federal
                    programs
                    must also sign, regardless of the contract amount. The
                    Agency for Health Care Administration cannot contract with these
                    types of
                    Vendors if they are debarred or suspended by the federal
                    government.

                

        

        

        
          	
                  2.

                	
                  This
                    certification is a material representation of fact upon which
                    reliance is
                    placed when this contract/subcontract is entered into. If it
                    is later
                    determined that the signer knowingly rendered an erroneous certification,
                    the Federal Government may pursue available remedies, including
                    suspension
                    and/or debarment.

                

        

        

        
          	
                  3.

                	
                  The
                    Vendor shall provide immediate written notice to the contract
                    manager at
                    any time the Vendor learns that its certification was erroneous
                    when
                    submitted or has become erroneous by reason of changed
                    circumstances.

                

        

        

        
          	
                  4.

                	
                  The
                    terms "debarred," "suspended," "ineligible," "person," "principal,"
                    and
                    "voluntarily excluded," as used in this certification, have the
                    meanings
                    set out in the Definitions and Coverage sections of rules implementing
                    Executive Order 12549. You may contact the contract manager for
                    assistance
                    in obtaining a copy of those
                    regulations.

                

        

        

        
          	
                  5.

                	
                  The
                    Vendor agrees by submitting this certification that, it shall
                    not
                    knowingly enter into any subcontract with a person who is debarred,
                    suspended, declared ineligible, or voluntarily excluded from
                    participation
                    in this contract/subcontract unless authorized by the Federal
                    Government.

                

        

        

        
          	
                  6.

                	
                  The
                    Vendor further agrees by submitting this certification that it
                    will
                    require each subcontractor of this contract/subcontract, whose
                    payment
                    will equal or exceed $25,000 in federal monies, to submit a signed
                    copy of
                    this certification.

                

        

        

        
          	
                  7.

                	
                  The
                    Agency for Health Care Administration may rely upon a certification
                    of a
                    Vendor that it is not debarred, suspended, ineligible, or voluntarily
                    excluded from contracting/subcontracting unless it knows that
                    the
                    certification is erroneous.

                

        

        

        
          	
                  8.

                	
                  This
                    signed certification must be kept in the contract manager's contract
                    file.
                    Subcontractor's certifications must be kept at the contractor's
                    business
                    location.

                

        

        

        CERTIFICATION

        

        
          	(1)	 	
                  The
                    prospective Vendor certifies, by signing this certification,
                    that neither
                    he nor his principals is presently debarred, suspended, proposed
                    for
                    debarment, declared ineligible, or voluntarily excluded from
                    participation
                    in this contract/subcontract by any federal department or
                    agency.

                

        

        

        
          	
                  (2)

                	
                  Where
                    the prospective Vendor is unable to certify to any of the statements
                    in
                    this certification, such prospective Vendor shall attach an explanation
                    to
                    this certification.

                

        

         

        
           
/s/ 
Todd
            S.
            Farha           

          Signature

           

          6/26/06

          Date

            

          Todd
            S. Farha, President &
CEO          

          Name
            and
            Title of Authorized Signer

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      CERTIFICATION
        REGARDING LOBBYING

      CERTIFICATION
        FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

      

      

      The
        undersigned certifies, to the best of his or her knowledge and belief,
        that:

      

      
        	(1)  	
                No
                  federal appropriated funds have been paid or will be paid, by or
                  on behalf
                  of the undersigned, to any person for influencing or attempting
                  to
                  influence an officer or employee of any agency, a member of congress,
                  an
                  officer or employee of congress, or an employee of a member of
                  congress in
                  connection with the awarding of any federal contract, the making
                  of any
                  federal grant, the making of any federal loan, the entering into
                  of any
                  cooperative agreement, and the extension, continuation, renewal,
                  amendment, or modification of any federal contract, grant, loan,
                  or
                  cooperative agreement.

              

      

       

      
        	(2)  	
                If
                  any funds other than federal appropriated funds have been paid
                  or will be
                  paid to any person for influencing or attempting to influence an
                  officer
                  or employee of any agency, a member of congress, an officer or
                  employee of
                  congress, or an employee of a member of congress in connection
                  with this
                  federal contract, grant, loan, or cooperative agreement, the undersigned
                  shall complete and submit Standard Form-LLL, “Disclosure Form to Report
                  Lobbying,” in accordance with its
                  instructions.

              

      

       

      
        	(3)  	
                The
                  undersigned shall require that the language of this certification
                  be
                  included in the award documents for all sub-awards at all tiers
                  (including
                  subcontracts, sub-grants, and contracts under grants, loans, and
                  cooperative agreements) and that all sub-recipients shall certify
                  and
                  disclose accordingly.

              

      

      

      This
        certification is a material representation of fact upon which reliance was
        placed when this transaction was made or entered into. Submission of this
        certification is a prerequisite for making or entering into this transaction
        imposed by section 1352, Title 31, U.S. Code. Any person who fails to file
        the
        required certification shall be subject to a civil penalty of not less than
        $10,000 and not more than $100,000 for each such failure.

      

       

      
        	 

                 
/s/ 
Todd
                  S.
                  Farha           
                  

                Signature

              	 

                6/26/06

                Date

              
	 

                Todd
                  S.
                  Farha                             
                  

                Name
                  of Authorized Individual

                 

              	
                 FAR 009

                Application or Contract Number

              
	
                 WellCare of Florida, Inc. d/b/a Staywell Health Plan of
                  Florida, inc.  P.O Box 26011,  Tampa, FL 33623

                Name and Address of OrganziationEX-10.1

Exhibit 10.1

EXECUTIVE SEVERANCE AGREEMENT

AGREEMENT between Saia, Inc., a Delaware corporation (“Saia”), and James A. Darby (the
“Executive”),

WITNESSETH:

WHEREAS, the Compensation Committee of the Board of Directors (the “Board”) of Saia has
recommended, and the Board has approved, Saia entering into severance agreements with key
executives of Saia and its Subsidiaries (hereinafter sometimes collectively referred to as the
“Corporation”); and

WHEREAS, the Executive is a key executive of Saia or one of its Subsidiaries and has been
selected by the Board as a key executive; and

WHEREAS, should Saia receive any proposal from a third person concerning a possible Business
Combination with, or acquisition of equity securities of, Saia, the Board believes it important
that the Corporation and the Board be able to rely upon the Executive to continue in his position,
and that Saia have the benefit of the Executive performing his duties without his being distracted
by the personal uncertainties and risks created by such a proposal;

NOW, THEREFORE, the parties agree as follows:

1. Definitions.

(a) “Affiliate” and “Associates” shall have the respective meanings given
those terms in Rule 12b-2 of the General Rules and Regulations under the Securities Exchange Act of
1934, as in effect on the date hereof.

(b) “Beneficial Owner” of shares shall include any Voting Shares:

(i) which such person or any of its Affiliates or Associates beneficially own, directly
or indirectly, or

(ii) which such person or any of its Affiliates or Associates has (1) the right to
acquire (whether such right is exercisable immediately or only after the passage of time),
pursuant to any agreement, arrangement or understanding or upon the exercise of conversion
rights, exchange rights, warrants, or options, or otherwise, or (2) the right to vote
pursuant to any agreement, arrangement or understanding, or

(iii) which are beneficially owned, directly or indirectly, by any other person with
which such first mentioned person or any of its Affiliates or Associates has any agreement,
arrangement or understanding for the purpose of acquiring, holding, voting or disposing of
any shares of capital stock of Saia.

(c) “Business Combination” means:

(i) any merger or consolidation of Saia with or into (1) any Substantial Stockholder
(as hereinafter defined) or (2) any other corporation (whether or not itself a Substantial
Stockholder) which, after such merger or consolidation, would be an Affiliate of a
Substantial Stockholder, or

(ii) any sale, lease, exchange, mortgage, pledge, transfer or other disposition (in one
transaction or a series of related transactions) to or with (1) any Substantial Stockholder
or (2) an Affiliate of a Substantial Stockholder of any assets of the Saia or any Subsidiary
having an aggregate fair market value of $5,000,000 or more, or

(iii) the issuance or transfer by Saia (in one transaction or a series of related
transactions) of any securities of the Corporation or any Subsidiary to (1) any Substantial
Stockholder or (2) any other corporation (whether or not itself a Substantial Stockholder )
which, after such issuance or transfer, would be an Affiliate of a Substantial Stockholder
in exchange for cash, securities or other property (or a combination thereof) having an
aggregate fair market value of $5,000,000 or more, or

(iv) the adoption of any plan or proposal for the liquidation or dissolution of the
Corporation proposed by or on behalf of a Substantial Stockholder or an Affiliate of a
Substantial Stockholder, or

(v) any reclassification of securities (including any reverse stock split),
recapitalization, reorganization, merger or consolidation of the Corporation with any of its
Subsidiaries or any similar transaction (whether or not with or into or otherwise involving
a Substantial Stockholder or an Affiliate of a Substantial Stockholder) which has the
effect, directly or indirectly, of increasing the proportionate share of the outstanding
 shares of any class of equity or convertible securities of the Corporation or any Subsidiary
which is directly or indirectly owned by any Substantial Stockholder or by an Affiliate of a
Substantial Stockholder.

(d) “Cause” means conviction of a felony involving moral turpitude by a court of
competent jurisdiction, which is no longer subject to direct appeal, or an adjudication by a court
of competent jurisdiction, which is no longer subject to direct appeal, that the Executive is
mentally incompetent or that he is liable for willful misconduct in the performance of his duty to
the Corporation which is demonstrably and materially injurious to the Corporation.

(e) “Change of Control,” for the purposes of this Agreement, shall be deemed to have
taken place if: (i) a third person, including a “group” as defined in Section 13(d)(3) of the
Securities Exchange Act of 1934, purchases or otherwise acquires shares of the Corporation after
the date hereof and as a result thereof becomes the beneficial owner of shares of the Corporation
having 20% or more of the total number of votes that may be cast for election of directors of Saia;
or (ii) as the result of, or in connection with any cash tender or exchange offer, merger or other
Business Combination, or contested election, or any combination of the foregoing transactions, the
directors then serving on the Board of Directors of Saia shall cease to constitute a majority of
the Board of Directors of Saia or any successor to Saia.

(f) “Corporation” means Saia and its Subsidiaries.

(g) “Normal Retirement Age” means the last day of the calendar month in which the
Executive’s 65th birthday occurs.

(h) “Permanent Disability” means a physical or mental condition which permanently
renders the Executive incapable of exercising the duties and responsibilities of the position he
held immediately prior to any Change of Control.

(i) “Potential Change of Control” shall be deemed to have occurred if the event set
forth in any one of the following paragraphs shall have occurred: (i)  Saia enters into an
agreement, the consummation of which would result in the occurrence of a Change of Control; (ii) 
Saia or any person or “group” as defined in Section 3(d)(3) of the Securities Exchange Act of 1934,
as amended, publicly announces an intention to take or consider taking actions which, if
consummated would constitute a Change in Control; (iii) the Board of Directors adopts a resolution
to the effect that, for purposes of this Agreement, a Potential Change in Control has occurred.

(j) “Subsidiary” means any domestic or foreign corporation, a majority of whose shares
normally entitled to vote in electing directors is owned directly or indirectly by Saia or by other
Subsidiaries.

(k) “Substantial Stockholder” means, in respect of any Business Combination, any
person (other than Saia) who or which is on the record date for the determination of stockholders
entitled to notice of and to vote on such Business Combination, or as of the time of the vote on
such Business Combination, or immediately prior to the consummation of any such transaction,

(i) is the Beneficial Owner, directly or indirectly, of not less than 10% of the Voting
Shares, or

(ii) is an Affiliate of Saia and at any time within five years prior thereto was the
Beneficial Owner, directly or indirectly, of not less than 10% of the then outstanding
Voting Shares, or

(iii) is an assignee of or has otherwise succeeded to any shares of capital stock of
Saia which were at any time within five years prior thereto beneficially owned by any
Substantial Stockholder, and such assignment or succession shall have occurred in the course
of a transaction or a series of transactions not involving a public offering within the
meaning of the Securities Act of 1933, as amended.

(m) “Voting Shares” means the outstanding shares of capital stock of Saia entitled to
vote generally in the election of the directors.

2. Services During Certain Events. In the event a third person begins a tender or
exchange offer or takes other steps seeking to effect a Change of Control, the Executive agrees
that he will not voluntarily leave the employ of the Corporation without the consent of the
Corporation, and will render the services contemplated in the recitals of this Agreement, until the
third person has abandoned or terminated his or its efforts to effect a Change of Control or until
90 days after a Change of Control has occurred. In the event the Executive fails to comply with
the provisions of this paragraph, the Corporation will suffer damages which are difficult, if not
impossible, to ascertain. Accordingly, should the Executive fail to comply with the provisions of
this paragraph, the Corporation shall retain the amounts which would otherwise be payable to the
Executive hereunder as fixed, agreed and liquidated damages but shall have no other recourse
against the Executive.

3. Termination After Change of Control. “Termination” shall include (a) termination
by the Corporation of the employment of Executive with the Corporation within two years after a
Change of Control for any reason other than death, Permanent Disability, retirement at or after his
Normal Retirement Age, or Cause or (b) resignation of the Executive after the occurrence of any of
the following events within two years after a Change of Control of Saia:

(a) An adverse change of the Executive’s title or a reduction or adverse change in the nature
or scope of the Executive’s authority or duties from those being exercised and performed by the
Executive immediately prior to the Change of Control.

(b) A transfer of the Executive to a location which is more than 50 miles away from the
location where the Executive was employed immediately prior to the Change of Control.

(c) Any reduction in the rate of Executive’s annual salary below his rate of annual salary
immediately prior to the Change of Control.

(d) Any reduction in the level of Executive’s fringe benefits or bonus below a level
consistent with the Corporation’s practice prior to the Change of Control.

4. Termination Payment. In the event of a Termination, as defined in Paragraph 3,
Saia shall provide the Executive the following benefits:

(a) Saia shall pay to the Executive on or before the Executive’s last day of employment with
the Corporation, as additional compensation for services rendered to the Corporation, a lump sum
cash amount (subject to the minimum applicable federal, state or local lump sum withholding
requirements, if any, unless the Executive requests that a greater amount be withheld) equal to two
times the highest base salary and annual cash incentive bonuses paid or payable to the Executive by
the Corporation with respect to any 12 consecutive month period during the three years ending with
the date of the Executive’s Termination.

(b) During the two years following the Executive’s Termination, the Executive shall be deemed
to remain an employee of the Corporation for purposes of the applicable medical, life insurance and
long-term disability plans and programs covering key executives of the Corporation and shall be
entitled to receive the benefits available to key executives thereunder, provided; however, that in
the event the Executive’s participation in any such employee benefit plan or program is barred, the
Corporation shall arrange to provide the Executive with substantially similar benefits.

(c) The Executive shall be entitled to the Gross-Up Payment, if any, described in Paragraph 6.

(d) The Corporation shall pay the Executive the Termination Payment set forth in this
paragraph upon termination of the Executive’s employment following a Potential Change in Control
but before a Change in Control and during the term of this Agreement if: (i) the termination is
initiated, caused or directed by any person or group which has initiated a transaction, the
consummation of which would result in a Change of Control; and (ii) the termination would have been
by the Executive for any of the reasons enumerated in paragraph 3(a)-3(d) or by the Corporation
without Cause if a Change of Control had occurred on the date of the Potential Change in Control.

5. Stock-Out of Options. In the event of a Change of Control, the Executive’s
non-qualified stock options and incentive stock options granted by the Corporation which are
outstanding on the date of the Change of Control, shall immediately vest and Executive shall have
12 months from the date of the Change of Control to exercise said options.

6. Additional Payments by Saia.

(a) Gross-Up Payment. In the event it shall be determined that any payment or benefit
of any type by the Corporation to or for the benefit of the Executive, whether paid or payable or
distributed or distributable pursuant to the terms of this Agreement or otherwise (determined
without regard to any additional payments required under this Paragraph 6) (the “Total Payments”)
would be subject to the excise tax imposed by Section 4999 of the Internal Revenue Code of 1986, as
amended (the “Code”) (or any similar tax that may hereafter be imposed) or any interest or
penalties with respect to such excise tax (such excise tax, together with any such interest and
penalties, are collectively referred to as the “Excise Tax”), then the Executive shall be entitled
to receive an additional payment (a “Gross-Up Payment”) in an amount such that after payment by the
Executive of all taxes (including any interest or penalties imposed with respect to such taxes),
including any Excise Tax, imposed upon the Gross-Up Payment, the Executive retains an amount of the
Gross-Up Payment equal to the Excise Tax imposed upon the Total Payments. Payment of the Gross-Up
Payment shall be made promptly following the determination by the Accounting Firm as described in
subparagraph (b) of this Paragraph 6 or in accordance with subparagraph (c) of this Paragraph 6.

(b) Determination by Accountant. All determinations required to be made under this
Paragraph 6, including whether a Gross-Up Payment is required and the amount of such Gross-Up
Payment, shall be made by an independent accounting firm retained by Saia (the “Accounting Firm”),
which shall provide detailed supporting calculations both to Saia and the Executive within 15
business days of the date of Termination, if applicable, or such earlier time as is requested by
Saia. If the Accounting Firm determines that no Excise Tax is payable by the Executive, it shall
furnish the Executive with an opinion that he has substantial authority not to report any Excise
Tax on his federal income tax return. Any determination by the Accounting Firm shall be binding
upon Saia and the Executive. As a result of the uncertainty in the application of Section 4999 of
the Code at the time of the initial determination by the Accounting Firm hereunder, it is possible
that Gross-Up Payments which will not have been made by Saia should have been made (“Underpayment”)
consistent with the calculations required to be made hereunder. In the event that Saia exhausts
its remedies pursuant to subparagraph (c) of this Paragraph 6 and the Executive thereafter is
required to make a payment of any Excise Tax, the Accounting Firm shall determine the amount of the
Underpayment that has occurred and any such Underpayment shall be promptly paid by Saia to or for
the benefit of the Executive. Saia shall promptly pay all expenses of the Accounting Firm pursuant
to this Paragraph 6.

(c) Notification Required. The Executive shall notify Saia in writing of any claim by
the Internal Revenue Service that, if successful, would require the payment by Saia of the Gross-Up
Payment. Such notification shall be given as soon as practicable but no later than ten business
days after the Executive knows of such claim and shall apprise Saia of the nature of such claim and
the date on which such claim is requested to be paid. The Executive shall not pay such claim prior
to the expiration of the thirty-day period following the date on which it gives such notice to Saia
(or such shorter period ending on the date that any payment of taxes with respect to such claim is
due). If Saia notifies the Executive in writing prior to the expiration of such period that it
desires to contest such claim, the Executive shall:

(i) give Saia any information reasonably requested by Saia relating to such claim;

(ii) take such action in connection with contesting such claim as Saia shall reasonably
request in writing from time to time, including, without limitation, accepting legal
representation with respect to such claim by an attorney reasonably selected by Saia;

(iii) cooperate with Saia in good faith in order to effectively contest such claim; and

(iv) permit Saia to participate in any proceeding relating to such claim; provided,
however, that Saia shall bear and pay directly all costs and expenses (including additional
interest and penalties) incurred in connection with such contest and shall indemnify and
hold the Executive harmless, on an after-tax basis, for any Excise Tax or income tax,
including interest and penalties with respect thereto, imposed as a result of such
representation and payment of costs and expenses. Without limitation on the foregoing
provisions of this subparagraph (c), Saia shall control all proceedings taken in connection
with such contest and, at its sole option, may pursue or forego any and all administrative
appeals, proceedings, hearings and conferences with the taxing authority in respect of such
claim and may, at it sole option, either direct the Executive to pay the tax claimed and sue
for a refund, or contest the claim in any permissible manner, and the Executive agrees to
prosecute such contest to a determination before any administrative tribunal, in a court of
initial jurisdiction and in one or more appellate courts, as Saia shall determine; provided,
however, that if Saia directs the Executive to pay such claim and sue for a refund, Saia
shall advance the amount of such payment to the Executive, on an interest-free basis and
shall indemnify and hold the Executive harmless, on an after-tax basis, from any excise tax
or income tax, including interest or penalties with respect thereto, imposed with respect to
such advance or with respect to any imputed income with respect to such advance; and further
provided that any extension of the statute of limitations relating to payment of taxes for
the taxable year of the Executive with respect to which such contested amount is claimed to
be due is limited solely to such contested amount. Furthermore, Saia’s control of the
contest shall be limited to issues with respect to which a Gross-Up Payment would be payable
hereunder and the Executive shall be entitled to settle or contest, as the case may be, any
other issue raised by the Internal Revenue Service or any other taxing authority.

(d) Repayment. If, after the receipt by Executive of an amount paid or advanced by
Saia pursuant to this Paragraph 6, the Executive becomes entitled to receive any refund with
respect to such claim, the Executive shall (subject to Saia’s complying with the requirements of
this Paragraph 6), promptly pay to Saia the amount of such refund (together with any interest paid
or credited thereon after taxes applicable thereto). If, after the receipt by the Executive of an
amount paid or advanced by Saia pursuant to this Paragraph 6, a determination is made that the
Executive shall not be entitled to any refund with respect to such claim and Saia does not notify
the Executive in writing of its intent to contest such denial of refund prior to the expiration of
thirty days after such determination, then such payment or advance shall be forgiven and shall not
be required to be repaid and the amount of such payment or advance shall offset, to the extent
thereof, the amount of the Gross-Up Payment required to be paid.

7. General.

(a) Arbitration. Any dispute between the parties hereto arising out of, in connection
with, or relating to this Agreement or the breach thereof shall be settled by arbitration in Kansas
City, Missouri, in accordance with the rules then in effect of the American Arbitration Association
(“AAA”). Arbitration shall be the exclusive remedy for any such dispute except only as to failure
to abide by an arbitration award rendered hereunder. Regardless of whether or not both parties
hereto participate in the arbitration proceeding, any arbitration award rendered hereunder shall be
final and binding on each party hereto and judgment upon the award rendered may be entered in any
court having jurisdiction thereof.

The party seeking arbitration shall notify the other party in writing and request the AAA to
submit a list of 5 or 7 potential arbitrators. In the event the parties do not agree upon an
arbitrator, each party shall, in turn, strike one arbitrator from the list, the Corporation having
the first strike, until only one arbitrator remains, who shall arbitrate the dispute. The
arbitration hearing shall be conducted within 30 days of the selection of an arbitrator or at the
earliest date thereafter that the arbitrator is available.

(b) Indemnification. If arbitration occurs as provided for herein, the Corporation
shall reimburse the Executive for his reasonable attorneys’ fees, costs and disbursements incurred
in such arbitration and hereby agrees to pay interest on any money award obtained by the Executive
from the date payment should have been made until the date payment is made, calculated at the prime
interest rate of Bank of America, N.A., in effect from time to time, plus 2%, from the date that
payment(s) to him should have been made under this Agreement. If the Executive enforces the
arbitration award in court, the Corporation shall reimburse the Executive for his reasonable
attorneys’ fees, costs and disbursements incurred in such enforcement.

(c) Payment Obligations Absolute. Saia’s obligation to pay the Executive the
compensation and to make the arrangements provided herein shall be absolute and unconditional and
shall not be affected by any circumstance, including, without limitation, any setoff, counterclaim,
recoupment, defense or other right which the Corporation may have against him or anyone else,
except as provided in paragraph 2 hereof. All amounts payable by Saia hereunder shall be paid
without notice or demand. Each and every payment made hereunder by Saia shall be final and Saia
will not seek to recover all or any part of such payment from the Executive or from whosoever may
be entitled thereto, for any reason whatsoever. The Executive shall not be obligated to seek other
employment in mitigation of the amounts payable or arrangements made under any provision of this
Agreement, and the obtaining of any such other employment shall in no event affect any reduction of
Saia’s obligation to make the payments required to be made under this Agreement.

(d) Continuing Obligations. The Executive shall retain in confidence any confidential
information known to him concerning the Corporation and its respective businesses until such
information is publicly disclosed.

(e) Successors. This Agreement shall be binding upon and inure to the benefit of the
Executive and his estate and the Corporation and any successor of the Corporation, but neither this
Agreement nor any rights arising hereunder may be assigned or pledged by the Executive.

(f) Severability. Any provision of this Agreement which is prohibited or
unenforceable in any jurisdiction shall, as to such jurisdiction, be ineffective only to the extent
of such prohibition or unenforceability without invalidating or affecting the remaining provisions
hereof, and any such prohibition or unenforceability in any jurisdiction shall not invalidate or
render unenforceable such provision in any other jurisdiction.

(g) Controlling Law. This Agreement shall in all respects be governed by and
construed in accordance with the laws of the State of Delaware.

(h) Termination. This Agreement shall terminate if a majority of the Board of
Directors of Saia determines that the Executive is no longer a key executive and so notifies the
Executive; except that such determination shall not be made, and if made shall have no
effect, (i) within two years after the Change of Control in question or (ii) during any period of
time when Saia has knowledge that any third person has taken steps reasonably calculated to effect
a Change of Control until, in the opinion of a majority of the Board of Directors of Saia the third
person has abandoned or terminated his efforts to effect a Change of Control.

[Remainder of page intentionally left blank.]

1

IN WITNESS WHEREOF, the parties have executed this Agreement on the 1st day of
September, 2006.

	 	 	 	 	 
	 
	 	SAIA, INC.

	EXECUTIVE:
	 	By: /s/ Herbert A. Trucksess, III

	/s/ James A. Darby
	 	 	—	 
	—
	 	Herbert A. Trucksess, III

	James A. Darby
	 	President and Chief Executive Officer

	 
	 	ATTEST:

	 
	 	By: Richard D. O’Dell

2

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