Document:

far009amend9.htm

    
Back to Form 8-K

    Exhibit 10.3

    
Addendum
to Exhibit 3-C

    
       

      The
Agency and the Vendor acknowledge and agree that the rates reflected in this
AHCA Contract No. FAR 009 Amendment No. 9 do not reflect the parties' prior
understanding. Accordingly, the Agency agrees to increase the Children and
Families and Aged and Disabled (No Medicare. Medicare Parts A and B and Medicare
Part B Only) by approximately 2% to be effective September 1,
2008.

    

    
       

      WellCare
of Florida, Inc.

    

    
      d/b/a
Staywell Health Plan of Florida

    

     

    Signed

    

    By: /s/ Heath
Schiesser                                    

    Name:
Heath
Schiesser                                    

    Title:
President and
CEO                                  

    Date: August 29,
2008                                      

    
       

      State of
Florida, Agency for Health Care Administration

    

    
      

    

    
      
        By: /s/ William H.
Roberts                        
       

        
          Name: William H. Roberts for
Holly Benson

          
            Title:
Deputy General
Counsel               
         

            
              Date:
8/29/08                                                      

            

          

        

      

    

    
       

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      EXHIBIT
3-C

    

    
       

      MEDICAID
REFORM HMO CAPITATION RATES

    

    
      (By
Area, Age, and Eligibility Category)

    

    
      September
1, 2008 - August 31, 2009

    

    
      TABLE
2

      

    

    
      	
              Area:
      10         
      

            	
              County:
      Broward          
      

            	
              September
      1, 2008

            

    

    
      

    

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

       

    

    
      	
              
                Eligibility
      Category/ 

                Population

              

            	
              
                Total
      Rates for Comprehensive 

                and
      Catastrophic Components

              

            	
              
                Total
      Rate for Comprehensive 

                Component
      Only

              

            
	
              
                Children and
      Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $         868.52

              

            	
              
                 
      $       
        750.55

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $         191.05

              

            	
              
                 
      $       
        181.72

              

            
	
              
                Age
      1 and Up - Base Rate for Risk adjustment

              

            	
              
                 
      $       
     107.11

              

            	
              
                 
      $         105.39

              

            

    

     

    
      	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $    17,572.21

              

            	
              
                 
      $      9,173.75

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $      3,896.35

              

            	
              
                 
      $      2,187.93

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                 
      $         789.84

              

            	
              
                  $     
         725.69

              

            

    

     

    
      	
              
                Medicare
      Parts A and B

              

            	 
      
	
              
                Under
      Age 65

              

            	
              
                 
      $    
        139.11

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                  $    
            99.49

              

            	
              
                N/A

              

            

    

     

    
      	
              
                Medicare
      Part B Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                 
      $    
        265.17

              

            	
              
                N/A

              

            

    

     

    
      	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                 
      $      1,823.74

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                 
      $      3,422.47

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                 
      $         256.03

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                 
      $         546.61

              

            	
              
                N/A

              

            

    

     

    
      	
               

              Kick
      Payments Amounts for Covered Obstetrical Delivery
      Services:

               

            
	
              CPT

              Code

            	
              Obstetrical
      Delivery CPT Code Description

               

            	
              Payment

              Amount

            
	
              59409

            	
              Vaginal
      delivery only

            	
               

               

              $3,941.45

            
	
              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 inc postpartum
care

            

    

    
       

    

    
      AHCA
Contract No. FAR009, Exhibit 3-C, Page 1 of
3

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      EXHIBIT
3-C

    

    
      MEDICAID REFORM HMO CAPITATION
RATES

    

    
      (By Area,
Age, and Eligibility Category)

    

    
      September
1, 2008 - August 31, 2009

    

    
                                                                                            September
1, 2008

    

    
      Area:  4   
      County:  Duval,
Bakar, Clay and Nassau

    

    
      

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

    

     

    
      	
              
                Eligibility
      Category/

                Population

              

            	
              
                Total
      Rates for Comprehensive 

                and
      Catastrophic Component

              

            	
              
                Total
      Rate for 

                Comprehensive

                Component
      Only

              

            
	
              
                Children
      and Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $            895.21

              

            	
              
                 
      $                773.61

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $         
        196.74

              

            	
              
                 
      $        
             187.13

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                 
      $         
        110.24

              

            	
              
                 
      $         
            108.46

              

            
	 
      
	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $       14,234.51

              

            	
              
                 
      $             7,431.27

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $         3,172.94

              

            	
              
                 
      $             1,765.42

              

            
	
              
                Age1
      and Up-Base Rate for Risk Adjustment

              

            	
              
                 
      $          
       610.65

              

            	
              
                 
      $          
           561.06

              

            
	 
      	 
      
	
              
                Medicare
      Parts A and B

              

            	 
      	 
      
	
              
                Under
      Age 65

              

            	
              
                 
      $            158.06

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                 
      $            112.96

              

            	
              
                N/A

              

            
	
              
                 

              

            
	
              
                Medicare
      Part B Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                 
      $            326.42

              

            	
              
                N/A

              

            
	 
      	 
      
	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                 
      $         1,161.19

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                 
      $         2,285.96

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                 
      $            157.41

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                 
      $      
           336.05

              

            	
              
                N/A

              

            
	 
      	 
      	 
      

    

     

    
      	
              
                 

                Kick Payments
      Amounts for Covered Obstetrical Delivery
      Services:

                 

              

            
	
              
                CPT
      

                Code

                 

              

            	
              
                Obstetrical
      Delivery CPT Code Description

              

            	
              
                Payment
      

                Amount

              

            
	
              
                59409

              

            	
              
                Vaginal
      delivery only

              

            	
              
                 

              

              
                 

              

              
                 

              

              
                 

              

              
                $3,977.49

              

            
	
              
                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 inc postpartum
care

              

            

    

    
      

      AHCA Contract No. FAR009, Exhibit 3-C,
Page 2 of 3

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      EXHIBIT
3-C

    

    
      MEDICAID
REFORM HMO CAPITATION RATES

    

    
      (By
Area, Age. and Eligibility Category)

    

    
      September
1, 2008 - August 31, 2009

       

    

    
      	
              Area:  10   
      

            	
              County:  Broward

            	
              September
      1, 2008

            
	
              Area:  4    
      

            	
              County:  Duval, Baker, Clay and
      Nassau

            	 
      

    

    
      
 

    

    
      	
              
                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

              

            	
              
                All
      Age Groups

              

            	
              
                $162,000.00

              

            
	
              
                47135

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            
	
              
                47136

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            

    

    
      

      AHCA Contract No. FAR009, Exhibit 3-C,
Page 3 of
3
 

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

     

    
      	
              Wellcare
      of Florida, Inc. d/b/a

              
                Staywell
      Health Plan of Florida

              

            	
              Medicaid
      Reform HMO Contract

            

    

    
       

      AHCA
CONTRACT NO. FAR009 AMENDMENT NO. 9

    

    
       

      THIS
CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH
CARE ADMINISTRATION,
hereinafter referred to as the "Agency," and WELLCARE OF FLORIDA, INC,
D/B/A
STAYWELL HEALTH PLAN OF
FLORIDA, hereinafter referred to as the "Vendor," Is hereby amended as
follows;

    

    
       

      
        	
                1.

              	
                Effective
      September 1, 2008, Standard Contract, Section III, Item C, Contract
      Managers, sub-item 1, Is hereby amended to now read as
      follows;

              

      

    

    
       

      
        	
                 

              	 1.	
                The
      Agency's Contract Manager's name, address and telephone number for this
      Contract is as follows;

              

      

    

    
       

             
Suzanne Stacknik

             
Agency
for Health Care Administration

             
2727 Mahan Drive, MS #30

             
Tallahassee,
FL 32308

              (850)
487-2355

    

    
       

      
        	
                2.

              	
                Attachment
      I, Scope of Services, Exhibit 1-B, effective January 1, 20-09, is hereby
      included and made a part of the Contract. Exhibit 1-A will remain in
      effect until December 31, 2008.  After January 1, 2009, all
      references in the Contract to Exhibit I-A, shall hereinafter refer to
      Exhibit 1-B.

              

      

    

    
       

      
        	
                3.

              	
                Effective
      September l, 2003, Attachment I, Scope of Services, Exhibit 2-B is hereby
      Included and made a part of the Contract. All references in the Contract
      to Exhibit 2-A, shall hereinafter refer to Exhibit
  2-B.

              

      

    

    
       

      
        	
                4.

              	
                Effective
      September 1, 2008, Attachment I, Scope of Services, Exhibit 3-C is hereby
      included and made a part of the Contract. All references in the Contract
      to Exhibit 3-B, shall hereinafter refer respectively to Exhibit
      3-C.

              

      

    

    
       

      
        	
                5.

              	
                Effective
      September 1, 2008, Attachment II, Medicaid Reform Health Plan Model
      Contract, Section XIII, Method of Payment, Section B, Capitation Rate
      Payments, is hereby revised as
follows;

              

      

    

    
       

      -     
Sub-item l,b,(l)(b), is hereby amended to include the
following:

    

    
       

         
   Contract Year 2008-2009 Medicaid Reform rates under current
Capitation Rate methodology.

    

    
      
      

      -   
  Sub-item l.b.(l)(i), the first paragraph is hereby amended to now
read as follows;

    

    
       

      
        	
                 
      

              	
                (1)
      100% of Risk Adjusted Methodology: The capitation amount based on the
      percentage of Risk-Adjusted methodology (n) multiplied by the Base Rates
      column for Risk-Adjusted methodology after budget neutrality factor
      (g).

              

      

    

    
       

      -     Sub-Item
l.b.(l)(j), the first sentence is hereby amended to now read as
follows:

    

    
       

      
        	
                 
      

              	
                (j)
      Final Rate (with Enhanced Benefit Adjustment); Tne current methodology
      capitation amount (d) added to the 100% of Risk-Adjusted methodology
      amount (l).

              

      

    

    
       

      AHCA
Contract No. FAR009, Amendment No. 9, Page 1of 2

    

    
      AHCA Form
2100-0002 (Rev. NOV03)

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      	
              
                WellCare
      of Florida, Inc. d/b/a

              

              
                Staywell
      Health Plan of Florida

              

            	
              
                Medicaid
      Reform HMO Contract

              

            

    

    
       

      
        	
                 
      

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

              

      

    

    
       

      
        	
                 
      

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

              

      

    

    
       

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

    

    
       

      This Amendment cannot be executed
unless ail previous Amendments to this Contract have been fully
executed.

    

    
      

    

    
      IN
WITNESS WHEREOF, the parties hereto have caused this ten (10) page Amendment
(including all attachments) to be executed by their officials thereunto duly
authorized,

    

    
       

    

    
      	
              
                WELLCARE
      OF FLORIDA, INC.

              

              
                D/B/A
      STAYWELL HEALTH PLAN

              

              
                OF
      FLORIDA

              

               

            	
              STATE
      OF FLORIDA, AGENCY FOR

              HEALTH
      CARE ADMINISTRATION

            
	
              SIGNED

            	
              SIGNED

            
	
              BY:
      /s/ Heath
      Schiesser            
      

            	
              BY:
      Holly
      Benson                    

            
	
               

              NAME:
      Heath
      Schiesser           
      

            	
               

              NAME:
      Holly
      Benson            
      

            
	
               

              TITLE:
      President and
      CEO        

            	
               

              TITLE:
      Secretary                     
      

            
	
               

              DATE:
      8/29/08                           
      

            	
               

              DATE:
      8/29/08                         
      

            

    

    
       

    

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

    

    
      

    

    
      	
              Specify/

              Type

            	
              Letter/

              Number

            	
               

              Description

            
	
              Exhibit

            	
              1-B

            	
              Benefit
      Grid (4 Pages)

            
	
              Exhibit

            	
              2-B

            	
              Second
      Revised Enrollment Levles (1 Page)

            
	
              Exhibit

            	
              3-C

            	
              Medicaid
      Reform HMO Capitation Rates (3
Pages)

            

    

    
       

    

    
      REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK

    

    
      

    

    
      AHCA
Contract No. FAR009, Amendment No. 9, Page 2 of 2

    

    
      AHCA Form
2100-0002 (Rev. NOV03)

    

    
       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

    

    
      	
              WellCare
      of Florida, Inc. d/b/a

              Staywell
      Health Plan of Florida

            	
              2008-2009

            

    

    
      

    

    
      
        
          Exhibit
1-B

        

      

    

    
      
        
          Benefit
Grid

          (i) Area 10 Broward- Children and
Families

        

        
          
            
              	
                      COVERED
      SERVICE CATEGORY

                    	
                      Visit/Script

                      Limit

                    	
                      Limit
      Period

                      (Annual/Monthly)

                    	
                      Dollar
      Limit

                    	
                      Limit
      Period

                      (Annual)

                    	
                      Copay

                      Amount

                    	
                      Copay

                      Application

                    
	
                      Hospital
      Inpatient

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Behavioral
      Health

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      admit

                    
	
                       Physical
      Health

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      admit

                    
	 
      	 
      
	
                      Transplant
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      
	
                      Outpatient
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Emergency
      Room

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Medical/Drug
      Therapies (Chemo, Dialysis)

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Ambulatory
      Surgery - ASC

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Hospital
      Outpatient Surgery

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      visit

                    
	
                      Lab
      / X-ray

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      day

                    
	
                      Hospital
      Outpatient Services NOS

                    	 
      	 
      	 
      	
                      Annual

                    	
                            
      $

                    	
                      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

                    	 
      	 
      	 
      	 
      	
                          
       
      $           -

                    	
                      visit

                    
	
                      Specialty
      Physician

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      visit

                    
	
                      ARNP
      / Physician Assistant

                    	 
      	 
      	 
      	 
      	
                         $           -

                    	
                      visit

                    
	
                      Clinic
      (FQHC, RHC)

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      visit

                    
	
                      Clinic
      (CHD)

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Other

                    	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      
	
                      Other
      Outpatient Professional Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Home
      Health Services

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                            
      $

                    	
                      visit

                    
	
                      Chiropractor

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                            
      $

                    	
                      visit

                    
	
                      Podiatrist

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                             $

                    	
                      visit

                    
	
                      Dental
      Services

                    	 
      	
                       
      

                    	 
      	
                      Annual

                    	
                                  
             -

                    	
                      coinsurance

                    
	
                      Vision
      Services

                    	 
      	 
      	 
      	
                      Annual

                    	
                             $           -

                    	
                      visit

                    
	
                       Hearing
      Services

                    	 
      	 
      	 
      	
                      Annual

                    	 
      	
                       
      

                    
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Outpatient
      Mental Health

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      visit

                    
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Outpatient
      Pharmacy

                    	
                      10

                    	
                      Monthly

                    	 
      	
                       Annual

                    	 
      	 
      
	 
      	
                       
      

                    
	
                      Other
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Ambulance

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Non-emergent
      Transportation

                    	 
      	 
      	 
      	 
      	
                            
      $

                    	
                      trip

                    
	
                      Durable
      Medical Equipment

                    	 
      	 
      	 
      	
                      Annual

                    	 
      	 
      

            

          

        

         

        
          	
                  Enhanced
      benefits

                	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      

        

      

    

    
       

      AHCA
Contract No. FAR009, Exhibit 1-B, Page 1 of 4

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      	
              WellCare
      of Florida, Inc. d/b/a

              Staywell
      Health Plan of Florida

            	
              2008-
      2009

            

    

    
      

    

    
      Exhibit
1-B

    

    
      Benefit
Grid

    

    
      

    

    
      (ii)
Area 10 Broward- Aged and Disabled

    

    
      
        
          	
                  COVERED
      SERVICE CATEGORY

                	
                  Visit/Script
      Limit

                	
                  Limit
      Period (Annual/Monthly)

                	
                  Dollar
      Limit

                	
                  Limit
      Period (Annual)

                	
                  Copay
      Amount

                	
                  Copay
      Application

                
	
                  Hospital
      Inpatient

                	 
      	 
      	 
      	 
      	
                         

                	
                   

                
	
                  Behavioral
      Health

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  admit

                
	
                  Physical
      Health

                	 
      	 
      	 
      	 
      	       
      $	           
       admit
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Transplant
      Services

                	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Outpatient
      Services

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Emergency
      Room

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Medical/Drug
      Therapies (Chemo, Dialysis)

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Ambulatory
      Surgery - ASC

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Hospital
      Outpatient Surgery

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  visit

                
	
                  Lab
      / X-ray

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  day

                
	
                  Hospital
      Outpatient Services NOS

                	 
      	 
      	 
      	
                  Annual

                	
                         
      $

                	
                  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

                	 
      	 
      	 
      	 
      	
                         
      $           -

                	
                  visit

                
	
                  Specialty
      Physician

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  visit

                
	
                  ARNP
      / Physician Assistant

                	 
      	 
      	 
      	 
      	
                         
      $           -

                	
                  visit

                
	
                  Clinic
      (FQHC, RHC)

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  visit

                
	
                  Clinic
      (CHD)

                	 
      	 
      	 
      	 
      	 
      	
                   
      

                
	
                  Other

                	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Other
      Outpatient Professional Services

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Home
      Health Services

                	 
      	
                  Annual

                	 
      	
                  Annual

                	
                         
      $

                	
                  visit

                
	
                  Chiropractor

                	 
      	
                  Annual

                	 
      	
                  Annual

                	
                         
      $

                	
                  visit

                
	
                  Podiatrist

                	 
      	
                  Annual

                	 
      	
                  Annual

                	
                         
      $

                	
                  visit

                
	
                  Dental
      Services

                	 
      	 
      	
                  $

                	
                  Annual

                	
                         
                  
      -

                	
                  coinsurance

                
	
                  Vision
      Services

                	 
      	 
      	 
      	
                  Annual

                	
                        
      $           
      -

                	
                  visit

                
	
                  Hearing
      Services

                	 
      	 
      	 
      	
                  Annual

                	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Outpatient
      Mental Health

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  visit

                
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Outpatient
      Pharmacy

                	
                  17

                	
                              Monthly

                	 
      	
                            
       Annual

                	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Other
      Services

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Ambulance

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  Non-emergent
      Transportation

                	 
      	 
      	 
      	 
      	
                         
      $

                	
                  trip

                
	
                  Durable
      Medical Equipment

                	 
      	 
      	 
      	
                  Annual

                	 
      	 
      

        

         

        
          
            	
                    Enhanced
      benefits

                  
	
                       
      (Circumcision, boys up to one year)

                  
	
                       
      ($25 OTC, per household per month)

                  
	
                       
      (Expanded dental services – Exams / X-rays / Deep Cleaning / Clear and
      Silver Fillings / Crown (limited)

                  
	
                       
      Flouride / Periodontal Scaling and root planning)

                  
	
                       
      (Respite Events – up to 1 per
month)

                  

          

        

      

       

      AHCA
Contract No. FAR009, Exhibit 1-B, Page 2 of 4

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      	
              WellCare
      of Florida Inc.

              d/b/a
      Staywell Health Plan of Florid

            	
              2008-2009

            

    

    
       

    

    
      
        Exhibit 1-B

        Benefit Grid

        (i) Area 4 Duval- Children and
Families

        
          
            
              	
                      COVERED
      SERVICE CATEGORY

                    	
                      Visit/Script
      Limit

                    	
                      Limit
      Period (Annual/Monthly)

                    	
                      Dollar
      Limit

                    	
                      Limit
      Period (Annual)

                    	
                      Copay
      Amount

                    	
                      Copay
      Application

                    
	
                      Hospital
      Inpatient

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Behavioral
      Health

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      admit

                    
	
                      Physical
      Health

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      admit

                    
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Transplant
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Outpatient
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Emergency
      Room

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Medical/Drug
      Therapies (Chemo, Dialysis)

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Ambulatory
      Surgery - ASC

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Hospital
      Outpatient Surgery

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      visit

                    
	
                      Lab
      / X-ray

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      day

                    
	
                      Hospital
      Outpatient Services NOS

                    	 
      	 
      	 
      	
                      Annual

                    	
                             
      $

                    	
                      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

                    	 
      	 
      	 
      	 
      	
                             
      $           -

                    	
                      visit

                    
	
                      Specialty
      Physician

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      visit

                    
	
                      ARNP
      / Physician Assistant

                    	 
      	 
      	 
      	 
      	
                             
      $           -

                    	
                      visit

                    
	
                      Clinic
      (FQHC, RHC)

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      visit

                    
	
                      Clinic
      (CHD)

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Other

                    	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Other
      Outpatient Professional Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Home
      Health Services

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                             
      $

                    	
                      visit

                    
	
                      Chiropractor

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                             
      $

                    	
                      visit

                    
	
                      Podiatrist

                    	 
      	
                      Annual

                    	 
      	
                      Annual

                    	
                             
      $

                    	
                      visit

                    
	
                      Dental
      Services

                    	 
      	 
      	       
      $   	
                      Annual

                    	
                                          
      -

                    	
                      coinsurance

                    
	
                      Vision
      Services

                    	 
      	 
      	 
      	
                      Annual

                    	
                             
      $           -

                    	
                      visit

                    
	
                      Hearing
      Services

                    	 
      	 
      	 
      	
                      Annual

                    	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Outpatient
      Mental Health

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      visit

                    
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Outpatient
      Pharmacy

                    	
                      9

                    	
                           Monthly

                    	 
      	
                        Annual

                    	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Other
      Services

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Ambulance

                    	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Non-emergent
      Transportation

                    	 
      	 
      	 
      	 
      	
                             
      $

                    	
                      trip

                    
	
                      Durable
      Medical Equipment

                    	 
      	 
      	 
      	
                      Annual

                    	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                      Enhanced
      benefits

                    	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      

            

          

        

         

        AHCA Contract No. FAR009, Exhibit
1-B, Page 3 of 4

      

       

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        	
                WellCare
      of Florida Inc.

                d/b/a
      Staywell Health Plan of Florid

              	
                2008-2009

              

      

       

    

    Exhibit
1-B

    
      Benefit
Grid

    

    
      
        (ii) Area 4 Duval- Aged and
Disabled

        
          
            	
                    COVERED
      SERVICE CATEGORY

                  	
                    Visit/Script
      Limit

                  	
                    Limit
      Period (Annual/Monthly)

                  	
                    Dollar
      Limit

                  	
                    Limit
      Period (Annual)

                  	
                    Copay
      Amount

                  	
                    Copay
      Application

                  
	
                    Hospital
      Inpatient

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    admit

                  
	
                    Physical
      Health

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    admit

                  
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Transplant
      Services

                  	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Outpatient
      Services

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Emergency
      Room

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Medical/Drug
      Therapies (Chemo, Dialysis)

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Ambulatory
      Surgery - ASC

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                     Hospital
      Outpatient Surgery

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    visit

                  
	
                    Lab
      / X-ray

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    day

                  
	
                    Hospital
      Outpatient Services NOS

                  	 
      	 
      	 
      	
                    Annual

                  	
                           
      $

                  	
                    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

                  	 
      	 
      	 
      	 
      	
                           
      $           -

                  	
                    visit

                  
	
                    Specialty
      Physician

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    visit

                  
	
                    ARNP
      / Physician Assistant

                  	 
      	 
      	 
      	 
      	
                           
      $           -

                  	
                    visit

                  
	
                    Clinic
      (FQHC, RHC)

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    visit

                  
	
                    Clinic
      (CHD)

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Other

                  	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Other
      Outpatient Professional Services

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Home
      Health Services

                  	 
      	
                    Annual

                  	 
      	
                    Annual

                  	
                           
      $

                  	
                    visit

                  
	
                    Chiropractor

                  	 
      	
                    Annual

                  	 
      	
                    Annual

                  	
                           
      $

                  	
                    visit

                  
	
                     Podiatrist

                  	 
      	
                    Annual

                  	 
      	
                    Annual

                  	
                           
      $

                  	
                    visit

                  
	
                     Dental
      Services

                  	 
      	 
      	
                    $

                  	
                    Annua

                  	
                                     
      -

                  	
                    coinsurance

                  
	
                    Vision
      Services

                  	 
      	 
      	 
      	
                    Annual

                  	
                           
      $           -

                  	
                    visit

                  
	
                    Hearing
      Services

                  	 
      	 
      	 
      	
                    Annual

                  	 
      	
                     
      

                  
	 
      	 
      	 
      	 
      	
                     
      

                  	 
      	 
      
	
                    Outpatient
      Mental Health

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    visit

                  
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Outpatient
      Pharmacy

                  	
                    17

                  	
                        
                 Monthly

                  	
                     Annual

                  	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Other
      Services

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Ambulance

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    Non-emergent
      Transportation

                  	 
      	 
      	 
      	 
      	
                           
      $

                  	
                    trip

                  
	
                    Durable
      Medical Equipment

                  	 
      	 
      	 
      	
                    Annual

                  	 
      	 
      

          

        

         

        
          
            	
                    Enhanced
      benefits

                  
	 
      
	 
      
	 
      

          

        

      

    

    
       

    

    
      AHCA
Contract No. FAR009, Exhibit 1-B, Page 4 of 4

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

     

    
      STAYWELL
HEALTH PLAN OF FLORIDA

      
        EXHIBIT
2-B

        
          SECOND
REVISED ENROLLMENT LEVELS

        

      

       

    

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

    

    
      Agency
Area 04

    

     

    
      	
              
                Eligibility
      Category/ Population

              

            	
              
                County

              

            	
              
                Health
      Plan

              

              
                Provider

              

              
                Number

              

            	
              
                Plan
      Type

              

              
                (Comp
      orComp & Catastrophic)

              

            	
              
                Maximum

              

              
                Enrollment

              

              
                Level

              

            
	
              
                TANF

              

            	
              
                Duval

              

            	 
      	
              
                Comprehensive
      &
      Catastrophic

                 

              

            	
              
                 

                3,200

              

            
	
              
                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

              

            	
              
                 

                30,000

              

            
	
              
                SSI

                 

              

            	
              
                Broward

              

            	 
      	
              
                Comprehensive
      &
      Catastrophic

              

            
	
              
                HIV/AIDS

                 

              

            	 
      	 
      	 
      	 
      
	
              
                Children
      with Chronic
      Conditions

                 

              

            	 
      	 
      	 
      	 
      

    

    
      

    

    
      REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK

    

    
      

    

    
      AHCA
Contract No. FAR009, Exhibit 2-B, Page 1 of 1

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

     

    
      EXHIBIT
3-C

    

    
      MEDICAID
REFORM HMO CAPITATION RATES

      (By Area,
Age, and Eligibility Category)

      
        September
1, 2008 - August 31, 2009

      

    

    
       

      
        TABLE 2

         

        
          	 Area: 10           	 County: 
      Broward	
                   September 1,
      2008

                

        

         

      

    

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

    

     

    
      	
              
                Eligibility
      Category/ 

                Population

              

            	
              
                Total
      Rates for Comprehensive and Catastrophic Components

              

            	
              
                Total
      Rate for Comprehensive 

                Component
      Only

              

            
	
              
                Children
      and Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $              868.52

              

            	
              
                 
      $                 750.55

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $              191.05

              

            	
              
                 
      $                 181.72

              

            
	
              
                Age
      1 and Up - Base Rate for Risk adjustment

              

            	
              
                 
      $              107.11

              

            	
              
                 
      $                 105.39

              

            
	 
      
	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $     
         17,572.21

              

            	
              
                 
      $              9,173.75

              

            
	
              
                Newborns
      aged 3-11
      months                

              

            	
              
                 
      $ 
               3,896.35

              

            	
              
                 
      $              2,167.93

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                 
      $           
        789.84

              

            	
              
                 
      $                 725.69

              

            
	 
      
	
              
                Medicare
      Parts A and B

              

            	 
      	 
      
	
              
                Under
      Age 65

              

            	
              
                 
      $              139.11

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                 
      $            
         99.49

              

            	
              
                N/A

              

            
	
               
      

            
	
              
                Medicare Part B
      Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                 
      $          
         265.17

              

            	
              
                N/A

              

            
	 
      
	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                 
      $         
       1,823.74

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                 
      $          
      3,422.47

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                 
      $            
       256.03

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                 
      $             
      546.61

              

            	
              
                N/A

              

            

    

    
       

      
        
          
            	
                    
                       

                      Kick Payments
      Amounts for Covered Obstetrical Delivery
      Services:

                       

                    

                  

          

        

      

    

    
      	
              
                CPT
      

                Code

              

            	
              
                Obstetrical
      Delivery CPT Code Description

              

            	
              
                Payment
      

                Amount

              

            
	
              
                5440'/

              

            	
              
                Vaginal
      delivery only

              

            	
              
                 

                 

                $3,941.45

              

            
	
              
                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 inc postpartum

              

              
                care

              

            

    

    
       

      AHCA
Contract No. FAR009, Exhibit 3-C, Page 1 of 3

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      EXHIBIT
3-C

    

    
      MEDICAID
REFORM HMO CAPITATION RATES

    

    
      (By Area,
Age, and Eligibility Category)

    

    
      September
1,200S - August 31, 2009

                                                                                                                                                                                                                                                                                       
 September
1, 2008

    

    
      

       

      Area:  4      County:  Duval.
Baker, Clay and Nassau

    

    
       

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

    

     

     

    
      	
              
                Eligibility
      Category/

                Population

              

            	
              
                Total
      Rates for Comprehensive and Catastrophic Component

              

            	
              
                Total
      Rate for 

                Comprehensive

                Component
      Only

              

            
	
              
                Children
      and Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $            895.21

              

            	
              
                 
      $                  773.61

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $            196.74

              

            	
              
                 
      $                  187.13

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                 
      $            110.24

              

            	
              
                 
      $                  108.46

              

            
	 
      
	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                 
      $       14,234.51

              

            	
              
                 
      $          
          7,431.27

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                 
      $     
         3,172.94

              

            	
              
                 
      $               1,765.42

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                 
      $        
         610.65

              

            	
              
                 
      $       
                561.06

              

            
	 
      	 
      
	
              
                Medicare
      Parts A and B

              

            	 
      	 
      
	
              
                Under
      Age 65

              

            	
              
                 
      $            158.06

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                 
      $            112.96

              

            	
              
                N/A

              

            
	 
      	 
      
	
              
                Medicare
      Part B Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                 
      $            326.42

              

            	
              
                N/A

              

            
	 
      	 
      
	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                 
      $        
      1,161.19

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                 
      $        
      2,285.96

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                 
      $            157.41

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                 
      $            336.05

              

            	
              
                N/A

              

            

    

     

    
      	
              
                 

                Kick
      Payments Amounts for Covered Obstetrical Delivery
      Services:

                livery Services:

              

            
	
              
                CPT
      

                Code

              

            	
              
                Obstetrical
      Delivery CPT Code Description

              

            	
              
                Payment
      Amount

              

            
	
              
                59409

              

            	
              
                Vaginal
      delivery only

              

            	
              
                 

                 

                 

                $3,977.49

              

            
	
              
                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
      deliver)1
      only, following atlempted vaginal delivery after previous cesarean
      delivery inc postpartum care

              

            

    

    
       

      AHCA
Contract No. FAR009, Exhibit 3-C, Page 2 of 3

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      EXHIBIT
3-C

    

    
      MEDICAID
REFORM HMO CAPITATION RATES

    

    
      (By Area,
Age, and Eligibility Category)

    

    
      September
1, 2008 - August 31, 2009

    

     

    
      	
              Area:  10    
      

            	
              County:  Broward

            	 September
      1,2008
	
              Area:  4      
      

            	
              County:  Duval, Baker, Clay and
      Nassau

            	 

    

    

     

    
      	
              
                CPT

              

              
                Code

              

            	
              
                Transplant
      CPT Code Description

              

            	
              
                Children/Adolescents
      or Adult

              

            	
              
                Payment

              

              
                Amount

              

            
	
              
                32851

              

            	
              
                lung
      single, without bypass

              

            	
              
                C
      hi1dren/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

              

            	
              
                All
      Age Groups

              

            	
              
                $162,000.00

              

            
	
              
                47135

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            
	
              
                47136

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            

    

    
      

      AHCA
Contract No. FAR009, Exhibit 3-C, Page 3 of 3far009amend10.htm

    Back to Form 8-K

    Exhibit 10.4

     

    
      	
              
                WellCare
      of Florida, Inc. d/b/a

              

              
                Staywell
      Health Plan of Florida

              

            	
              
                Medicaid
      Reform HMO Contract

              

            

    

    
      

    

    
      AHCA
CONTRACT NO. FAR009

    

    
      AMENDMENT
NO. 10

    

    
       

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

    

    
       

      
        	
                1.

              	
                Effective
      September 1, 2008, Attachment I, Scope of Services, Exhibit 3-D is hereby
      included and made a part of the Contract. All references in the Contract
      to Exhibit 3-C, shall hereinafter refer respectively to Exhibit
      3-D.

              

      

    

    
       

      
        	
                 
      

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

              

      

    

    
       

      
        	
                 
      

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

              

      

    

    
       

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

    

    
       

      
        	
                 
      

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

              

      

    

    
      

    

    
      
        	
                 
      

              	
                IN
      WITNESS WHEREOF, the parties hereto have caused this four (4) page
      Amendment (including all attachments) to be executed by their officials
      thereunto duly authorized.

              

      

    

    
       

    

    
      	
              WELLCARE
      OF FLORIDA, INC.

              D/B/A
      STAYWELL HEALTH PLAN

              OF
      FLORIDA

            	
              STATE
      OF FLORIDA, AGENCY FOR 

              HEALTH
      CARE ADMINISTRATION

            
	
               

              SIGNED

              BY: /s/
      Heath
      Schiesser                  
           

            	
               

              SIGNED

              BY:
      /s/ Mark Thomas
      for Holly Benson

            
	
              NAME:
      Heath
      Schiesser               
            

            	
              NAME:
      Holly
      Benson                              
      

            
	
              TITLE:
      President and
      CEO           
            

            	
              TITLE:
      Secretary                                       
      

            
	
              DATE:
      9-10-08                                
            

            	
              DATE:
      9-10-08                                           
      

            

    

    
       

       

      List of
Attachments/Exhibits Included as part of this Amendment:

    

    
       

    

    
      	
              Specify

              Type

            	
              Letter/

              Number

            	
              Description

            
	
              Exhibit

            	
              3-D

            	
              Medicaid
      Reform HMO Capitation Rates (3
Pages)

            

    

    
       

    

    
      REMAINDER
OF THIS PAGE INTENTIONALLY LEFT BLANK

    

    
       

      AHCA
Contract No. FAR009, Amendment No. 10, Page 1 of 1

      AHCA Form
2100-0002 (Rev. NOV03)

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
       

    

    
      EXHIBIT 3-D

      MEDICAID REFORM HMO CAPITATION
RATES

      
        (By Area,
Age, and Eligibility Category)

        
          September
1,2008 - August 31, 2009

        

      

      

    

    
      TABLE
2

    

    
      

    

    
      	
              Area:  10

            	
              County:  Broward

            	
              September
      1, 2008

            

    

    
      

    

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

    

     

    
      	
              
                Eligibility
      Category/ 

                Population

              

            	
              
                Total
      Rates for Comprehensive and Catastrophic Components

              

            	
              
                Total
      Rate for 

                Comprehensive

                Component
      Only

              

            
	
              
                Children
      and Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                      
      $            885.88

              

            	
              
                    
      $               765.55

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                      
      $            194.87

              

            	
              
                    
      $               185.35

              

            
	
              
                Age
      1 and Up - Base Rate for Risk adjustment

              

            	
              
                      
      $            109.25

              

            	
              
                    
      $               107.50

              

            

    

     

    
      	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                $

              

            	
              
                17,923.49

              

            	
              
                     
      $

              

            	
              
                9,357.13

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                $

              

            	
              
                 
      3,974.24

              

            	
              
                     
      $

              

            	
              
                2,211:26

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                $

              

            	
              
                    
      805.53

              

            	
              
                     
      $

              

            	
              
                  
      740.20

              

            

    

     

    
      	
              
                Medicare
      Parts A and B

              

            	 
      	 
      
	
              
                Under
      Age 65

              

            	
              
                      
      $            141.89

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                      
      $            101.48

              

            	
              
                N/A

              

            

    

     

    
      	
              
                Medicare
      Part B Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                      
      $            270.48

              

            	
              
                N/A

              

            

    

     

    
      	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                      
      $         1,860.68

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                      
      $         3,491.79

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                      
      $            261.22

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                      
      $            557.68

              

            	
              
                N/A

              

            

    

     

    
      	
              
                 

                Kick
      Payments Amounts for Covered Obstetrical Delivery Services:

                 

              

            
	
              
                CPT
      

                Code

              

            	
              
                Obstetrical
      Delivery CPT Code Description

              

            	
              
                Payment
      Amount

              

            
	
              
                59409

              

            	
              
                Vaginal
      delivery only

              

            	
              
                 

              

              
                 

              

              
                $3,941.45

              

            
	
              
                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 inc postpartum
care

              

            

    

    
       

    

    
      AHCA
Contract No. FAR009, Exhibit 3-D, Page 1 of 3

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
       

    

    
      EXHIBIT 3-D 

      MEDICAID REFORM HMO CAPITATION
RATES

      
        (By Area,
Age, and Eligibility Category) 

        September 1, 2008 - August 31,
2009

      

      

    

    
      	
              Area:   4

            	
              County:  Duval, Baker, Clay and
      Nassau

            	
              September
      1, 2008

            

    

    
      

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

    

     

    
      	
              
                Eligibility
      Category/ 

                Population

              

            	
              
                Total
      Rates for Comprehensive 

                and
      Catastrophic Component

              

            	
              
                Total
      Rate for 

                Comprehensive

                Component
      Only

              

            
	
              
                Children
      and Families:

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                      
      $            913.11

              

            	
              
                    
      $      
              789.08

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                      
      $            200.67

              

            	
              
                    
      $  
                  190.87

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                      
      $            112.44

              

            	
              
                    
      $
                    110.63

              

            
	 
      
	
              
                Aged
      and Disabled:

              

            	 
      	 
      
	
              
                No
      Medicare

              

            	 
      	 
      
	
              
                Newborns
      aged 0-2 months

              

            	
              
                      
      $       14,519.07

              

            	
              
                    
      $ 
                7,579.82

              

            
	
              
                Newborns
      aged 3-11 months

              

            	
              
                      
      $         3,236.37
      

              

            	
              
                    
      $            1,800.71

              

            
	
              
                Age
      1 and Up - Base Rate for Risk Adjustment

              

            	
              
                      
      $            622.86

              

            	
              
                     $               572.27

              

            
	 
      	 
      
	
              
                Medicare
      Parts A and B

              

            	 
      	 
      
	
              
                Under
      Age 65

              

            	
              
                      
      $            161.22

              

            	
              
                N/A

              

            
	
              
                Age
      65 and over

              

            	
              
                      
      $            115.22

              

            	
              
                N/A

              

            
	 
      	 
      
	
              
                Medicare
      Part B Only

              

            	 
      	 
      
	
              
                All
      ages

              

            	
              
                      
      $            332.95

              

            	
              
                N/A

              

            
	 
      	 
      
	
              
                HIV/AIDS
      Specialty Population

              

            	 
      	 
      
	
              
                No
      Medicare HIV

              

            	
              
                       $         1,184.04

              

            	
              
                N/A

              

            
	
              
                No
      Medicare AIDS

              

            	
              
                      
      $         2,330.94

              

            	
              
                N/A

              

            
	
              
                Medicare
      HIV

              

            	
              
                      
      $            160.51

              

            	
              
                N/A

              

            
	
              
                Medicare
      AIDS

              

            	
              
                      
      $            342.66

              

            	
              
                N/A

              

            

    

    
       

    

    
      	
              
                 

                Kick
      Payments Amounts for Covered Obstetrical Delivery Services:

                 

              

            

    

    
      	
              
                CPT

                Code

              

            	
              
                Obstetrical
      Delivery CPT Code Description

              

            	
              
                Payment
      

                Amount

              

            
	
              
                59409

              

            	
              
                Vaginal
      delivery only

              

            	
              
                 

              

              
                 

              

              
                $3,977.49

              

            
	
              
                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 inc postpartum
care

              

            

    

    
       

    

    
      AHCA
Contract No. FAR009, Exhibit 3-D, Page 2 of 3

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
       

    

    
      EXHIBIT 3-D 

      MEDICAID REFORM HMO CAPITATION
RATES
(By Area,
Age, and Eligibility Category) 

      
        September 1, 2008 - August 31,
2009

      

    

    
      
      

       

      
        	 Area:  10	 County:  Broward	
                 September 1,
      2008

              
	
                 

                Area:  4  

              	
                 

                County:  Duval, Baker, Clay and
      Nassau

              	 

      

       

       

    

    
      	
              
                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

              

            	
              
                All
      Age Groups

              

            	
              
                $162,000.00

              

            
	
              
                47135

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            
	
              
                47136

              

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

              

            	
              
                All
      Age Groups

              

            	
              
                $122,600.00

              

            

    

    
      

       

      AHCA
Contract No. FAR009, Exhibit 3-D, Page 3 of
3

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