Document:

Exhibit 10.1

Exhibit 10.1

EMPLOYMENT AGREEMENT

THIS EMPLOYMENT AGREEMENT (this “Agreement”) is entered into to be effective as of November 3, 2009 (the
“Effective Date”), between PEERLESS MFG. CO. (“Employer”), and Warren Hayslip (“Employee”).

Section 1. Employment.

1.1 Employment and Term. Subject to the terms and conditions of this Agreement, Employer agrees to employ
Employee as the Vice President and Chief Operating Officer of the Employer pursuant to this Agreement for a term
beginning on the Effective Date and ending on the second anniversary of this agreement, (the “Term”) unless Employee’s
employment is terminated earlier as provided in Section 4 below. Sections 2, 3, and 5
of this Agreement shall survive any termination of Employee’s employment with Employer.

1.2 Duties. At all times during the course of Employee’s employment with Employer, Employee agrees to
perform the duties associated with his position diligently and to devote all of his business time, attention and
efforts to the business of Employer. Employee agrees to comply with the policies, procedures and guidelines
established by Employer from time to time. Employee agrees to perform his duties faithfully and loyally and to the
best of his abilities, and shall use his best efforts to promote the business of Employer. Employee understands and
agrees that both the business and personal standards and ethics of Employer’s employees must at all times be above
reproach. Employee agrees to act at all times so as to reflect this high standard. Employee further agrees to abide by
all rules, policies, or procedures established by Employer from time to time. Subject to the approval of the Board of
Directors of PMFG, Inc. (the “Board”).

1.3 Supervision. Employee shall perform the duties of employment under the direction and supervision of
Employer’s Chief Executive Officer.

1.4 Compensation. During Employee’s employment, Employer will pay Employee a base annualized salary of
$220,000 (“Base Salary”), less all applicable withholding as required by law and/or voluntarily elected by Employee, to
be paid in installments in accordance with Employer’s standard payroll practice and schedule. The Employer may adjust
the Employee’s annualized salary from time to time at its sole discretion, but Employee’s Base Salary shall never be
reduced below $220,000 without his consent. Employer will provide Employee with Employee benefits generally made
available by Employer to other similarly situated employees, as per company policy. During Employee’s employment,
Employer shall reimburse Employee for all reasonable and necessary expenses incurred by Employee in furtherance of
Employer’s business interests upon appropriate documentation of such expenditures in accordance with Employer’s general
policy.

1.5 Bonus. Employee shall be eligible to participate in and receive bonuses according to such bonus
structure and plan as may be established or modified from time to time by the Employer on the same basis as other
similarly situated officers of the Employer.

1.6 Long Term Incentive. Subject to the discretion and approval of the Board, Employee may be awarded
stock awards in the form of options and/or restricted stock on an annual basis subject to the terms of the applicable incentive plan as such may be established or modified by the
Board from time to time.

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Section 2. Non-Competition.

2.1 Non Competition.

(a) In consideration of his employment under this Agreement and Employer’s agreement to provide Employee
with Confidential Information under Section 3 below, Employee agrees that during the term of his employment
and for a period of two (2) years following termination of his employment (regardless of whether Employee is
terminated without Cause, for Cause (as defined in Section 4.1(c) below), voluntarily resigns or
otherwise), neither Employee nor any person or entity directly or indirectly controlling, controlled by or
under common control with Employee, shall directly or indirectly, on his own behalf or as an employee or other
agent of or an investor in another person:

(i) engage in any business conducted by Employer during Employee’s term of employment with
Employer (collectively, the “Business”);

(ii) influence or attempt to influence any customer or supplier of Employer or any affiliate of
Employer to purchase goods or services related to the Business from any person other than Employer or
such affiliate; or

(iii) employ or attempt to employ any individuals who are then or have been employees of
Employer or any affiliate of Employer during the preceding 12 months, or influence or seek to
influence any such employees to leave Employer’s or such affiliate’s employment.

(b) Employee specifically acknowledges that Employer’s products are sold in a world market and that
Employee has been engaged with regard to Employer’s products and Employer’s customers throughout the world
without geographic limitation, and accordingly that the restrictive covenant regarding competition contained
in this Section 2.1 shall apply without geographic limitation.

(c) Employee acknowledges that his obligations under this Section 2.1 are a material inducement
and condition to Employer’s entering into this Agreement and a material inducement and condition to Employee
receiving or having access to Confidential Information (as defined in Section 3.1). Employee
acknowledges and agrees that the terms and provisions of this Agreement (including the severance provisions of
Section 4.1) and Employee’s receipt and access to Confidential Information are sufficient
consideration for the restrictions set forth in this Section 2.1. Employee acknowledges and agrees
further that such restrictions are reasonable as to time, geographic area and scope of activity and do not
impose a greater restraint than is necessary to protect the goodwill and other business interests of Employer,
and Employee agrees that Employer is justified in believing the foregoing.

(d) If any provision of this Section 2.1 should be found by any court of competent jurisdiction
to be unenforceable by reason of its being too broad as to the period of time, territory, and/or scope, then, and in that event, such provision shall nevertheless
remain valid and fully effective, but shall be considered to be amended so that the period of time, territory,
and/or scope set forth shall be changed to be the maximum period of time, the largest territory, and/or the
broadest scope, as the case may be, which would be found enforceable by such court

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(e) Employee acknowledges that Employee’s violation or attempted violation of this Section 2.1
will cause irreparable damage to Employer or its affiliates, and Employee therefore agrees that Employer shall
be entitled as a matter of right to an injunction, out of any court of competent jurisdiction, restraining any
violation or further violation of such agreements by Employee or others acting on his behalf. Employer’s
right to injunctive relief will be cumulative and in addition to any other remedies provided by law or equity.

(f) Employee shall not be subject to the provisions of this Section 2 if Employer fails to pay any
uncontested amounts due to Employee under Section 4 and such failure is not cured within thirty (30) days
after written notice to Employer.

Section 3. Confidentiality; Nondisparagement; Conflict of Interest.

3.1 Confidentiality.

(a) In the course of his employment with Employer, Employer shall provide Employee with access to
commercially valuable, confidential or proprietary information of the Employer (“Confidential Information”).
Confidential Information means all information, whether oral or written, previously or hereafter developed,
acquired or used by Employer and relating to the business of Employer that is not generally known to the
public or others in Employer’s area of business, including without limitation (i) any trade secrets, work
product, processes, analyses or know-how of Employer; (ii) Employer’s advertising, product development,
strategic and business plans and information, including customer and prospect lists; (iii) the prices at which
Employer has sold or offered to sell its products or services; and (iv) Employer’s internal financial
statements, budgets, cost information, pricing information and other financial information.

(b) Employee acknowledges and agrees that the Confidential Information is and shall be the sole and
exclusive property of Employer. Employee shall not use any Confidential Information for his own benefit or
disclose any Confidential Information to any third party (except in the course of performing his authorized
duties for Employer under this Agreement), either during or subsequent to his employment with Employer.

(c) Specifically, Employee agrees that, except as expressly authorized in writing by Employer, or as may
be required by law or court order, Employee shall (i) not disclose Confidential Information to any third
party, (ii) not copy Confidential Information for any reason, and (iii) not remove Confidential Information
from Employer’s premises. Upon termination of his employment with Employer, Employee shall promptly deliver
to the Employer all Confidential Information, including documents, computer disks and other computer storage
devices and other papers and materials (including all copies thereof in whatever form) containing or incorporating any Confidential
Information or otherwise relating in any way to the Employer’s business that are in his possession or under
his control.

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(d) Employee acknowledges that Employee’s violation or attempted violation of this Section 3.1
will cause irreparable damage to Employer or its affiliates, and Employee therefore agrees that Employer shall
be entitled as a matter of right to an injunction, out of any court of competent jurisdiction, restraining any
violation or further violation of such agreements by Employee or others acting on his behalf. Employer’s
right to injunctive relief will be cumulative and in addition to any other remedies provided by law or equity.

3.2. Covenant of Nondisparagement. In consideration of this Agreement, Employee agrees and promises that,
during the Term and at all times after the termination of this Agreement (regardless of whether Employee is terminated
without Cause, for Cause, voluntarily resigns or otherwise), not to make any libelous, disparaging or otherwise
injurious statements about or concerning Employer or any of its affiliates, their officers, employees or
representatives. Such prohibited statements include any statement that is injurious to the business or business
reputation of any of Employer, its affiliates or their employees or representatives, but does not include reasonable
statements of disagreement that Employee makes for the purpose of protecting or enforcing any of his rights or
interests hereunder or defending against any claim or claims of Employer, so long as such statements are not slanderous
or libelous and are delivered in terms as would ordinarily be considered customary and appropriate.

3.3. Conflict of Interest. Employee agrees that during the Term, without the prior approval of the Board,
Employee shall not engage, either directly or indirectly, in any activity which may involve a conflict of interest with
Employer or its affiliates (a “Conflict of Interest”), including ownership in any supplier, contractor, subcontractor,
customer or other entity with which Employer does business (other than as a shareholder of less than one percent of a
publicly traded class of securities) or accept any material payment, service, loan, gift, trip, entertainment or other
favor from a supplier, contractor, subcontractor, customer or other entity with which Employer does business and that
Employee shall promptly inform the Board as to each offer received by Employee to engage in any such activity.
Employee further agrees to disclose to Employer any other facts of which Employee becomes aware which might involve or
give rise to a Conflict of Interest or potential Conflict of Interest.

Section 4. Termination.

4.1 Termination by Employer.

(a) Employer may terminate Employee’s employment without Cause upon no less than 30 days prior notice of
termination to Employee. Employer shall pay the Severance Compensation (as defined in Section 5.1(h)) to
Employee after the effective date of such termination, except as otherwise provided by the terms of any stock
option or restricted stock agreement entered into with Employee during the Term.

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(b) Employer may discharge Employee for Cause at any time without prior notice. In the event of any such
termination for Cause, Employer’s obligations to pay any base salary, incentive compensation or bonus or
provide for any benefits to Employee shall terminate immediately upon the effective date of such termination,
except as otherwise provided by the terms of any stock option or restricted stock agreement entered into with
Employee during the Term.

(c) As used herein, “Cause” shall mean any of the following:

(i) the conviction of Employee by a court of competent jurisdiction of any felony or crime
involving moral turpitude;

(ii) commission by Employee of an act of fraud, dishonesty, slander, or other act reflecting
unfavorably upon the public image of Employer as reasonably determined by Chief Executive Officer;

(iii) the failure by Employee to substantially perform his duties hereunder, or any wrongdoing
by Employee resulting in injury to Employer, in each case as reasonably determined by Chief Executive
Officer;

(iv) the failure by Employee to follow a directive of the Chief Executive Officer or Board; or

(v) violation of any policies or procedures of Employer, including without limitation, any human
relations policy.

4.2 Termination by Employee. Employee may resign from Employee’s employment hereunder (whether for
voluntary retirement or otherwise) upon no less than 30 days prior notice of resignation to Employer, unless such prior
notice is otherwise waived by Employer in its absolute and sole discretion. The effective date of Employee’s
resignation shall be as stated in Employee’s notice of resignation or at the sole option of Employer, such earlier date
as determined by Employer in its sole discretion. If Employee voluntarily resigns from his employment with Employer
during the term hereof (whether for voluntary retirement or otherwise), Employer’s obligations to pay any base salary,
incentive compensation or bonus or provide for any benefits shall terminate immediately upon the effective date of such
resignation. Upon retirement, Employee shall be entitled to all benefits (if any) provided by Employer in the ordinary
course to other executive officers of Employer at comparable retirement age.

4.3 Termination on Death of Employee. This Agreement shall terminate automatically upon the death of
Employee and all rights of Employee, his heirs, executors and administrators to salary, bonus, incentive compensation
or benefits shall terminate immediately, except as otherwise provided in Employer’s benefit plans in effect at such
time.

4.4 Termination by Disability. Employer may terminate Employee’s employment hereunder upon Employee
becoming Disabled (as defined below). Upon such termination, Employer shall pay Employee an amount equal to his then
current monthly base salary for a period of six months, which payment amounts will be reduced by any disability
payments Employee receives during such period from the disability insurance provided through Employer, if any. Employee shall be entitled to all other disability benefits then in effect (if any) provided by Employer
to other similarly situated executive officers of Employer. In the event of termination due to Employee being
Disabled, except as aforesaid or as otherwise agreed to in writing by Employee and Employer, Employer shall have no
other obligation to pay any base salary, incentive compensation or bonus or provide for any benefits to Employee after
the effective date of termination. For purposes of this Section, “Disabled” means any mental or physical impairment
lasting (or that will last) more than 180 consecutive or non-consecutive calendar days that prevents Employee from
performing the essential functions of his position with or without reasonable accommodation as determined by a
competent physician chosen by Employer and consented to by Employee or his legal representatives, which consent will
not be unreasonably withheld or delayed. Employee agrees to submit to appropriate medical examinations and authorize
his physicians to release medical information necessary to determine whether Employee is Disabled for purposes of this
Agreement.

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Section 5. Termination.

5.1 Definitions. For Purposes of this Section 5, the following definitions apply.

	 	(a)	 	Acquiring Person. An “Acquiring Person” shall mean any person that, together with all
Affiliates and Associates of such person, is the beneficial owner of 50.1% or more of the outstanding
Common Stock of the Employer or its parent. The term “Acquiring Person” shall not include the Employer,
its parent, any subsidiary of the Employer, any employee benefit plan of the Employer (or trust with
respect thereto) or subsidiary of the Employer, or any person holding Common Stock of the Employer for or
pursuant to the terms of any such plan.

	 	(b)	 	Affiliate and Associate. “Affiliate” and “Associate” shall have the respective
meanings ascribed to such terms in Rule 12b-2 of the General Rules and Regulations under the Securities
Exchange Act of 1934, as amended (the “Exchange Act”) in effect on the date of this Agreement.

	 	(c)	 	Cause. For “Cause” shall have the meaning set forth in Section 4.1(c) above.

	 	(d)	 	Change in Control. A “Change in Control” of the Employer or PMFG, Inc., shall have
occurred if at any time during the Term any of the following events shall occur:

	 	(i)	 	The Employer or PMFG, Inc., is merged, consolidated or reorganized into or
with another corporation or other legal person and as a result of such merger, consolidation or
reorganization less than 50.1% of the combined voting power to elect Directors of the then
outstanding securities of the remaining corporation or legal person or its ultimate parent
immediately after such transaction is available to be received by all stockholders on a pro rata
basis and is actually received in respect of or exchange for voting securities of the Employer
or PMFG, Inc. pursuant to such transaction;

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	 	(ii)	 	The Employer or PMFG, Inc. sells all or substantially all of its assets to
any other corporation or other legal person not controlled by or under common control with the
Employer or PMFG, Inc.;

	 	(iii)	 	Any person or group (including any “person” as such term is used in Section
13(d)(3) or Section 14(d)(2) of the Exchange Act has become the beneficial owner (as the term
“beneficial owner” is defined under Rule 13d-3 or any successor rule or regulation promulgated
under the Exchange Act) of securities which when added to any securities already owned by such
person would represent in the aggregate 50% or more of the then outstanding securities of the
Employer or PMFG, Inc., which are entitled to vote to elect Directors;

	 	(iv)	 	If at any time, the Continuing Directors then serving on the Board, cease for
any reason to constitute at least a majority thereof;

	 	(v)	 	Any occurrence that would be required to be reported in response to Item 6(e)
of Schedule 14A of Regulation 14A or any successor rule or regulation promulgated under the
Exchange Act; or

	 	(vi)	 	Such other events that cause a change in control of the Employer, as
determined by the Board in its sole discretion;

provided, however, a Change in Control of the Employer or PMFG, Inc. shall not be
deemed to have occurred as the result of any transaction having one or more of the foregoing effects
if such transaction is both (1) proposed by, and (2) includes a significant equity participation of,
executive officers of the Employer or PMFG, Inc. as constituted immediately prior to the occurrence
of such transaction or any Employer employee stock ownership plan or pension plan.

	 	(e)	 	Code. The “Code” shall mean the Internal Revenue Code of 1986, as amended.

	 	(f)	 	Continuing Director. A “Continuing Director” shall mean a member of the Board who (i)
is not an Acquiring Person, an Affiliate or Associate, a representative of an Acquiring Person or
nominated for election by an Acquiring Person, and (ii) was a member of the Board, on the date of this
Agreement or subsequently became a member of the Board of PMFG, Inc., and whose initial election or
initial nomination for election by the PMFG, Inc.’s stockholders was approved by a majority of the
Continuing Directors then on the Board.

	 	(g)	 	Disabled. “Disabled” shall have the meaning defined in Section 4.4 above.

	 	(h)	 	Severance Compensation. The “Severance Compensation” shall be:

	 	(i)	 	A lump sum amount equal to 75.0% of the Employee’s then current annualized
base salary in effect as of the date of the Termination;

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	 	(ii)	 	in any year in which Employee has been provided a bonus target under a bonus
plan adopted by the Board of PMFG, Inc., a pro rated bonus amount based upon the portion of the
year served by Employee, provided, however, such bonus amount shall be calculated and paid at
the time such bonuses are usually calculated by the Employer at year end; and

	 	(iii)	 	For a period of three (3) months, provide Employee with benefits
substantially similar to those which Employee was entitled to receive immediately prior to the
date of termination under all of the Employer’s “employee welfare benefit plans” within the
meaning of Section 3(1) of The Employee Retirement Income Security Act of 1974, as amended.

	 	(i)	 	Termination Date. The “Termination Date” shall be the effective date upon which the
Employer terminates the employment of Employee with the Employer within one year following a Change in
Control.

5.2. Rights of Employee Upon Change in Control and Subsequent Termination.

	 	(a)	 	The Employer shall provide Employee, within ten days following the Termination Date, Severance
Compensation, but without affecting the rights of Employee or the Employer at law or in equity, if,
within one year following the occurrence of a Change in Control, either of the following two events shall
occur:

	 	(1)	 	the Employer terminates Employee’s employment except for any of the following
reasons:

	 	(i)	 	Employee dies;

	 	(ii)	 	Employee becomes Disabled; or

	 	(iii)	 	The Employer terminates the Employee for Cause; or

	 	(2)	 	Employee terminates his employment after such Change in Control and the
occurrence of at least one of the following events:

	 	(i)	 	an material adverse change in the positions held by
Employee or a material diminution in the nature or scope of the authorities, functions
or duties attached to the positions with the Employer that Employee had immediately
prior to the Change in Control (provided however, a material adverse change or material
diminution shall not be deemed to have occurred simply because the parent of the
Employer has sold all or a substantial part of its interest in Employer, that Employer
becomes a subsidiary of another entity, or that Employee ceases to be a Vice President
of the Employer (PMFG, Inc.,), any reduction in Employee’s base salary (excluding bonus
and incentive compensation) during the Term or a material diminution in scope or value
of the aggregate other base benefits to which Employee was entitled from the Employer immediately prior to the Change in Control, any of which is not remedied
within ten calendar days after receipt by the Employer of written notice from
Employee of such change, reduction, alteration or termination, as the case may be;

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	 	(ii)	 	the relocation of the Employer’s principal executive
offices, or the requirement by the Employer that Employee have as his principal
location of work any location not within the greater Dallas, Texas metropolitan area or
that he/she travel away from his office in the course of discharging his duties
hereunder significantly more (in terms of either consecutive days or aggregate days in
any calendar year) than required of his prior to the Change in Control; or

	 	(iii)	 	the Employer commits any material breach of this
Agreement, which is not cured within ten calendar days after receipt by the Employer of
written notice from Employee of such breach.

	 	(b)	 	Upon written notice given by Employee to the Employer prior to the receipt of Severance
Compensation, Employee, at his sole option, may elect to have all or any part of any such amount paid to
them, without interest, on an installment basis selected by them.

	 	(c)	 	The payment of Severance Compensation by the Employer to Employee shall not affect any rights
and benefits which Employee may have pursuant to any other agreement, policy, plan, program or
arrangement with the Employer prior to the Termination Date, which rights shall be governed by the terms
thereof, except that payments hereunder after termination under this Section 5 shall reduce by an equal
amount any sums payable after termination of employment under Section 4.1(a) above, as may be amended,
restated or modified.

5.3 No Mitigation Required. In the event that this Agreement or the employment of Employee hereunder is
terminated, Employee shall not be obligated to mitigate his damages nor the amount of any payment provided for in this
Agreement by seeking other employment or otherwise, and the acceptance of employment elsewhere after termination shall
in no way reduce the amount of Severance Compensation payable under this Section 5.

Section 6. Miscellaneous.

6.1 Section 409A. For purposes of Section 4 or 5, whether a “termination of employment” has occurred
shall be determined as set forth in Proposed Regulation §1.409A-3(h)(1) or any successor regulations. Notwithstanding
the foregoing provisions of this Section 4 or 5, in the event as of the date of termination of employment, Employee is
a “specified employee” as such term is defined under Section 409A of the Internal Revenue Code of 1986 (the “Code”)(or
any regulations or proposed regulations promulgated thereunder) each payment that would have been due to be made to
employee during the first six (6) months after such termination shall be delayed to the extent required and all such
delayed payments shall be made in a single lump sum on the first business day after the six –month anniversary of such termination unless an exception to such delay is otherwise applicable under the Code or regulations thereunder.

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6.2 Notice. Except as set forth below in this Section 6.2, any notice under this Agreement must
be in writing and shall be deemed to have been given when delivered personally or by overnight courier service or three
days after being sent by mail, postage prepaid, at the address indicated below or to such changed address as such
person may subsequently give such notice of:

if to Employer:

Peerless Mfg. Co.

14651 North Dallas Pkwy

Dallas, Texas 75254

Attn: Chairman, Board of Directors

if to Employee:

Warren Hayslip

5070 Rosewood Dr.

Doylestown, PA 18902

Notwithstanding the foregoing, the party receiving notice may waive any provisions of this Section 6.2 in its
or his sole and absolute discretion.

6.3 Assignment. This Agreement shall inure to the benefit of and be binding upon the parties hereto and
their respective heirs, personal representatives, successors, and assigns. Except as otherwise provided herein, this
Agreement may not be assigned by Employee without the prior written consent of the Employer and PMFG, Inc. Employer
shall require any successor, and any corporation or other person which is in control of such successor, to all or
substantially all of the business and/or assets of Employer (by purchase, merger, consolidation or otherwise), by
agreement in form and substance reasonably satisfactory to Employee, to expressly assume and agree to perform this
Agreement in the same manner and to the same extent that Employer would be required to perform it if no such succession
had taken place. Failure of Employer to obtain such agreement prior to the effectiveness of any such succession shall
be a material breach of this Agreement by Employer. As used in this Agreement, “Employer” shall mean Employer as
herein before defined and any successor to its business and/or all or part of its assets as aforesaid which executes
and delivers the assumption agreement provided for in this Section 6.3 or which otherwise becomes bound by all
the terms and provisions of this Agreement by operation of law.

6.4 Headings. The section headings used herein are for reference and convenience only and shall not enter
into the interpretation hereof.

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6.5 Counterparts. This Agreement may be executed in one or more counterparts for the convenience of the
parties hereto, all of which together shall constitute one and the same instrument.

6.6 Amendment and Waiver. The provisions of this Agreement may be amended or waived only by written
agreement of Employer and Employee, and no course of conduct, failure or delay in enforcing the provisions of this
Agreement shall effect the validity, binding effect or enforceability of this Agreement.

6.7 Severability. Any provision or portion of a provision of this Agreement that is held to be invalid or
unenforceable will be severable, and this Agreement will be construed and enforced as if such provision, or portion
thereof, did not comprise a part hereof, and the remaining provisions or portions of provisions will remain in full
force and effect. In lieu of each invalid or unenforceable provision there will be added automatically as part of this
Agreement a provision as similar in terms to such invalid or unenforceable provision as may be possible and be legal,
valid, and enforceable.

6.8 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the
State of Texas, without giving effect to any conflicts of law rule or principle that might require the application of
the laws of another jurisdiction.

6.9 Indemnification. Employee shall be subject to, and entitled to the benefit of, the indemnification
provisions contained in the Employer’s Articles of Incorporation and Bylaws, as amended, to the same extent and degree
as other similarly situated officers and/or directors of Employer.

6.10 Disputes. The parties to this Agreement agree that in the event there is a dispute or controversy
between them that cannot be settled through direct discussions, it is in the best interests of all for such dispute or
controversy to be resolved in the shortest time and with the lowest cost of resolution as practicable. Consequently,
any such dispute, controversy or claim between the parties to this Agreement will not be litigated, but instead will be
resolved by arbitration in accordance with Title 9 of the U.S. Code (United States Arbitration Act) and the Commercial
Arbitration Rules of the American Arbitration Association (the “Rules”), and judgment upon the award rendered by the
arbitrator may be entered in any court having jurisdiction thereof. The arbitration will be before one neutral
arbitrator and will proceed under the Expedited Procedures of said Rules. The arbitration will be held in Dallas,
Texas, or such other place as may be selected by mutual agreement. The arbitrator will have the discretion to order a
prehearing exchange of information by the parties, and to set limits for both the scope and time period of such
exchange. All issues regarding exchange requests will be decided by the arbitrator. Neither party nor the arbitrator
may disclose the existence, content or results of any arbitration hereunder, unless required to do so by court or
regulatory order, without the prior written consent of both parties. Administrative fees and expenses of the
arbitration itself will be borne by the parties equally unless otherwise required by law, a court of competent
jurisdiction or the Rules; provided, that, in no event will Employee be required to pay in excess of $1,000 of such
fees and expenses. The arbitrator will also be authorized to award to the prevailing party all or that fraction of its
reasonable costs and fees as is deemed equitable. Costs of a party’s representation by counsel or preparation costs
for hearing are not considered administrative fees and expenses for purposes hereof. This provision will not apply to any claim for injunctive relief sought by the
Employer or any of its affiliates under Section 2 or 3 of this Agreement.

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6.11 Entire Agreement. This Agreement embodies the complete agreement between Employer and Employee
regarding the subject matter hereof and supersedes all prior agreements or understandings, whether oral, written or
otherwise, between the parties hereto that may have related in any way to the subject matter hereof.

EMPLOYER:

PEERLESS MFG. CO.

                                                                                  

Peter J. Burlage,

Chief Executive Officer

EMPLOYEE:

                                                                                   

Warren Hayslip

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Exhibit 10.1

Contract No. FA913

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STANDARD CONTRACT

     THIS CONTRACT is entered into between the State of Florida, AGENCY FOR HEALTH CARE
ADMINISTRATION, hereinafter referred to as the “Agency”, whose address is 2727 Mahan Drive,
Tallahassee, Florida 32308, and AMERIGROUP FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY CARE,
hereinafter referred to as the “Vendor” or the “Health Plan”, whose address is 4425 Corporation
Lane, Virginia Beach, Virginia 23562, a Florida For Profit Corporation, to provide health care
services to eligible Medicaid recipients.

I. THE VENDOR HEREBY AGREES:

	 	A.	 	General Provisions

	 	1.	 	To provide services according to the terms and conditions set forth
in this Contract, Attachment I and Attachment II, and all other attachments
named herein which are attached hereto and incorporated by reference.
	 
	 	2.	 	To perform as an independent vendor and not as an agent,
representative, or employee of the Agency.
	 
	 	3.	 	To recognize that the State of Florida, by virtue of its
sovereignty, is not required to pay any taxes on the services or goods purchased
under the terms of this Contract.

	 	B.	 	Federal Laws and Regulations

	 	1.	 	I. This Contract contains federal funds, therefore, the Vendor
shall comply with the provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and
other applicable regulations.
	 
	 	2.	 	This Contract contains federal funding in excess of $100,000,
therefore, the Vendor must, upon Contract execution, complete the Certification
Regarding Lobbying form, Attachment IV. If a Disclosure of Lobbying Activities
form, Standard Form LLL, is required, it may be obtained from the Agency’s
Contract Manager. All disclosure forms as required by the Certification
Regarding Lobbying form must be completed and returned to the Agency’s
Procurement Office.
	 
	 	3.	 	Pursuant to 45 CFR, Part 76, the Vendor must, upon Contract
execution, complete the Certification Regarding Debarment, Suspension,
ineligibility, and Voluntary Exclusion Contracts/Subcontracts, Attachment V.

	 	C.	 	Audits and Records

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

AHCA Contract No. FA913, Page 1 of 10

 

 

	 	2.	 	To assure that these records shall be subject at all reasonable times to inspection,
review, or audit by state personnel and other personnel duly authorized by the Agency,
as well as by federal personnel.
	 
	 	3.	 	To maintain and file with the Agency such progress, fiscal and inventory
reports as specified in Attachment II and other reports as the Agency may require within
the period of this Contract. In addition, access to relevant computer data and
applications which generated such reports should be made available upon request.
	 
	 	4.	 	To ensure that all related party transactions are disclosed to the Agency
Contract Manager.
	 
	 	5.	 	To include these aforementioned audit and record keeping requirements in all
approved subcontracts and assignments.

	 	D.	 	Retention of Records

	 	1.	 	To retain all financial records, supporting documents, statistical records, and
any other documents (including electronic storage media) pertinent to performance under
this Contract for a period of five (5) years after termination of this Contract, or if
an audit has been initiated and audit findings have not been resolved at the end of
five (5) years, the records shall be retained until resolution of the audit findings.
	 
	 	2.	 	Persons duly authorized by the Agency and federal auditors, pursuant to 45 CFR,
Part 74 and/or 45 CFR, Part 92, shall have full access to and the right to examine any
of said records and documents.
	 
	 	3.	 	The rights of access in this section must not be limited to the required
retention period but shall last as long as the records are retained.

	 	E.	 	Monitoring

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

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

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

	 	G.	 	Insurance

	 	1.	 	To the extent required by law, the Vendor will be self-insured against, or will
secure and maintain during the life of the Contract, Worker’s Compensation Insurance for
all his employees connected with the work of this project and, in

AHCA Contract No. FA913, Page 2 of 10

 

 

	 	 	 	case any work is subcontracted, the Vendor shall require the subcontractor similarly to
provide Worker’s Compensation Insurance for all of the latter’s employees unless such
employees engaged in work under this Contract are covered by the Vendor’s self insurance
program. Such self insurance or insurance coverage shall comply with the Florida Worker’s
Compensation law. In the event hazardous work is being performed by the Vendor under this
Contract and any class of employees performing the hazardous work is not protected under
Worker’s Compensation statutes, the Vendor shall provide, and cause each subcontractor to
provide, adequate insurance satisfactory to the Agency, for the protection of his
employees not otherwise protected.
	 
	 	2.	 	The Vendor shall secure and maintain Commercial General Liability insurance
including bodily injury, property damage, personal & advertising injury and products
and completed operations. This insurance will provide coverage for all claims that may
arise from the services and/or operations completed under this Contract, whether such
services and/or operations are by the Vendor or anyone directly, or indirectly employed
by him. Such insurance shall include a Hold Harmless Agreement in favor of the State of
Florida and also include the State of Florida as an Additional Named Insured for the
entire length of the Contract. The Vendor is responsible for determining the minimum
limits of liability necessary to provide reasonable financial protections to the Vendor
and the State of Florida under this Contract.
	 
	 	3.	 	All insurance policies shall be with insurers licensed or eligible to transact
business in the State of Florida. The Vendor’s current certificate of insurance shall
contain a provision that the insurance will not be canceled for any reason except after
thirty (30) days written notice to the Agency’s Contract Manager.

	 	H.	 	Assignments and Subcontracts
	 
	 	 	 	To neither assign the responsibility of this Contract to another party nor subcontract for
any of the work contemplated under this Contract without prior written approval of the
Agency. No such approval by the Agency of any assignment or subcontract shall be deemed in
any event or in any manner to provide for the incurrence of any obligation of the Agency in
addition to the total dollar amount agreed upon in this Contract. All such assignments or
subcontracts shall be subject to the conditions of this Contract and to any conditions of
approval that the Agency shall deem necessary.
	 
	 	I.	 	Return of Funds
	 
	 	 	 	To return to the Agency any overpayments due to unearned funds or funds disallowed pursuant
to the terms of this Contract that were disbursed to the Vendor by the Agency. The Vendor
shall return any overpayment to the Agency within forty (40) calendar days after either
discovery by the Vendor, its independent auditor, or notification by the Agency, of the
overpayment.
	 
	 	J.	 	Purchasing

	 	1.	 	P.R.I.D.E.
	 
	 	 	 	It is expressly understood and agreed that any articles which are the subject of, or
required to carry out this Contract shall be purchased from the corporation identified
under Chapter 946, Florida Statutes, if available, in the same manner and under the same
procedures set forth in Section 946.515(2), (4), Florida Statutes; and for purposes of
this Contract the person, firm or other business

AHCA Contract No. FA913, Page 3 of 10

 

 

	 	 	 	entity carrying out the provisions of this Contract shall be deemed to be substituted for
this agency insofar as dealings with such corporation are concerned.
	 
	 	 	 	The “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:
	 
	 	 	 	P.R.I.D.E.

2720-G Blair Stone Road

Tallahassee, Florida 32301

(850) 487-3774

Toll Free: 1-800-643-8459

Website: www.pridefl.com

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

	 	 	 	RESPECT of Florida.

2475 Apalachee Parkway, Suite 205

Tallahassee, Florida 32301-4946

(850) 487-147]

Website: www.respectofflorida.org

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

	 	K.	 	Civil Rights Requirements/Vendor Assurance

     The Vendor assures that it will comply with:

	 	1.	 	Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et seq.,
which prohibits discrimination on the basis of race, color, or national origin.
	 
	 	2.	 	Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794, which
prohibits discrimination on the basis of handicap.
	 
	 	3.	 	Title IX of the Education Amendments of 1972, as amended, 20 U.S.C. 1681 et
seq., which prohibits discrimination on the basis of sex.
	 
	 	4.	 	The Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq., which
prohibits discrimination on the basis of age.

AHCA Contract No. FA913, Page 4 of 10

 

 

	 	5.	 	Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended, 42 U.S.C.
9849, which prohibits discrimination on the basis of race, creed, color, national
origin, sex, handicap, political affiliation or beliefs.
	 
	 	6.	 	The Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
discrimination on the basis of disability and requires reasonable accommodation for
persons with disabilities.
	 
	 	7.	 	All regulations, guidelines, and standards as are now or may be lawfully
adopted under the above statutes.

	 	 	 	The Vendor agrees that compliance with this assurance constitutes a condition of continued
receipt of or benefit from funds provided through this Contract, and that it is binding upon
the Vendor, its successors, transferees, and assignees for the period during which services
are provided. The Vendor further assures that all contractors, subcontractors, subgrantees,
or others with whom it arranges to provide services or benefits to participants or employees
in connection with any of its programs and activities are not discriminating against those
participants or employees in violation of the above statutes, regulations, guidelines, and
standards.
	 
	 	L.	 	Discrimination
	 
	 	 	 	An entity or affiliate who has been placed on the discriminatory vendor list may not submit
a bid, proposal, or reply on a contract to provide any goods or services to a public entity;
may not submit a bid, proposal, or reply on a contract with a public entity for the
construction or repair of a public building or public work; may not submit bids, proposals,
or replies on leases of real property to a public entity; may not be awarded or perform work
as a contractor, supplier, subcontractor, or consultant under a contract with any public
entity; and may not transact business with any public entity. The Florida Department of
Management Services is responsible for maintaining the discriminatory vendor list and
intends to post the list on its website. Questions regarding the discriminatory vendor list
may be directed to the Florida Department of Management Services, Office of Supplier
Diversity at (850) 487-0915.
	 
	 	M.	 	Requirements of Section 287.058, Florida Statutes

	 	1.	 	To submit bills for fees or other compensation for services or expenses in
sufficient detail for a proper pre-audit and post-audit thereof.
	 
	 	2.	 	Where applicable, to submit bills for any travel expenses in accordance with
Section 112.061, Florida Statutes.
	 
	 	3.	 	To provide units of deliverables, including reports, findings, and drafts, in
writing and/or in an electronic format agreeable to both parties, as specified in
Attachment II, to be received and accepted by the Contract Manager prior to payment.
	 
	 	4.	 	To comply with the criteria and final date by which such criteria must be met
for completion of this Contract as specified in Section III, Paragraph A. of this
Contract.
	 
	 	5.	 	To allow public access to all documents, papers, letters, or other material
made or received by the Vendor in conjunction with this Contract, unless the records
are exempt from Section 24(a) of Article I of the State Constitution and Section
119.07(1), Florida Statutes. It is expressly understood that substantial

AHCA Contract No. FA913, Page 5 of 10

 

 

	 	 	 	evidence of the Vendor’s refusal to comply with this provision shall constitute a breach
of Contract.

	 	N.	 	Sponsorship
	 
	 	 	 	As required by Section 286.25, Florida Statutes, if the Vendor is a nongovernmental
organization which sponsors a program financed wholly or in part by state funds, including
any funds obtained through this Contract, it shall, in publicizing, advertising or
describing the sponsorship of the program, state:
	 
	 	 	 	“Sponsored by AMERIGROUP FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY CARE and the State of
Florida, AGENCY FOR HEALTH CARE ADMINISTRATION”.
	 
	 	 	 	If the sponsorship reference is in written material, the words “State of Florida, AGENCY FOR
HEALTH CARE ADMINISTRATION” shall appear in the same size letters or type as the name of the
organization.
	 
	 	O.	 	Use Of Funds For Lobbying Prohibited
	 
	 	 	 	To comply with the provisions of Section 216.347, Florida Statutes, which prohibits the
expenditure of Contract funds for the purpose of lobbying the Legislature, the judicial
branch or a state agency.
	 
	 	P.	 	Public Entity Crime
	 
	 	 	 	A person or affiliate who has been placed on the convicted vendor list following a
conviction for a public entity crime may not be awarded or perform work as a contractor,
supplier, subcontractor, or consultant under a contract with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in
Section 287.017, Florida Statutes, for category two, for a period of 36 months from the date
of being placed on the convicted vendor list.
	 
	 	Q.	 	Health Insurance Portability and Accountability Act
	 
	 	 	 	To comply with the Department of Health and Human Services Privacy Regulations in the Code
of Federal Regulations, Title 45, Sections 160 and 164, regarding disclosure of protected
health information as specified in Attachment III.
	 
	 	R.	 	Confidentiality of Information
	 
	 	 	 	Not to use or disclose any confidential information, including social security numbers that
may be supplied under this Contract pursuant to law, and also including the identity or
identifying information concerning a Medicaid recipient or services under this Contract for
any purpose not in conformity with state and federal laws, except upon written consent of
the recipient, or his/her guardian.
	 
	 	S.	 	Employment
	 
	 	 	 	To comply with Section 274A (e) of the Immigration and Nationality Act. The Agency shall
consider the employment by any contractor of unauthorized aliens a violation of this Act. If
the Vendor knowingly employs unauthorized aliens, such violation shall be cause for
unilateral cancellation of this Contract. The Vendor

AHCA Contract No. FA913, Page 6 of 10

 

 

	 	 	 	shall be responsible for including this provision in all subcontracts with private
organizations issued as a result of this Contract.
	 
	 	T.	 	Vendor Performance
	 
	 	 	 	Penalties or sanctions for unsatisfactory performance under this Contract are specified
in Attachment II, if applicable.

II. THE AGENCY HEREBY AGREES:

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

III. THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

	 	A.	 	Effective/End Date
	 
	 	 	 	This Contract shall begin upon execution by both parties on September 1, 2009,
(whichever is later) and end August 31, 2012, inclusive.
	 
	 	B.	 	Termination

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

AHCA Contract No. FA913, Page 7 of 10

 

 

	 	2.	 	Termination Due To Lack of Funds
	 
	 	 	 	In the event funds to finance this Contract become unavailable, the Agency may
terminate the Contract upon no less than twenty-four (24) hours written notice to
the Vendor. Said notice shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery. The Agency shall be the final
authority as to the availability of funds.
	 
	 	3.	 	Termination for Breach
	 
	 	 	 	Unless the Vendor’s breach is waived by the Agency in writing, the Agency may, by
written notice to the Vendor, terminate this Contract upon no less than twenty-four
(24) hours written notice. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery. If applicable, the Agency
may employ the default provisions in Chapter 60A-1.006(4), Florida Administrative
Code.
	 
	 	 	 	Waiver of breach of any provisions of this Contract shall not be deemed to be a
waiver of any other breach and shall not be construed to be a modification of the
terms of this Contract. The provisions herein do not limit the Agency’s right to
remedies at law or to damages.

	C.	 	Contract Managers

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

Agency for Health Care

Administration 2727 Mahan Drive,

MS# 50

Tallahassee, FL 32308

(850) 487-2355
	 
	 	2.	 	The Vendor’s Contract Manager’s name, address and telephone number for
this Contract is as follows:
	 
	 	 	 	Chelise Bowery
	 
	 	 	 	AMERIGROUP Florida, Inc. d/b/a

AMERIGROUP CommunityCare

4425 Corporation Lane

Virginia Beach, VA 23562

(757) 473-2737
	 
	 	3.	 	All matters shall be directed to the Contract Managers for appropriate
action or disposition. A change in Contract Manager by either party shall be
reduced to writing through an amendment to this Contract by the Agency.

	 	D.	 	Renegotiation or Modification

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

AHCA Contract No. FA913, Page 8 of 10

 

 

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

	 	E.	 	Name, Mailing and Street Address of Payee

	 	1.	 	The name (Vendor name as shown on Page 1 of this Contract) and mailing
address of the official payee to whom the payment shall be made:
	 
	 	 	 	AMERIGROUP Florida, Inc. d/b/a

AMERIGROUP Community

Care 4425 Corporation Lane

Virginia Beach, VA 23562
	 
	 	2.	 	The name of the contact person and street address where financial and
administrative records are maintained:
	 
	 	 	 	Margaret Mary Roomsberg

AMERIGROUP Florida, Inc. d/b/a

AMERIGROUP Community

Care 4425 Corporation Lane

Virginia Beach, VA 23562

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

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AHCA Contract No. FA913, Page 9 of 10

 

 

     IN WITNESS THEREOF, the parties hereto have caused this two hundred and ninety (290) page
Contract, which includes any referenced attachments, to be executed by their undersigned
officials as duly authorized. This Contract is not valid until signed and dated by both
parties.

	 	 	 
	AMERIGROUP FLORIDA, INC. D/B/A

	 	STATE OF FLORIDA, AGENCY FOR
	AMERIGROUP COMMUNITY CARE

	 	HEALTH CARE ADMINISTRATION

	 	 	 	 	 	 	 	 	 
	SIGNED

	 	 	 	SIGNED	 	 	 	 
	BY:

	 	/s/ William L. McHugh
 

	 	BY:
	 	/s/ Holly Benson
 

	 	 
	NAME:

	 	William L. McHugh
	 	NAME:
	 	Holly Benson	 	 
	TITLE:

	 	CEO
	 	TITLE:
	 	Secretary	 	 
	DATE:

	 	8/31/09
	 	DATE:
	 	9/1/09	 	 

FEDERAL ID NUMBER (or SS Number for an individual): 65-0318864

VENDOR FISCAL YEAR ENDING DATE: 12/31

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

	 	 	 	 	 	 	 
	 

	 	Attachment
	 	I
	 	Scope of Services (11 Pages)
	 

	 	Exhibits
	 	1-2
	 	Attachment I Exhibits (10 Pages)
	 

	 	Attachment
	 	II
	 	Core Contract Provisions (186 Pages)
	 

	 	Exhibits
	 	1-16
	 	Attachment II Exhibits (68 Pages)
	 

	 	Attachment
	 	III
	 	Business Associate Agreement (3 Pages)
	 

	 	Attachment
	 	IV
	 	Lobbying Certification (1 Page)
	 

	 	Attachment
	 	V
	 	Debarment Certification (1 Page)

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AHCA Contract No. FA913, Page 10 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

ATTACHMENT I

SCOPE OF SERVICES

CAPITATED HEALTH PLANS

A. Plan Type

The Vendor (Health Plan) is approved to provide contracted services as the following health
plan type as denoted by “X”:

TABLE 1

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	Specialty
	Health	 	Fee- for-Service	 	 	 	Specialty Health	 	Plan for
	Maintenance	 	(FFS) Provider	 	 	 	Plan for Children	 	Recipients
	Organization	 	Service Network	 	 	 	with Chronic	 	Living with
	(HMO)	 	(PSN)	 	Capitated PSN	 	Conditions	 	HIV/AIDS
	X	 	 	 	 	 	 	 	 

B. Population(s) to be Served

     1. Population Groups

The Health Plan shall deliver covered services as defined in Attachment II to the specific
population(s) approved below with “X” and as listed in Attachment II, Section III,
Eligibility and Enrollment:

TABLE 2

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Non-	 	Non-	 	 	 	 	 	 	 	Reform	 	 
	Non-	 	Non-	 	Reform	 	Reform	 	 	 	 	 	Reform	 	Children with	 	Reform
	Reform	 	Reform	 	Dually	 	Frail/	 	Reform	 	Reform	 	Dually	 	Chronic	 	HIV/
	TANF	 	SSI	 	Eligible	 	Elderly*	 	TANF	 	SSI	 	Eligible	 	Conditions**	 	AIDS***
	X
	 	X
	 	X
	 	 	 	X
	 	X
	 	X	 	 	 	 

	 	•	 	Enrollees, who have been determined to be at risk for nursing home
institutionalization by the Comprehensive Assessment and Review for Long Term Care
(CARES) Unit, and are enrolled in an Agency-authorized plan which participates in the
Frail/Elderly Program. **
	 
	 	•	 	Enrolled in an Agency-authorized specialty plan for children with chronic conditions
and screened by the Florida Department of Health as clinically eligible for Children’s
Medical Services using an Agency-approved screening tool as specified in Attachment II,
Section III, Eligibility and Enrollment, Exhibit III.
	 
	 	•	 	Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS.

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AHCA Contract No. FA913, Attachment I, Page 1 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

     2. Age Restrictions

The Health Plan’s enrollment is restricted as indicated by “X” below in regard to the age
range for the population groups referenced in Item 1 above that the Health Plan is
authorized by the Agency to serve:

TABLE 3

	 	 	 	 	 
	 	 	Non-Reform	 	Reform
	Age Restriction	 	Restricted	 	Restricted
	None
	 	X
	 	X
	Only ages 0 up to 21	 	 	 	 
	Only ages 21 and over	 	 	 	 

     3. Enrollment Levels and Authorized Counties of Operation

The Agency assigns the Health Plan an authorized maximum enrollment level for each
operational county indicated in Exhibit 1 of this attachment for Reform and non-Reform
populations if those populations are covered in this Contract as specified in Section B.
above. The authorized maximum enrollment level listed is effective on September 1, 2009,
or upon Contract execution, whichever is later.

	 	a.	 	The Agency must approve in writing any increase or decrease in the Health
Plan’s maximum enrollment level for each operational county to be served.
	 
	 	b.	 	Such approval shall be based upon the Health Plan’s satisfactory
performance of terms of the Contract and upon the Agency’s approval of the Health
Plan’s administrative and service resources, as specified in this Contract, in
support of each enrollment level.

C. Service Level Required

The Health Plan shall deliver Medicaid covered services at the service level(s) listed below
in Table 4 with “X.” In addition, if the Health Plan is listed as approved to provide both
Reform comprehensive component only and Reform comprehensive and catastrophic components, then
the Health Plan is approved to provide services at the “Reform comprehensive component only”
service level only for the county populations listed below:

TABLE 4

	 	 	 	 	 
	Non-Reform	 	Reform Comprehensive	 	Reform Comprehensive and
	Medicaid State Plan	 	Component Only	 	Catastrophic Components
	X
	 	 	 	X

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AHCA Contract No. FA913, Attachment I, Page 2 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

D. Service(s) to be Provided

     1. Covered Medicaid Services

	 	a.	 	The Health Plan shall ensure the provision of the Medicaid services
listed below in Table 5 with “X” and as specified in applicable exhibits to this
attachment and as defined in Attachment II, Section I, Definitions; Section V,
Covered Services; and Section VI, Behavioral Health Care, and as specified in
applicable exhibits to Attachment I.
	 
	 	b.	 	For non-Reform populations, Medicaid State Plan dental services and
transportation services (notated in Table 5 with an asterisk and in bold-type
font) are considered optional services, and the Health Plan may request that the
Agency allow the Health Plan to provide these services under this Contract. The
denotation of “X” in Table 5 below indicates the Agency has approved the Health
Plan to cover these services. See Attachment II, Exhibit 5, for more information
regarding the provision of these optional benefits. See Item 3., Other Service
Requirements, of this subsection for more information regarding optional
services.

	 	(1)	 	For optional dental services for the non-Reform population, the
Health Plan is further limited as follows:

	 	(a)	 	Dental services include the arrangement and provision of
Medicaid State Plan dental services to the adult and child populations.
The Health Plan shall comply with the limitations and exclusions in the
Medicaid Dental Services Coverage and Limitations & Reimbursement
Handbooks.
	 
	 	(b)	 	In no instance may the limitations or exclusions imposed
by the Health Plan be more stringent than those specified in the
Medicaid Dental Services Coverage and Limitations & Reimbursement
Handbooks.

	 	(2)	 	For optional transportation for the non-Reform population, the
Health Plan is further limited as follows:

	 	(a)	 	Only certain HMOs are authorized to provide
transportation services to non- Reform populations. The only county for
which optional transportation services may be authorized is Miami Dade
County.
	 
	 	(b)	 	Transportation services include the arrangement and
provision of an appropriate mode of transportation, including emergency
transportation services, for enrollees to receive medically necessary
health care services. The Health Plan shall comply with the limitations
and exclusions in the Medicaid Transportation Coverage and Limitations
Handbook. In no instance may the limitations or exclusions imposed by
the Health Plan be more stringent than those specified in the Medicaid
Transportation Coverage and Limitations Handbook.
	 
	 	(c)	 	If an “X” is listed in the non-Reform column, the Agency
has authorized the Health Plan to provide such transportation services
in Miami Dade County. See Item 3., Other Service Requirements, of this
subsection for more information regarding optional services.

AHCA Contract No. FA913, Attachment I, Page 3 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

	 	(3)	 	For the optional frail/elderly program for the non-Reform
population, the Health Plan is further limited as follows:

	 	(a)	 	Only certain HMOs are authorized to provide frail/elderly
services to non- Reform populations. The only county for which optional
frail/elderly services may be authorized is Miami Dade County.
	 
	 	(b)	 	Frail/elderly services include the provision,
coordination, and management of services to prevent or delay placement in
a nursing home. A variety of mandatory and supportive services shall be
available to enrollees who meet the eligibility requirements as set out
in Attachment II, Exhibit III, Non-Reform HMO Frail/Elderly Program.
	 
	 	(c)	 	If an “X” is listed in the non-Reform column, the Agency
has authorized the Health Plan to provide such frail/elderly services in
Miami Dade County.

TABLE 5

	 	 	 	 	 
	 	 	Non-	 	 
	 	 	Reform	 	Reform
	Health Plan Covered Services Chart	 	Covered	 	Covered
	Advanced Registered Nurse Practitioner Services

	 	X
	 	X
	Ambulatory Surgical Center Services

	 	X
	 	X
	Birth Center Services

	 	X
	 	X
	Child Health Check-Up Services

	 	X
	 	X
	Chiropractic Services

	 	X
	 	X
	Community Behavioral Health Services

	 	X
	 	X
	County Health Department Services

	 	X
	 	X
	Dental
Services*

	 	 	 	X
	Durable Medical Equipment and Medical Supplies

	 	X
	 	X
	Dialysis Services

	 	X
	 	X
	Emergency Room Services

	 	X
	 	X
	Family Planning Services

	 	X
	 	X
	Federally Qualified Health Center Services

	 	X
	 	X
	Frail/Elderly Program Services*
	 	 	 	 
	Freestanding Dialysis Centers

	 	X
	 	X
	Hearing Services

	 	X
	 	X
	Home Health Care Services

	 	X
	 	X
	Hospital Services — Inpatient

	 	X
	 	X
	Hospital Services — Outpatient

	 	X
	 	X
	Immunizations

	 	X
	 	X
	Independent Laboratory Services

	 	X
	 	X
	Licensed Midwife Services

	 	X
	 	X

AHCA Contract No. FA913, Attachment I, Page 4 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

TABLE 5

	 	 	 	 	 
	 	 	Non-	 	 
	 	 	Reform	 	Reform
	Health Plan Covered Services Chart	 	Covered	 	Covered
	Optometric Services

	 	X
	 	X
	Physician Services

	 	X
	 	X
	Physician Assistant Services

	 	X
	 	X
	Podiatry Services

	 	X
	 	X
	Portable X-ray Services

	 	X
	 	X
	Prescribed Drugs

	 	X
	 	X
	Prescribed Pediairic Extended Care Services
	 	 	 	 
	Primary Care Case Management Services

	 	X
	 	X
	Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY)
	 	 	 	 
	Rural Health Clinic Services

	 	X
	 	X
	Targeted Case Management

	 	X
	 	X
	Therapy Services: Occupational

	 	X
	 	X
	Therapy Services: Physical

	 	X
	 	X
	Therapy Services: Respiratory

	 	X
	 	X
	Therapy Services: Speech

	 	X
	 	X
	Transplant Services

	 	X
	 	X
	Transportation Services*

	 	 	 	X
	Vision Services

	 	X
	 	X

     2. Approved Expanded Benefits

	 	a.	 	The Health Plan shall provide the following expanded benefits to
non-Reform enrollees as specified below in accordance with Contract provisions
including Attachment I, Section B., Population(s) to be Served, and Attachment
II, Section V, Covered Services, of this Contract.

TABLE 6

Expanded Services

$10 per household, per month OTC drugs and/or health supplies

Enhanced hearing aid benefit — Upgrade from standard, medically necessary, behind-
the-ear hearing aid to digital canal hearing aid up to $500.

Respite Care Annual maximum of not more than an initial home-health visit by RN @
$65.00 and eight (8) follow-up visits by an aide at $23.00 per visit. Follow-up visits are
four (4) hours in length. Maximum of sixteen (16) hours in a given month and thirty-two
(32) hours per year.

	 	b.	 	The Health Plan shall provide the expanded benefits listed in Section
G, Benefit Grid/Customized Benefit Package — Reform Capitated Plans Only, below
as part
of the Health Plan’s customized benefit package to Reform enrollees in accordance

AHCA Contract No. FA913, Attachment I, Page 5 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	with Contract provisions including Attachment I, Section B., Population(s) to be
Served, and Attachment II, Section V, Covered Services, of this Contract.

     3. Other Service Requirements

	 	a.	 	The Health Plan shall meet the minimum service requirements as outlined
and defined in Attachments I and II of this Contract.
	 
	 	b.	 	Health plans serving Reform populations agree to provide the services
listed in Section G. of this attachment in accordance with Contract provisions.
	 
	 	c.	 	The Health Plan shall submit for approval any changes to the optional
services listed in Table 5 and expanded services listed in Table 6 and, for
health plans serving Reform populations, those covered services listed in
Section G. below, to the Agency’s Bureau of Health Systems Development (HSD) by
June 15 of each contract year. These services may be changed on a contract year
basis and only if approved by the Agency in writing.
	 
	 	d.	 	The Health Plan shall use the following service provisions for
prescribed drug services as allowed in Attachment II, Section V, Covered
Services, and as listed by “X” below.

TABLE 7

	 	 	 
	Pharmacy Authorizations	 	Authorized
	The Health Plan shall use a pharmacy benefits manager
as specified in Attachment II, Section V.

	 	X

	 	e.	 	The Health Plan has agreed to and is authorized by the Agency to use
the Medicaid redetermination date data provided in its enrollment files as
specified in Attachment II, Section IV, Enrollee Services, Community Outreach
and Marketing only if listed by “X” below.

TABLE 8

	 	 	 
	Medicaid redetermination date data	 	Authorized
	The Health Plan shall use Medicaid redetermination date
data as specified in Attachment II, Section IV, Enrollee
Services, Community Outreach and Marketing.

	 	X

E. Method of Payment

     1. General

This is a fixed price (unit cost) Contract. The Agency will manage this Contract for
the delivery of services to enrollees (service units). The Health Plan will be paid
through the Agency’s Medicaid fiscal agent, in accordance with the terms of this
Contract, a total dollar amount not to exceed ***REDACTED*** subject to the
availability of funds in accordance with Attachment II, Section XIII, Method of
Payment.

AHCA Contract No. FA913, Attachment I, Page 6 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	The Health Plan shall be paid capitation payments for each Agency
service area, based upon the tables in Exhibit 2 of this attachment.
	 
	 	b.	 	All payments made to the Health Plan shall be in accordance with this
section and Attachment II, Section XIII, Method of Payment.

     2. Health Plan Capitation Rates and Reform Kick Payments

	 	a.	 	The Health Plan provider numbers associated with the capitation rates
indicated in the Exhibit 2—NR and 2-R tables are provided in Exhibit 1, Maximum
Enrollment Levels, of this attachment.
	 
	 	b.	 	For health plans serving non-Reform populations, Attachment I, Exhibit
2-NR table(s) provides the capitation rates respective to the authorized areas
of operation. The capitation rate payment shall be in accordance with Attachment
II, Section XIII, Method of Payment. These rates are titled “ESTIMATED HEALTH
PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”
	 
	 	c.	 	For health plans serving Reform populations, Exhibit 2-R table(s) of
this attachment provides the capitation rates and Reform kick payments
respective to the authorized areas of operation. The capitation rate payment
shall be in accordance with Attachment II, Section XIII, Method of Payment.
These rates are titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED
BY CMS.”

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA913, Attachment I, Page 7 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

F. Applicable Exhibits 

Any additions or variations from Contract requirements specified in Attachments I and II are
provided in the exhibits to those attachments. Exhibits required are noted by “X” below
depending on health plan type and population served. There are no additional requirements or
changes to the Health Plan’s Contract in those exhibits marked N/A.

Table 9 — Applicable Exhibits

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Specially	 	Fee-	 	 	 	 	 	 	 	Speciality	 	HMO
	 	 	 	 	 	 	Plan for	 	for-	 	 	 	Fee-	 	 	 	Plan for	 	Non-
	 	 	 	 	 	 	Recipients	 	Service	 	Capitated	 	for-	 	 	 	Children with	 	Reform
	 	 	 	 	HMO	 	Living with	 	PSN	 	PSN	 	Service	 	Capitated	 	Chronic	 	With Frail/
	Attachment/	 	HMO	 	Non-	 	HIV/AIDS	 	Non-	 	Non-	 	PSN	 	PSN	 	Conditions	 	Elderly
	Exhibit*	 	Reform	 	Reform	 	Reform	 	Reform	 	Reform	 	Reform	 	Reform	 	Reform	 	Program
	Att. I. Exh. 1

	 	X
	 	X
	 	X
	 	 	 	X
	 	 	 	X
	 	 	 	X
	Att. I. Exh. 1-FFS

	 	 	 	 	 	 	 	X
	 	 	 	X
	 	 	 	X	 	 
	Att. I. Exh. 2-NR

	 	 	 	X
	 	 	 	 	 	X
	 	 	 	 	 	 	 	X
	Att. I. Exh. 2-R

	 	X
	 	 	 	X
	 	 	 	 	 	 	 	X	 	 	 	 
	Att. I. Exh.
2-FFS-NR

	 	 	 	 	 	 	 	X	 	 	 	 	 	 	 	 	 	 
	Att. I. Exh.
2-FFS-R

	 	 	 	 	 	 	 	 	 	 	 	X
	 	 	 	X	 	 
	Att. II. Exh. 1

	 	 	 	 	 	X	 	 	 	 	 	 	 	 	 	 	 	 
	Att. II. Exh. 2

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. 2. Exh. 3

	 	X
	 	 	 	X
	 	X
	 	 	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 4

	 	X
	 	 	 	X
	 	 	 	 	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 5

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 6
HMO&R

	 	X
	 	X
	 	X
	 	 	 	 	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 6
PSN-NR

	 	 	 	 	 	 	 	X
	 	X	 	 	 	 	 	 	 	 
	Att. II. Exh. 7

	 	X
	 	 	 	X
	 	X
	 	 	 	X
	 	X
	 	X	 	 
	Att. II. Exh. 8

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 9
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Att. II. Exh. 10

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 11

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 12
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Att. II. Exh.
13-CAP-R

	 	X
	 	 	 	X
	 	 	 	 	 	X
	 	X
	 	X	 	 
	Att. II. Exh.
13-CAP-NR

	 	 	 	X
	 	 	 	 	 	X
	 	 	 	 	 	 	 	X
	Att. II. Exh. 13-FFS

	 	 	 	 	 	 	 	X
	 	 	 	X	 	 	 	 	 	 
	Att. II. Exh. 14
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Att. II. Exh. 15

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	Att. II. Exh. 16

	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X
	 	X

 

			
	*	 	Plans offering certain optional coverage also will have additional language in the
exhibits as follows: Exhibits 3, 4, 5, 8 and 13 — Frail/Elderly
Program; Exhibit 5 — dental and transportation. Safety net hospital-based PSNs will have
additional language in the exhibits as follows: — Exhibit 13 — Method of Payment.

AHCA Contract No. FA913, Attachment I, Page 8 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

	G.	 	Benefit Grid/Customized Benefit Package — Reform Capitated Plans Only
	 
	 	 	The benefit grids below describe the Reform Health Plan’s Customized Benefit Packages
(CBP). The CBP comprises all covered services including expanded services as specified
in Attachment I, Scope of Services, Attachment II, Section V, Covered Services, and
Section VI, Behavioral Health Care. The CBP has been determined to meet actuarial
equivalency and sufficiency standards for the population or populations covered by the
CBP. The Health Plan shall provide these services to all enrollees in accordance with
Contract provisions.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA913, Attachment I, Page 9 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

Benefit Grid

1. Area 10 Broward- Children and Families

*****REDACTED*****

Benefit Grid

     2. Area 10 Broward- Aged and Disabled

***REDACTED***

AHCA Contract No. FA913, Attachment I, Page 10 of 11

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

ATTACHMENT I

EXHIBIT 1

MAXIMUM ENROLLMENT LEVELS

Maximum enrollment levels and Health Plan provider numbers associated with the counties and
populations served. Exhibit 2-NR provides the capitation rate tables respective to the areas
of operation listed below.

A. Non-Reform

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

     Area 03 Counties: HERNANDO, LAKE

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	HERNANDO
	 	 	8,000	 	 	 	015005350	 
	LAKE
	 	 	8,000	 	 	 	015005341	 

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental
Health Rates

     Area 04 Counties: VOLUSIA

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	VOLUSIA
	 	 	8,000	 	 	 	015005342	 

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental
Health Rates

     Area 05 Counties: PASCO, PINELLAS

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	PASCO
	 	 	15,000	 	 	 	015005304	 
	PINELLAS
	 	 	25,000	 	 	 	015005305	 

AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 1 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

     Area 05 Counties: HILLSBOROUGH, MANATEE, POLK

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	HILLSBOROUGH
	 	 	40,000	 	 	 	015005300	 
	MANATEE
	 	 	8,000	 	 	 	015005318	 
	POLK
	 	 	30,000	 	 	 	015005307	 

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

     Area 07 Counties: BREVARD, ORANGE, OSCEOLA, SEMINOLE

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	BREVARD
	 	 	8,000	 	 	 	015005336	 
	ORANGE
	 	 	30,000	 	 	 	015005308	 
	OSCEOLA
	 	 	8,500	 	 	 	015005314	 
	SEMINOLE
	 	 	8,000	 	 	 	015005313	 

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

     Area 08 Counties: LEE, SARASOTA

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	LEE
	 	 	18,000	 	 	 	015005302	 
	SARASOTA
	 	 	8,000	 	 	 	015005306	 

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

	 	 	Area 10 Counties: BROWARD

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	BROWARD
	 	 	14,000	 	 	 	015005311	 

AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 2 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc.

	 	Medicaid Non-Reform and Reform
	d/b/a AMERIGROUP Community Care

	 	HMO Contract

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

     Area 11 Counties: DADE

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Effective Date: 09/01/2009  
	County	 	Enrollment Level	 	Provider Number
	DADE
	 	 	25,000	 	 	 	015005312	 

B. Reform 

See Exhibit 2-R Table 1

     Area 10 Counties: Broward

***REDACTED***

AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 3 of 10

 

 

     

ATTACHMENT I

EXHIBIT 2-NR

“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”

MEDICAID Non-Reform HMO CAPITATION RATES

By Area, Age and Eligibility Category

September 1, 2009 — August 31, 2010 HMO RATES

TABLE 1 ***AREA 10 REDACTED***

     General Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	JMO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO + 2MO	 	JMO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65+)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,130.45	 	 	 	171.80	 	 	 	102.22	 	 	 	61.92	 	 	 	136.81	 	 	 	72.25	 	 	 	266.35	 	 	 	158.36	 	 	 	341.82	 	 	 	12,166.96	 	 	 	1,661.31	 	 	 	450.32	 	 	 	195.11	 	 	 	211.04	 	 	 	684.60	 	 	 	713.62	 	 	 	345.23	 	 	 	81.09	 	 	 	75.25	 
	02
	 	 	1,130.45	 	 	 	171.80	 	 	 	102.22	 	 	 	61.32	 	 	 	136.81	 	 	 	72.25	 	 	 	266.35	 	 	 	158.36	 	 	 	341.82	 	 	 	12,166.98	 	 	 	1,661.31	 	 	 	450.32	 	 	195.11	 	 	211.04	 	 	 	684.60	 	 	 	713.62	 	 	 	345.23	 	 	 	81.01	 	 	 	75.25	 
	03
	 	 	1,204.98	 	 	 	184.85	 	 	 	110.04	 	 	 	67.83	 	 	 	147.39	 	 	 	78.95	 	 	 	288.08	 	 	 	172.19	 	 	 	374.81	 	 	 	12,984.80	 	 	 	1,768.35	 	 	 	485.21	 	 	 	215.10	 	 	 	232.17	 	 	 	751.31	 	 	 	786.48	 	 	 	219.92	 	 	 	78.09	 	 	 	72.84	 
	04
	 	 	1,050.61	 	 	 	162.46	 	 	 	96.93	 	 	 	60.59	 	 	 	129.54	 	 	 	70.25	 	 	 	254.54	 	 	 	152.86	 	 	 	335.21	 	 	 	12,420.29	 	 	 	1,710.68	 	 	 	467.26	 	 	 	210.34	 	 	 	226.43	 	 	 	732.37	 	 	 	768.86	 	 	 	158.79	 	 	 	76.07	 	 	 	71.40	 
	05
	 	 	1,104.66	 	 	 	182.33	 	 	 	106.66	 	 	 	67.27	 	 	 	145.40	 	 	 	78.31	 	 	 	284.72	 	 	 	170.69	 	 	 	372.41	 	 	 	14,030.18	 	 	 	1,934.34	 	 	 	624.96	 	 	 	233.58	 	 	 	251.40	 	 	 	814.40	 	 	 	853.04	 	 	 	267.97	 	 	 	63.54	 	 	 	69.91	 
	06
	 	 	1,085.08	 	 	 	165.73	 	 	 	99.12	 	 	 	62.65	 	 	 	132.43	 	 	 	72.63	 	 	 	260.83	 	 	 	157.83	 	 	 	347.13	 	 	 	12,740.87	 	 	 	1,765.91	 	 	 	479.44	 	 	 	216.29	 	 	 	232.64	 	 	 	751.93	 	 	 	789.61	 	 	 	332.29	 	 	 	65.62	 	 	 	61.55	 
	07
	 	 	1,094.60	 	 	 	170.03	 	 	 	101.66	 	 	 	64.09	 	 	 	135.85	 	 	 	74.27	 	 	 	267.33	 	 	 	161.18	 	 	 	354.76	 	 	 	13.686.78	 	 	 	1,905.44	 	 	 	518.10	 	 	 	236.50	 	 	 	253.97	 	 	 	819.80	 	 	 	862.97	 	 	 	278.88	 	 	 	58.32	 	 	 	64.02	 
	08
	 	 	1,037.09	 	 	 	161.01	 	 	 	96.20	 	 	 	60.62	 	 	 	128.67	 	 	 	70.25	 	 	 	253.12	 	 	 	162.46	 	 	 	335.67	 	 	 	12,799.17	 	 	 	1,774.58	 	 	 	462.11	 	 	 	218.12	 	 	 	234.44	 	 	 	756.47	 	 	 	794.55	 	 	 	315.60	 	 	 	66.83	 	 	 	62.63	 
	09
	 	 	1.052.10	 	 	 	161.97	 	 	 	96.51	 	 	 	59.97	 	 	 	129.16	 	 	 	69.61	 	 	 	253.28	 	 	 	151.74	 	 	 	331.35	 	 	 	12,607.35	 	 	 	1.749.I9	 	 	 	475.00	 	 	 	215.23	 	 	 	231.33	 	 	 	746.37	 	 	 	783.86	 	 	 	278.68	 	 	 	73.65	 	 	 	68.76	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,387.45	 	 	 	213.12	 	 	 	126.92	 	 	 	78.43	 	 	 	169.76	 	 	 	91.10	 	 	 	332.48	 	 	 	199.01	 	 	 	433.39	 	 	 	16,510.81	 	 	 	2,276.81	 	 	 	618.22	 	 	 	275.31	 	 	 	256.69	 	 	 	960.17	 	 	 	1,005.22	 	 	 	380.61	 	 	 	117.49	 	 	 	109.41	 
	6B*
	 	 	1,064.96	 	 	 	165.71	 	 	 	99.11	 	 	 	62.64	 	 	 	132.41	 	 	 	72.62	 	 	 	260.80	 	 	 	157.36	 	 	 	347.08	 	 	 	12,740.29	 	 	 	1,765.81	 	 	 	479.42	 	 	 	216.27	 	 	 	232.63	 	 	 	751.89	 	 	 	789.57	 	 	 	332.29	 	 	 	65.62	 	 	 	61.55	 

TABLE 2 ***AREA 10 REDACTED***

General + Mental Health Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE(55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,130.48	 	 	 	171.83	 	 	 	104.08	 	 	 	74.27	 	 	 	148.20	 	 	 	83.64	 	 	 	270.41	 	 	 	162.42	 	 	 	345.39	 	 	 	12,167.05	 	 	 	1,661.36	 	 	 	458.53	 	 	 	246.96	 	 	 	257.82	 	 	 	765.70	 	 	 	745.22	 	 	 	353.34	 	 	 	93.65	 	 	 	87.79	 
	02
	 	 	1,130.47	 	 	 	171.82	 	 	 	103.70	 	 	 	73.65	 	 	 	148.12	 	 	 	83.56	 	 	 	271.15	 	 	 	163.16	 	 	 	346.04	 	 	 	12,167.09	 	 	 	1,661.42	 	 	 	462.52	 	 	 	271.63	 	 	 	261.47	 	 	 	815.61	 	 	 	764.75	 	 	 	353.34	 	 	 	93.65	 	 	 	78.79	 
	03
	 	 	1,205.00	 	 	 	184.87	 	 	 	111.59	 	 	 	80.12	 	 	 	159.24	 	 	 	90.80	 	 	 	293.11	 	 	 	177.22	 	 	 	379.23	 	 	 	12,964.86	 	 	 	1,788.41	 	 	 	491.02	 	 	 	256.66	 	 	 	270.33	 	 	 	822.40	 	 	 	814.16	 	 	 	228.03	 	 	 	90.63	 	 	 	85.38	 
	04
	 	 	1,050.63	 	 	 	162.48	 	 	 	98.39	 	 	 	72.22	 	 	 	140.75	 	 	 	81.46	 	 	 	259.29	 	 	 	157.61	 	 	 	339.39	 	 	 	12,420.35	 	 	 	1,720.74	 	 	 	474.10	 	 	 	253.25	 	 	 	265.92	 	 	 	805.95	 	 	 	797.55	 	 	 	166.90	 	 	 	88.61	 	 	 	83.94	 
	05
	 	 	1,184.68	 	 	 	182.35	 	 	 	110.60	 	 	 	82.70	 	 	 	160.27	 	 	 	93.18	 	 	 	291.03	 	 	 	175.90	 	 	 	377.96	 	 	 	14,030.25	 	 	 	1,834.41	 	 	 	532.50	 	 	 	361.37	 	 	 	295.39	 	 	 	896.35	 	 	 	884.97	 	 	 	266.08	 	 	 	76.08	 	 	 	72.45	 
	06
	 	 	1,065.10	 	 	 	165.75	 	 	 	100.09	 	 	 	69.11	 	 	 	138.39	 	 	 	78.59	 	 	 	262.96	 	 	 	159.61	 	 	 	349.00	 	 	 	12,740.90	 	 	 	1,765.94	 	 	 	483.54	 	 	 	242.20	 	 	 	256.02	 	 	 	792.46	 	 	 	805.41	 	 	 	340.40	 	 	 	78.16	 	 	 	74.09	 
	07
	 	 	1,094.63	 	 	 	170.06	 	 	 	104.05	 	 	 	83.04	 	 	 	154.12	 	 	 	92.54	 	 	 	275.08	 	 	 	158.93	 	 	 	361.57	 	 	 	13,685.85	 	 	 	1,905.51	 	 	 	525.43	 	 	 	282.49	 	 	 	296.30	 	 	 	898.66	 	 	 	893.70	 	 	 	286.99	 	 	 	80.86	 	 	 	76.56	 
	08
	 	 	1,037.10	 	 	 	161.02	 	 	 	97.10	 	 	 	68.36	 	 	 	136.14	 	 	 	77.72	 	 	 	256.29	 	 	 	156.63	 	 	 	336.45	 	 	 	12,799.21	 	 	 	1,774.62	 	 	 	486.19	 	 	 	243.72	 	 	 	258.00	 	 	 	800.37	 	 	 	811.65	 	 	 	323.71	 	 	 	79.37	 	 	 	75.17	 
	09
	 	 	1,062.12	 	 	 	161.99	 	 	 	98.40	 	 	 	74.97	 	 	 	143.62	 	 	 	84.07	 	 	 	259.41	 	 	 	157.87	 	 	 	336.74	 	 	 	12,607.42	 	 	 	1,749.26	 	 	 	482.36	 	 	 	261.41	 	 	 	273.83	 	 	 	825.55	 	 	 	814.71	 	 	 	288.79	 	 	 	86.19	 	 	 	81.29	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,387.47	 	 	 	213.14	 	 	 	128.49	 	 	 	90.88	 	 	 	181.77	 	 	 	103.11	 	 	 	337.67	 	 	 	204.10	 	 	 	437.87	 	 	 	16,510.92	 	 	 	2,276.92	 	 	 	630.84	 	 	 	354.52	 	 	 	369.60	 	 	 	1,096.00	 	 	 	1,058.15	 	 	 	386.62	 	 	 	130.03	 	 	 	121.95	 
	6B*
	 	 	1,064.97	 	 	 	165.72	 	 	 	99.91	 	 	 	68.99	 	 	 	138.53	 	 	 	78.74	 	 	 	283.40	 	 	 	159.96	 	 	 	349.36	 	 	 	12,740.32	 	 	 	1,765.84	 	 	 	483.29	 	 	 	249.54	 	 	 	254.97	 	 	 	793.50	 	 	 	805.79	 	 	 	340.40	 	 	 	78.16	 	 	 	74.09	 

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 4 of 10

 

     

ATTACHMENT I

EXHIBIT 2-NR

“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”

MEDICAID Non-Reform HMO CAPITATION RATES

By Area, Age and Eligibility Category

September 1, 2009 — August 31, 2010 HMO RATES

TABLE 3***AREA 10 REDACTED***

General + MH + Dental Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	 	 	 	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,130.49	 	 	 	171.84	 	 	 	105.46	 	 	 	76.79	 	 	 	150.71	 	 	 	85.83	 	 	 	271.81	 	 	 	163.93	 	 	 	348.70	 	 	 	12,167.05	 	 	 	1,661.38	 	 	 	459.71	 	 	 	248.69	 	 	 	259.34	 	 	 	767.10	 	 	 	747.24	 	 	 	353.34	 	 	 	94.73	 	 	 	88.76	 
	02
	 	 	1,130.48	 	 	 	171.83	 	 	 	105.08	 	 	 	76.17	 	 	 	150.63	 	 	 	85.75	 	 	 	272.65	 	 	 	164.67	 	 	 	349.35	 	 	 	12,167.09	 	 	 	1,661.42	 	 	 	463.70	 	 	 	273.37	 	 	 	282.99	 	 	 	817.21	 	 	 	766.77	 	 	 	350.34	 	 	 	94.73	 	 	 	88.76	 
	03
	 	 	1,205.01	 	 	 	184.89	 	 	 	114.60	 	 	 	85.61	 	 	 	164.70	 	 	 	95.58	 	 	 	295.57	 	 	 	179.97	 	 	 	385.26	 	 	 	12,984.86	 	 	 	1,788.42	 	 	 	494.55	 	 	 	260.76	 	 	 	273.98	 	 	 	824.81	 	 	 	817.66	 	 	 	229.28	 	 	 	92.53	 	 	 	87.02	 
	04
	 	 	1,050.64	 	 	 	162.49	 	 	 	100.16	 	 	 	75.46	 	 	 	143.97	 	 	 	84.27	 	 	 	261.36	 	 	 	169.84	 	 	 	344.27	 	 	 	12,420.35	 	 	 	1,720.74	 	 	 	475.76	 	 	 	255.71	 	 	 	268.06	 	 	 	808.10	 	 	 	800.67	 	 	 	168.79	 	 	 	90.28	 	 	 	85.30	 
	05
	 	 	1,184.69	 	 	 	182.37	 	 	 	114.20	 	 	 	89.29	 	 	 	166.83	 	 	 	98.92	 	 	 	294.84	 	 	 	181.00	 	 	 	386.95	 	 	 	14,000.26	 	 	 	1,934.42	 	 	 	536.45	 	 	 	287.10	 	 	 	300.37	 	 	 	899.47	 	 	 	889.49	 	 	 	266.16	 	 	 	79.19	 	 	 	75.00	 
	06
	 	 	1,065.11	 	 	 	165.77	 	 	 	102.78	 	 	 	74.04	 	 	 	143.29	 	 	 	82.87	 	 	 	265.06	 	 	 	161.76	 	 	 	353.94	 	 	 	12,740.90	 	 	 	1,765.95	 	 	 	486.45	 	 	 	246.51	 	 	 	259.76	 	 	 	795.04	 	 	 	809.16	 	 	 	343.25	 	 	 	80.33	 	 	 	75.87	 
	07
	 	 	1,094.64	 	 	 	170.08	 	 	 	106.68	 	 	 	87.86	 	 	 	158.91	 	 	 	96.73	 	 	 	276.71	 	 	 	170.68	 	 	 	366.40	 	 	 	13,685.85	 	 	 	1,905.52	 	 	 	528.40	 	 	 	286.88	 	 	 	300.12	 	 	 	900.23	 	 	 	895.97	 	 	 	287.74	 	 	 	82.30	 	 	 	77.75	 
	08
	 	 	1,037.12	 	 	 	161.05	 	 	 	101.81	 	 	 	76.83	 	 	 	144.58	 	 	 	85.09	 	 	 	258.91	 	 	 	158.45	 	 	 	344.63	 	 	 	12,799.22	 	 	 	1,774.63	 	 	 	489.94	 	 	 	249.27	 	 	 	262.83	 	 	 	802.91	 	 	 	815.32	 	 	 	326.18	 	 	 	81.28	 	 	 	76.74	 
	09
	 	 	1,062.13	 	 	 	162.01	 	 	 	101.61	 	 	 	80.84	 	 	 	149.46	 	 	 	89.17	 	 	 	260.82	 	 	 	159.38	 	 	 	340.05	 	 	 	12,607.42	 	 	 	1,749.27	 	 	 	485.15	 	 	 	265.54	 	 	 	277.43	 	 	 	827.10	 	 	 	816.96	 	 	 	292.18	 	 	 	87.67	 	 	 	82.50	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,387.53	 	 	 	213.20	 	 	 	134.76	 	 	 	98.83	 	 	 	189.24	 	 	 	110.58	 	 	 	338.63	 	 	 	250.24	 	 	 	440.36	 	 	 	16,511.00	 	 	 	2,277.00	 	 	 	637.97	 	 	 	361.66	 	 	 	375.08	 	 	 	1,097.92	 	 	 	1,060.93	 	 	 	391.98	 	 	 	132.45	 	 	 	123.94	 
	6B*
	 	 	1,064.98	 	 	 	166.74	 	 	 	102.60	 	 	 	73.92	 	 	 	143.43	 	 	 	83.02	 	 	 	263.40	 	 	 	159.96	 	 	 	349.36	 	 	 	12,740.32	 	 	 	1,765.85	 	 	 	486.20	 	 	 	244.85	 	 	 	258.71	 	 	 	793.50	 	 	 	806.79	 	 	 	343.25	 	 	 	80.33	 	 	 	75.87	 

TABLE 4***AREA 10 REDACTED***

General + MH + Transportation Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,135.62	 	 	 	173.12	 	 	 	104.94	 	 	 	74.77	 	 	 	150.36	 	 	 	85.08	 	 	 	273.90	 	 	 	165.08	 	 	 	349.30	 	 	 	12,218.57	 	 	 	1,694.83	 	 	 	463.16	 	 	 	249.41	 	 	 	263.76	 	 	 	785.58	 	 	 	762.27	 	 	 	361.36	 	 	 	106.87	 	 	 	97.94	 
	02
	 	 	1,135.61	 	 	 	173.11	 	 	 	104.56	 	 	 	74.15	 	 	 	150.28	 	 	 	85.00	 	 	 	274.64	 	 	 	165.82	 	 	 	349.95	 	 	 	12,218.61	 	 	 	1,694.87	 	 	 	467.15	 	 	 	274.09	 	 	 	287.41	 	 	 	835.69	 	 	 	781.80	 	 	 	361.36	 	 	 	106.87	 	 	 	97.94	 
	03
	 	 	1,211.17	 	 	 	186.41	 	 	 	112.62	 	 	 	80.72	 	 	 	161.83	 	 	 	92.53	 	 	 	297.30	 	 	 	180.41	 	 	 	383.92	 	 	 	13,050.22	 	 	 	1,830.85	 	 	 	497.71	 	 	 	259.69	 	 	 	277.86	 	 	 	847.61	 	 	 	835.81	 	 	 	236.63	 	 	 	109.68	 	 	 	99.91	 
	04
	 	 	1,054.64	 	 	 	163.49	 	 	 	99.06	 	 	 	72.61	 	 	 	142.43	 	 	 	82.58	 	 	 	262.02	 	 	 	169.69	 	 	 	342.45	 	 	 	12,468.39	 	 	 	1,751.96	 	 	 	478.42	 	 	 	255.66	 	 	 	271.46	 	 	 	824.49	 	 	 	813.45	 	 	 	173.13	 	 	 	103.96	 	 	 	95.64	 
	05
	 	 	1,188.16	 	 	 	183.22	 	 	 	111.18	 	 	 	83.04	 	 	 	161.73	 	 	 	94.16	 	 	 	293.39	 	 	 	178.70	 	 	 	380.61	 	 	 	14,071.98	 	 	 	1,961.61	 	 	 	536.34	 	 	 	283.37	 	 	 	300.20	 	 	 	912.65	 	 	 	898.78	 	 	 	272.12	 	 	 	89.99	 	 	 	83.06	 
	06
	 	 	1,068.60	 	 	 	166.62	 	 	 	100.67	 	 	 	69.45	 	 	 	139.86	 	 	 	79.57	 	 	 	265.34	 	 	 	161.32	 	 	 	361.66	 	 	 	12,781.60	 	 	 	1,792.38	 	 	 	487.20	 	 	 	244.15	 	 	 	260.70	 	 	 	808.15	 	 	 	818.87	 	 	 	346.35	 	 	 	89.27	 	 	 	82.67	 
	07
	 	 	1,098.45	 	 	 	171.02	 	 	 	104.67	 	 	 	83.42	 	 	 	165.72	 	 	 	93.60	 	 	 	277.67	 	 	 	170.90	 	 	 	364.47	 	 	 	13,731.89	 	 	 	1,935.41	 	 	 	629.58	 	 	 	284.70	 	 	 	301.60	 	 	 	916.43	 	 	 	908.94	 	 	 	293.06	 	 	 	92.62	 	 	 	85.52	 
	08
	 	 	1,042.08	 	 	 	162.27	 	 	 	98.01	 	 	 	68.84	 	 	 	138.22	 	 	 	79.11	 	 	 	259.67	 	 	 	158.21	 	 	 	342.24	 	 	 	12,849.85	 	 	 	1,807.50	 	 	 	490.75	 	 	 	246.16	 	 	 	263.83	 	 	 	819.90	 	 	 	828.40	 	 	 	329.66	 	 	 	93.23	 	 	 	85.73	 
	09
	 	 	1,057.08	 	 	 	163.23	 	 	 	99.23	 	 	 	76.46	 	 	 	145.70	 	 	 	85.46	 	 	 	262.78	 	 	 	160.44	 	 	 	340.51	 	 	 	12,659.96	 	 	 	1,783.38	 	 	 	487.10	 	 	 	263.94	 	 	 	279.88	 	 	 	845.83	 	 	 	832.09	 	 	 	292.82	 	 	 	101.59	 	 	 	83.03	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,390.09	 	 	 	213.87	 	 	 	128.97	 	 	 	91.16	 	 	 	183.00	 	 	 	103.93	 	 	 	339.56	 	 	 	205.61	 	 	 	440.10	 	 	 	16,547.82	 	 	 	2,300.88	 	 	 	634.16	 	 	 	358.30	 	 	 	373.86	 	 	 	1,110.23	 	 	 	1,070.36	 	 	 	394.16	 	 	 	141.29	 	 	 	130.63	 
	6B*
	 	 	1,068.47	 	 	 	166.59	 	 	 	100.49	 	 	 	69.33	 	 	 	140.00	 	 	 	79.72	 	 	 	265.78	 	 	 	161.77	 	 	 	362.02	 	 	 	12,781.02	 	 	 	1,792.28	 	 	 	486.95	 	 	 	242.49	 	 	 	259.56	 	 	 	809.19	 	 	 	819.25	 	 	 	346.36	 	 	 	89.27	 	 	 	82.57	 

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 5 of 10

 

     

ATTACHMENT I

EXHIBIT 2-NR

“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”

MEDICAID Non-Reform HMO CAPITATION RATES

By Area, Age and Eligibility Category

September 1, 2009 — August 31, 2010 HMO RATES

TABLE 5 ***AREA 10 REDACTED***

General + Transportation Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,135.59	 	 	 	173.09	 	 	 	103.08	 	 	 	62.42	 	 	 	138.97	 	 	 	73.69	 	 	 	269.84	 	 	 	161.02	 	 	 	345.73	 	 	 	12,218.50	 	 	 	1,694.76	 	 	 	454.95	 	 	 	197.57	 	 	 	216.98	 	 	 	704.48	 	 	 	730.67	 	 	 	353.25	 	 	 	94.33	 	 	 	85.40	 
	02
	 	 	1,135.59	 	 	 	173.09	 	 	 	103.08	 	 	 	62.42	 	 	 	138.97	 	 	 	73.69	 	 	 	269.84	 	 	 	161.02	 	 	 	345.73	 	 	 	12,218.50	 	 	 	1,694.76	 	 	 	454.95	 	 	 	197.57	 	 	 	216.98	 	 	 	704.48	 	 	 	730.67	 	 	 	353.25	 	 	 	94.33	 	 	 	85.40	 
	03
	 	 	1,211.16	 	 	 	186.39	 	 	 	111.07	 	 	 	68.43	 	 	 	149.98	 	 	 	80.68	 	 	 	292.27	 	 	 	175.38	 	 	 	379.50	 	 	 	13,050.16	 	 	 	1,830.79	 	 	 	491.10	 	 	 	218.23	 	 	 	239.69	 	 	 	776.52	 	 	 	808.11	 	 	 	228.42	 	 	 	97.14	 	 	 	87.37	 
	04
	 	 	1,054.62	 	 	 	163.47	 	 	 	97.60	 	 	 	60.98	 	 	 	131.22	 	 	 	71.37	 	 	 	267.27	 	 	 	154.94	 	 	 	338.27	 	 	 	12,468.33	 	 	 	1,751.89	 	 	 	471.58	 	 	 	212.66	 	 	 	231.97	 	 	 	760.91	 	 	 	784.78	 	 	 	166.02	 	 	 	91.42	 	 	 	83.10	 
	05
	 	 	1,188.14	 	 	 	183.20	 	 	 	109.24	 	 	 	67.61	 	 	 	146.86	 	 	 	79.28	 	 	 	287.08	 	 	 	172.39	 	 	 	375.06	 	 	 	14,071.91	 	 	 	1,951.44	 	 	 	528.72	 	 	 	235.58	 	 	 	256.21	 	 	 	830.50	 	 	 	866.85	 	 	 	264.01	 	 	 	77.45	 	 	 	70.52	 
	06
	 	 	1,068.58	 	 	 	166.50	 	 	 	99.70	 	 	 	62.99	 	 	 	133.80	 	 	 	73.61	 	 	 	263.21	 	 	 	159.19	 	 	 	349.79	 	 	 	12,781.57	 	 	 	1,792.35	 	 	 	483.10	 	 	 	218.24	 	 	 	237.32	 	 	 	767.62	 	 	 	803.07	 	 	 	338.24	 	 	 	75.73	 	 	 	70.03	 
	07
	 	 	1,098.42	 	 	 	170.99	 	 	 	102.30	 	 	 	64.47	 	 	 	137.45	 	 	 	75.33	 	 	 	269.92	 	 	 	163.16	 	 	 	357.66	 	 	 	13,731.82	 	 	 	1,935.34	 	 	 	522.25	 	 	 	238.71	 	 	 	259.27	 	 	 	837.57	 	 	 	878.21	 	 	 	284.95	 	 	 	80.08	 	 	 	72.98	 
	08
	 	 	1,042.07	 	 	 	162.26	 	 	 	97.03	 	 	 	61.10	 	 	 	130.75	 	 	 	71.64	 	 	 	236.50	 	 	 	155.04	 	 	 	339.46	 	 	 	12,849.81	 	 	 	1,807.45	 	 	 	486.67	 	 	 	220.55	 	 	 	240.27	 	 	 	776.00	 	 	 	811.30	 	 	 	321.56	 	 	 	80.69	 	 	 	73.19	 
	09
	 	 	1,057.06	 	 	 	163.21	 	 	 	97.34	 	 	 	60.46	 	 	 	131.24	 	 	 	71.00	 	 	 	256.65	 	 	 	154.31	 	 	 	336.12	 	 	 	12,659.89	 	 	 	1,783.31	 	 	 	479.74	 	 	 	217.76	 	 	 	237.38	 	 	 	766.65	 	 	 	801.24	 	 	 	284.71	 	 	 	89.05	 	 	 	80.49	 
	10
	11
	 	 	1,390.37	 	 	 	213.85	 	 	 	127.40	 	 	 	78.71	 	 	 	170.99	 	 	 	91.92	 	 	 	334.47	 	 	 	200.52	 	 	 	435.62	 	 	 	16,547.71	 	 	 	2,300.77	 	 	 	621.54	 	 	 	277.09	 	 	 	300.94	 	 	 	974.40	 	 	 	1,017.43	 	 	 	386.04	 	 	 	128.75	 	 	 	117.99	 
	6B *
	 	 	1,058.46	 	 	 	166.58	 	 	 	99.69	 	 	 	62.98	 	 	 	133.88	 	 	 	73.60	 	 	 	263.18	 	 	 	159.17	 	 	 	349.74	 	 	 	12,780.99	 	 	 	1,792.25	 	 	 	483.08	 	 	 	218.22	 	 	 	237.31	 	 	 	767.58	 	 	 	803.03	 	 	 	338.24	 	 	 	76.73	 	 	 	70.03	 

TABLE 6 ***AREA 10 REDACTED***

General + Dental Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,130.46	 	 	 	171.81	 	 	 	103.60	 	 	 	64.44	 	 	 	139.32	 	 	 	74.44	 	 	 	267.75	 	 	 	159.87	 	 	 	346.13	 	 	 	12,166.98	 	 	 	1,661.31	 	 	 	451.50	 	 	 	196.85	 	 	 	212.56	 	 	 	686.00	 	 	 	715.64	 	 	 	345.23	 	 	 	82.19	 	 	 	76.22	 
	02
	 	 	1,130.46	 	 	 	171.81	 	 	 	103.60	 	 	 	64.44	 	 	 	139.32	 	 	 	74.44	 	 	 	267.75	 	 	 	159.87	 	 	 	346.13	 	 	 	12,166.98	 	 	 	1,661.31	 	 	 	451.50	 	 	 	196.85	 	 	 	212.56	 	 	 	686.00	 	 	 	715.64	 	 	 	345.23	 	 	 	82.19	 	 	 	76.22	 
	03
	 	 	1,204.99	 	 	 	184.87	 	 	 	113.05	 	 	 	73.32	 	 	 	152.85	 	 	 	83.73	 	 	 	290.64	 	 	 	174.94	 	 	 	380.94	 	 	 	12,984.80	 	 	 	1,788.36	 	 	 	488.04	 	 	 	219.30	 	 	 	235.82	 	 	 	753.72	 	 	 	789.96	 	 	 	221.17	 	 	 	80.09	 	 	 	74.48	 
	04
	 	 	1,050.62	 	 	 	162.47	 	 	 	98.70	 	 	 	63.82	 	 	 	132.76	 	 	 	73.06	 	 	 	256.61	 	 	 	155.09	 	 	 	340.09	 	 	 	12,420.29	 	 	 	1,720.68	 	 	 	468.92	 	 	 	212.80	 	 	 	228.57	 	 	 	734.52	 	 	 	772.00	 	 	 	160.58	 	 	 	77.74	 	 	 	72.76	 
	05
	 	 	1,184.67	 	 	 	182.35	 	 	 	112.26	 	 	 	73.86	 	 	 	151.96	 	 	 	84.05	 	 	 	288.53	 	 	 	174.69	 	 	 	381.40	 	 	 	14,030.19	 	 	 	1,934.35	 	 	 	526.83	 	 	 	239.31	 	 	 	256.38	 	 	 	817.52	 	 	 	857.56	 	 	 	258.05	 	 	 	66.65	 	 	 	62.46	 
	06
	 	 	1,065.09	 	 	 	165.75	 	 	 	101.81	 	 	 	67.58	 	 	 	137.13	 	 	 	76.91	 	 	 	262.93	 	 	 	159.63	 	 	 	352.07	 	 	 	12,740.87	 	 	 	1,765.92	 	 	 	482.35	 	 	 	220.60	 	 	 	236.38	 	 	 	754.51	 	 	 	793.35	 	 	 	335.14	 	 	 	67.79	 	 	 	63.33	 
	07
	 	 	1,094.61	 	 	 	170.05	 	 	 	104.29	 	 	 	68.91	 	 	 	140.64	 	 	 	78.46	 	 	 	268.96	 	 	 	162.93	 	 	 	358.59	 	 	 	13,685.78	 	 	 	1,905.45	 	 	 	521.07	 	 	 	240.89	 	 	 	257.79	 	 	 	821.37	 	 	 	965.24	 	 	 	279.63	 	 	 	69.76	 	 	 	65.21	 
	08
	 	 	1,037.11	 	 	 	161.04	 	 	 	100.83	 	 	 	69.09	 	 	 	137.11	 	 	 	77.62	 	 	 	255.74	 	 	 	155.28	 	 	 	341.85	 	 	 	12,799.18	 	 	 	1,774.59	 	 	 	485.86	 	 	 	223.67	 	 	 	239.27	 	 	 	759.01	 	 	 	798.22	 	 	 	318.07	 	 	 	68.74	 	 	 	64.20	 
	09
	 	 	1,052.11	 	 	 	161.99	 	 	 	99.72	 	 	 	65.94	 	 	 	135.00	 	 	 	74.71	 	 	 	254.69	 	 	 	153.25	 	 	 	334.65	 	 	 	12,607.35	 	 	 	1,749.20	 	 	 	477.79	 	 	 	219.36	 	 	 	234.93	 	 	 	747.92	 	 	 	796.11	 	 	 	284.07	 	 	 	75.13	 	 	 	69.96	 
	10
	11
	 	 	1,387.51	 	 	 	213.18	 	 	 	133.19	 	 	 	86.38	 	 	 	177.23	 	 	 	98.57	 	 	 	333.54	 	 	 	200.15	 	 	 	435.99	 	 	 	16,510.89	 	 	 	2,276.89	 	 	 	625.35	 	 	 	282.45	 	 	 	302.17	 	 	 	962.03	 	 	 	1,008.00	 	 	 	383.87	 	 	 	119.91	 	 	 	111.40	 
	6B *
	 	 	1,054.97	 	 	 	165.73	 	 	 	101.80	 	 	 	67.57	 	 	 	137.31	 	 	 	76.90	 	 	 	260.80	 	 	 	157.36	 	 	 	347.06	 	 	 	12,740.29	 	 	 	1,765.82	 	 	 	482.33	 	 	 	220.58	 	 	 	236.37	 	 	 	751.89	 	 	 	789.57	 	 	 	335.14	 	 	 	67.79	 	 	 	63.33	 

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 6 of 10

 

     

ATTACHMENT I

EXHIBIT 2-NR

“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”

MEDICAID Non-Reform HMO CAPITATION RATES

By Area, Age and Eligibility Category

September 1, 2009 — August 31, 2010 HMO RATES

TABLE 7***AREA 10 REDACTED***

General + Dental + Transportation Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SS1-N	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65+)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,135.60	 	 	 	173.10	 	 	 	104.46	 	 	 	64.94	 	 	 	141.48	 	 	 	75.88	 	 	 	271.24	 	 	 	162.53	 	 	 	349.04	 	 	 	12,218.50	 	 	 	1,694.76	 	 	 	456.13	 	 	 	199.31	 	 	 	218.60	 	 	 	705.88	 	 	 	732.69	 	 	 	353.25	 	 	 	95.51	 	 	 	86.37	 
	02
	 	 	1,135.60	 	 	 	173.10	 	 	 	104.46	 	 	 	64.94	 	 	 	141.48	 	 	 	75.88	 	 	 	271.24	 	 	 	162.53	 	 	 	349.04	 	 	 	12,218.50	 	 	 	1,694.76	 	 	 	456.13	 	 	 	199.31	 	 	 	218.60	 	 	 	705.88	 	 	 	732.69	 	 	 	353.25	 	 	 	95.51	 	 	 	86.37	 
	03
	 	 	1,211.15	 	 	 	186.41	 	 	 	114.08	 	 	 	73.92	 	 	 	155.44	 	 	 	85.46	 	 	 	284.83	 	 	 	178.13	 	 	 	385.53	 	 	 	13,050.16	 	 	 	1,830.80	 	 	 	493.93	 	 	 	222.43	 	 	 	243.34	 	 	 	778.93	 	 	 	811.59	 	 	 	229.67	 	 	 	99.14	 	 	 	89.01	 
	04
	 	 	1,054.63	 	 	 	163.48	 	 	 	98.37	 	 	 	64.21	 	 	 	134.44	 	 	 	74.18	 	 	 	259.34	 	 	 	157.17	 	 	 	343.15	 	 	 	12,468.33	 	 	 	1,751.89	 	 	 	473.24	 	 	 	215.11	 	 	 	234.11	 	 	 	753.06	 	 	 	787.90	 	 	 	166.91	 	 	 	93.09	 	 	 	84.46	 
	05
	 	 	1,188.15	 	 	 	183.22	 	 	 	112.84	 	 	 	74.20	 	 	 	153.42	 	 	 	85.03	 	 	 	290.89	 	 	 	176.49	 	 	 	384.05	 	 	 	14,071.92	 	 	 	1,961.45	 	 	 	532.59	 	 	 	241.31	 	 	 	261.19	 	 	 	833.62	 	 	 	871.37	 	 	 	264.09	 	 	 	80.56	 	 	 	73.07	 
	06
	 	 	1,068.69	 	 	 	166.62	 	 	 	102.39	 	 	 	67.92	 	 	 	138.80	 	 	 	77.89	 	 	 	265.31	 	 	 	161.44	 	 	 	354.73	 	 	 	12,781.57	 	 	 	1,792.36	 	 	 	486.01	 	 	 	222.55	 	 	 	241.06	 	 	 	770.20	 	 	 	806.81	 	 	 	341.09	 	 	 	78.90	 	 	 	71.81	 
	07
	 	 	1,098.43	 	 	 	171.01	 	 	 	104.93	 	 	 	69.29	 	 	 	142.24	 	 	 	79.52	 	 	 	271.55	 	 	 	164.90	 	 	 	361.49	 	 	 	13,731.82	 	 	 	1,936.36	 	 	 	525.22	 	 	 	243.10	 	 	 	263.09	 	 	 	839.14	 	 	 	880.48	 	 	 	256.70	 	 	 	81.52	 	 	 	74.17	 
	08
	 	 	1,042.09	 	 	 	162.29	 	 	 	101.66	 	 	 	69.57	 	 	 	139.19	 	 	 	79.01	 	 	 	259.12	 	 	 	157.86	 	 	 	345.64	 	 	 	12,849.82	 	 	 	1,807.47	 	 	 	490.42	 	 	 	226.10	 	 	 	245.10	 	 	 	778.54	 	 	 	814.97	 	 	 	324.02	 	 	 	82.60	 	 	 	74.76	 
	09
	 	 	1,057.07	 	 	 	163.23	 	 	 	100.55	 	 	 	66.33	 	 	 	137.06	 	 	 	76.10	 	 	 	258.06	 	 	 	155.82	 	 	 	338.43	 	 	 	12,659.89	 	 	 	1,783.32	 	 	 	482.63	 	 	 	221.89	 	 	 	240.98	 	 	 	768.20	 	 	 	803.49	 	 	 	290.10	 	 	 	90.53	 	 	 	81.70	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,390.43	 	 	 	213.91	 	 	 	133.67	 	 	 	86.66	 	 	 	178.46	 	 	 	99.39	 	 	 	335.53	 	 	 	201.66	 	 	 	438.11	 	 	 	16,547.79	 	 	 	2,300.85	 	 	 	628.67	 	 	 	284.23	 	 	 	306.42	 	 	 	976.33	 	 	 	1,020.21	 	 	 	389.40	 	 	 	131.17	 	 	 	119.98	 
	6B *
	 	 	1,068.47	 	 	 	166.60	 	 	 	102.38	 	 	 	67.91	 	 	 	138.78	 	 	 	77.88	 	 	 	263.18	 	 	 	159.17	 	 	 	349.74	 	 	 	12,780.99	 	 	 	1,792.26	 	 	 	485.99	 	 	 	222.53	 	 	 	241.05	 	 	 	767.58	 	 	 	803.03	 	 	 	341.09	 	 	 	78.90	 	 	 	71.81	 

TABLE 8***AREA 10 REDACTED***

General + Mental Health + Dental + Transportation Rates:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SS1-N	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65+)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	1,136.63	 	 	 	173.13	 	 	 	106.32	 	 	 	77.29	 	 	 	152.87	 	 	 	87.27	 	 	 	275.30	 	 	 	166.59	 	 	 	352.61	 	 	 	12,218.57	 	 	 	1,694.83	 	 	 	464.34	 	 	 	251.15	 	 	 	266.28	 	 	 	786.98	 	 	 	764.29	 	 	 	361.36	 	 	 	108.05	 	 	 	98.91	 
	02
	 	 	1,135.62	 	 	 	173,12	 	 	 	105.94	 	 	 	76.67	 	 	 	152.79	 	 	 	87.19	 	 	 	276.04	 	 	 	167.33	 	 	 	353.26	 	 	 	12,218.61	 	 	 	1.694.87	 	 	 	468.33	 	 	 	275.53	 	 	 	288.93	 	 	 	837.09	 	 	 	783.82	 	 	 	361.36	 	 	 	108.05	 	 	 	98.91	 
	03
	 	 	1,211,18	 	 	 	186,43	 	 	 	115.63	 	 	 	86.21	 	 	 	167.29	 	 	 	97.31	 	 	 	299.86	 	 	 	183.16	 	 	 	389.95	 	 	 	13,050.22	 	 	 	1,830.86	 	 	 	500.54	 	 	 	263.89	 	 	 	281.50	 	 	 	850.02	 	 	 	839.29	 	 	 	237.78	 	 	 	111.68	 	 	 	101.55	 
	04
	 	 	1,054.65	 	 	 	163.50	 	 	 	100.83	 	 	 	75.84	 	 	 	146.65	 	 	 	85.39	 	 	 	264.09	 	 	 	161.92	 	 	 	347.33	 	 	 	12,468.39	 	 	 	1,751.95	 	 	 	480.08	 	 	 	255.02	 	 	 	273.60	 	 	 	826.64	 	 	 	815,57	 	 	 	175.02	 	 	 	105.63	 	 	 	97.00	 
	05
	 	 	1,188.17	 	 	 	183,24	 	 	 	114.78	 	 	 	89.63	 	 	 	168.29	 	 	 	99.90	 	 	 	297.20	 	 	 	182.80	 	 	 	389.60	 	 	 	14.071.99	 	 	 	1,961.52	 	 	 	540.21	 	 	 	289.10	 	 	 	305.18	 	 	 	915.57	 	 	 	903.30	 	 	 	272.20	 	 	 	93.10	 	 	 	85.61	 
	06
	 	 	1,068.61	 	 	 	155.64	 	 	 	103.36	 	 	 	74.38	 	 	 	144.76	 	 	 	83.85	 	 	 	267.44	 	 	 	163.57	 	 	 	356.60	 	 	 	12,781.60	 	 	 	1,792.39	 	 	 	490.11	 	 	 	248.46	 	 	 	264.44	 	 	 	810.73	 	 	 	822.61	 	 	 	349.20	 	 	 	91.44	 	 	 	84.35	 
	07
	 	 	1,098.46	 	 	 	171.04	 	 	 	107.32	 	 	 	88.24	 	 	 	160.51	 	 	 	97.79	 	 	 	279.30	 	 	 	172.65	 	 	 	368.30	 	 	 	13,731.89	 	 	 	1,936.42	 	 	 	532.55	 	 	 	289.09	 	 	 	305.42	 	 	 	918.00	 	 	 	911.21	 	 	 	293.81	 	 	 	94.06	 	 	 	86.71	 
	08
	 	 	1,042.10	 	 	 	162.30	 	 	 	102.64	 	 	 	77.31	 	 	 	146.66	 	 	 	86.48	 	 	 	262.29	 	 	 	161.03	 	 	 	348.42	 	 	 	12,849.56	 	 	 	1,807.51	 	 	 	494.50	 	 	 	251.70	 	 	 	268.56	 	 	 	822.44	 	 	 	832.07	 	 	 	332.13	 	 	 	95.14	 	 	 	87.30	 
	09
	 	 	1,057.09	 	 	 	163.25	 	 	 	102.44	 	 	 	81.33	 	 	 	151.54	 	 	 	90.56	 	 	 	264.19	 	 	 	161.95	 	 	 	343.82	 	 	 	12,659.96	 	 	 	1,783.39	 	 	 	489.89	 	 	 	268.07	 	 	 	283.48	 	 	 	847.38	 	 	 	834.34	 	 	 	298.21	 	 	 	103.07	 	 	 	94.24	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	1,390.45	 	 	 	213.93	 	 	 	135.24	 	 	 	99.11	 	 	 	190.47	 	 	 	111.40	 	 	 	340.62	 	 	 	206.75	 	 	 	442.59	 	 	 	16,547.90	 	 	 	2,300.96	 	 	 	641.29	 	 	 	363.44	 	 	 	379.33	 	 	 	1,112.15	 	 	 	1,073.14	 	 	 	397.51	 	 	 	143.71	 	 	 	132.52	 
	6B *
	 	 	1,068.48	 	 	 	166.61	 	 	 	103.18	 	 	 	74.26	 	 	 	144.90	 	 	 	84.00	 	 	 	266.78	 	 	 	161.77	 	 	 	362.02	 	 	 	12,781.02	 	 	 	1,792.29	 	 	 	489.86	 	 	 	246.50	 	 	 	263.39	 	 	 	809.19	 	 	 	819.25	 	 	 	349.20	 	 	 	91.44	 	 	 	84.35	 

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 7 of 10

 

ATTACHMENT I

EXHIBIT 2-NR

“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”

MEDICAID Non-Reform HMO CAPITATION RATES

By Area, Age and Eligibility Category

September 1, 2009 — August 31, 2010 HMO RATES

	 	 	 
	AREA

	 	CORRESPONDING COUNTIES
	Area 1

	 	Escambia, Okaloosa, Santa Rosa, Walton
	Area 2

	 	Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jeflerson, Leon, Liberty, Madison, Taylor, Washington, Wakulla
	Area 3

	 	Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumtor, Suwannee, Union
	Area 4

	 	Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
	Area 5

	 	Pasco, Pinellas
	Area 6

	 	Hardee, Highlands, Manatee, Polk
	Area 6B

	 	Hills borough
	Area 7

	 	Brevard, Orange, Osceola, Seminole
	Area 8

	 	Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasola
	Area 9

	 	Indian River, Okeechobee, St. Lucle, Martin, Palm Beach
	Area 10

	 	Broward
	Area 11

	 	Dade, Monroe

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 8 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

ATTACHMENT I

EXHIBIT 2-R

September 1, 2009 — August 31, 2012 HMO RATES

(MEDICAID Reform HMO CAPITATION RATES)

By Area, Age and Eligibility Category/Population

			
	TABLE 1:	 	COMPREHENSIVE COMPONENT AND CATASTROPHIC COMPONENT CAPITATION RATES

Effective September 1, 2009

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

***AREA 10 REDACTED***

	 	 	 	 	 	 	 	 	 
	 	 	AREA 4	 	AREA 10
	Eligibility Category: Children and Families
	Month 0-2 All
	 	 	924.33	 	 	 	 	 
	Month 3-11 All
	 	 	203.14	 	 	 	 	 
	1-5 All
	 	 	113.83	 	 	 	 	 
	6-13 All
	 	 	113.83	 	 	 	 	 
	14-20 Female
	 	 	113.83	 	 	 	 	 
	14-20 Male
	 	 	113.83	 	 	 	 	 
	21-54 Female
	 	 	113.83	 	 	 	 	 
	21-54 Male
	 	 	113.83	 	 	 	 	 
	55+ All
	 	 	113.83	 	 	 	 	 
	Eligibility Category: Aged and Disabled
	Month 0-2 All
	 	 	14,697.48	 	 	 	 	 
	Month 3-11 All
	 	 	3,276.14	 	 	 	 	 
	1-5 All
	 	 	630.52	 	 	 	 	 
	6-13All
	 	 	630.52	 	 	 	 	 
	14-20 All
	 	 	630.52	 	 	 	 	 
	21-54 All
	 	 	630.52	 	 	 	 	 
	55+ All
	 	 	630.52	 	 	 	 	 
	Eligibility Category: Aged and Disabled with Medicare Parts A & B
	Month 0-2 All
	 	 	14,697.48	 	 	 	 	 
	Month 3-11 All
	 	 	3,276.14	 	 	 	 	 
	1-5 All
	 	 	630.52	 	 	 	 	 
	6-13 All
	 	 	630.52	 	 	 	 	 
	14-20 All
	 	 	630.52	 	 	 	 	 
	21-54 All
	 	 	630.52	 	 	 	 	 
	55+ All
	 	 	630.52	 	 	 	 	 
	Eligibility Category: Aged and Disabled with Medicare Parts A & B
	Under Age 65
	 	 	163.20	 	 	 	 	 
	Age 65 and Over
	 	 	116.64	 	 	 	 	 
	Eligibility Category: Aged and Disabled with Medicare Part B Only
	AlI Ages
	 	 	337.04	 	 	 	 	 
	Population: HIV/AIDS Specialty Population
	 	 	 	 	 	 	 	 
	No Medicare HIV
	 	 	1,294.05	 	 	 	 	 
	No Medicare AIDS
	 	 	2,547.50	 	 	 	 	 
	Medicare HIV
	 	 	175.42	 	 	 	 	 
	Medicare AIDS
	 	 	187.25	 	 	 	 	 

AHCA Contract No. FA913, Attachment I, Exhibit 2-R, Page 9 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

			
	TABLE 2:	 	KICK PAYMENT AMOUNTS FOR COVERED OBSTETRICAL DELIVERY SERVICES

Effective September 1, 2009

***AREA 10 REDACTED***

	 	 	 	 	 	 	 	 	 	 	 	 	 
	CPT	 	 	 	 	 	 
	Code	 	Obstetrical Delivery CPT Code Description	 	Area 4	 	Area 10
	 	59409	 	 	Vaginal delivery only
	 	 	 	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	59410	 	 	Vaginal delivery including postpartum care
	 	 	4,210.92	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	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
	 	 	 	 	 	 	 	 

			
	TABLE 3:	 	KICK PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES

	 	 	 	 	 	 	 	 	 	 	 	 	 
	CPT	 	 	 	 	 	Children/Adolescents	 	 
	Code	 	Transplant CPT Code Description	 	or Adult	 	All Areas

***REDACTED***

AHCA Contract No. FA913, Attachment I, Exhibit 2-R, Page 10 of 10

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

ATTACHMENT II

CORE CONTRACT PROVISIONS

TABLE OF CONTENTS

	 	 	 	 	 
	Section I — Definitions and Acronyms
	 	 	6	 
	A. Definitions
	 	 	6	 
	B. Acronyms
	 	 	25	 
	Section II — General Overview
	 	 	29	 
	A. Background
	 	 	29	 
	B. Purpose
	 	 	29	 
	C. Responsibilities of the State of Florida and the Agency
for Health Care Administration
	 	 	29	 
	D. General Responsibilities of the Health Plan
	 	 	31	 
	Section III — Eligibility and Enrollment
	 	 	34	 
	A. Eligibility
	 	 	34	 
	1. Mandatory Populations
	 	 	34	 
	2. Voluntary Populations
	 	 	34	 
	3. Excluded Populations
	 	 	35	 
	B. Enrollment
	 	 	36	 
	1. General Provisions
	 	 	36	 
	2. Enrollment in a Specialty Plan
	 	 	37	 
	3. Unborn Activation and Newborn Enrollment
	 	 	37	 
	4. Stopping or Limiting Enrollment
	 	 	38	 
	C. Disenrollment
	 	 	39	 
	1. General Provisions
	 	 	39	 
	2. When Disenrollment Can Occur
	 	 	39	 
	3. Cause for Disenrollment
	 	 	40	 
	4. Involuntary Disenrollment Requests
	 	 	41	 
	5. Disenrollment Notice
	 	 	42	 
	Section IV — Enrollee Services, Community Outreach and Marketing
	 	 	43	 
	A. Enrollee Services
	 	 	43	 
	1. General Provisions
	 	 	43	 
	2. Requirements for Written Materials
	 	 	44	 
	3. New Enrollee Materials
	 	 	44	 
	4. Enrollee ID Card
	 	 	45	 
	5. Enrolling with a Primary Care Provider
	 	 	45	 
	6. Enrollee Handbook Requirements
	 	 	46	 
	7. Provider Directory
	 	 	50	 
	8. New Enrollee Procedures
	 	 	51	 
	9. Enrollee Assessments
	 	 	52	 
	10. Enrollee Authorized Representative
	 	 	52	 
	11. Toll-Free Help Line
	 	 	52	 
	12. Translation Services
	 	 	53	 
	13. Preferred Drug List
	 	 	54	 
	14. Incentive Programs
	 	 	54	 
	15. Enhanced Services
	 	 	55	 
	16. Notices of Action
	 	 	55	 
	17. Medicaid Redetermination Notices
	 	 	55	 

AHCA
Contract No. FA913, Attachment II, Page 1 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 
	B. Community Outreach and Marketing
	 	 	58	 
	1. General Provisions
	 	 	58	 
	2. Prohibited Activities
	 	 	59	 
	3. Permitted Activities
	 	 	60	 
	4. Community Outreach Notification Process
	 	 	61	 
	5. Provider Compliance
	 	 	62	 
	6. Community Outreach Representatives
	 	 	62	 
	Section V — Covered Services
	 	 	64	 
	A. Covered Services
	 	 	64	 
	B. Optional Services
	 	 	64	 
	C. Expanded Services
	 	 	64	 
	D. Customized Benefit Package
	 	 	65	 
	E. Excluded Services
	 	 	65	 
	F. Moral or Religious Objections
	 	 	65	 
	G. Copayments
	 	 	66	 
	H. Coverage Provisions
	 	 	66	 
	1. Requirements
	 	 	66	 
	2. Child Health Check-Up Program
	 	 	66	 
	3. Dental Services
	 	 	67	 
	4. Hearing Services
	 	 	67	 
	5. Vision Services
	 	 	67	 
	6. Diabetes Supplies and Education
	 	 	68	 
	7. Emergency Services
	 	 	68	 
	8. Out-of-Plan Use of Non-Emergency Services
	 	 	70	 
	9. Family Planning Services
	 	 	71	 
	10. Hospital Services — Inpatient
	 	 	71	 
	11. Hospital Services — Outpatient
	 	 	74	 
	12. Hospital Services — Ancillary Services
	 	 	75	 
	13. Hysterectomies, Sterilizations and Abortions
	 	 	75	 
	14. Immunizations
	 	 	76	 
	15. Pregnancy-Related Requirements
	 	 	77	 
	16. Prescription Drug Services
	 	 	81	 
	17. Quality Enhancements
	 	 	84	 
	18. Protective Custody
	 	 	86	 
	19. Therapy Services
	 	 	86	 
	20. Transportation Services
	 	 	87	 
	Section VI — Behavioral Health Care
	 	 	88	 
	A. General Provisions
	 	 	88	 
	Section VII — Provider Network
	 	 	90	 
	A. General Provisions
	 	 	90	 
	B. Network Standards
	 	 	91	 
	1. Primary Care Providers
	 	 	91	 
	2. Specialists and Other Providers
	 	 	92	 
	3. Public Health Providers
	 	 	94	 
	4. Facilities and Ancillary Providers
	 	 	95	 
	C. Network Changes
	 	 	96	 
	D. Provider Contract Requirements
	 	 	97	 
	E. Provider Termination
	 	 	101	 
	F. Appointment Waiting Times and Geographic Access Standards
	 	 	101	 
	G. Continuity of Care
	 	 	102	 
	H. Credentialing and Recredentialing
	 	 	103	 

AHCA
Contract No. FA913, Attachment II, Page 2 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 
	I. Provider Services
	 	 	105	 
	1. General Provisions
	 	 	105	 
	2. Provider Handbook
	 	 	106	 
	3. Education and Training
	 	 	107	 
	4. Toll-Free Provider Help Line
	 	 	107	 
	5. Provider Complaint System
	 	 	108	 
	J. Medical Records Requirements
	 	 	109	 
	Section VIII — Quality Management
	 	 	111	 
	A. Quality Improvement
	 	 	111	 
	1. General Requirements
	 	 	111	 
	2. Specific Required Components of the QI Program
	 	 	111	 
	3. Health Plan QI Activities
	 	 	113	 
	4. Cultural Competency Plan
	 	 	117	 
	5. EQRO Coordination Requirements
	 	 	118	 
	6. Agency Annual Medical Records Audit
	 	 	118	 
	B. Utilization Management
	 	 	118	 
	1. General Requirements
	 	 	118	 
	2. Care Management
	 	 	120	 
	3. Practice Protocols
	 	 	121	 
	4. Changes to Utilization Management Components
	 	 	121	 
	5. Disease Management
	 	 	121	 
	Section IX — Grievance System
	 	 	122	 
	A. General Requirements
	 	 	122	 
	B. Types of Issues
	 	 	123	 
	C. Notices
	 	 	123	 
	D. Filing Grievances and Appeals
	 	 	124	 
	E. Resolution and Notification
	 	 	125	 
	F. Expedited Appeals
	 	 	126	 
	G. Medicaid Fair Hearings
	 	 	126	 
	H. Continuation of Benefits
	 	 	127	 
	Section X — Administration and Management
	 	 	128	 
	A. General Provisions
	 	 	128	 
	B. Staffing
	 	 	128	 
	C. Claims
	 	 	130	 
	D. Encounter Data
	 	 	130	 
	E. Fraud and Abuse Prevention
	 	 	132	 
	Section XI — Information Management and Systems
	 	 	137	 
	A. General Provisions
	 	 	137	 
	1. General Requirements
	 	 	137	 
	2. Systems Capacity
	 	 	137	 
	3. E-Mail System
	 	 	137	 
	4. Participation in Information Systems Work Groups/Committees
	 	 	137	 
	5. Connectivity to the Agency/State Network and Systems
	 	 	137	 
	B. Data and Document Management Requirements
	 	 	137	 
	1. Adherence to Data and Document Management Standards
	 	 	137	 
	2. Data Model and Accessibility
	 	 	138	 
	3. Data and Document Relationships
	 	 	138	 
	4. Information Retention
	 	 	138	 
	5. Information Ownership
	 	 	138	 
	C. Systems and Data Integration Requirements
	 	 	138	 
	1. Adherence to Standards for Data Exchange
	 	 	138	 

AHCA
Contract No. FA913, Attachment II, Page 3 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 
	2. HIPAA Compliance Checker
	 	 	138	 
	3. Data and Report Validity and Completeness
	 	 	139	 
	4. State/Agency Website/Portal Integration
	 	 	139	 
	5. Functional Redundancy with FMMIS
	 	 	139	 
	6. Data Exchange in Support of the Agency’s Program Integrity and Compliance
Functions
	 	 	139	 
	7. Address Standardization
	 	 	139	 
	8. Eligibility and Enrollment Data Exchange Requirements
	 	 	139	 
	D. Systems Availability, Performance and Problem Management Requirements
	 	 	140	 
	1. Availability of Critical Systems Functions
	 	 	140	 
	2. Availability of Data Exchange Functions
	 	 	140	 
	3. Availability of Other Systems Functions
	 	 	140	 
	4. Problem Notification
	 	 	140	 
	5. Recovery from Unscheduled System Unavailability
	 	 	140	 
	6. Exceptions to System Availability Requirement
	 	 	141	 
	7. Information Systems Corrective Action Plan
	 	 	141	 
	8. Business Continuity-Disaster Recovery (BC-DR) Plan
	 	 	141	 
	E. Systems Testing and Change Management Requirements
	 	 	142	 
	1. Notification and Discussion of Potential System Changes
	 	 	142	 
	2. Response to Agency Reports of Systems Problems not Resulting in System
Unavailability
	 	 	142	 
	3. Valid Window for Certain System Changes
	 	 	142	 
	4. Testing
	 	 	142	 
	F. Information Systems Documentation Requirements
	 	 	143	 
	1. Types of Documentation
	 	 	143	 
	2. Content of System Process and Procedure Manuals
	 	 	143	 
	3. Content of System User Manuals
	 	 	143	 
	4. Changes to Manuals
	 	 	143	 
	5. Availability of/Access to Documentation
	 	 	143	 
	G. Reporting Requirements
	 	 	143	 
	H. Community Health Records/Electronic Medical Records and Related Efforts
	 	 	143	 
	I. Compliance with Standard Coding Schemes
	 	 	144	 
	1. Compliance with HIPAA-Based Code Sets
	 	 	144	 
	2. Compliance with Other Code Sets
	 	 	144	 
	J. Data Exchange and Formats and Methods Application to Health Plans
	 	 	145	 
	1. HIPAA-Based Formatting Standards
	 	 	145	 
	2. Methods for Data Exchange
	 	 	145	 
	3. Agency-Based Formatting Standards and Methods
	 	 	145	 
	Section XII — Reporting Requirements
	 	 	146	 
	A. Health Plan Reporting Requirements
	 	 	146	 
	Table 1 — Summary of Reporting Requirements
	 	 	147	 
	Table 2 — Summary of Submission Requirements
	 	 	154	 
	Section XIII — Method of Payment
	 	 	166	 
	Section XIV — Sanctions
	 	 	167	 
	A. General Provisions
	 	 	167	 
	B. Corrective Action Plans
	 	 	167	 
	C. Specific Sanctions
	 	 	168	 
	D. Intermediate Sanctions
	 	 	169	 
	E. Civil Monetary Penalties
	 	 	169	 
	F. Notice of Sanction
	 	 	169	 

AHCA
Contract No. FA913, Attachment II, Page 4 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 
	Section XV — Financial Requirements
	 	 	171	 
	A. Insolvency Protection
	 	 	171	 
	B. Insolvency Protection Account Waiver
	 	 	171	 
	C. Surplus Start Up Account
	 	 	171	 
	D. Surplus Requirements
	 	 	171	 
	E. Interest
	 	 	171	 
	F. Inspection and Audit of Financial Records
	 	 	171	 
	G. Physician Incentive Plans
	 	 	171	 
	H. Third Party Resources
	 	 	172	 
	I. Fidelity Bonds
	 	 	172	 
	J. Financial Reporting
	 	 	172	 
	Section XVI — Terms and Conditions
	 	 	173	 
	A. Agency Contract Management
	 	 	173	 
	B. Applicable Laws and Regulations
	 	 	173	 
	C. Assignment
	 	 	174	 
	D. Attorney’s Fees
	 	 	174	 
	E. Conflict of Interest
	 	 	174	 
	F. Contract Variation
	 	 	175	 
	G. Court of Jurisdiction or Venue
	 	 	175	 
	H. Damages for Failure to Meet Contract Requirements
	 	 	175	 
	I. Disputes
	 	 	175	 
	J. Force Majeure
	 	 	176	 
	K. Legal Action Notification
	 	 	176	 
	L. Licensing
	 	 	176	 
	M. Misuse of Symbols, Emblems or Names in Reference to Medicaid
	 	 	176	 
	N. Offer of Gratuities
	 	 	177	 
	O. Subcontracts
	 	 	177	 
	P. Hospital Provider Contracts
	 	 	181	 
	Q. Termination Procedures
	 	 	181	 
	R. Waiver
	 	 	182	 
	S. Withdrawing Services from a County
	 	 	182	 
	T. MyFloridaMarketPlace Vendor Registration
	 	 	183	 
	U. MyFloridaMarketPlace Vendor Registration/Transaction Fee Exemption
	 	 	183	 
	V. Ownership and Management Disclosure
	 	 	183	 
	W. Minority Recruitment and Retention Plan
	 	 	185	 
	X. Independent Provider
	 	 	185	 
	Y. General Insurance Requirements
	 	 	185	 
	Z. Workers’ Compensation Insurance
	 	 	186	 
	AA. State Ownership
	 	 	186	 
	BB. Emergency Management Plan
	 	 	186	 
	CC. Indemnification
	 	 	186	 

AHCA
Contract No. FA913, Attachment II, Page 5 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Section I

Definitions and Acronyms

A. Definitions (See Attachment II, Exhibit 1, for HIV/AIDS-related definitions)

The following terms as used in this Contract shall be construed and/or interpreted as
follows, unless the Contract otherwise expressly requires a different construction and/or
interpretation. Some defined terms do not appear in all contracts.

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

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

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

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

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

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

Agent — A term that refers to certain independent contractors with the state that
perform administrative functions, including but not limited to: fiscal agent activities;
outreach, eligibility and enrollment activities; systems and technical support. The term as
used herein does not create a principal-agent relationship.

Ancillary Provider — A provider of ancillary medical services who has contracted
with a health plan to serve the health plan’s enrollees.

Appeal - A formal request from an enrollee to seek a review of an action taken by
the Health Plan pursuant to 42 CFR 438.400(b).

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	 	HMO Contract

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

Automatic Assignment (or Auto-Assign) — The enrollment of an eligible Medicaid
recipient, for whom enrollment is mandatory, in a Health Plan chosen by the Agency or its
agent, and/or the assignment of a new enrollee to a primary care provider chosen by the
Health Plan.

Baker Act — The Florida Mental Health Act, pursuant to ss. 394.451-394.4789, F.S.

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

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

Behavioral Health Care Provider — A licensed behavioral health professional, such as
a clinical psychologist, or registered nurse qualified due to training or competency in
behavioral health care, who is responsible for the provision of behavioral health care to
patients, or a physician licensed under Chapters 458 or 459, F.S., who is under contract to
provide behavioral health services to enrollees.

Beneficiary Assistance Program - (PSNs only) — A state external conflict resolution
program authorized under s. 409.91211(3)(q), F.S., similar to the Subscriber Assistance
Program, available to Medicaid participants, that provides an additional level of appeal if
the Health Plan’s process does not resolve the conflict.

Benefit Maximum - (Reform only) — The point when the cost of covered services
received by a non-pregnant enrollee, age 21 or older, reaches ***REDACTED*** in a Contract
year, based on Medicaid fee-for-service payment levels. Care coordination services and
emergency services and care must continue to be offered by the Health Plan, but the cost of
additional services, excluding emergency services and care, will not be covered by the
Medicaid program for the remainder of the Contract year in which the benefit maximum is met.
In addition, the Health Plan shall provide benefit reporting in accordance with Attachment
II, Section V, Covered Services, and Section XII, Reporting Requirements.

Benefits — A schedule of health care services to be delivered to enrollees covered
by the Health Plan as set forth in Attachment II, Section V, Covered Services, and Section
VI, Behavioral Health Care.

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

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

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

Calendar Days — All seven (7) days of the week. Unless otherwise specified, the term
“days” in this attachment refers to calendar days.

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

Capitated Health Plan - A health maintenance organization, provider service network
or other health plan that is paid a per-member/per-month fee to cover the cost of providing
health care to its enrollees.

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

Catastrophic Component - (Reform Health Plans only) — The amount of financial risk
assumed by a Health Plan or the Agency to provide covered services above $50,000 per
enrollee, based on Medicaid fee-for-service payment levels, and up to the overall annual
benefit maximum.

Catastrophic Component Threshold - (Capitated Reform Health Plans in counties where
no HMO is present and Reform FFS PSNs only) — The point at which the cost of covered
services, based on Medicaid fee-for-service payment levels, reaches $50,000 for an enrollee
in a Contract year. For a Health Plan that accepts the comprehensive capitation rate only,
the Agency begins reimbursing the Health Plan for the cost of covered services received by
the enrollee for the remainder of the Contract year. This reimbursement is based on a
percentage of Medicaid fee-for-service payment levels.

Cause — Special reasons that allow mandatory enrollees to change their Health Plan
choice outside their open enrollment period. May also be referred to as “good cause.” (See
59G-8.600, FAC.)

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

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

Child Health Check-Up-Program (CHCUP) — A set of comprehensive and preventive
health examinations provided on a periodic basis to identify and correct medical conditions

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

in children/adolescents. Policies and procedures are described in the Child Health Check- Up
Services Coverage and Limitations Handbook.

Children/Adolescents — Enrollees under the age of 21. For purposes of the provision
of Behavioral Health Services, excluding inpatient psychiatric services, adults are persons
age 18 and older, and children/adolescents are persons under age 18, as defined by the
Department of Children and Families.

Children & Families, Department of (DCF) — The state agency responsible for
overseeing programs involving behavioral health, childcare, family safety, domestic
violence, economic self-sufficiency, refugee services, homelessness, and programs that
identify and protect abused and neglected children and adults.

Choice Counselor/Enrollment Broker — The state’s contracted or designated entity
that performs functions related to outreach, education, counseling, enrollment, and
disenrollment of potential enrollees into a Health Plan.

Choice Counseling Specialists — Individuals authorized by an Agency-approved process
who provide one-on-one information to Medicaid recipients to help them choose the health
plan that best meets the health care needs of them and their families.

Claim—  (1) A bill for services, (2) a line item of service, or (3) all services for
one (1) recipient within a bill, pursuant to 42 CFR 447.45, in a format prescribed by the
Agency through its Medicaid provider handbooks.

Clean Claim — A claim that can be processed without obtaining additional information
from the provider of the service or from a third party. It does not include a claim from a
provider who is under investigation for fraud or abuse, or a claim under review for medical
necessity, pursuant to 42 CFR 447.45.

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

Commission for the Transportation Disadvantaged (CTD) — An independent commission
housed administratively within the Florida Department of Transportation. The CTD’s mission
is to ensure the availability of efficient, cost-effective, and quality transportation
services for transportation disadvantaged persons.

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

Community Outreach — The provision of health or nutritional information or information
for
the benefit and education of, or assistance to, a community in regard to health-related

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

matters or public awareness that promotes healthy lifestyles. Community outreach also
includes the provision of information about health care services, preventive techniques and
other health care projects and the provision of information related to health, welfare and
social services or social assistance programs offered by the State of Florida or local
communities.

Community Outreach Materials — Materials regarding health or nutritional information
or information for the benefit and education of, or assistance to, a community on
health-related matters or public awareness that promotes healthy lifestyles. Such materials
are meant specifically for the community at large and may also include information about
health care services, preventive techniques and other health care projects and the provision
of information related to health, welfare, and social services or social assistance programs
offered by the State of Florida or local communities. Community outreach materials are
limited to brochures, fact sheets, billboards, posters, and ad copy for radio, television,
print or the Internet.

Community Outreach Representative — A person who provides health information,
information that promotes healthy lifestyles, information that provides guidance about
social assistance programs, and information that provides culturally and linguistically
appropriate health or nutritional education. Such representatives must be appropriately
trained, certified and/or licensed, including but not limited to, social workers,
nutritionists, physical therapists and other health care professionals.

Complaint — Any oral or written expression of dissatisfaction by an enrollee
submitted to the Health Plan or to a state agency and resolved by close of business the
following business day. Possible subjects for complaints include, but are not limited to,
the quality of care, the quality of services provided, aspects of interpersonal
relationships such as rudeness of a provider or Health Plan employee, failure to respect the
enrollee’s rights, Health Plan administration, claims practices or provision of services
that relates to the quality of care rendered by a provider pursuant to the Health Plan’s
Contract. A complaint is an informal component of the grievance system.

Comprehensive Component — (Capitated Reform Health Plans in counties where no HMOs
are present and Reform FFS PSNs only) — The amount of financial risk assumed by a Health
Plan to provide covered service up to ***REDACTED*** per enrollee based on Medicaid fee
for-service payment levels.

Contested Claim — (FFS PSNs only) — A claim that has not been authorized and
forwarded to the Medicaid fiscal agent by the Health Plan because it has a material defect
or impropriety.

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

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

Contract Period — The term of the Contract beginning no earlier than September 1,
2009, and ending August 31, 2012.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Contract Year — Each September 1 through August 31 within the Contract
period.

Contracting Officer — The Secretary of the Agency or designee.

Cost Effective — The Health Plan’s per-member, per-month costs to the state,
including, but not limited to, FFS costs, administrative costs, and case-management fees,
must be no greater than the state’s costs associated with capitated health plans. (See
s.409.912(44), F.S.)

County Health Department (CHD) — Organizations administered by the Department of
Health to provide health services as defined in Chapter 154, ES., including promoting public
health, controlling and eradicating preventable diseases, and providing primary health care
for special populations.

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

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

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

Customized Benefit Package (CBP) — (Reform only) — Covered services, which may vary
in amount, scope and/or duration from those listed in Section V, Covered Services, and
Section VI, Behavioral Health Care. The CBP must meet state standards for actuarial
equivalency and sufficiency. CBP is also referred to as “benefit grid.”

Direct Ownership Interest — The ownership of stock, equity in capital or any
interest in the profits of a disclosing entity.

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

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

Disease Management — A system of coordinated health care intervention and
communication for populations with conditions in which patient self-care efforts are
significant. Disease management supports the physician or practitioner/patient relationship
and plan of care; emphasizes prevention of exacerbations and complications using
evidence-based practice guidelines and patient empowerment strategies, and evaluates

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving
overall health.

Disenrollment — The Agency-approved discontinuance of an enrollee’s participation in
a Health Plan.

Downward Substitution of Care — The use of less restrictive, lower cost services
than otherwise might have been provided, that are considered clinically acceptable and
necessary to meet specified objectives outlined in an enrollee’s plan of treatment, provided
as an alternative to higher cost services.

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

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

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

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

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

Emergency Transportation – The provision of emergency transportation services in
accordance with s. 409.908 (13)(c)4., F.S.

Encounter Data – A record of covered services provided to a Health Plan’s enrollees.
An “encounter” is an interaction between a patient and provider (Health Plan, rendering
physician, pharmacy, lab, etc.) who delivers services or is professionally responsible for
services delivered to a patient.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

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

Enhanced Benefit Account — (Reform only) — The individual account resulting from an
enrollee’s earning rewards for healthy behaviors under the Enhanced Benefit Program.

Enhanced Benefit Program — (Reform only) – Also known as Enhanced Benefits Reward$,
a program offered through Medicaid Reform that rewards enrollees for healthy behaviors.

Enrollee — A Medicaid recipient enrolled in a Health Plan.

Enrollment — The process by which an eligible Medicaid recipient signs up to
participate in a Health Plan.

Expanded Services — A service covered by the Health Plan for which it receives no
direct payment from the Agency.

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

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

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

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

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

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

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

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

Florida Medicaid Management Information System (FMMIS or FL MMIS) — The
information system used to process Florida Medicaid claims and payments to Health Plans,
and to produce management information and reports relating to the Florida Medicaid

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

program. This system is used to maintain Medicaid eligibility data and provider enrollment
data.

Florida Mental Health Act — Includes the Baker Act that covers admissions for
persons who are considered to have an emergency mental health condition (a threat to
themselves or others) as specified in ss. 394.451 through 394.4789, F.S.

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

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

Good Cause — See Cause.

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

Grievance Procedure — The procedure for addressing enrollees’ grievances.

Grievance System — The system for reviewing and resolving enrollee complaints,
grievances and appeals. Components must include a complaint process, a grievance process, an
appeal process, access to an applicable review outside the Health Plan (Subscriber
Assistance Program or Beneficiary Assistance Program), and access to a Medicaid Fair Hearing
through the Department of Children and Families.

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

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

Health Fair — An event conducted in -a setting that is open to the public
or segment of the public (such as the “elderly” or “schoolchildren”) during which
information about health-care services, facilities, research, preventive techniques or other
health-care subjects is disseminated. At least one (1) community organization or two (2)
health-related organizations that are not affiliated under common ownership must actively
participate in the health fair.

Health Maintenance Organization (HMO) — An organization or entity licensed in
accordance with Chapter 641, F.S., or in accordance with the Florida Medicaid State Plan
definition of an HMO.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Health Plan — An entity that integrates financing and management with the delivery
of health care services to an enrolled population. It employs or contracts with an organized
system of providers, which delivers services, and frequently shares financial risk. The term
includes health plans contracted with the Agency to provide Medicaid services under the
Florida Medicaid Reform program as well as 1915(b) managed care waiver (non-Reform) areas,
and includes health maintenance organizations authorized under Chapter 641, F.S., exclusive
provider organizations as defined in Chapter 627, F.S., health insurers authorized under
Chapter 624, F.S., and provider service networks as defined in s. 409.912, F.S., including
the specialty plan for children with chronic conditions as authorized under Section
409.91211(3)(bb) and (12), F.S.

HEDIS – Healthcare Effectiveness Data and Information Set developed and published by
the National Committee for Quality Assurance. HEDIS includes technical specifications for
the calculation of performance measures.

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

Hospital Services Agreement — The agreement between the Health Plan and a hospital
to provide medical services to the Health Plan’s enrollees.

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

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

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

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

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

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

Kick Payment – (Reform only) — The method of reimbursing capitated Health Plans in
the form of a separate one (1) time fixed payment for specific services.

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

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

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

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

Mandatory Assignment — The process the Agency uses to assign enrollees to a Health
Plan. The Agency automatically assigns those enrollees required to be in a Health Plan who
did not voluntarily choose one.

Mandatory Enrollee — The categories of eligible Medicaid recipients who must be
enrolled in a Health Plan or MediPass or, if subject to Reform, must be enrolled only in a
Health Plan.

Mandatory Potential Enrollee — A Medicaid recipient who is required to enroll in a
Health Plan or IVIediPass but has not yet made a choice.

Market Area — The geographic area in which the Health Plan is authorized to conduct
community outreach.

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

Medicaid Area — The specific counties designated by the Agency and overseen by an
Agency field office manager.

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

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Medicaid Fair Hearing – An administrative hearing conducted by the Department of
Children and Families to review an action taken by a Health Plan that limits, denies, or
stops a requested service.

Medicaid Program Integrity (MPI) – The unit of the Agency responsible for preventing
and identifying fraud and abuse in the Medicaid program.

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

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

Medical Foster Care Services — Services provided to enable medically-complex
children under the age of 21, whose parents cannot care for them in their own home, to live
and receive care in foster homes rather than in hospitals or other institutional settings.
Medical foster care services are authorized by Title XIX of the Social Security Act and s.
409.903, F.S., and Chapter 59G, FAC.

Medical Record — Documents corresponding to medical or allied care, goods or
services furnished in any place of business. The records may be on paper, magnetic material,
film or other media. In order to qualify as a basis for reimbursement, the records must be
dated, legible and signed or otherwise attested to, as appropriate to the media, and meet
the requirements of 42 CFR 456.111 and 42 CFR 456.211.

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

	 	1.	 	Meet the following conditions:

	 	a.	 	Be necessary to protect life, to prevent significant illness or
significant disability or to alleviate severe pain;
	 
	 	b.	 	Be individualized, specific and consistent with symptoms or confirm
diagnosis of the illness or injury under treatment and not in excess of the
patient’s needs;
	 
	 	c.	 	Be consistent with the generally accepted professional medical
standards as determined by the Medicaid program, and not be experimental or
investigational;
	 
	 	d.	 	Be reflective of the level of service that can be furnished safely
and for which no equally effective and more conservative or less costly
treatment is available statewide; and
	 
	 	e.	 	Be furnished in a manner not primarily intended for the convenience
of the enrollee, the enrollee’s caretaker or the provider.

	 	2.	 	For those services furnished in a hospital on an inpatient basis, medical
necessity means that appropriate medical care cannot be effectively furnished more
economically on an outpatient basis or in an inpatient facility of a different type.

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	 	3.	 	The fact that a provider has prescribed, recommended or approved medical or
allied goods or services does not, in itself, make such care, goods or services
medically necessary, a medical necessity or a covered service/benefit.

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

Medicare Advantage Special Needs Plan - A Medicare plan defined by Section
1859(b)(6) of the Social Security Act and 42 CFR Section 422.2 that exclusively enrolls or
enrolls a disproportionate percentage of special needs individuals as set forth in 42 CFR
Section 422.4(a)(1)(iv).

Meds AD — Individuals who have income up to 88% of federal poverty level and assets
up to $5,000 ($6,000 for a couple) and who do not have Medicare, or who have Medicare and
are receiving institutional care or hospice care, are enrolled in PACE or an HCBS program,
or live in an assisted living facility or adult family care home licensed to provide
assistive care services.

National Provider Identifier (NPI) – An identification number assigned through the
National Plan and Provider Enumerator System of the federal Department of Health and Human
Services. NPIs can be obtained online at https://nppes.cms.hhs.gov.

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

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

Non-Covered Service — A service that is not a benefit under either the Medicaid
State Plan or the Health Plan.

Non-Reform Health Plan – An organization that offers health care coverage under
Medicaid as authorized in s. 409.912, F.S., and as defined in the Agency’s 1915(b) managed
care waiver.

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

Open Enrollment — The 60-day period before the end of certain enrollees’ enrollment
year, during which the enrollee may choose to change health plans for the following
enrollment year.

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

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

Participating Provider – A health care practitioner or entity authorized to do
business in Florida and contracted with the Health Plan to provide services to the Health
Plan’s enrollees.

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

Peer Review — An evaluation of the professional practices of a provider by the
provider’s peers. It assesses the necessity, appropriateness and quality of care furnished
by comparing it to that customarily furnished by the provider’s peers and to recognized
health care standards.

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

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

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

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

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

Plan Factor – (Reform only) — A budget-neutral calculation using a Health Plan’s
available historical enrollee diagnosis data grouped by a health-based risk assessment
model. A Health Plan’s plan factor is developed from the aggregated individual risk scores
of the Health Plan’s prior month’s enrollment. The plan factor modifies a Health Plan’s
monthly capitation payment to reflect the health status of its enrollees.

Portable X-Ray Equipment — X-ray equipment transported to a setting other than a
hospital, clinic or office of a physician or other licensed practitioner of the healing
arts.

Post-Stabilization Care Services — Covered services related to an emergency medical
condition that are provided after an enrollee is stabilized in order to maintain, improve or
resolve the enrollee’s condition pursuant to 42 CFR 422.113.

Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid recipient
who is subject to mandatory assignment or one who may voluntarily elect to enroll in a given
health plan, but is not yet actually enrolled in a health plan.

Pre-Enrollment — The provision of marketing materials to a Medicaid recipient.

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	 	HMO Contract

Preferred Drug List – A listing of prescription products selected by a
pharmaceutical and therapeutics committee as cost effective choices for clinician
consideration when prescribing for Medicaid recipients.

Prescribed Pediatric Extended Care (PPEC) – A nonresidential health care center for
children who are medically complex or technologically dependent and require continuous
therapeutic intervention or skilled nursing services.

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

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

Primary Care Provider (PCP) — A Health Plan staff or contracted physician practicing
as a general or family practitioner, internist, pediatrician, obstetrician, gynecologist,
advanced registered nurse practitioner, physician assistant or other specialty approved by
the Agency, who furnishes primary care and patient management services to an enrollee.

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

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

Provider — A person or entity eligible to provide Medicaid services and that has a
contractual agreement with a Health Plan to provide services. PSN fee-for-service providers
must have an active Medicaid provider agreement. All other providers must be eligible for a
Medicaid provider agreement.

Provider Contract — An agreement between the Health Plan and a health care provider
to serve Health Plan enrollees.

Provider Service Network (PSN) — A network established or organized and operated by
a health care provider, or group of affiliated health care providers that provides a
substantial proportion of the health care items and services under a contract directly
through the provider or affiliated group of providers. The PSN may make arrangements with
physicians or other health care professionals, health care institutions, or any combination
of such individuals or institutions to assume all or part of the financial risk on a
prospective basis for the provision of basic health services by the physicians, by other
health professionals, or through the institutions. The health care providers must have a
controlling interest in the governing body of the provider service network organization.
(See ss. 409.912(4)(d) and 409.91211(3)(e.), F.S.)

Public Event — An event that is organized or sponsored by an organization for the benefit
and education of or assistance to a community in regard to health-related matters or public
awareness. A Health Plan may sponsor a public event if the event includes active

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participation of at least one (1) community organization or two (2) health-related
organizations not affiliated with the Health Plan.

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

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

Quality Improvement (QI) — The process of monitoring that the delivery of health
care services is available, accessible, timely, and medically necessary. The Health Plan
must have a quality improvement program (QI program) that includes standards of excellence.
It also must have a written quality improvement plan (QI plan) that draws on its quality
monitoring to improve health care outcomes for enrollees.

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

Remediation – The act or process of correcting a fault or deficiency.

Residential Services — As applied to the Department of Juvenile Justice, refers to
the out of-home placement for use in a level 4, 6, 8 or 10 facility as a result of a
delinquency disposition order. Also referred to as a residential commitment program.

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

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

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

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

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

Service Area — The designated geographical area within which the Health Plan is
authorized by the Contract to furnish covered services to enrollees.

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

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

Share of Cost-Savings — (FFS PSNs only) — Potential payment to the Health Plan when
amount of the savings pool exceeds the administrative allocation to the Health Plan as
determined through a reconciliation process.

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

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

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

Specialty Plan – A Health Plan designed for a specific population and whose
enrollees are primarily composed of Medicaid recipients, children with chronic conditions or
for Medicaid Reform recipients who have been diagnosed with the human immunodeficiency virus
or acquired immunodeficiency syndrome (HIV/AIDS). A Health Plan must be licensed under
Chapter 641, F.S., in order to offer a specialty plan for the Reform population with
HIV/AIDS.

State — State of Florida.

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

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

Subscriber Assistance Program – (HMOs only) — The state panel authorized under s.
408.7056, F.S., that hears appeals from HMO enrollees whose complaints have not been
resolved through the Health Plan’s grievance and appeal process.

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

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

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

Systems — See Information Systems.

Temporary Assistance to Needy Families (TANF) — Public financial assistance provided
to low-income families through the Department of Children and Families.

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

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

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

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

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

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

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

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

Voluntary Enrollee — A Medicaid recipient who is not mandated to enroll in a Health
Plan, but chooses to do so.

Voluntary Potential Enrollee — A Medicaid recipient who is not mandated to enroll in
a Health Plan, has expressed a desire to do so, but is not yet enrolled in a health plan.

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

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B. Acronyms

ACCESS — Automated Community Connection to Economic Self-Sufficiency, the Department of
Children and Families public assistance service delivery system.

ADL — Activities of Daily Living

AHCA — Agency for Health Care Administration (Agency)

ALF — Assisted Living Facility

APD — Agency for People with Disabilities

ARNP – Advanced Registered Nurse Practitioner

BBA — Balanced Budget Act of 1997

BMHC — Bureau of Managed Health Care

CAP — Corrective Action Plan

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

CDC — Centers for Disease Control and Prevention

CFARS — Children’s Functional Assessment Rating Scales

CHD — County Health Department

CMS — Centers for Medicare & Medicaid Services

CFR — Code of Federal Regulations (cites may be searched online at:

www.qpoaccess.qov/cfr/retrieve.qtrril 

CHCUP — Child Health Check-Up Program

CPT — Physicians’ Current Procedural Terminology

CTD — Commission for the Transportation Disadvantaged

CWPMHP — Child Welfare Prepaid Mental Health Plan

DCF — Department of Children & Families

DFS — Department of Financial Services

DHHS — United States Department of Health & Human Services

DOH — Department of Health

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DJJ — Department of Juvenile Justice

DEA — Drug Enforcement Administration

DME — Durable Medical Equipment

EDI — Electronic Data Interchange

ET — Eastern Time

EH — Emotionally Handicapped

EPSDT — Early and Periodic Screening, Diagnosis & Treatment Program

EQR — External Quality Review

EQRO — External Quality Review Organization

EST — Eastern Standard Time

FAC — Florida Administrative Code

FARS — Functional Assessment Rating Scales

FFS — Fee-for-Service

FQHC — Federally Qualified Health Center

F.S. — Florida Statutes

FSFN — Florida Safe Families Network (formerly HomeSafeNet)

FTE — Full-Time Equivalent Position

HCBS — Home and Community Based Services

NEDIS — Healthcare Effectiveness Data and Information Set

HIRAA — Health Insurance Portability & Accountability Act

HMO — Health Maintenance Organization

HSA — Health Savings Account

HSD —Bureau of Health Systems Development

IBNR — Incurred But Not Reported

LEIE — List of Excluded Individuals & Entities

MBHO — Managed Behavioral Health Organization

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MFCU — Medicaid Fraud Control Unit, Office of the Attorney General

MPI — Medicaid Program Integrity Bureau, Office of the AHCA Inspector General

NMHPA — Newborns and Mothers Health Protection Act

NCQA — National Committee for Quality Assurance

NPI — National Provider Identifier

ODBC — Open Database Connectivity

PA — Physician’s Assistant

PACE — Program of All-Inclusive Care for the Elderly

PCCB — Per Capita Capitation Benchmark

PCP — Primary Care Physician

PPEC — Prescribed Pediatric Extended Care

PDL — Preferred Drug List

PHI — Protected Health Information, as defined in 42 CFR 431.305(b)

PIP — Performance Improvement Plan

PMHP — Prepaid Mental Health Plan

PSN — Provider Service Network

QE — Quality Enhancement

QI — Quality Improvement

RFP — Request for Proposal

RHC — Rural Health Clinic

SAMH — Substance Abuse & Mental Health Office of the Florida Department of Children &
Families

SED — Severely Emotionally Disturbed

SFTP — Secure File Transfer Protocol

SIPP — Statewide Inpatient Psychiatric Program

SNIP — Strategic National Implementation Process

SOBRA — Sixth Omnibus Budget Reconciliation Act

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     SQL — Structured Query Language

     SSI — Supplemental Security Income

     TANF — Temporary Assistance for Needy Families

     TGCS — Therapeutic Group Care Services

     LIM — Utilization Management

     WEDI — Workgroup for Electronic Data Interchange

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

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Section II

General Overview

	A.	 	Background

	 	1.	 	Florida has offered Medicaid services since 1970. In July 2006 a demonstration
pilot, also known as Medicaid Reform, began operating in Broward and Duval Counties.
The pilot was later extended to Nassau, Clay and Baker Counties.
	 
	 	2.	 	In addition to its fee-for-service program, Medicaid contracts with several types
of organizations to provide services to recipients. They are:

	 	a.	 	Reform capitated Health Plans (HMOs and PSNs)
	 
	 	b.	 	Reform fee-for-service PSNs
	 
	 	c.	 	Reform specialty plan for children with chronic conditions
	 
	 	d.	 	Reform specialty plan for recipients living with HIV/AIDS
	 
	 	e.	 	Non-Reform HMOs
	 
	 	f.	 	Non-Reform fee-for-service PSNs
	 
	 	g.	 	Non-Reform capitated PSNs

	B.	 	Purpose
	 
	 	 	Medicaid provides health care coverage for income-eligible children, seniors, disabled
adults and pregnant women. It is funded by both the state and federal governments and
includes both capitated health plans as well as fee-for-service coverage. This attachment
describes elements that are common to all Medicaid Health Plans unless specifically noted
otherwise. Provisions unique to each Health Plan are described in Attachments I and II and
their exhibits.
	 
	C.	 	Responsibilities of the State of Florida (state) and the Agency for Health Care
Administration (Agency) (See Exhibit 2, Attachment II)

	 	1.	 	The Agency is responsible for administering the Medicaid program. The Agency
will administer contracts, monitor Health Plan performance, and provide oversight in
all aspects of Health Plan operations.
	 
	 	2.	 	The state has sole authority for determining eligibility for Medicaid and
whether Medicaid recipients are required to enroll in, may volunteer to enroll in,
may not enroll in a Medicaid health plan or are subject to annual open enrollment.
	 
	 	3.	 	The Agency or its agent will review the Florida Medicaid Management Information
System (FMMIS) file daily and will send written notification and information to all
potential enrollees.
	 
	 	4.	 	The Agency or its agent will use an established algorithm to assign mandatory
potential enrollees who do not select a Health Plan during their thirty-day (30-day)
choice period. The process may differ for Reform and non-Reform populations as
required by state law and federally approved waivers.

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	 	5.	 	Enrollment in a Health Plan, whether chosen or assigned, will be effective at 12:01
a.m. on the first calendar day of the month following a selection or assignment that
occurs between the first calendar day of the month and the penultimate Saturday of the
month. For those enrollees who choose or are assigned a Health Plan between the Sunday
after the penultimate Saturday and before the last calendar day of the month,
enrollment in a Health Plan will be effective on the first calendar day of the second
month after choice or assignment.
	 
	 	6.	 	The Agency or its agent will notify the Health Plan of an enrollee’s selection or
assignment to the Health Plan.
	 
	 	7.	 	The Agency or its agent will send written confirmation to enrollees of the chosen
or assigned Health Plan. If the enrollee has not chosen a PCP, the confirmation notice
will advise the enrollee that a PCP will be assigned by the Health Plan. Notice to the
enrollee will be sent by surface mail. Notice to the Health Plan will be by file
transfer.
	 
	 	8.	 	Conditioned on continued eligibility, mandatory enrollees have a lock-in period
of twelve (12) consecutive months. After an initial ninety (90) day change period,
mandatory enrollees may disenroll from the Health Plan only for cause. The Agency or
its agent will notify enrollees at least once every twelve (12) months, and for
mandatory enrollees at least sixty (60) calendar days before the lock-in period ends
that an open enrollment period exists giving them an opportunity to change health
plans. Mandatory enrollees who do not make a change during open enrollment will be
deemed to have chosen to remain with the current health plan, unless that health plan
no longer participates. In that case, the enrollee will be assigned to a new health
plan.
	 
	 	9.	 	The Agency or its agent will automatically re-enroll an enrollee into the Health
Plan in which the person was most recently enrolled if the enrollee has a temporary
loss of eligibility. “Temporary loss” is defined for purposes of this Contract as less
than sixty (60) calendar days for non-Reform enrollees and less than one-hundred and
eighty (180) calendar days for Reform enrollees. In this instance, for mandatory
enrollees, the lock-in period will continue as though there had been no break in
eligibility, keeping the original twelve (12) month period.
	 
	 	10.	 	If a temporary loss of eligibility causes the enrollee to miss the open
enrollment period, the Agency or its agent will enroll the person in the Health Plan
in which he or she was enrolled before loss of eligibility. The enrollee will have
ninety (90) calendar days to disenroll without cause.
	 
	 	11.	 	The Department of Children and Families (DCF) will issue a Medicaid
identification (ID) number to a newborn upon notification from the Health Plan, the
hospital, or other authorized Medicaid provider, consistent with the unborn activation
process described in Attachment II, Section III, Eligibility and Enrollment.
	 
	 	12.	 	The Agency or its agent will notify enrollees of their right to request
disenrollment as described in Attachment II, Section III, Eligibility and Enrollment,
Item C., Disenrollment, sub-item 2.
	 
	 	13.	 	The Agency or its agent will process all disenrollments from the Health Plan. The
Agency or its agent will make final determinations about granting disenrollment
requests and will notify the Health Plan by file transfer and the enrollee by surface
mail of any

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	 	 	 	disenrollment decision. Enrollees dissatisfied with an Agency determination may request
a Medicaid Fair Hearing.
	 
	 	14.	 	When disenrollment is necessary because an enrollee loses Medicaid eligibility,
disenrollment shall be at the end of the month in which eligibility was lost.
	 
	 	15.	 	The Agency and/or its agent shall determine the activities and behaviors that
qualify for contributions to the individual’s enhanced benefit account (Reform
enrollees only).
	 
	 	16.	 	The Agency will monitor Health Plan operations for compliance with the provisions
of the Contract and applicable federal and state laws and regulations.

	D.	 	General Responsibilities of the Health Plan (See Attachment I and Attachment II,
Exhibit 2)

	 	1.	 	The Health Plan shall comply with all provisions of this Contract, including all
attachments, applicable exhibits, Report Guide requirements and any amendments and
shall act in good faith in the performance of the Contract provisions. The core
provisions in Attachment II apply to all Health Plans unless otherwise specifically
noted. Health Plan specific provisions are in Attachment I and the exhibits that
accompany Attachments I and II. Attachment II exhibits are numbered to correspond to
section numbers.
	 
	 	2.	 	The Health Plan shall verify that information it submits to the Agency or its
agents is accurate.
	 
	 	3.	 	The Health Plan shall develop and maintain written policies and procedures to
implement all provisions of this Contract.
	 
	 	4.	 	The Health Plan shall submit all policies and procedures, model provider agreements
and amendments, all subcontracts (including behavioral health, if applicable), and all
other materials related to this Contract to the Bureau of Managed Health Care (BMHC)
for approval before implementation. Likewise, any changes in such materials must be
prior approved by BMHC before they take effect.

	 	a.	 	The Health Plan shall provide written materials to BMHC at least
forty-five (45) calendar days before the effective date of the change.
	 
	 	b.	 	The Health Plan shall provide written notice of such changes affecting
enrollees to those enrollees at least thirty (30) calendar days before the
effective date of change.

	 	5.	 	The Health Plan agrees that failure to comply with all provisions of this Contract
may result in the assessment of sanctions and/or termination of the Contract, in whole
or in part, in accordance with Attachment II, Section XIV, Sanctions.
	 
	 	6.	 	The Health Plan shall make enrollee materials, including the preferred drug list,
provider directory and enrollee handbook(s), available online at the Health Plan’s
website without requiring enrollee log-in.
	 
	 	7.	 	The Health Plan shall comply with all pertinent Agency rules in effect throughout
the duration of the Contract.

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	 	HMO Contract

	 	8.	 	The Health Plan shall comply with all current Florida Medicaid handbooks
(Handbooks) as noticed in the Florida Administrative Weekly (FAW), or incorporated by
reference in rules relating to the provision of services set forth in Attachment II,
Section V, Covered Services, and Section VI, Behavioral Health Care, except where the
provisions of the Contract alter the requirements set forth in the Handbooks. In
addition, the Health Plan shall comply with the limitations and exclusions in the
Handbooks, unless otherwise specified by this Contract. In no instance may the
limitations or exclusions imposed by the Health Plan be more stringent than those
specified in the Handbooks. The Health Plan may not arbitrarily deny or reduce the
amount, duration or scope of a required service solely because of the diagnosis, type
of illness, or condition. The Health Plan may exceed these limits by offering expanded
services, as described in the exhibits of Attachment H.
	 
	 	9.	 	This Contract, including all attachments and exhibits, represents the entire
agreement between the Health Plan and the Agency and supersedes all other contracts
between the parties when it is executed by duly authorized signatures of the Health
Plan and the Agency. Correspondence and memoranda of understanding do not constitute
part of this Contract. In the event of a conflict of language between the Contract and
the attachments, the provisions of the Contract shall govern, unless otherwise noted.
The Agency reserves the right to clarify any contractual relationship in writing and
such clarification shall govern. Pending final determination of any dispute over any
Agency decision, the Health Plan shall proceed diligently with the performance of its
duties as specified under the Contract and in accordance with the direction of the
Agency’s Division of Medicaid.
	 
	 	10.	 	The Health Plan shall have a quality improvement program that ensures enhancement
of quality of care and emphasizes improving the quality of patient outcomes. The
Agency may restrict the Health Plan’s enrollment activities if the Health Plan does
not meet acceptable quality improvement and performance indicators, based on HEDIS
reports and other outcome measures to be determined by the Agency. Such restrictions
may include, but shall not be limited to, the termination of mandatory assignments.
	 
	 	11.	 	The Health Plan shall demonstrate that it has adequate knowledge of Medicaid
programs, provision of health care services, disease management initiatives, medical
claims data, and the capability to design and implement cost savings methodologies.
The Health Plan shall demonstrate the capacity for financial analyses, as necessary to
fulfill the requirements of this Contract. Additionally, the Health Plan shall meet
all requirements for doing business in the State of Florida.
	 
	 	12.	 	The Health Plan may be required to provide to the Agency or its agent information
or data relative to this Contract. In such instances, and at the direction of the
Agency, the Health Plan shall fully cooperate with such requests and furnish all
information in a timely manner, in the format in which it is requested. The Health
Plan shall have at least thirty (30) calendar days to fulfill such ad hoc requests.
	 
	 	13.	 	A Reform Health Plan shall fully cooperate with, and provide necessary data to,
the Agency and its agent for the design, management, operations and monitoring of the
Enhanced Benefits Program.

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	 	HMO Contract

	 	14.	 	The Health Plan shall provide care management services and monitor utilization of
services through the prior authorization of claims for Medicaid covered services for
its enrollees.
	 
	 	15.	 	If the Health Plan is capitated by the Agency for a covered service, then the
Health Plan shall enroll all network providers for such services who are not verified
as Medicaid- enrolled providers with the Agency’s fiscal agent, in the manner and
format determined by the Agency.
	 
	 	16.	 	The Health Plan shall collect and submit encounter data for each Contract year
in accordance with Attachment II, Section X, Administration and Management. The
Medicaid Encounter Data System Companion Guide is located on the Medicaid web site
http://ahca.mvflorida.com/Medicaid/meds/index.shtml. The Health Plan shall
ensure that its provision of provider information to the Agency is sufficient to
ensure that its providers are recognized as participating providers of the Health
Plan for choice counseling and encounter data acceptance purposes.
	 
	 	17.	 	The Health Plan shall provide covered services to enrollees as required for
each enrollee without regard to the frequency or cost of services relative to the
amount paid pursuant to the Contract. In the event of insolvency, the Health Plan
shall cover continuation of services to enrollees for the duration of the period for
which payment has been made, as well as for inpatient admissions up until discharge.
	 
	 	18.	 	The Health Plan shall comply with all requirements of the Health Plan Report
Guide referenced in Attachment II, Section XII, Reporting Requirements.

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	AMERIGROUP Community Care

	 	HMO Contract

Section III

Eligibility and Enrollment

A. Eligibility (See Attachment II, Exhibit 3)

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

	 	1.	 	Mandatory Populations

	 	a.	 	The categories of eligible recipients authorized to be enrolled in the Health Plan are:

	 	(1)	 	Low Income Families and Children;
	 
	 	(2)	 	Sixth Omnibus Budget Reconciliation Act (SOBRA) Children;
	 
	 	(3)	 	Supplemental Security Income (SSI) Medicaid Only,
	 
	 	(4)	 	Refugees;
	 
	 	(5)	 	Title XXI MediKids, in accordance with s. 409.8132, F.S., and
	 
	 	(6)	 	Medicaid Eligible Designated by SOBRA/Aged and Disabled
population (Meds AD) unless they otherwise meet a requirement of a voluntary
or excluded population.

	 	b.	 	Except as otherwise specified in this Contract, Title XXI
MediKids-eligible participants are entitled to the same conditions and services
as currently eligible Title XIX Medicaid recipients.

	 	2.	 	Voluntary Populations
	 
	 	 	 	The following categories describe recipients who may enroll in a Health Plan but are
not required to do so:

	 	a.	 	Foster care children/adolescents, including children/adolescents
receiving medical foster care services or receiving adoption assistance;
	 
	 	b.	 	Individuals diagnosed with developmental disabilities, as defined by
the Agency, including those in the Developmental Disabilities Waiver;
	 
	 	c.	 	Children with chronic conditions who are eligible to participate in
the Children’s Medical Services Program or a specialty plan for children with
chronic conditions but not enrolled in the program;
	 
	 	d.	 	Individuals with Medicare coverage (dual eligible individuals with
either Medicare Part B coverage or Medicare Parts A and B coverage) who are not
enrolled in a Medicare Advantage Plan;

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	 	HMO Contract

	 	e.	 	Children and adolescents who have an open case for services in the Department
of Children and Families’ Florida Safe Families Network (FSFN) database system
(formerly HomeSafenet) unless they otherwise meet a requirement of a mandatory
population or an excluded population;
	 
	 	f.	 	Women enrolled in the Health Plan who change eligibility categories to
the SOBRA category due to their pregnancy will remain eligible for enrollment in
the Health Plan or may disenroll;
	 
	 	g.	 	Individuals who are residents in ALFs and are not enrolled in an
Assisted Living for the Elderly (ALE) waiver program and are not otherwise in a
mandatory population;
	 
	 	h.	 	For Reform populations, individuals enrolled in Project AIDS Care
(PAC) waiver unless they otherwise meet a requirement of a mandatory or excluded
population; and
	 
	 	i.	 	Individuals enrolled in the Channeling Waiver, Aged and Disabled Adult
Waiver, Adult Cystic Fibrosis Waiver, Adult Day Health Care Waiver, Alzheimer’s
Disease Waiver, Traumatic Brain and Spinal Cord Injury Waiver, Familial
Dysautonomia Waiver, Family and Supported Living Waiver, or Model Waiver.

	 	3.	 	Excluded Populations
	 
	 	 	 	The following categories describe Medicaid recipients who are not eligible to enroll
in a Health Plan:

	 	a.	 	Pregnant women who have not enrolled in Medicaid prior to the
effective date of their SOBRA eligibility;
	 
	 	b.	 	Medicaid recipients who, at the time of application for enrollment
and/or at the time of enrollment, are living in an institution, including a
nursing facility (and have been CARES assessed), Statewide Inpatient Psychiatric
(SIPP) facility for individuals under the age of 21, an Intermediate Care
Facility/Developmentally Disabled (ICFDD), a state mental health hospital or a
correctional facility;
	 
	 	c.	 	Medicaid recipients whose Medicaid eligibility was determined through
the Medically Needy program;
	 
	 	d.	 	Qualified Medicare Beneficiaries (QMBs), Special Low Income Medicare
Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s);
	 
	 	e.	 	Medicaid recipients who have other creditable health care coverage,
such as TriCare or a private commercial health plan;
	 
	 	f.	 	Medicaid recipients who reside in the following:

	 	(1)	 	Residential commitment programs/facilities operated through
the Department of Juvenile Justice (DJJ);
	 
	 	(2)	 	Residential group care operated by the Family Safety &
Preservation Program of Department of Children and Families (DCF);

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	 	HMO Contract

	 	(3)	 	Children’s residential treatment facilities purchased through the
Substance Abuse & Mental Health District (SAMH) Offices of DCF (also referred
to as Purchased Residential Treatment Services — PRTS);
	 
	 	(4)	 	SAMH residential treatment facilities licensed as Level I and
Level II facilities; and
	 
	 	(5)	 	Residential Level I and Level II substance abuse treatment
programs. (See ss. 65D-30.007(2)(a) and (b), F.A.C.);

	 	g.	 	Medicaid recipients participating in the Family Planning Waiver;
	 
	 	h.	 	Title XXI-funded children with chronic conditions who are enrolled in
Children’s Medical Services Network;
	 
	 	i.	 	Women eligible for Medicaid due to breast and/or cervical cancer;
	 
	 	j.	 	Individuals eligible under a hospice-related eligibility group or
receiving hospice services;
	 
	 	k.	 	Individuals enrolled in the Nursing Home Diversion Program or the
Program of All Inclusive Care for the Elderly (PACE);
	 
	 	l.	 	For non-Reform populations, individuals enrolled in the PAC Waiver; and
	 
	 	m.	 	For Reform populations and non-Reform HMO populations, Medicaid
recipients who are members of the Florida Assertive Community Treatment Team
(FACT team) unless they disenroll from the FACT team. These recipients are
allowed to enroll in non-Reform PSNs.

B. Enrollment (See Attachment I and Attachment II, Exhibit 3)

	 	1.	 	General Provisions

	 	a.	 	Only Medicaid recipients who meet eligibility requirements in
Attachment II and are living in counties with authorized Health Plans are
eligible to enroll and receive services from the Health Plan.
	 
	 	b.	 	The Agency or its agent shall be responsible for enrollment, including
enrollment into the Health Plan, disenrollment, and outreach and education
activities. The Health Plan shall coordinate with the Agency and its agent as
necessary for all enrollment and disenrollment functions.
	 
	 	c.	 	The Health Plan shall accept Medicaid recipients without restriction
and in the order in which they enroll. The Health Plan shall not discriminate on
the basis of religion, gender, race, color, age, or national origin, health
status, pre-existing condition, or need for health care services and shall not
use any policy or practice that has the effect of such discrimination.

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	 	HMO Contract

	 	d.	 	The Health Plan shall accept new enrollees throughout the Contract period up to
the authorized maximum enrollment levels approved in Attachment I.
	 
	 	e.	 	Each month the Health Plan shall review its X12-834 enrollment files to
ensure that all enrollees are residing in the same county in which they were
enrolled. The Health Plan shall update the records for all enrollees who have
moved from one county to another but are still residing in the Health Plan’s
service area and provide those enrollees with a new provider directory for that
county, if necessary or requested.

	 	2.	 	Enrollment in a Specialty Plan (See Attachment II, Exhibit 3)
	 
	 	3.	 	Unborn Activation and Newborn Enrollment (See Attachment II, Exhibit 3)

	 	a.	 	The Health Plan shall use the unborn activation process to facilitate
enrollment and shall be responsible for newborns from the date their enrollment
in the Health Plan is effective. The Health Plan shall comply with all
requirements set forth by the Agency or its agent related to unborn activation.
	 
	 	b.	 	Upon unborn activation, during the next enrollment cycle the newborn
shall be enrolled in the mother’s Health Plan. If no unborn eligibility record
exists, the Health Plan shall follow the process described in subparagraph d.
below.
	 
	 	c.	 	Unborn activation shall occur through the following procedures:

	 	(1)	 	Upon identification of an enrollee’s pregnancy through medical
history, examination, testing, claims, or otherwise, the Health Plan shall
immediately notify DCF of the pregnancy and any relevant information known
(for example, due date and gender). The Health Plan must provide this
notification by completing the DCF Excel spreadsheet and submitting it, via
electronic mail, to the appropriate DCF Customer Call Center address and
copied to MPI at email: mcobabvahca.mvflorida.com. The Health Plan
shall indicate its name and number as the entity initiating the referral. The
DCF Excel spreadsheet and directions for completion are located on the
Medicaid web site:
http://ahca.myflorida.com/Medicaid/Newborn/index.shtml.
	 
	 	(2)	 	DCF will generate a Medicaid ID number for the unborn child.
This information will be transmitted to the Medicaid fiscal agent. The
Medicaid ID number will remain inactive until the child is born and DCF is
notified of the birth.
	 
	 	(3)	 	Upon notification that a pregnant enrollee has presented to
the hospital for delivery, the Health Plan shall inform the hospital, the
pregnant enrollee’s attending physician and the newborn’s attending and
consulting physicians that the newborn is an enrollee only if the Health
Plan has verified that the newborn has an unborn record on the system that
is awaiting activation. At this time the Health Plan or its designee shall
complete and submit the Excel spreadsheet for unborn activation to DCF, and
to IVIPI for its information. (Special provisions apply to fee-for-service
PSNs; see Exhibit 3.)
	 
	 	(4)	 	E-mail submissions shall include the password-protected
spreadsheet as an attachment, and the spreadsheet shall contain all
pregnancy notifications and

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	 	HMO Contract

	 	 	 	newborn births for that Health Plan (or that Health Plan’s designated
subcontractor). Each Health Plan (or Health-Plan-designated subcontractor)
shall send no more than one (1) e-mail submission, per day, to each DCF
customer call center region based on the enrollee’s region of residence.
(Refer to the Medicaid website referenced above for DCF customer call center
information.)
	 
	 	(5)	 	With regard to participating hospitals, the Health Plan shall
include, as part of its participating hospital contract, a clause that states
whether the Health Plan or the hospital will complete the DCF Excel
spreadsheet for unborn activation (see Attachment II, Section XVI, Terms and
Conditions).
	 
	 	(6)	 	The Health Plan shall periodically check Medicaid eligibility to
determine if the baby’s Medicaid ID has been activated. Frequent monitoring
is recommended. Monitoring may be done through the following:

	 	(a)	 	The Health Plan’s contracted Medicaid Eligibility Vendor
System (MEVS);
	 
	 	(b)	 	The Medicaid Fiscal Agent’s toll-free provider inquiry
line and asking a representative for assistance;
	 
	 	(c)	 	The Medicaid Automated Voice Response System (AVRS); or
	 
	 	(d)	 	The X12-270 transmission to the Medicaid fiscal agent.

	 	(7)	 	If the unborn activation process is properly completed by the
capitated Health Plan, then the newborn will be enrolled in the Health Plan
retroactive to birth.
	 
	 	(8)	 	If the unborn activation process is properly completed by the FFS PSN, the
newborn will be enrolled using the process in Attachment II, Exhibit 3.
	 
	 	(9)	 	Failure to use the unborn activation process for known
pregnancies per subparagraph(s) c.(1), (3), (5) and (6) above shall result in
sanctions as described in Attachment II, Section XIV, Sanctions.

	 	d.	 	If a pregnant enrollee presents for delivery without having an unborn
eligibility record that is awaiting activation, the Health Plan or designee shall
submit the spreadsheet to DCF immediately upon birth of the child. The newborn
will not automatically become a Health Plan enrollee upon birth.

	 	4.	 	Stopping or Limiting Enrollment
	 
	 	 	 	The Health Plan may ask the Agency to halt or reduce enrollment temporarily if
continued full enrollment would exceed the Health Plan’s capacity to provide required
services under the Contract. The Agency may also limit Health Plan enrollments when
such action is considered to be in the Agency’s best interest in accordance with the
provisions of this Contract.

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	 	HMO Contract

C. Disenrollment (See Attachment II, Exhibit 3)

	 	1.	 	General Provisions

	 	a.	 	If the Contract is renewed, the enrollment status of all enrollees shall
continue uninterrupted.
	 
	 	b.	 	The Health Plan shall ensure that it does not restrict the enrollee’s
right to disenroll voluntarily in any way.
	 
	 	c.	 	The Health Plan or its agents shall not provide or assist in the
completion of a disenrollment request or assist the Agency’s contracted choice
counselor/enrollment broker in the disenrollment process.
	 
	 	d.	 	The Health Plan shall ensure that enrollees that are disenrolled and
wish to file an appeal have the opportunity to do so. All enrollees shall be
afforded the right to file an appeal on disenrollment except for the following
reasons:

	 	(1)	 	Moving out of the service area;
	 
	 	(2)	 	Loss of Medicaid eligibility;
	 
	 	(3)	 	Determination that an enrollee is in an excluded population,
as defined in Attachment II, Section III, Eligibility and Enrollment, Item
A., Eligibility, sub-item 3., Excluded Populations; or
	 
	 	(4)	 	Enrollee death.

	 	e.	 	An enrollee subject to open enrollment may submit to the Agency or its
agent a request to disenroll from the Health Plan. This may be done without
cause during the ninety (90) calendar day change period following the date of
the enrollee’s initial enrollment with the Health Plan, or the date the Agency
or its agent sends the enrollee notice of the enrollment, whichever is later. An
enrollee may request disenrollment without cause every twelve (12) months
thereafter during the annual open enrollment period. Those not subject to open
enrollment may disenroll at any time.
	 
	 	f.	 	The effective date of an approved disenrollment shall be the last
calendar day of the month in which disenrollment was made effective by the Agency
or its agent. In no case shall disenrollment be later than the first calendar day
of the second month following the month in which the enrollee or the Health Plan
files the disenrollment request. If the Agency or its agent fails to make a
disenrollment determination within this timeframe, the disenrollment is
considered approved.

	 	2.	 	When Disenrollment Can Occur
	 
	 	 	 	An enrollee may request disenrollment at any time. The Agency or the choice
counselor/enrollment broker performs disenrollment as follows:

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	 	HMO Contract

	 	a.	 	For cause at any time (see below for list of for-cause reasons), or
	 
	 	b.	 	Without cause, for enrollees subject to open enrollment, at the following times:

	 	(1)	 	During the ninety (90) days following the enrollee’s initial
enrollment, or the date the Agency or its agent sends the enrollee notice of
the enrollment, whichever is later;
	 
	 	(2)	 	At least every twelve (12) months;
	 
	 	(3)	 	If the temporary loss of Medicaid eligibility has caused the
enrollee to miss the open enrollment period;
	 
	 	(4)	 	When the Agency or its agent grants the enrollee the right to
terminate enrollment without cause (done on a case-by-case basis); or
	 
	 	(5)	 	(Reform Only) If the individual chooses to opt out and enroll
in an employer- sponsored health plan.

	 	c.	 	Without cause, for enrollees not subject to open enrollment, at any
time.

	 	3.	 	Cause for Disenrollment

	 	a.	 	A mandatory enrollee may request disenrollment from the Health Plan for
cause at any time. Such request shall be submitted to the Agency or its agent. The
following reasons constitute cause for disenrollment from the Health Plan:

	 	(1)	 	The enrollee moves out of the county, or the enrollee’s address
is incorrect and the enrollee does not live in a county where the Health Plan
is authorized to provide services.
	 
	 	(2)	 	The provider is no longer with the Health Plan.
	 
	 	(3)	 	The enrollee is excluded from enrollment.
	 
	 	(4)	 	A substantiated marketing or community outreach violation has
occurred.
	 
	 	(5)	 	The enrollee is prevented from participating in the development
of his/her treatment plan.
	 
	 	(6)	 	The enrollee has an active relationship with a provider who is
not on the Health Plan’s panel, but is on the panel of another health plan.
	 
	 	(7)	 	The enrollee is in the wrong health plan as determined by the
Agency.
	 
	 	(8)	 	The Health Plan no longer participates in the county.
	 
	 	(9)	 	The state has imposed intermediate sanctions upon the Health
Plan, as specified in 42 CFR 438.702(a)(3).

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	 	HMO Contract

	 	(10)	 	The enrollee needs related services to be performed concurrently, but not
all related services are available within the Health Plan network. or the
enrollee’s PCP has determined that receiving the services separately would
subject the enrollee to unnecessary risk.
	 
	 	(11)	 	The Health Plan does not, because of moral or religious
objections, cover the service the enrollee seeks.
	 
	 	(12)	 	The enrollee missed open enrollment due to a temporary loss of
eligibility, defined as sixty (60) days or less for non-Reform populations and
one-hundred and eighty (180) days or less for Reform populations.
	 
	 	(13)	 	Other reasons per 42 CFR 438.56(d)(2), including, but not limited
to, poor quality of care; lack of access to services covered under the
Contract; inordinate or inappropriate changes of PCPs; service access
impairments due to significant changes in the geographic location of services;
lack of access to providers experienced in dealing with the enrollee’s health
care needs; or fraudulent enrollment.

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

	 	4.	 	Involuntary Disenrollment Requests (See Attachment II, Exhibit 3)

	 	a.	 	With proper written documentation, the following are acceptable reasons
for which the Health Plan may submit involuntary disenrollment requests to the
Agency or its agent:

	 	(1)	 	Fraudulent use of the enrollee ID card. In such cases the
Health Plan shall report the event to MPI.
	 
	 	(2)	 	The enrollee’s behavior is disruptive, unruly, abusive or
uncooperative to the extent that enrollment in the Health Plan seriously
impairs the organization’s ability to furnish services to either the enrollee
or other enrollees.

	 	(a)	 	This section does not apply to enrollees with mental
health diagnoses if the enrollee’s behavior is attributable to the mental
illness.
	 
	 	(b)	 	An involuntary disenrollment request related to enrollee
behavior must include documentation that the Health. Plan:

	 	(i)	 	Provided the enrollee at least one (1) oral warning
and at least one (1) written warning of the full implications of the
enrollee’s actions;
	 
	 	(ii)	 	Attempted to educate the enrollee regarding rights and
responsibilities;
	 
	 	(iii)	 	Offered assistance through case management that
would enable the enrollee to comply;
	 
	 	(iv)	 	Determined that the enrollee’s behavior is not
related to the enrollee’s medical or behavioral condition.

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	 	HMO Contract

	 	b.	 	The Health Plan shall promptly submit such disenrollment requests to BMHC. In no
event shall the Health Plan submit a disenrollment request at such a date as would
cause the disenrollment to be effective later than forty-five (45) calendar days
after the Health Plan’s receipt of the reason for involuntary disenrollment. The
Health Plan shall ensure that involuntary disenrollment documents are maintained in
an identifiable enrollee record.
	 
	 	c.	 	All requests will be reviewed on a case-by-case basis and subject to the
sole discretion of the Agency. Any request not approved is final and not subject
to Health Plan dispute or appeal.
	 
	 	d.	 	The Health Plan shall not request disenrollment of an enrollee due to:

	 	(1)	 	Health diagnosis;
	 
	 	(2)	 	Adverse changes in an enrollee’s health status;
	 
	 	(3)	 	Utilization of medical services;
	 
	 	(4)	 	Diminished mental capacity;
	 
	 	(5)	 	Pre-existing medical condition;
	 
	 	(6)	 	Uncooperative or disruptive behavior resulting from the
enrollee’s special needs (with the exception of Item C., Disenrollment,
sub-item 4.a.(2)(b) above);
	 
	 	(7)	 	Attempt to exercise rights under the Health Plan’s grievance
system;
	 
	 	(8)	 	Request of one (1) PCP to have an enrollee assigned to a
different provider out of the Health Plan.

	 	e.	 	When the Health Plan requests an involuntary disenrollment, it shall
notify the enrollee in writing that the Health Plan is requesting disenrollment,
the reason for the request, and an explanation that the Health Plan is requesting
that the enrollee be disenrolled in the next Contract month, or earlier if
necessary. Until the enrollee is disenrolled, the Health Plan shall be responsible
for the provision of services to that enrollee.

	 	5.	 	Disenrollment Notice (See Attachment II, Exhibit 3)
	 
	 	 	 	Each month the Health Plan shall review its X12-834 enrollment files to determine which
enrollees were disenrolled due to moving outside the service area. Non-Reform Health
Plans shall send notice of disenrollment to all such recipients with instructions to
contact the choice counselor/enrollment broker to make a plan choice in the new service
area.

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	 AMERIGROUP Florida, Inc. d/b/a 

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Section IV

Enrollee Services, Community Outreach and Marketing

A. Enrollee Services

	 	1.	 	General Provisions

	 	a.	 	The Health Plan shall ensure that enrollees are notified of their rights
and responsibilities, the role of PCPs, how to obtain care, what to do in an
emergency or urgent medical situation, how to pursue a complaint, a grievance,
appeal or Medicaid Fair Hearing, how to report suspected fraud and abuse,
procedures for obtaining required behavioral health services, including any
additional Health Plan telephone numbers to be used for obtaining services, and
all other requirements and benefits of the Health Plan.
	 
	 	b.	 	The Health Plan shall have the capability to answer enrollee inquiries
through written materials, telephone, electronic transmission, and face-to-face
communication.
	 
	 	c.	 	Mailing envelopes for enrollee materials shall contain a request for
address correction. When enrollee materials are returned to the Health Plan as
undeliverable, the Health Plan shall use and maintain in a file a record of all
of the following methods to contact the enrollee:

	 	(1)	 	Telephone contact at the number obtained from the local
telephone directory, directory assistance, city directory, or other
directory;
	 
	 	(2)	 	Routine checks (at least once a month for the first three (3)
months of enrollment) on services or claims authorized or denied by the
Health Plan to determine if the enrollee has received services, and to
locate updated address and telephone number information.

	 	d.	 	New enrollee materials are not required for a former enrollee who was
disenrolled because of the loss of Medicaid eligibility and who regains
eligibility within sixty (60) days for a non-Reform enrollee and one-hundred and
eighty (180) days for a Reform enrollee and is automatically reinstated in the
Health Plan. In addition, unless requested by the enrollee, new enrollee
materials are not required for a former enrollee subject to open enrollment who
was disenrolled because of the loss of Medicaid eligibility, regains eligibility
within the time specified in this paragraph and is reinstated as a Health Plan
enrollee. A notation of the effective date of the reinstatement is to be made on
the most recent application or conspicuously identified in the enrollee’s
administrative file. Enrollees who were previously enrolled in a Health Plan, and
who lose and regain eligibility after the specified number of days for Reform or
non-Reform, will be treated as new enrollees.
	 
	 	e.	 	The Health Plan shall notify, in writing, each person who is to be
reinstated, of the effective date of the reinstatement and the assigned primary
care physician. The notifications shall distinguish between enrollees subject to
open enrollment and those who are not and shall include information about change
procedures for cause, or general health plan change procedures through the
Agency’s toll-free choice counselor/enrollment broker telephone number as
appropriate. The notification shall also instruct the enrollee to contact the
Health Plan if a new enrollee card and/or a

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	new enrollee handbook are needed. The Health Plan shall provide such notice to
each affected enrollee by the first calendar day of the month following the Health
Plan’s receipt of the notice of reinstatement or within five (5) calendar days
from receiving the enrollment file, whichever is later.

	 	2.	 	Requirements for Written Material

	 	a.	 	The Health Plan shall make all written materials available in
alternative formats and in a manner that takes into consideration the enrollee’s
special needs, including those who are visually impaired or have limited reading
proficiency. The Health Plan shall notify all enrollees and, upon request,
potential enrollees that information is available in alternative formats and how
to access those formats.
	 
	 	b.	 	The Health Plan shall make all written material available in English,
Spanish, and all other appropriate foreign languages. The appropriate foreign
languages comprise all languages in the Health Plan service area spoken by
approximately five percent (5%) or more of the total population. Upon request,
the Health Plan shall provide, free of charge, interpreters for potential
enrollees or enrollees whose primary language is not English.
	 
	 	c.	 	The Health Plan shall provide enrollee information in accordance with
42 CFR 438.10, which addresses information requirements related to written and
oral information provided to enrollees, including: languages; format; Health
Plan features, such as benefits, cost sharing, service area, provider network and
physician incentive plans; enrollment and disenrollment rights and
responsibilities; grievance system; and advance directives.
-I-he Health Plan shall notify enrollees on at least an
annual basis of their right to request and obtain information in accordance with
the above requirements.
	 
	 	d.	 	All written materials and web sites shall be at or near the fourth
(4th) grade comprehension level. Suggested reference materials to
determine whether the written materials meet this requirement are:

	 	(1)	 	Fry Readability Index;
	 
	 	(2)	 	PROSE The Readability Analyst (software developed by Education
Activities, Inc.);
	 
	 	(3)	 	Gunning FOG Index;
	 
	 	(4)	 	McLaughlin SMOG Index;
	 
	 	(5)	 	The Flesch-Kincaid Index; and/or
	 
	 	(6)	 	Other software approved by the Agency.

	 	3.	 	New Enrollee Materials

	 	a.	 	By the first day of the assigned enrollee’s enrollment or within five
(5) calendar days following receipt of the enrollment file from Medicaid or its
agent, whichever is later, the Health Plan shall mail to the new enrollee: the
enrollee handbook; the provider directory; the enrollee identification card; and
the following additional materials:

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(1)	 	The actual date of enrollment and the name, telephone number and address
of the enrollee’s PCP assignment;
	 
	 	(2)	 	The enrollee’s right to choose a different PCP;
	 
	 	(3)	 	An explanation that enrollees may choose to have all family
members served by the same PCP or may choose different PCPs;
	 
	 	(4)	 	Procedures for changing PCPs, including notice of the Health
Plan’s toll-free member services telephone number, etc.;
	 
	 	(5)	 	The enrollees’ right to change their health plan selections,
subject to Medicaid limitations;
	 
	 	(6)	 	A request to update the enrollee’s name, address (home and
mailing), county of residence, and telephone number;
	 
	 	(7)	 	A notice that enrollees who lose eligibility and are
disenrolled shall be automatically re-enrolled in the Health Plan if
eligibility is regained within sixty (60) days for non-Reform participants
and one-hundred and eighty (180) days for Reform participants; and
	 
	 	(8)	 	A postage-paid, pre-addressed return envelope.

	 	b.	 	Each mailing shall be documented in the Health Plan’s records.
	 
	 	c.	 	Materials may be sent in separate mailings.

	 	4.	 	Enrollee ID Card
	 
	 	 	 	The enrollee ID card shall include, at a minimum:

	 	a.	 	The enrollee’s name and Medicaid ID number;
	 
	 	b.	 	The Health Plan’s name, address and enrollee services number; and
	 
	 	c.	 	A telephone number that a non-contracted provider may call for billing information.

	 	5.	 	Enrollment with a Primary Care Provider (PCP)

	 	a.	 	The Health Plan shall offer each enrollee a choice of PCPs. After
making a choice, each enrollee shall have a single or group PCP.
	 
	 	b.	 	The Health Plan shall assign a PCP to those enrollees who did not
choose a PCP at the time of health plan selection. The Health Plan shall take
into consideration the enrollee’s last PCP (if the PCP is known and available in
the Health Plan’s network), closest PCP to the enrollee’s ZIP code location,
keeping children/adolescents within the same family together, and age (adults
versus children/adolescents).
	 
	 	c.	 	The Health Plan shall permit enrollees to request to change PCPs at
any time. If the enrollee request is not received by the Health Plan’s
established monthly cut-off date

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	for system processing, the PCP change will be effective the first day of the next
month.
	 
	 	d.	 	The Health Plan shall assign all enrollees that are reinstated after a
temporary loss of eligibility to the PCP who was treating them prior to loss of
eligibility, unless the enrollee specifically requests another PCP, the PCP no
longer participates in the Health Plan or is at capacity, or the enrollee has
changed geographic areas.

	 	6.	 	Enrollee Handbook Requirements

	 	a.	 	The Health Plan shall have separate enrollee handbooks for Reform and
non-Reform populations. The handbooks shall include the following information:

	 	(1)	 	Table of contents;
	 
	 	(2)	 	Terms, conditions and procedures for enrollment including the
reinstatement process and enrollee rights and protections;
	 
	 	(3)	 	Description of the ninety (90) day change period and the open
enrollment process (see subparagraph (15), below, for required standardized
language);
	 
	 	(4)	 	How to change PCPs;
	 
	 	(5)	 	Description of services provided, including limitations and
general restrictions on provider access, exclusions and out-of-network use,
and any restrictions on enrollee freedom of choice among network providers;
	 
	 	(6)	 	Procedures for obtaining required services, including second
opinions, and authorization requirements, including those services available
without prior authorization;
	 
	 	(7)	 	Information regarding newborn enrollment, including the
mother’s responsibility to notify the Health Plan and DCF of the pregnancy
and the newborn’s birth;
	 
	 	(8)	 	Information about how to select the newborn’s PCP;
	 
	 	(9)	 	Emergency services and procedures for obtaining services both
in and out of the Health Plan’s service area, including explanation that
prior authorization is not required for emergency or post-stabilization
services, the locations of any emergency settings and other locations at
which providers and hospitals furnish emergency services and
post-stabilization care services, use of the 911- telephone system or its
local equivalent, and other post-stabilization requirements in 42 CFR
422.113(c);
	 
	 	(10)	 	The extent to which, and how, after-hours and emergency coverage is
provided, and that the enrollee has a right to use any hospital or other
setting for emergency care;
	 
	 	(11)	 	Enrollee rights and responsibilities, including the extent to which and how
enrollees may obtain services from out-of-network providers; the right to obtain
family planning services from any participating Medicaid provider without prior
authorization; and other provisions in accordance with 42 CFR 438.100;

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	 AMERIGROUP Florida, Inc. d/b/a 

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(12)	 	Information about the Subscriber Assistance Program (SAP, for HMOs only)
and the Beneficiary Assistance program (BAP, for PSNs only) and the Medicaid
Fair Hearing process, including an explanation that a review by the SAP/BAP
must be requested within one (1) year after the date of the occurrence that
initiated the appeal, how to initiate a review by the SAP/BAP and the SAP/BAP
address and telephone number:
	 
	 	 	 	Agency for Health Care Administration

Subscriber Assistance Program/Beneficiary Assistance Program

Building 1, MS #26

2727 Mahan Drive, Tallahassee, FL 32308

(850) 921-5458

(888) 419-3456 (toll-free)
	 
	 	(13)	 	Clear specifics on the required procedural steps in the
grievance process, including the address, telephone number and office hours
of the grievance staff. The Health Plan shall specify telephone numbers to
call to present a complaint, grievance, or appeal. Each telephone number
shall be toll-free within the caller’s geographic area and provide
reasonable access to the Health Plan without undue delays;
	 
	 	(14)	 	Information that services will continue upon appeal of a
denied authorization and that the enrollee may have to pay in case of an
adverse ruling;
	 
	 	(15)	 	Enrollee rights and procedures for enrollment and
disenrollment, including the toll-free telephone number for the Agency’s
contracted choice
counselor/enrollment broker. The Health Plan shall include the following
language verbatim in the enrollee handbook:

Enrollment:

If you are a mandatory enrollee required to enroll in a plan,
once you are enrolled in [INSERT HEALTH PLAN NAME] or the
state enrolls you in a plan, you will have 90 days from the
date of your first enrollment to try the health plan. During
the first 90 days you can change health plans for any reason.
After the 90 days, if you are still eligible for Medicaid,
you will be enrolled in the plan for the next nine months.
This is called “lock-in.”

Open Enrollment:

If you are a mandatory enrollee, the state will send you a
letter 60 days before the end of your enrollment year telling
you that you can change plans if you want to. This is called
“open enrollment.” You do not have to change health plans. If
you choose to change plans during open enrollment, you will
begin in the new plan at the end of your current enrollment
year. Whether you pick a new plan or stay in the same plan,
you will be locked into that plan for the next 12 months.
Every year you can change health plans during your 60 day
open enrollment period.

AHCA Contract No. FA913, Attachment II, Page 47 of 186

 

 

	 	 	 
	 AMERIGROUP Florida, Inc. d/b/a 

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Disenrollment:

If you are a mandatory enrollee and you want to change plans
after the initial 90 day period ends or after your open
enrollment period ends, you must have a state-approved good
cause reason to change plans. The following are state-
approved cause reasons to change health plans: [INSERT CAUSE
LIST LANGUAGE VERBATIM FROM SECTION III, ELIGIBILITY AND
ENROLLMENT, ITEM C., DISENROLLMENT, SUB-ITEM 3.A., CAUSE FOR
DISENROLLMENT].

	 	(16)	 	Procedures for filing a request for disenrollment for cause. As
noted in subparagraph (15), the state-approved for-cause reasons listed in
Attachment II, Section III, Eligibility and Enrollment, Item C.,
Disenrollment, sub-item 3.,a. shall be listed verbatim in the disenrollment
section of the enrollee handbook. In addition, the Health Plan shall include
the following language verbatim in the disenrollment section of the enrollee
handbook:

Some Medicaid recipients can change health plans whenever they
choose, for any reason. For example, people who are eligible
for both Medicaid and Medicare benefits and children who
receive SSI benefits can change plans at any time for any
reason. To find out if you can change plans, call the [INSERT
EITHER “CHOICE COUNSELOR” OR “ENROLLMENT BROKER” AND
APPROPRIATE TELEPHONE NUMBER].

	 	(17)	 	Information that interpretation services and alternative
communication systems are available, free of charge, including for all
foreign languages and vision and hearing impairment, and how to access these
services;
	 
	 	(18)	 	Information regarding health care advance directives pursuant
to ss. 765.302 through 765.309, F.S., 42 CFR 438.6(i)(1)-(2) and 42 CFR
422.128, as follows:

	 	(a)	 	The Health Plan shall provide these policies and
procedures to all enrollee’s age 18 and older and shall advise enrollees
of:

	 	(i)	 	Their rights under state law, including the right
to accept or refuse medical or surgical treatment and the right to
formulate advance directives; and
	 
	 	(ii)	 	The Health Plan’s written policies respecting the
implementation of those rights, including a statement of any limitation
regarding the implementation of advance directives as a matter of
conscience.

	 	(b)	 	The information must include a description of state law
and must reflect changes in state law as soon as possible, but no later
than ninety (90) calendar days after the effective change.
	 
	 	(c)	 	The Health Plan’s information shall inform enrollees
that complaints about non-compliance with advance directive laws and
regulations may be filed with the state’s complaint hotline.

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	 AMERIGROUP Florida, Inc. d/b/a 

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(d)	 	The Health Plan shall educate enrollees about their ability to direct
their care using this mechanism and shall specifically designate which
staff and/or network providers are responsible for providing this
education.

	 	(19)	 	Cost sharing for the enrollee, if any;
	 
	 	(20)	 	How and where to access any benefits that are available under
the Medicaid State Plan but are not covered under this Contract, including
any cost sharing;
	 
	 	(21)	 	Instructions explaining how enrollees may obtain information
from the Health Plan about how it rates on performance measures in specific
areas of service;
	 
	 	(22)	 	How to obtain information from the Health Plan about quality
enhancements;
	 
	 	(23)	 	Procedures for reporting fraud, abuse and overpayment that
includes the following specific language:

To report suspected fraud and/or abuse in Florida Medicaid, call the
Consumer Complaint Hotline toll-free at 1-888-419-3456 or complete a
Medicaid Fraud and Abuse Complaint Form, which is available online at

https://ahcaxnet.fdhc.state.fl.us/InspectorGeneral/fraudcomplaintform.
aspx;

	 	(24)	 	Information regarding HIPAA relative to the enrollee’s personal
health information (PHI);
	 
	 	(25)	 	Toll-free telephone number of the appropriate Area Medicaid Office;
	 
	 	(26)	 	Information to help the enrollee assess a potential behavioral health
problem;
	 
	 	(27)	 	How to get information about the structure and operation of the
Health Plan and any physician incentive plans, as set forth in 42 CFR
438.10(g)(3);
	 
	 	(28)	 	(Reform Health Plans and non-Reform HMOs) A separate section for
behavioral health services that provides the following information:

	 	(a)	 	The extent to which and how after-hours and emergency
coverage is provided and that the enrollee has a right to use any
hospital or other setting for emergency care;
	 
	 	(b)	 	Information that post-stabilization services are
provided without prior authorization and other post stabilization care
services rules set forth in 42 CFR 422.113(c);
	 
	 	(c)	 	A clear statement that the enrollee may select an
alternative behavioral health case manager or direct service provider
within the Health Plan, if one is available;
	 
	 	(d)	 	A description of behavioral health services provided,
including limitations, exclusions and out-of-network use;

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(e)	 	A description of emergency behavioral health services procedures both in
and out of the Health Plan’s service area.

	 	(29)	 	(Reform Health Plans Only) Information on the enhanced benefit
program and how to access the enrollee’s enhanced benefit account.

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

	 	7.	 	Provider Directory

	 	a.	 	The Health Plan shall mail a provider directory to all new enrollees,
including those who reenrolled after the open enrollment period. The Health Plan
shall provide the most recently printed provider directory and append to it a
list of the providers who have left the network and those who have been added
since the directory was printed. In lieu of the appendix to the provider
directory the Health Plan may enclose a letter stating that the most current
listing of providers is available by calling the Health Plan at its toll-free
telephone number and at the Health Plan’s website. The letter shall include the
telephone number and the Internet address that will take the enrollee directly to
the online provider directory.
	 
	 	b.	 	The provider directory shall include the names, locations, office
hours, telephone numbers of, and non-English languages spoken by current Health
Plan providers. The provider directory shall include, at a minimum, information
relating to PCPs, specialists, pharmacies, hospitals, certified nurse midwives
and licensed midwives, and ancillary providers. The provider directory also shall
identify providers that are not accepting new patients. The provider directory
shall also include information on how to determine a provider’s hospital
affiliations. Such information must be available online and through customer
service.
	 
	 	c.	 	The Health Plan shall maintain an online provider directory containing
all the information described in subsection 7.b., above. The Health Plan shall
update the online provider directory at least monthly. The Health Plan shall file
an attestation to this effect with BMHC each month, even if no changes have
occurred.
	 
	 	d.	 	If a Health Plan elects to use a more restrictive pharmacy network than
the network available to people enrolled in the Medicaid fee-for-service program,
then the provider directory must include the names of the participating
pharmacies. If all pharmacies are part of a chain and all within the Health
Plan’s service area are under contract with the Health Plan, the provider
directory need list only the chain name.
	 
	 	e.	 	In accordance with s. 1932(b)(3) of the Social Security Act, the
provider directory shall include a statement that some providers may choose not
to perform certain services based on religious or moral beliefs.
	 
	 	f.	 	The Health Plan shall arrange the provider directory as follows:

	 	(1)	 	Providers listed by name in alphabetical order, showing the provider’s specialty;
	 
	 	(2)	 	Providers listed by specialty, in alphabetical order; and

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(3)	 	(Reform Health Plans and non-Reform HMOs only) Behavioral health providers
listed in a separate section by county and by provider type, where applicable.

	 	g.	 	The Health Plan shall have procedures to inform potential enrollees and
enrollees, upon request, of any changes to service delivery and/or the provider
network including the following:

	 	(1)	 	Up-to-date information about any restrictions on access to
providers, including providers who are not taking new patients;
	 
	 	(2)	 	An explanation to all potential enrollees that an enrolled
family may choose to have all family members served by the same PCP or they
may choose different PCPs based on each family member’s needs;
	 
	 	(3)	 	Any restrictions on counseling and referral services based on
moral or religious grounds within ninety (90) days after adopting the policy
with respect to any service.

	 	8.	 	New Enrollee Procedures

	 	a.	 	The Health Plan shall contact each new enrollee at least twice, if
necessary, within ninety (90) calendar days of the enrollee’s enrollment to offer
to schedule the enrollee’s initial appointment with the PCP, which should occur
within one-hundred and eighty (180) days of enrollment. This appointment is to
obtain a health risk assessment and/or CHCUP screening. For this subsection
“contact” is defined as mailing a notice to or telephoning an enrollee at the
most recent address or telephone number available.
	 
	 	b.	 	Within thirty (30) calendar days of enrollment, the Health Plan shall
ask the enrollee to authorize release of the medical and behavioral health
records to the new PCP or other appropriate provider and shall assist by
requesting those records from the enrollee’s previous provider(s).
	 
	 	c.	 	The Health Plan shall honor any written documentation of prior
authorization of ongoing covered services for a period of thirty (30) calendar
days after the effective date of enrollment, or until the enrollee’s PCP reviews
the enrollee’s treatment plan, whichever comes first.
	 
	 	d.	 	For all enrollees, written documentation of prior authorization of
ongoing services includes the following, provided that the services were
prearranged prior to enrollment with the Health Plan:

	 	(1)	 	Prior existing orders;
	 
	 	(2)	 	Provider appointments, e.g. dental appointments, surgeries, etc.; and
	 
	 	(3)	 	Prescriptions (including prescriptions at non-participating pharmacies).

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	e.	 	The Health Plan shall not delay service authorization if written
documentation is not available in a timely manner. However, the Health Plan is not
required to approve claims for which it has received no written documentation.

	 	9.	 	Enrollee Assessments

	 	a.	 	Within thirty (30) calendar days of enrollment, the Health Plan shall
notify enrollees of, and ensure the availability of, a screening for all
enrollees known to be pregnant or who advise the Health Plan that they may be
pregnant. The Health Plan shall refer enrollees who are, or may be, pregnant to a
provider to obtain appropriate care.
	 
	 	b.	 	The Health Plan shall use the enrollee’s health risk assessments and/or
released medical records to identify enrollees who have not received CHCUP
screenings in accordance with the Agency-approved periodicity schedule.
	 
	 	c.	 	The Health Plan shall contact, twice if necessary, any enrollee more
than two (2) months behind in the Agency-approved periodicity screening schedule
to urge those enrollees, or their legal representatives, to make an appointment
with the enrollee’s PCP for a screening visit.
	 
	 	d.	 	The Health Plan shall take immediate action to address any identified
urgent medical needs. “Urgent medical needs” means any sudden or unforeseen
situation that requires immediate action to prevent hospitalization or nursing
home placement. Examples include hospitalization of spouse or caregiver or
increased impairment of an enrollee living alone who suddenly cannot manage basic
needs without immediate help, hospitalization or nursing home placement.

	 	10.	 	Enrollee Authorized Representative

The enrollee’s guardian, next of kin or legally authorized responsible person is
permitted to act on the enrollee’s behalf in matters relating to the enrollee’s
enrollment, plan of care, and/or provision of services, if the enrollee:

	 	a.	 	Was adjudicated incompetent in accordance with the law;
	 
	 	b.	 	Is found by the provider to be medically incapable of understanding his
or her rights; or
	 
	 	c.	 	Exhibits a significant communication barrier.

	 	11.	 	Toll-Free Help Line

	 	a.	 	The Health Plan shall operate a toll-free telephone help line, which
shall respond to all areas of enrollee inquiry.
	 
	 	b.	 	If the Health Plan has authorization requirements for prescribed drug
services and is subject to the Hernandez Settlement Agreement (HSA), the Health
Plan may allow the telephone help line staff to act as Hernandez Ombudsman,
pursuant to the terms of the HSA, so long as the Health Plan maintains a
Hernandez Ombudsman log. The Health Plan may maintain the Hernandez Ombudsman log
as part of its telephone help line log, so long as the Health Plan can access the
Hernandez

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Ombudsman log information separately for reporting purposes. The log shall contain
information as described in Attachment II, Section V, Covered Services, Item H.,
Coverage Provisions, sub-item 16, Prescribed Drug Services.
	 
	 	c.	 	The Health Plan shall have telephone call policies and procedures that
shall include requirements for staffing, personnel, hours of operation, call
response times, maximum hold times, and maximum abandonment rates, monitoring of
calls via recording or other means, and compliance with performance standards.
	 
	 	d.	 	The telephone helpline shall handle calls from non-English speaking
enrollees, as well as calls from enrollees who are hearing impaired.
	 
	 	e.	 	The telephone help line shall be fully staffed between the hours of 8:00
a.m. and 7:00 p.m. in the enrollee’s time zone (Eastern or Central), Monday
through Friday, excluding state holidays. The telephone help line staff shall be
trained to respond to enrollee questions in all areas, including but not limited
to, covered services, provider network, and transportation.
	 
	 	f.	 	The Health Plan shall develop performance standards and monitor telephone
help line performance by recording calls and employing other monitoring
activities. Such standards shall be submitted to and approved by BMHC before the
Health Plan begins operation. At a minimum, the standards shall require that,
measured on a monthly basis:

	 	(1)	 	All calls are answered within four (4) rings (these calls may
be placed in a queue);
	 
	 	(2)	 	Wait time in the queue shall not exceed three (3) minutes;
	 
	 	(3)	 	The blocked call rate does not exceed one percent (1 %); and
	 
	 	(4)	 	The rate of abandoned calls does not exceed five percent (5%).

	 	g.	 	The Health Plan shall have an automated system available between the
hours of 7:00 p.m. and 8:00 a.m., in the enrollee’s time zone, Monday through
Friday and at all hours on weekends and holidays. This automated system must
provide callers with clear instructions on what to do in case of an emergency and
shall include, at a minimum, a voice mailbox for callers to leave messages. The
Health Plan shall ensure that the voice mailbox has adequate capacity to receive
all messages. A Health Plan representative shall respond to messages on the next
business day.

	 	12.	 	Translation Services

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

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	13.	 	Preferred Drug List (PDL) (See Attachment II, Exhibit 4)

If the Health Plan adopts the Agency’s PDL, the Health Plan’s website shall include an
explanation and a link to the Agency’s online PDL. If the Health Plan uses a pharmacy
benefits manager, the Health Plan’s website shall include its PDL. The Health Plan may
update the online PDL by providing thirty (30) calendar days’ written notice of any
changes to the Bureaus of Managed Health Care and Pharmacy Services.

	 	14.	 	Incentive Programs

	 	a.	 	The Health Plan may offer incentives for enrollees to receive
preventive care services. The Health Plan shall receive written approval from
BMHC before offering any incentives. The Health Plan shall make all incentives
available to all enrollees and shall not use incentives to direct individuals to
select a particular provider.
	 
	 	b.	 	The Health Plan may inform enrollees, once they are enrolled, about
the specific incentives available.
	 
	 	c.	 	The Health Plan shall not include the provision of gambling, alcohol,
tobacco or drugs (except for over-the-counter drugs) in any of its incentives
and shall state on the incentive award that it may not be used for such
purposes.
	 
	 	d.	 	Incentives may have some health- or child development-related function
(e.g., clothing, food, books, safety devices, infant care items, subscriptions
to publications that include health-related subjects, membership in clubs
advocating educational advancement and healthy lifestyles, etc.). Incentive
dollar values shall be in proportion to the importance of the health service being incentivized (e.g., a
tee-shirt for attending one (1) prenatal class, but a car seat for completion of
a series of classes).
	 
	 	e.	 	Incentives shall be limited to a value of $20, except in the case of
incentives for the completion of a series of services, health education classes
or other educational activities, in which case the incentive shall be limited to
a value of $50. The Agency will allow a special exception to the dollar value
relating to infant car seats, strollers, and cloth baby carriers or slings.
	 
	 	f.	 	The Health Plan shall not include in the dollar limits on incentives
any money spent on the transportation of enrollees to services or childcare
provided during the delivery of services.
	 
	 	g.	 	The Health Plan may offer an Agency-approved program for pregnant
women to encourage beginning prenatal care visits in the first trimester of
pregnancy. The prenatal and postpartum care incentive program must be aimed at
promoting early intervention and prenatal care to decrease infant mortality and
low birth weight and to enhance healthy birth outcomes. The prenatal and
postpartum incentives may include the provision of maternity and health related
items and education.
	 
	 	h.	 	The Health Plan’s request for Agency approval of all incentives shall
contain a detailed description of the incentive and its mission.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	15.	 	Enhanced Services (Reform Only; See Attachment II, Exhibit 4)

	 	16.	 	Notices of Action (See 42 CFR 438.210)

	 	a.	 	The Health Plan shall notify the provider and give the enrollee
written notice of any decision to deny a service authorization request, or to
authorize a service in an amount, duration, or scope that is less than
requested.
	 
	 	b.	 	For standard authorization decisions, the Health Plan shall provide
notice as expeditiously as the enrollee’s health condition requires and within
no more than fourteen (14) calendar days following receipt of the request for
service.
	 
	 	c.	 	The timeframe can be extended up to fourteen (14) additional calendar
days if the enrollee or the provider requests extension or the Health Plan
justifies the need for additional information and how the extension is in the
enrollee’s interest.
	 
	 	d.	 	Expedited authorization is required when a provider indicates or the
Health Plan determines that following the standard timeline could seriously
jeopardize the enrollee’s life of health or ability to attain, maintain, or
regain maximum function. An expedited decision must be made no later than three
(3) working days after receipt of the request for service.
	 
	 	e.	 	The Health Plan may extend the three (3) working days for expedited
cases by up to fourteen (14) calendar days if the enrollee requests an extension
or if the Health Plan justifies the extension as prescribed in subparagraph
16.c. above.

	 	17.	 	Medicaid Redetermination Notices

The Agency will provide Medicaid recipient redetermination date information to the
Health Plan.

	 	a.	 	This information shall be used by the Health Plan only as indicated in
this subsection.
	 
	 	b.	 	Annually, the Agency will decide whether to continue to provide this
information to the Health Plan and will notify the Health Plan of its decision
by May 1 for the coming Contract year if it decides to stop providing the
information. In addition, the Agency reserves the right to stop at any time with
thirty (30) calendar days’ notice.
	 
	 	c.	 	By June 1 each year the Health Plan shall notify BMHC, in writing, if
it wants to change the use of this information for the coming Contract year. The
Health Plan’s participation in using this information is voluntary.

	 	(1)	 	If the Health Plan chooses to participate in the use of this
information, it shall provide its policies and procedures regarding this
subsection to MHO for its approval along with its response indicating it will
participate.

	 	(a)	 	A Health Plan that chooses to participate in the use of
this information may decide to discontinue using it at any time and must
so notify BN/IHC in writing thirty (30) calendar days prior to the date it
will discontinue such use. The

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	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Agency will then delete the Health Plan from the list of health plans
receiving this information for the remainder of the Contract year.
	 
	 	(b)	 	A Health Plan that chooses to participate in the use of
this information must train all affected staff, prior to implementation,
on its policies and procedures and the Agency’s requirements regarding
this subsection. The Health Plan must document such training has occurred,
including a record of those trained, for the Agency’s review within five
(5) business days after the Agency’s request.

	 	(2)	 	Regardless of whether the Health Plan has declined to
participate in the use of this information, the Health Plan is subject to the
sanctioning indicated in this subsection if the Health Plan misuses the
information at any time.

	 	d.	 	A Health Plan that chooses to participate in using this information
shall use the redetermination date information only in the methods listed below
and shall use either or both methods to communicate this information.

	 	(1)	 	The Health Plan may use redetermination date information in
written notices to be sent to their enrollees reminding them that their
Medicaid eligibility may end soon and to reapply for Medicaid if needed. A
Health Plan that chooses to use this method to provide this information to
its enrollees must adhere to the following requirements:

	 	(a)	 	The Health Plan shall mail the redetermination date
notice to each enrollee for whom it has received a redetermination date.
The Health Plan may send one (1) notice to the enrollee’s household when
there are multiple enrollees within a family who have the same Medicaid
redetermination date, provided that these enrollees share the same
mailing address.
	 
	 	(b)	 	The Health Plan shall use the Agency-provided template
for its redetermination date notices. The Health Plan may put this
template on its letterhead for mailing; however, the Health Plan shall
make no other changes, additions or deletions to the letter text.
	 
	 	(c)	 	The Health Plan shall mail the redetermination date
notice to each enrollee no more than sixty (60) calendar days and no less
than thirty (30) calendar days before the redetermination date occurs.

	 	(2)	 	The Health Plan may use redetermination date information in
automated voice response (AVR) or integrated voice response (IVR) automated
messages sent to enrollees reminding them that their Medicaid eligibility may
end soon and to reapply for Medicaid if needed. A Health Plan that chooses to
use this method to provide this information to its enrollees must adhere to
the following requirements:

	 	(a)	 	The Health Plan shall send the redetermination date
messages to each enrollee for whom that Health Plan has received a
redetermination date and for whom the Health Plan has a telephone number.
The Health Plan may send an automated message to the enrollee’s household
when there are multiple enrollees within a family who have the same
Medicaid

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	redetermination date provided that these enrollees share the same
mailing address/phone number.
	 
	 	(b)	 	For the voice messages, the Health Plan shall use only
the language in the Agency’s redetermination date notice template
provided to the Health Plan. The Health Plan may add its name to the
message but shall make no other changes, additions or deletions to the
message text.
	 
	 	(c)	 	The Health Plan shall make such automated calls to each
enrollee no more than sixty (60) calendar days and no less than thirty
(30) calendar days before the redetermination date occurs.

	 	(3)	 	The Health Plan shall not include the redetermination date
information in any file viewable by customer service or community outreach
staff. This information shall be used only in the letter templates and
automated scripts provided by the Agency and cannot be referenced or
discussed by the Health Plan with the enrollees, unless in response to an
enrollee inquiry about the letter received, nor shall it be used at a future
time by the Health Plan. If the Health Plan receives enrollee inquiries about
the notices, such inquiries must be referred to the Department of Children
and Families.

	 	e.	 	If the Health Plan chooses to participate in using this information, it
shall keep the following information about each mailing made available for the
Agency’s review within five (5) business days after the Agency’s request.

	 	(1)	 	For each month of mailings, a dated hard copy or pdf of the
monthly template used for that specific mailing;

	 	(a)	 	A list of enrollees to whom a mailing was sent. This
list shall include each enrollee’s name and Medicaid identification
number, the address to which the notice was mailed, and the date of the
Agency’s enrollment file used to create the mailing list;
	 
	 	(b)	 	A log of returned, undeliverable mail received for
these notices, by month, for each enrollee for whom a returned notice
was received;

	 	(2)	 	For each month of automated calls made, a list of enrollees to
whom a call was made, the enrollee’s name, Medicaid identification number,
telephone number to which the call was made, the date each call was made, and
the date of the Agency’s enrollment file used to create the automated call
list.

	 	f.	 	A Health Plan that chooses to participate in using this information
shall keep up-to- date and approved policies and procedures regarding the use,
storage and securing of this information as well as address all requirements of
this subsection.
	 
	 	g.	 	A Health Plan that participates in using this information must submit to
the Agency’s BMHC a completed quarterly summary report in accordance with
Attachment II, Section XII, Reporting Requirements.
	 
	 	h.	 	Should any complaint or investigation by the Agency result in a finding
that the Health Plan has violated this subsection, the Health Plan will be
sanctioned in

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	accordance with Attachment II, Section XIV, Sanctions. In addition to any other
sanctions available in Section XIV, Sanctions, the first such violation will result
in a thirty (30) day suspension of use of Medicaid redetermination dates; any
subsequent violations will result in thirty-day (30-day) incremental increases in
the suspension of use of Medicaid redetermination dates. In the event of any
subsequent violations, additional penalties may be imposed in accordance with
Section XIV, Sanctions. Additional or subsequent violations may result in the
Agency’s rescinding provision of redetermination date information to the Health
Plan.

B. Community Outreach and Marketing

	 	1.	 	General Provisions

	 	a.	 	The Health Plan’s community outreach representative(s) may
provide community outreach materials at health fairs/public events as noticed
by the Health Plan to the Agency in accordance with sub-item 4, Community
Outreach Notification Process, below. The main purpose of a health
fair/public event shall be to provide community outreach and shall not be for
the purpose of Medicaid Health Plan marketing.
	 
	 	b.	 	For each new Contract period, the Health Plan shall submit to
BMHC for written approval all community outreach material no later than sixty
(60) calendar days before the start of the next Contract period, and, for any
changes in the community outreach material, no later than thirty (30)
calendar days before implementation. All materials developed shall be
governed by the requirements set forth in this section.
	 
	 	c.	 	To announce participation at a specific event (health
fair/public event), the Health Plan shall submit a notice to BMHC in
accordance with sub-item B.3., Permitted Activities.
	 
	 	d.	 	The Health Plan shall be responsible for developing and
implementing a written plan designed to control the actions of its community
outreach representatives.
	 
	 	e.	 	All community outreach policies set forth in this Contract
shall apply to staff, subcontractors, Health Plan volunteers and all persons
acting for or on behalf of the Health Plan.
	 
	 	f.	 	The Health Plan is vicariously liable for any outreach and
marketing violations of its employees, agents or subcontractors. In addition
to any other sanctions available in Attachment II, Section XIV, Sanctions,
any violations of this section shall subject the Health Plan to
administrative action by the Agency as determined by the Agency. The Health
Plan may dispute any such administrative action pursuant to Attachment II,
Section XVI, Terms and Conditions, Item I., Disputes.
	 
	 	g.	 	Nothing in this section shall preclude the Health Plan from
donating to or sponsoring an event with a community organization where time,
money or expertise is provided for the benefit of the community. If such
events are not health fairs/public events, no community outreach materials or
marketing materials shall be distributed by the Health Plan, but the Health
Plan may engage

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	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	in brand-awareness activities, including the display of Health Plan or product
logos. Inquiries at such events from prospective enrollees must be referred to
the Health Plan’s member services section or the Agency’s choice
counselor/enrollment broker.

	 	2.	 	Prohibited Activities

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

	 	a.	 	Marketing for enrollment to any potential members or conducting any
pre-enrollment activities not expressly allowed under this Contract;
	 
	 	b.	 	Any of the prohibited practices or activities listed in s. 409.912, F.S;
	 
	 	c.	 	Engaging in activities not expressly allowed under this Contract for the
purpose of recruitment or enrollment;
	 
	 	d.	 	Practices that are discriminatory, including, but not limited to,
attempts to discourage enrollment or re-enrollment on the basis of actual or
perceived health status, in accordance with ss. 409.912 and 409.91211, F.S.;
	 
	 	e.	 	Direct or indirect cold call marketing or other solicitation of Medicaid
recipients, either by door-to-door, telephone or other means, in accordance with
Section 4707 of the Balanced Budget Act of 1997 and s. 409.912, F.S.;
	 
	 	f.	 	Activities that could mislead or confuse Medicaid recipients or
misrepresent the Health Plan, its community outreach representatives or the
Agency, in accordance with s. 409.912, F.S. No fraudulent, misleading, or
misrepresentative information shall be used in community outreach, including
information about other government programs. Statements that could mislead or
confuse include, but are not limited to, any assertion, statement or claim
(whether written or oral) that:

	 	(1)	 	The Medicaid recipient must enroll in the Health Plan to
obtain Medicaid or to avoid losing Medicaid benefits;
	 
	 	(2)	 	The Health Plan is endorsed by any federal, state or county
government, the Agency, CMS, or any other organization that has not
certified its endorsement in writing to the Health Plan;
	 
	 	(3)	 	Community outreach representatives are employees or
representatives of the federal, state or county government, or of anyone
other than the Health Plan or the organization by whom they are reimbursed;
	 
	 	(4)	 	The state or county recommends that a Medicaid recipient
enroll with the Health Plan; and/or
	 
	 	(5)	 	A Medicaid recipient will lose benefits under the Medicaid
program or any other health or welfare benefits to which the person is
legally entitled if the recipient does not enroll with the Health Plan.

	 	g.	 	Granting or offering any monetary or other valuable consideration for enrollment;

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	 	HMO Contract

	 	h.	 	Offering insurance, such as but not limited to, accidental death,
dismemberment, disability or life insurance;
	 
	 	i.	 	Enlisting assistance of any employee, officer, elected official or agency
of the state in recruitment of Medicaid recipients except as authorized in writing
by the Agency;
	 
	 	j.	 	Offering material or financial gain to any persons soliciting, referring or
otherwise facilitating Medicaid recipient enrollment. The Health Plan shall ensure
that its staff do not market the Health Plan to Medicaid recipients at any location
including state offices or DCF ACCESS center;
	 
	 	k.	 	Giving away promotional items in excess of $5.00 retail value. Items to be
given away shall bear the Health Plan’s name and shall be given away only at health
fairs/public events. In addition, such promotional items must be offered to the
general public and shall not be limited to Medicaid recipients;
	 
	 	I.	 	Providing any gift, commission, or any form of compensation to the choice
counselor/enrollment broker, including its full-time, part-time or temporary
employees and subcontractors;
	 
	 	m.	 	Providing information before enrollment about the incentives to be
offered an enrollee as described in Attachment II, Section IV, Enrollee Services,
Community Outreach and Marketing, Item A., Enrollee Services, sub-item 14.,
Incentive Programs. The Health Plan may inform enrollees on or after their
enrollment effective date about the specific incentives or programs available;
	 
	 	n.	 	Discussing, explaining or speaking to a potential member about
Health-Plan-specific information other than to refer all Health Plan inquiries to
the member services section of the Health Plan or the Agency’s choice
counselor/enrollment broker;
	 
	 	o.	 	Distributing any community outreach materials without prior written
notice to BMHC except as otherwise allowed under Permitted Activities and
Provider Compliance subsections;
	 
	 	p.	 	Distributing any marketing materials not expressly allowed under this Contract;
	 
	 	q.	 	Subcontracting with any brokerage firm or independent agent as defined
in Chapters 624-651, F.S., for purposes of marketing or community outreach;
	 
	 	r.	 	Paying commission compensation to community outreach representatives for
new enrollees. The payment of a bonus to a community outreach representative shall
not be considered a commission if such bonus is not related to enrollment or
membership growth; and
	 
	 	s.	 	All activities included in s. 641.3903, F.S.

	 	3.	 	Permitted Activities

The Health Plan may engage in the following activities upon prior written notice to
BMHC:

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	The Health Plan may attend health fairs/public events upon request by the
sponsor and after written notification to BMHC as described in sub-item 4.,
Community Outreach Notification Process, below.
	 
	 	b.	 	The Health Plan may leave community outreach materials at health
fairs/public events at which the Health Plan participates.
	 
	 	c.	 	The Health Plan may provide BMHC-approved community outreach materials.
Such materials may include Medicaid enrollment and eligibility information and
information related to other health care projects and health, welfare and social
services provided by the State of Florida or local communities. The Health Plan
staff, including community outreach representatives, shall refer all Health Plan
inquiries to the member services section of the Health Plan or the Agency’s
choice counselor/enrollment broker. BMHC approval of the script used by the
Health Plan’s member services section must be obtained before usage.
	 
	 	d.	 	The Health Plan may distribute community outreach materials to
community agencies.

	 	4.	 	Community Outreach Notification Process

	 	a.	 	The Health Plan shall submit to BMHC a written notice of its intent to
attend and provide community outreach materials at health fairs/public events.
(See sub-items 4.b. and 4.c. below for further notice information.)

	 	(1)	 	The Agency requires the following health fair/public event information:

	 	(a)	 	The event announcement to be given to the public;
	 
	 	(b)	 	Date, time and location of the event;
	 
	 	(c)	 	Name and type of sponsoring organization;
	 
	 	(d)	 	Event contact person and contact information;
	 
	 	(e)	 	Health Plan contact person and contact information; and
	 
	 	(f)	 	Names of participating community outreach
representatives, their contact information and services they will
provide at the event.

	 	(2)	 	In addition to the disclosure information listed in (1) above, if the Health Plan
is the primary organizer of the event, the Health Plan shall submit in its
community outreach health fairs/public events notification report specified in
b., below, to BMHC, complete disclosure information from each organization
participating. Information shall include the name of the organization, contact
person information, and confirmation of participation.
	 
	 	(3)	 	In addition to the disclosure information listed in (1) above, if the Health Plan has been invited by a community organization to be a sponsor or attendee of an
event, the Health Plan shall submit in its community outreach health
fairs/public events notification report specified in b., below, to BMHC, a
copy of the letter of invitation from the event sponsor(s) requesting the
Health Plan’s participation.

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	AMERIGROUP Community Care

	 	HMO Contract

	 	b.	 	The Health Plan shall report health fair/public event notices to BMHC by
submitting a community outreach health fairs/public events notification report by
the 20th calendar day of the month prior to the event month. Amendments
to the report are due no later than two weeks prior to the event. See Attachment
II, Section XII, Reporting Requirements.
	 
	 	c.	 	Notwithstanding the other notice requirements in this subsection, the
monthly and two-week advance notice requirements are waived in cases of force
majeure provided the Health Plan notices MHO by the time of the event. Force
majeure events include destruction due to hurricanes, fires, war, riots, and
other similar acts. When providing the Agency with notice of attendance at such
events, the Health Plan shall include a description of the force majeure event
requiring waiver of notice.
	 
	 	d.	 	BMHC will establish a statewide log to track the community outreach
notifications received and may monitor such events.

	 	5.	 	Provider Compliance

The Health Plan shall ensure, through provider education and outreach, that its health
care providers are aware of and comply with the following requirements:

	 	a.	 	Health care providers may display health-plan-specific materials in their
own offices.
	 
	 	b.	 	Health care providers cannot orally or in writing compare benefits or
provider networks among health plans, other than to confirm whether they
participate in a Health Plan’s network.
	 
	 	c.	 	Health care providers may announce a new affiliation with a Health Plan
and give their patients a list of health plans with which they contract.
	 
	 	d.	 	Health care providers may co-sponsor events, such as health fairs and
advertise with the Health Plan in indirect ways; such as television, radio,
posters, fliers, and print advertisement.
	 
	 	e.	 	Health care providers shall not furnish lists of their Medicaid
patients to the Health Plan with which they contract, or any other entity, nor
can providers furnish other health plans’ membership lists to the Health Plan,
nor can providers assist with Health Plan enrollment.
	 
	 	f.	 	For the Health Plan, health care providers may distribute information
about nonhealth-plan-specific health care services and the provision of health,
welfare and social services by the State of Florida or local communities as long
as any inquiries from prospective enrollees are referred to the member services
section of the Health Plan or the Agency’s choice counselor/enrollment broker.

	 	6.	 	Community Outreach Representatives

	 	a.	 	The Health Plan shall register each community outreach representative
that represents the Health Plan with BMHC as specified below.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(1)	 	The Health Plan shall submit its registration file to BMHC at the following
e-mail address prior to any initial community outreach activity: MMCDATAahca.myflorida.com. The Agency-supplied template must be used as
specified in Attachment II, Section XII, Reporting Requirements, and in the
Report Guide.
	 
	 	(2)	 	The Health Plan shall submit changes to the community outreach
representative’s initial registration to BMHC, using the same Agency-supplied
template, immediately upon occurrence, at e-mail address:MMCDATAahca.mvfiorida.com. The Agency-supplied template shall be used.

	 	b.	 	While attending health fairs/public events, community outreach
representatives shall wear picture identification that shows the Health Plan
represented.
	 
	 	c.	 	If asked, the community outreach representative shall inform the
Medicaid recipient that the representative is not a state employee and is not a
choice counseling specialist but is a representative of the Health Plan.
	 
	 	d.	 	The Health Plan shall instruct and provide initial and periodic
training to its community outreach representatives about the outreach and
marketing provisions of this Contract.
	 
	 	e.	 	The Health Plan shall implement procedures for background and reference
checks for use in hiring community outreach representatives.
	 
	 	f.	 	The Health Plan shall report to BMHC any Health Plan staff or community
outreach representative who violates any requirements of this Contract within
fifteen (15) calendar days of knowledge of such violation.

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	 	HMO Contract

Section V

Covered Services

(Also See Attachment I and Attachment II, Exhibit 5)

A. Covered Services

	 	1.	 	The Health Plan shall ensure the provision of services in sufficient amount,
duration and scope to be reasonably expected to achieve the purpose for which the
services are furnished and shall ensure the provision of the covered services
defined and specified in this Contract. The Health Plan shall not arbitrarily deny
or reduce the amount, duration, or scope of a required service solely because of the
enrollee’s diagnosis, type of illness or condition. The Health Plan may place
appropriate limits on a service on the basis of such criteria as medical necessity
or for utilization control, consistent with the terms of this Contract, provided the
services furnished can be reasonably expected to achieve their purpose.
	 
	 	2.	 	The Health Plan is responsible for ensuring that all providers, service and
product standards specified in the Agency’s Medicaid Services Coverage & Limitations
Handbooks and the Health Plan’s own provider handbooks are incorporated into the
Health Plan’s participation agreements. This includes professional licensure and
certification standards for all service providers. Exceptions exist where different standards are specified elsewhere in this Contract.
	 
	 	3.	 	The Health Plan shall require out-of-network providers to coordinate with
respect to payment and must ensure that cost to the enrollee is no greater than it
would be if the covered services were furnished within the network.
	 
	 	4.	 	In addition to this section, the Health Plan shall ensure the provision of
the covered services specified in Attachment I and Attachment II, Exhibit 5.

B. Optional Services (Non-Reform Only, See Attachment I and Attachment II, Exhibit 5)

C. Expanded Services (See Attachment I)

	 	1.	 	The following services are defined as expanded services that may be offered by
the Health Plan. The Health Plan shall define the services specifically in writing
and submit them to HSD for approval before implementation.

	 	a.	 	Services in excess of the amount, duration and scope of those listed in
Attachment II, Section V, Covered Services, and Section VI, Behavioral Health
Care;
	 
	 	b.	 	Services and benefits not listed in Attachment II, Section V, Covered
Services, or Section VI, Behavioral Health Care;
	 
	 	c.	 	The Health Plan may offer, upon written Agency approval, an
over-the-counter expanded drug benefit, not to exceed $25.00 per household, per
month. Such benefits shall be limited to nonprescription drugs containing a
national drug code (NDC) number, first aid supplies and birth control supplies.
Such benefits must be offered directly through the Health Plan’s fulfillment
house or through a

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	 	 	 	 subcontractor. The Health Plan shall make payments for the over-the-counter drug
benefit directly to the subcontractor, if applicable.

	 	d.	 	Adult Dental Services — routine preventive services, diagnostic and
restorative services, radiology services and discounts on dental services;
	 
	 	e.	 	Adult Vision Services — eye exams, eyeglasses and contact lenses;
	 
	 	f.	 	Adult Hearing Services — hearing evaluations, hearing aid devices and
hearing aid repairs.

	 	2.	 	The Health Plan’s approved expanded services under this Contract are listed in
Attachment I.

D. Customized Benefit Packages

Some health plans may be authorized by the Agency to offer a customized benefit
package for their Reform enrollees. Refer to Attachment I and Attachment II, Exhibit 5,
for any information applicable to this Contract.

E. Excluded Services

	 	1.	 	The Health Plan is not obligated to provide any services not specified in this
Contract. Enrollees who require services available through Medicaid but not covered
by this Contract shall receive the services through the Medicaid fee-for-service
reimbursement system. In such cases, the Health Plan’s responsibility is limited to
case coordination and referral. Therefore, the Health Plan shall determine the need
for the services and refer the enrollee to the appropriate service provider. The
Health Plan may request assistance from the local Medicaid Area Office for referral
to the appropriate service setting.
	 
	 	2.	 	The Health Plan shall consult the DCF office to identify appropriate methods
of assessment and referral for enrollees requiring long-term care institutional
services, institutional services for persons with developmental disabilities or
state hospital services. The Health Plan is responsible for transition and referral
of these enrollees to appropriate service providers, including helping the enrollees
obtain an attending physician. The Health Plan shall disenroll all enrollees
requiring these services in accordance with Attachment II, Section III, Eligibility
and Enrollment, Item C., Disenrollment, sub-item 3.a.(3).

F. Moral or Religious Objections

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

	 	1.	 	The Agency within one-hundred and twenty (120) calendar days before implementing
the policy with respect to any service; and

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	 	2.	 	Enrollees within thirty (30) calendar days before implementing the policy with
respect to any service.

G. Copayments (See Attachment I and Attachment II, Exhibit 5)

H. Coverage Provisions

	 	1.	 	Requirements

The Health Plan shall provide the following services in accordance with the provisions
herein, and in accordance with the Florida Medicaid Coverage and Limitations Handbooks
and the Florida Medicaid State Plan unless, for Reform HMOs, a customized benefit
package is certified in the benefit grid in Attachment I. The Health Plan shall comply
with all state and federal laws pertaining to the provision of such services.

	 	2.	 	Child Health Check-Up Program (CHCUP)

	 	a.	 	The Health Plan shall provide a health screening evaluation that shall
consist of: comprehensive health and developmental history (including assessment
of past medical history, developmental history and behavioral health status);
comprehensive unclothed physical examination; developmental assessment;
nutritional assessment; appropriate immunizations according to the appropriate
Recommended Childhood Immunization Schedule for the United States; laboratory
testing (including blood lead testing); health education (including anticipatory
guidance); dental screening (including a direct referral to a dentist for
enrollees beginning at age three or earlier as indicated); vision screening,
including objective testing as required; hearing screening, including objective
testing as required; diagnosis and treatment; and referral and follow-up as
appropriate.
	 
	 	b.	 	For children/adolescents whom the Health Plan identifies through blood
lead screenings as having abnormal levels of lead, the Health Plan shall provide
case management follow-up services as required in Chapter Two of the Child Health
Check-Up Services Coverage and Limitations Handbook. Screening for lead poisoning
is a required component of this Contract. The Health Plan shall require all
providers to screen all enrolled children for lead poisoning at ages 12 months
and 24 months. In addition, children between the ages of 12 months and 72 months
must receive a screening blood lead test if there is no record of a previous
test. The Health Plan shall provide additional diagnostic and treatment services
determined to be medically necessary to a child/adolescent diagnosed with an
elevated blood lead level. The Health Plan shall recommend, but shall not
require, the use of paper filter tests as part of the lead screening requirement.
	 
	 	c.	 	The Health Plan shall inform enrollees of all testing/screenings due in
accordance with the periodicity schedule specified in the Medicaid Child Health
Check-Up Services Coverage and Limitations Handbook. The Health Plan shall
contact enrollees to encourage them to obtain health assessment and preventive
care.
	 
	 	d.	 	The Health Ran shall authorize enrollee referrals to appropriate
providers within four (4) weeks of these examinations for further assessment and
treatment of conditions found during the examination. The Health Plan shall
ensure that the referral appointment is scheduled for a date within six (6)
months of the initial examination,

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	 	 	 	 or within the time periods set forth in Attachment II, Section VII, Provider
Network, Item F., Appointment Waiting Times and Geographic Access Standards, as
applicable.

	 	e.	 	The Health Plan shall cover fluoride treatment by a physician or a
dentist for children/adolescents even if the Health Plan does not provide dental
coverage.
	 
	 	f.	 	If the Health Plan Contract covers transportation, the Health Plan
shall offer transportation to enrollees in order to assist them to keep, and
travel to, medical appointments. If the Contract does not cover transportation
services, the Health Plan shall offer to help enrollees schedule transportation.
	 
	 	g.	 	The CHCUP program includes the maintenance of a coordinated system to
follow the enrollee through the entire range of screening and treatment, as well
as supplying CHCUP training to medical care providers.
	 
	 	h.	 	The Health Plan shall achieve a CHCUP screening rate of at least sixty
percent (60%) for those enrollees who are continuously enrolled for at least
eight (8) months during the federal fiscal year (October 1 — September 30) in
accordance with s. 409.912, F.S. This screening compliance rate shall be based
on the CHCUP screening data reported by the Health Plan and due to the Agency by
January 15 following the end of each federal fiscal year as specified in
Attachment II, Section XII, Reporting Requirements. The data shall be monitored
by the Agency for accuracy, and, if the Health Plan does not achieve the sixty
percent (60%) screening rate for the federal fiscal year reported, the Health
Plan shall file a corrective action plan (CAP) with the Agency no later than
February 15, following the fiscal year reported. Failure to meet the sixty
percent (60%) screening requirement may result in sanctions. Any data reported
by the Health Plan that is found to be inaccurate shall be disallowed by the
Agency, and the Agency shall consider such findings as being in violation of the
Contract and may sanction the Health Plan accordingly. (See Attachment II,
Section XIV, Sanctions)
	 
	 	i.	 	The Health Plan shall adopt annual screening and participation goals
to achieve at least an eighty percent (80%) CHCUP screening and participation
rates, as required by the Centers for Medicare and Medicaid Services. For each
federal fiscal year that the Health Plan does not meet the eighty percent (80%)
screening and participation rates, it must file a CAP with the Agency no later
than February 15 following the federal fiscal year being reported. Any data
reported by the Health Plan that is found to be inaccurate shall be disallowed
by the Agency, and the Agency shall consider such findings as being in violation
of the Contract and may sanction the Health Plan accordingly. (See s.
1902(a)(43)(D)(iv) of the Social Security Act.)

	 	3.	 	Dental Services (See Attachment I and Attachment II, Exhibit 5)
	 
	 	4.	 	Hearing Services (See Attachment I)
	 
	 	5.	 	Vision Services (See Attachment I)

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	AMERIGROUP Community Care

	 	HMO Contract

	 	6.	 	Diabetes Supplies and Education

In the same manner as specified in s. 641.31, F.S., the Health Plan shall provide
coverage for medically necessary equipment, supplies, and services used to treat
diabetes, including outpatient self-management training and educational services, if
the enrollee’s PCP, or the physician to whom the enrollee has been referred who
specializes in treating diabetes, certifies that the equipment, supplies and services
are medically necessary.

	 	7.	 	Emergency Services (See also Item 10. Hospital Services — Inpatient, below)

	 	a.	 	The Health Plan shall advise all enrollees of the provisions governing
emergency services and care. The Health Plan shall not deny claims for emergency
services and care received at a hospital due to lack of parental consent. In
addition, the Health Plan shall not deny payment for treatment obtained when a
representative of the Health Plan instructs the enrollee to seek emergency
services and care in accordance with s. 743.064, F.S.
	 
	 	b.	 	The Health Plan shall not:

	 	(1)	 	Require prior authorization for an enrollee to receive
pre-hospital transport or treatment or for emergency services and care;
	 
	 	(2)	 	Specify or imply that emergency services and care are covered
by the Health Plan only if secured within a certain period of time;
	 
	 	(3)	 	Use terms such as “life threatening” or “bona fide” to qualify
the kind of emergency that is covered; or
	 
	 	(4)	 	Deny payment based on a failure by the enrollee or the hospital
to notify the Health Plan before, or within a certain period of time after,
emergency services and care were given.

	 	c.	 	The Health Plan shall provide pre-hospital and hospital-based trauma
services and emergency services and care to enrollees. See ss. 395.1041, 395.4045
and 401.45, F.S.
	 
	 	d.	 	When an enrollee presents at a hospital seeking emergency services and
care, the determination that an emergency medical condition exists shall be made,
for the purposes of treatment, by a physician of the hospital or, to the extent
permitted by applicable law, by other appropriate personnel under the supervision
of a hospital physician. See ss. 409.9128, 409.901, F.S. and 641.513, F.S.

	 	(1)	 	The physician, or the appropriate personnel, shall indicate on
the enrollee’s chart the results of all screenings, examinations and
evaluations.
	 
	 	(2)	 	The Health Plan shall cover all screenings, evaluations and
examinations that are reasonably calculated to assist the provider in
arriving at the determination as to whether the enrollee’s condition is an
emergency medical condition.

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	 	HMO Contract

	 	(3)	 	If the provider determines that an emergency medical condition does not
exist, the Health Plan is not required to cover services rendered subsequent to
the provider’s determination unless authorized by the Health Plan.

	 	e.	 	If the provider determines that an emergency medical condition exists,
and the enrollee notifies the hospital or the hospital emergency personnel
otherwise have knowledge that the patient is an enrollee of the Health Plan, the
hospital must make a reasonable attempt to notify:

	 	(1)	 	The enrollee’s PCP, if known, or
	 
	 	(2)	 	The Health Plan, if the Health Plan has previously requested in
writing that it be notified directly of the existence of the emergency
medical condition.

	 	f.	 	If the hospital, or any of its affiliated providers, do not know the
enrollee’s PCP, or have been unable to contact the PCP, the hospital must:

	 	(1)	 	Notify the Health Plan as soon as possible before discharging
the enrollee from the emergency care area; or
	 
	 	(2)	 	Notify the Health Plan within twenty-four (24) hours or on the
next business day after the enrollee’s inpatient admission.

	 	g.	 	If the hospital is unable to notify the Health Plan, the hospital must
document its attempts to notify the Health Plan, or the circumstances that
precluded the hospital’s attempts to notify the Health Plan. The Health Plan shall
not deny coverage for emergency services and care based on a hospital’s failure to
comply with the notification requirements of this section.
	 
	 	h.	 	If the enrollee’s PCP responds to the hospital’s notification, and the
hospital physician and the PCP discuss the appropriate care and treatment of the
enrollee, the Health Plan may have a member of the hospital staff with whom it has
a participating provider contract participate in the treatment of the enrollee
within the scope of the physician’s hospital staff privileges.
	 
	 	i.	 	The Health Plan shall cover any medically necessary duration of stay in a
non- contracted facility, which results from a medical emergency, until such time
as the Health Ran can safely transport the enrollee to a participating facility.
The Health Plan may transfer the enrollee, in accordance with state and federal
law, to a participating hospital that has the service capability to treat the
enrollee’s emergency medical condition. The attending emergency physician, or the
provider actually treating the enrollee, is responsible for determining when the
enrollee is sufficiently stabilized for transfer discharge, and that determination
is binding on the entities identified in 42 CFR 438.114(b) as responsible for
coverage and payment.
	 
	 	j.	 	Notwithstanding any other state law, a hospital may request and collect
from an enrollee any insurance or financial information necessary to determine if
the patient is an enrollee of the Health Plan, in accordance with federal law, so
long as emergency services and care are not delayed in the process.

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	 	k.	 	In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the Health Plan shall
cover post-stabilization care services without authorization, regardless of
whether the enrollee obtains a service within or outside the Health Plan’s network
for the following situations:

	 	(1)	 	Post-stabilization care services that were pre-approved by the
Health Plan;
	 
	 	(2)	 	Post-stabilization care services that were not pre-approved by
the Health Plan because the Health Plan did not respond to the treating
provider’s request for pre-approval within one (1) hour after the treating
provider sent the request;
	 
	 	(3)	 	The treating provider could not contact the Health Plan for
pre-approval;
	 
	 	(4)	 	Those post-stabilization care services that a treating
physician viewed as medically necessary after stabilizing an emergency
medical condition are non- emergency services. The Health Plan can choose
not to cover them if they are provided by a non-participating provider,
except in those circumstances detailed in k.(1), (2), and (3) above.

	 	I.	 	The Health Plan shall not deny claims for the provision of emergency
services and care submitted by a nonparticipating provider solely based on the
period between the date of service and the date of clean claim submission, unless
that period exceeds three-hundred and sixty-five (365) days.

	 	m.	 	For capitated Health Plans, reimbursement for services provided to an
enrollee under this section by a non-participating provider shall be the lesser
of:

	 	(1)	 	The non-participating providers charges;
	 
	 	(2)	 	The usual and customary provider charges for similar services
in the community where the services were provided;
	 
	 	(3)	 	The amount mutually agreed to by the Health Plan and the
non-participating provider within sixty (60) calendar days after the
non-participating provider submits a claim; or
	 
	 	(4)	 	The Florida Medicaid reimbursement rate established for the
hospital or provider.

	 	n.	 	Notwithstanding the requirements set forth in this section, the Health
Plan shall approve all claims for emergency services and care by nonparticipating
providers pursuant to the requirements set forth in s. 641.3155, F.S., and 42 CFR
438.114.

	 	o.	 	See Attachment II, Section VI, Behavioral Health Care, and Attachment
II, Exhibit 6, for behavioral health emergency care requirements.

	 	8.	 	Out-of-Plan Use of Non-Emergency Services

The Health Plan shall provide timely approval or denial of authorization of
out-of-network use through the assignment of a prior authorization number, which
refers to and documents the approval. The Health Plan may not require paper
authorization as a condition of receiving treatment if the Health Plan has an
automated authorization

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	 	HMO Contract

system. Written follow-up documentation of the approval must be provided to the
out-of-network provider within one (1) business day from the request for approval. For
capitated Health Plan enrollees, the enrollee shall be liable for the cost of such
unauthorized use of covered services from non-participating providers.

	 	9.	 	Family Planning Services

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

	 	a.	 	The Health Plan shall furnish services on a voluntary and confidential
basis.
	 
	 	b.	 	The Health Plan shall allow enrollees freedom of choice of family
planning methods covered under the Medicaid program, including Medicaid-covered
implants, where there are no medical contra-indications.
	 
	 	c.	 	The Health Plan shall render the services to enrollees under the age of
18 provided the enrollee is married, a parent, pregnant, has written consent by a
parent or legal guardian, or, in the opinion of a physician, the enrollee may
suffer health hazards if the services are not provided. See s. 390.01114, F.S.
	 
	 	d.	 	The Health Plan shall allow each enrollee to obtain family planning
services from any provider and require no prior authorization for such services.
For capitated Health Plans, if the enrollee receives services from a non-network
Medicaid provider, then the Health Plan shall reimburse at the Medicaid
reimbursement rate, unless another payment rate is negotiated.
	 
	 	e.	 	The Health Plan shall make available and encourage all pregnant women
and mothers with infants to receive postpartum visits for the purpose of
voluntary family planning, including discussion of all appropriate methods of
contraception, counseling and services for family planning to all women and their
partners. The Health Plan shall direct providers to maintain documentation in the
enrollee’s medical records to reflect this provision. See s. 409.912, F.S.
	 
	 	f.	 	The provisions of this subsection shall not be interpreted so as to
prevent a health care provider or other person from refusing to furnish any
contraceptive or family planning service, supplies or information for medical or
religious reasons. A health care provider or other person shall not be held
liable for such refusal.

	 	10.	 	Hospital Services — Inpatient

	 	a.	 	Inpatient services are medically necessary services ordinarily furnished
by a state- licensed acute care hospital for the medical care and treatment of
inpatients provided under the direction of a physician or dentist in a hospital
maintained primarily for the care and treatment of patients with disorders other
than mental diseases.

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	 	(1)	 	Inpatient services include, but are not limited to,
rehabilitation hospital care (which are counted as inpatient hospital days),
medical supplies, diagnostic and therapeutic services, use of facilities,
drugs and biologicals, room and board, nursing care and all supplies and
equipment necessary to provide adequate care. See the Medicaid Hospital
Services Coverage & Limitations Handbook.
	 
	 	(2)	 	Inpatient services also include inpatient care for any
diagnosis including tuberculosis and renal failure when provided by general
acute care hospitals in both emergent and non-emergent conditions.
	 
	 	(3)	 	The Health Plan shall cover physical therapy services when
medically necessary and when provided during an enrollee’s inpatient stay.
	 
	 	(4)	 	The Health Plan shall provide up to twenty-eight (28) inpatient
hospital days in an inpatient hospital substance abuse treatment program for
pregnant substance abusers who meet ISD Criteria with Florida Medicaid
modifications, as specified in InterQual Level of Care Acute
Criteria-Pediatric and/or InterQual Level of Care Acute Criteria-Adult
(McKesson Health Solutions, LLC, “McKesson”), the most current edition, for
use in screening cases admitted to rehabilitative hospitals and CON-approved
rehabilitative units in acute care hospitals.
	 
	 	(5)	 	In addition, the Health Plan shall provide inpatient hospital
treatment for severe withdrawal cases exhibiting medical complications that
meet the severity of illness criteria under the alcohol/substance abuse
system-specific set which generally requires treatment on a medical unit
where complex medical equipment is available. Withdrawal cases (not meeting
the severity of illness criteria under the alcohol/substance abuse criteria)
and substance abuse rehabilitation (other than for pregnant women), including
court ordered services, are not covered in the inpatient hospital setting.
	 
	 	(6)	 	The Health Plan shall coordinate hospital and institutional
discharge planning for substance abuse detoxification to ensure inclusion of
appropriate post-discharge care.
	 
	 	(7)	 	The Health Plan shall adhere to the provisions of the Newborns
and Mothers Health Protection Act (NMHPA) of 1996 regarding postpartum
coverage for mothers and their newborns. Therefore, the Health Plan shall
provide for no less than a forty-eight (48) hour hospital length of stay
following a normal vaginal delivery, and at least a ninety-six (96) hour
hospital length of stay following a Cesarean section. In connection with
coverage for maternity care, the hospital length of stay is required to be
decided by the attending physician in consultation with the mother.
	 
	 	(8)	 	The Health Plan shall prohibit the following practices:

	 	(a)	 	Denying the mother or newborn child eligibility, or
continued eligibility, to enroll or renew coverage under the terms of the
Health Plan, solely for the purpose of avoiding the NMHPA requirements;
	 
	 	(b)	 	Providing monetary payments or rebates to mothers to
encourage them to accept less than the minimum protections available under
NMHPA;

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	 	(c)	 	Penalizing or otherwise reducing or limiting the
reimbursement of an attending physician because the physician provided
care in a manner consistent with NMHPA;
	 
	 	(d)	 	Providing incentives (monetary or otherwise) to an
attending physician to induce the physician to provide care in a manner
inconsistent with NMHPA;
	 
	 	(e)	 	Restricting any portion of the forty-eight (48) hour, or
ninety-six (96) hour, period prescribed by NVIHPA in a manner that is less
favorable than the benefits provided for any preceding portion of the
hospital stay; and

	 	(9)	 	The Health Plan shall cover any medically necessary duration of
stay in a non- contracted facility that results from a medical emergency until
such time as the Health Plan can safely transport the enrollee to a Health
Plan participating facility.
	 
	 	(10)	 	In Reform, for all child/adolescent enrollees (up to age 21) and
pregnant adults, the Health Plan shall be responsible for providing up to
three-hundred and sixty- five (365) days of health-related inpatient care,
including behavioral health (if behavioral health is covered by the Health
Plan as specified in Attachment I), for each state fiscal year. For all
non-pregnant adults in Reform, the Health Plan shall be responsible for up to
forty-five (45) days of inpatient coverage and up to three-hundred and
sixty-five (365) days of emergency inpatient care, including behavioral health
(if behavioral health is covered by the Health Plan as specified in Attachment
I), in accordance with the Medicaid Hospital Services Coverage & Limitations
Handbook, for each state fiscal year. For non-Reform populations, the Health
Plan shall provide up to forty-five (45) days of inpatient coverage per
enrollee, including behavioral health (if behavioral health is covered by the
Health Plan as specified in Attachment I), for each state fiscal year.

	 	b.	 	Transplants

The Health Plan shall provide medically necessary transplants and related
services as outlined in the chart below for applicable Reform and non-Reform
populations.

	 	1.	 	For transplant services specified with an asterisk, Reform
capitated Health Plans are paid by the Agency through kick payments. See
Attachment I and Attachment II, Section XIII, Method of Payment, for payment
details.
	 
	 	2.	 	Transplant services specified with two (2) asterisks, as well as
pre- and post- transplant follow-up care, are covered through fee-for-service
Medicaid and not by the Health Plan. If at the conclusion of the transplant
evaluation, the enrollee is listed with the United Network for Organ Sharing
(UNOS) as a level 1A, 1B, or 2 candidate for a heart or lung transplant, or
with a Model End Stage Liver Disease (MELD) score of 11-25 for a liver
transplant, then the Health Plan must submit a copy of the UNOS form to BMHC
with a request to disenroll the member
from the Health Plan. The recipient cannot re-enroll with the Health Plan until
at least one (1) year post transplant. This re-enrollment is not automatic.

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SUMMARY OF RESPONSIBILITY

	 	 	 	 	 	 	 	 	 
	 	 	Reform	 	Non-Reform
	 	 	Adult	 	Pediatric	 	Adult	 	Pediatric
	 	 	(21 and Over)	 	(20 and Under)	 	(21 and Over)	 	(20 and Under)
	Evaluation

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Bone Marrow

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Cornea

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Heart

	 	Health Plan*
	 	Health Plan*
	 	Medicaid**
	 	Medicaid**
	 
	 	 	 	 	 	 	 	 
	Intestinal/Multivisceral

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Kidney

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Liver

	 	Health Plan*
	 	Health Plan*
	 	Medicaid**
	 	Medicaid**
	 
	 	 	 	 	 	 	 	 
	Lung

	 	Health Plan*
	 	Health Plan*
	 	Medicaid**
	 	Medicaid**
	 
	 	 	 	 	 	 	 	 
	Pancreas

	 	Health Plan
	 	Health Plan
	 	Health Plan
	 	Health Plan
	 
	 	 	 	 	 	 	 	 
	Pre- and Post-Transplant
Care, including
Transplants Not Covered
by Medicaid

	 	Health Plan
	 	Health Plan
	 	Health Plan (except

heart, lung, or

liver)
	 	Health Plan (except

heart, lung, or

liver)
	 
	 	 	 	 	 	 	 	 
	Other Transplants Not 

Covered by Medicaid

	 	Not Covered
	 	Not Covered
	 	Not Covered
	 	Not Covered

	 	c.	 	See Attachment II, Section VI, Behavioral Health Care, and Attachment II,
Exhibit 6, for behavioral health inpatient care requirements.

11. Hospital Services — Outpatient

Outpatient hospital services consist of medically necessary preventive, diagnostic, therapeutic
or palliative care under the direction of a physician or dentist at a licensed

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acute care hospital. Outpatient hospital services include medically necessary
emergency room services, dressings, splints, oxygen and physician-ordered services and
supplies for the clinical treatment of a specific diagnosis or treatment.

	 	a.	 	The Health Plan shall provide emergency services and care without any
specified dollar limitations.
	 
	 	b.	 	The Health Plan shall have a procedure for the authorization of dental care
and associated ancillary medical services provided in an outpatient hospital setting
if that care meets the following requirements:

	 	(1)	 	Is provided under the direction of a dentist at a licensed hospital;
and
	 
	 	(2)	 	Although not usually considered medically necessary, is considered
medically necessary to the extent that the outpatient hospital services must be
provided in a hospital due to the enrollee’s disability, behavioral health
condition or abnormal behavior due to emotional instability or a developmental
disability.

12. Hospital Services — Ancillary Services

	 	a.	 	The Health Plan shall provide medically necessary ancillary medical services
at the hospital without limitation. Ancillary hospital services include, but are not
limited to, radiology, pathology, neurology, neonatology, and anesthesiology.

	 	(1)	 	When the capitated Health Plan or its authorized physician
authorizes these services (either inpatient or outpatient), the Health Plan
shall reimburse the provider of the service at the Medicaid line item rate,
unless the Health Plan and the hospital have negotiated another reimbursement
rate.
	 
	 	(2)	 	The Health Plan shall authorize payment for non-network physicians
for emergency ancillary services provided in a hospital setting.

	 	b.	 	If the Health Plan covers dental services, as specified in Attachment I, it
shall have a procedure for the authorization of medically necessary dental care and
associated ancillary services provided in licensed ambulatory surgical center
settings if that care is provided under the direction of a dentist as described in
the State Plan.

13. Hysterectomies, Sterilizations and Abortions

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

	 	a.	 	If the pregnancy is a result of an act of rape or incest; or
	 
	 	b.	 	The physician certifies that the woman is in danger of death unless an
abortion is performed.

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14. Immunizations

The Health Plan shall:

	 	a.	 	Provide immunizations in accordance with the Recommended Childhood
Immunization Schedule for the United States, or when medically necessary for the
enrollee’s health;
	 
	 	b.	 	Provide for the simultaneous administration of all vaccines for which an
enrollee under the age of 21 is eligible at the time of each visit;
	 
	 	c.	 	Follow only contraindications established by the Advisory Committee on
Immunization Practices (ACIP), unless:

	 	(1)	 	In making a medical judgment in accordance with accepted medical
practices, such compliance is deemed medically inappropriate; or
	 
	 	(2)	 	The particular requirement is not in compliance with Florida law,
including Florida law relating to religious or other exemptions;

	 	d.	 	Participate, or direct its providers to participate, in the Vaccines For
Children Program (“VFC”). See s. 1905(r)(1) of the Social Security Act. The VFC is
administered by the Department of Health, Bureau of Immunizations. The VFC provides
vaccines at no charge to physicians and eliminates the need to refer children to
CHDs for immunizations. Title XXI IViediKids enrollees do not qualify for the VFC
program. The Health Plan shall advise providers to bill Medicaid fee-for-service
directly for immunizations provided to Title XXI MediKids participants;
	 
	 	e.	 	Provide documentation annually by October 1 of each Contract year to MOHO
that the Health Plan, or its participating providers, are enrolled in the VFC
program;
	 
	 	f.	 	Provide coverage and reimbursement to the participating provider for
immunizations covered by Medicaid, but not provided through VFC;
	 
	 	g.	 	Ensure that providers have a sufficient supply of vaccines if the Health
Plan is enrolled in the VFC program. The Health Plan shall direct those providers
that are directly enrolled in the VFC program to maintain adequate vaccine supplies;
	 
	 	h.	 	(Capitated Health Plans only) Pay no more than the Medicaid program vaccine
administration fee of $10 per administration, unless another rate is negotiated with
the participating provider;
	 
	 	i.	 	(Capitated Health Plans only) Pay the immunization administration fee at no
less than the Medicaid rate when an enrollee receives immunizations from a
nonparticipating provider so long as:

	 	(1)	 	The non-participating provider contacts the Health Plan at the time of
service delivery;

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	 	(2)	 	The Health Plan is unable to document to the non-participating provider that
the enrollee has already received the immunization; and
	 
	 	(3)	 	The non-participating provider submits a claim for the
administration of immunization services and provides medical records documenting
the immunization to the Health Plan.

	 	j.	 	Encourage PCPs to provide immunization information for enrollees requesting
temporary cash assistance from DCF, upon request by DCF and receipt of the enrollee’s
written permission, in order to document that the enrollee has met the immunization
requirements for enrollees receiving temporary cash assistance.

15. Pregnancy-Related Requirements

The Health Plan shall provide the most appropriate and highest level of quality care for
pregnant enrollees. Required care includes the following:

	 	a.	 	Florida’s Healthy Start Prenatal Risk Screening — The Health Plan shall
ensure that the provider offers Florida’s Healthy Start prenatal risk screening to
each pregnant enrollee as part of her first prenatal visit. As required by s.
383.14, F.S., s. 381.004, F.S., and 64C-7.009, F.A.C.

	 	(1)	 	The Health Plan shall ensure that the provider uses the DOH prenatal
risk form (DH Form 3134), which can be obtained from the local CHD.
	 
	 	(2)	 	The Health Plan shall ensure that the provider keeps a copy of the
completed screening instrument in the enrollee’s medical record and provides a
copy to the enrollee.
	 
	 	(3)	 	The Health Plan shall ensure that the provider submits the completed
DH Form 3134 to the CHD in the county where the prenatal screen was completed
within ten (10) business days of completion of the screening.
	 
	 	(4)	 	The Health Plan shall collaborate with the Healthy Start care
coordinator within the enrollee’s county of residence to assure delivery of
risk-appropriate care.

	 	b.	 	Florida’s Healthy Start Infant (Postnatal) Risk Screening Instrument — The
Health Plan shall ensure that the provider completes the Florida Healthy Start
Infant (Postnatal) Risk Screening Instrument (DH Form 3135) with the Certificate of
Live Birth and transmits the documents to the CHD in the county where the infant was
born within ten (10) business days of the birth. The Health Plan shall ensure that
the provider keeps a copy of the completed DH Form 3135 in the enrollee’s medical
record and provides a copy to the enrollee.
	 
	 	c.	 	Pregnant enrollees or infants who do not score high enough to be eligible
for Healthy Start care coordination may be referred for services, regardless of
their score on the Healthy Start risk screen, in the following ways:

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

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	 	(2)	 	If the determination is made subsequent to risk screening, the provider may
refer the enrollee or infant directly to the Healthy Start care coordinator based
on assessment of actual or potential factors associated with high risk, such as
HIV, Hepatitis B, substance abuse or domestic violence.

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

	 	(1)	 	The Health Plan shall ensure providers provide:

	 	(a)	 	A completed Florida WIC program medical referral form with
the current height or length and weight (taken within sixty (60) calendar
days of the WIC appointment);
	 
	 	(b)	 	Hemoglobin or hematocrit; and
	 
	 	(c)	 	Any identified medical/nutritional problems.

	 	(2)	 	For subsequent WIC certifications, the Health Plan shall ensure that
providers coordinate with the local WIC office to provide the above referral
data from the most recent CHCUP.
	 
	 	(3)	 	Each time the provider completes a WIC referral form, the Health
Plan shall ensure that the provider gives a copy of the form to the enrollee and
keeps a copy in the enrollee’s medical record.

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

	 	(1)	 	The Health Plan shall ensure that its providers offer all pregnant
women counseling and HIV testing at the initial prenatal care visit and again at
twenty- eight (28) and thirty-two (32) weeks.
	 
	 	(2)	 	The. Health Plan shall ensure that its providers attempt to obtain a
signed objection if a pregnant woman declines an HIV test. See s. 384.31, F.S.
and 64D-3.019, F.A.C.
	 
	 	(3)	 	The Health Plan shall ensure that all pregnant women who are
infected with HIV are counseled about and offered the latest antiretroviral
regimen recommended by the U.S. Department of Health & Human Services (Public
Health Service Task Force Report entitled Recommendations for the Use of
Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and
Interventions to Reduce Perinatal HIV-1 Transmission in the United States).

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

	 	(1)	 	The Health Plan shall ensure that the providers perform a second HBsAg
test between twenty-eight (28) and thirty-two (32) weeks of pregnancy for all
pregnant

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	 	 	 	enrollees who tested negative at the first prenatal visit and are considered high-
risk for Hepatitis B infection. This test shall be performed at the same time that
other routine prenatal screening is ordered.
	 
	 	(2)	 	All HBsAg-positive women shall be reported to the local CHD and to
Healthy Start, regardless of their Healthy Start screening score.

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

	 	(1)	 	The Health Plan shall ensure that its providers test infants born to
HBsAgpositive enrollees for HBsAg and Hepatitis B surface antibodies (anti-HBs)
six (6) months after the completion of the vaccine series to monitor the success
or failure of the therapy.
	 
	 	(2)	 	The Health Plan shall ensure that providers report to the local CHD
a positive HBsAg result in any child age 24 months or less within twenty-four
(24) hours of receipt of the positive test results.
	 
	 	(3)	 	The Health Plan shall ensure that infants born to enrollees who are
HBsAgpositive are referred to Healthy Start regardless of their Healthy Start
screening score.

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

	 	(1)	 	The Health Plan shall report the following information — name, date
of birth, race, ethnicity, address, infants, contacts, laboratory test
performed, date the sample was collected, the due date or estimated date of
confinement, whether the enrollee received prenatal care, and immunization dates
for infants and contacts.
	 
	 	(2)	 	The Health Plan shall use the Perinatal Hepatitis B Case and Contact
Report (DH Form 1876) for reporting purposes.

	 	i.	 	The Health Plan shall ensure that the PCP maintains all documentation of
Healthy Start screenings, assessments, findings and referrals in the enrollees’
medical records.

	 	j.	 	Prenatal Care — The Health Plan shall:

	 	(1)	 	Require a pregnancy test and a nursing assessment with referrals to
a physician, PA or ARNP for comprehensive evaluation;
	 
	 	(2)	 	Require case management through the gestational period according to
the needs of the enrollee;

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	 	(3)	 	Require any necessary referrals and follow-up;
	 
	 	(4)	 	Schedule return prenatal visits at least every four (4) weeks until
week thirty-two (32), every two (2) weeks until week thirty-six (36), and every
week thereafter until delivery, unless the enrollee’s condition requires more
frequent visits;
	 
	 	(5)	 	Contact those enrollees who fail to keep their prenatal appointments
as soon as possible, and arrange for their continued prenatal care;
	 
	 	(6)	 	Assist enrollees in making delivery arrangements, if necessary; and
	 
	 	(7)	 	Ensure that all providers screen all pregnant enrollees for tobacco
use and make certain that the providers make available to pregnant enrollees
smoking cessation counseling and appropriate treatment as needed.

	 	k.	 	Nutritional Assessment/Counseling — The Health Plan shall ensure that its
providers supply nutritional assessment and counseling to all pregnant enrollees.
The Health Plan shall:

	 	(1)	 	Ensure the provision of safe and adequate nutrition for infants by
promoting breast-feeding and the use of breast milk substitutes;
	 
	 	(2)	 	Offer a mid-level nutrition assessment;
	 
	 	(3)	 	Provide individualized diet counseling and a nutrition care plan by
a public health nutritionist, a nurse or physician following the nutrition
assessment; and
	 
	 	(4)	 	Ensure documentation of the nutrition care plan in the medical
record by the person providing counseling.

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

	 	(1)	 	The Health Plan shall ensure that all providers document preterm
delivery risk assessments in the enrollee’s medical record by week twenty-eight
(28).
	 
	 	(2)	 	If the provider determines that the enrollee’s pregnancy is high
risk, the Health Plan shall ensure that the provider’s obstetrical care during
labor and delivery includes preparation by all attendants for symptomatic
evaluation and that the enrollee progresses through the final stages of labor
and immediate postpartum care.

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

	 	(1)	 	Instilling of prophylactic eye medications into each eye of the newborn;

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	 	(2)	 	When the mother is Rh negative, securing a cord blood sample for type Rh
determination and direct Coombs test;
	 
	 	(3)	 	Weighing and measuring of the newborn;
	 
	 	(4)	 	Inspecting the newborn for abnormalities and/or complications;
	 
	 	(5)	 	Administering one half (.5) milligram of vitamin K;
	 
	 	(6)	 	APGAR scoring;
	 
	 	(7)	 	Any other necessary and immediate need for referral in consultation
from a specialty physician, such as the Healthy Start (postnatal) infant
screen; and
	 
	 	(8)	 	Any necessary newborn and infant hearing screenings (to be
conducted by a licensed audiologist pursuant to Chapter 468, F.S., a physician
licensed under Chapters 458 or 459, F.S., or an individual who has completed
documented training specifically for newborn hearing screenings and who is
directly or indirectly supervised by a licensed physician or a licensed
audiologist).

	 	n.	 	Postpartum Care — The Health Plan shall:

	 	(1)	 	Provide a postpartum examination for the enrollee within six (6)
weeks after delivery;
	 
	 	(2)	 	Ensure that its providers supply voluntary family planning,
including a discussion of all methods of contraception, as appropriate;
	 
	 	(3)	 	Ensure that continuing care of the newborn is provided through the
CHCUP program component.

16. Prescribed Drug Services

	 	a.	 	The Health Plan shall provide those products and services associated with
the dispensing of medicinal drugs pursuant to a valid prescription, as defined in
Chapter 465, F.S. Prescribed drug services generally include all prescription drugs
listed in the Agency’s Preferred Drug List (PDL). See s. 409.91195, F.S. The Health
Plan’s PDL shall include at least two (2) products, when available, in each
therapeutic class. Pursuant to s. 409.912(39), F.S., policy requirements include,
but are not limited to, the following:

	 	(1)	 	The Health Plan shall make available those drugs and dosage forms
listed in its PDL.
	 
	 	(2)	 	The Health Plan shall not arbitrarily deny or reduce the amount,
duration or scope of prescriptions solely based on the enrollee’s diagnosis,
type of illness or condition. The Health Plan may place appropriate limits on
prescriptions based on criteria such as medical necessity, or for the purpose
of utilization control, provided the Health Plan reasonably expects said limits
to achieve the purpose of the prescribed drug services set forth in the
Medicaid State Plan.

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	 	(3)	 	The Health Plan shall make available those drugs not on its PDL, when
requested and approved, if the drugs on the PDL have been used in a step therapy
sequence or when other medical documentation is provided.
	 
	 	(4)	 	The Health Plan shall submit an updated PDL to BMHC and the Bureau
of Pharmacy Services by October 1 of each Contract year, and provide thirty (30)
days’ written notice of any changes. If the Health Plan adopts the Medicaid PDL,
the Health Plan shall be exempt from such reporting. Information on the Health
Plan’s use of the PDL is in Attachment I and Attachment II, Exhibit 5.
	 
	 	(5)	 	Antiretroviral agents are not subject to the PDL.

	 	b.	 	The Health Plan may delegate any or all functions to one (1) or more
pharmacy benefits administrators (PBA). Before entering into a subcontract, the
Health Plan shall work with the Agency’s fiscal agent.
	 
	 	c.	 	The Health Plan shall continue the medication prescribed to the enrollee in
a state mental health treatment facility for at least ninety (90) days after the
facility discharges the enrollee, unless the Health Plan’s prescribing psychiatrist,
in consultation and agreement with the facility’s prescribing physician, determines
that the medications:

	 	(1)	 	Are not medically necessary; or
	 
	 	(2)	 	Are potentially harmful to the enrollee.

	 	d.	 	The Health Plan shall provide to enrollees who want to quit smoking one (1)
course of nicotine replacement therapy, of twelve (12) weeks’ duration, or the
manufacturer’s recommended duration, per year. The Health Plan may use either
nicotine transdermal patches or nicotine gum.
	 
	 	e.	 	If the Health Plan has authorization requirements for prescribed drug
services, the Health Plan shall comply with all aspects of the Settlement Agreement
to Hernandez, et al v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA). An HSA
situation arises when an enrollee attempts to fill a prescription at a participating
pharmacy location and is unable to receive the prescription as a result of:

	 	(1)	 	An unreasonable delay in filling the prescription;
	 
	 	(2)	 	A denial of the prescription;
	 
	 	(3)	 	The reduction of a prescribed good or service; and/or
	 
	 	(4)	 	The termination of a prescription.

	 	f.	 	The Health Plan shall ensure that its enrollees are receiving the functional
equivalent of those goods and services received by fee-for-service Medicaid
recipients in accordance with the HSA.

	 	(1)	 	The Health Plan shall maintain a log of all correspondence and
communications from enrollees relating to the HSA ombudsman process. The
ombudsman log

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	 	 	 	shall contain, at a minimum, the enrollee’s name, address and telephone number
and any other contact information, the reason for the participating pharmacy
location’s denial (an unreasonable delay in filling a prescription, a denial of a
prescription and/or the termination of a prescription), the pharmacy’s name (and
store number, if applicable), the date of the call, a detailed explanation of the
final resolution, and the name of the prescribed good or service. The ombudsman
log report shall be submitted quarterly to BMHC, as required in Attachment II,
Section XII, Reporting Requirements.
	 
	 	(2)	 	The Health Plan’s enrollees are third party beneficiaries for this
section of the Contract.
	 
	 	(3)	 	The Health Plan shall conduct annual HSA surveys of no less than
five percent (5%) of all participating pharmacy locations to ensure compliance
with the HSA.

	 	(a)	 	The Health Plan may survey less than five percent (5%), with
written approval from the Agency, if the Health Plan can show that the
number of participating pharmacies it surveys is a statistically significant
sample that adequately represents the pharmacies that have contracted with
the Health Plan to provide pharmacy services.
	 
	 	(b)	 	The Health Plan shall not include in the HSA survey any
participating pharmacy location that the Health Plan found to be in complete
compliance with the HSA requirements within the past twelve (12) months.
	 
	 	(c)	 	The Health Plan shall require all participating pharmacy
locations that fail any aspect of the HSA survey to undergo mandatory
training within six (6) months and then be re-evaluated within one (1) month
of the training to ensure that the pharmacy location is in compliance with
the HSA.
	 
	 	(d)	 	The Health Plan shall ensure that it complies with all
aspects and surveying requirements set forth in Policy Transmittal 06-01,
Hernandez Settlement Requirements, an electronic copy of which can be found
at:

http://www.fdhc.state.fl.us/MCHQ/Manaqed Health Care/MHM0/06policv.shtml 

	 	(e)	 	The Health Plan shall submit a report annually, by August 1
of each Contract year to BMHC, providing survey results following
requirements in Attachment II, Section XII, Reporting Requirements.

	 	(4)	 	The Health Plan shall offer training to all new and existing
participating pharmacy locations about the HSA requirements.

	 	g.	 	The Health Plan shall cover the cost of a brand-name drug if the prescriber:

	 	(1)	 	Writes in his/her own handwriting on the valid prescription that the
“Brand Name is Medically Necessary” (pursuant to s. 465.025, F.S.); and
	 
	 	(2)	 	Submits a completed “Multisource Drug and Miscellaneous Prior
Authorization” form to the Health Plan indicating that the enrollee has had an
adverse reaction

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	 	 	 	to a generic drug or has had, in the prescriber’s medical opinion, better results
when taking the brand-name drug.

	 	h.	 	For PSNs, hemophilia factor-related drugs identified by the Agency for
distribution through the Comprehensive Hemophilia Disease Management Program are
reimbursed on a fee-for-service basis. During operation of the Comprehensive
Hemophilia Disease Management Program, the Health Plan shall coordinate the care of
its enrollees with Agency-approved organizations and shall not be responsible for
the distribution of hemophilia-related drugs.
	 
	 	i.	 	For HMOs, hemophilia factor-related drugs are reimbursed by Medicaid on a
fee-forservice basis. The HMO shall coordinate the care of its enrollees with
hemophilia and shall not be responsible for the distribution of hemophilia
factor-related drugs.
	 
	 	j.	 	Capitated Health Plans shall submit pharmacy encounter data, including behavioral
health pharmacy encounter data if behavioral health is a Health Plan covered service,
to the Medicaid Encounter Data System secure file transfer protocol site in a format
supplied by the Agency on an ongoing quarterly schedule, as specified in Attachment
II, Section XII, Reporting Requirements.

17. Quality Enhancements

In addition to the covered services specified in this section, the Health Plan shall
offer quality enhancements (QE) to enrollees as specified below.

	 	a.	 	The Health Plan shall offer QEs in community settings accessible to enrollees.
	 
	 	b.	 	The Health Plan shall provide information in the enrollee and provider
handbooks on the QEs and how to access related services.
	 
	 	c.	 	The Health Plan shall develop and maintain written policies and procedures
to implement QEs.
	 
	 	d.	 	The Health Plan may cosponsor the annual training of providers, provided
that the training meets the provider training requirements for the programs listed
below. The Health Plan is encouraged to actively collaborate with community agencies
and organizations, including CHDs, local Early Intervention Programs, Healthy Start
Coalitions and local school districts in offering these services.
	 
	 	e.	 	If the Health Plan involves the enrollee in an existing community program
for purposes of meeting the QE requirement, the Health Plan shall ensure
documentation in the enrollee’s medical record of referrals to the community program
and follow up on the enrollee’s receipt of services from the community program.
	 
	 	f.	 	QE programs shall include, but not be limited to, the following:

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

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	 	(a)	 	Children’s programs shall promote increased use of prevention and early
intervention services for at-risk enrollees. The Health Plan shall approve
claims for services recommended by the Early Intervention Program when they
are covered services and medically necessary.
	 
	 	(b)	 	The Health Plan shall offer annual training to providers
that promotes proper nutrition, breast-feeding, immunizations, CHCUP,
wellness, prevention and early intervention services.

	 	(2)	 	Domestic Violence — The Health Plan shall ensure that PCPs screen
enrollees for signs of domestic violence and shall offer referral services to
applicable domestic violence prevention community agencies.
	 
	 	(3)	 	Pregnancy Prevention — The Health Plan shall conduct regularly
scheduled pregnancy prevention programs, or shall make a good faith effort to
involve enrollees in existing community pregnancy prevention programs, such as
the Abstinence Education Program. The programs shall be targeted towards teen
enrollees, but shall be open to all enrollees, regardless of age, gender,
pregnancy status or parental consent.
	 
	 	(4)	 	Prenatal/Postpartum Pregnancy Programs — The Health Plan shall
provide regular home visits, conducted by a home health nurse or aide, and
counseling and educational materials to pregnant and postpartum enrollees who
are not in compliance with the Health Plan’s prenatal and postpartum programs.
The Health Plan shall coordinate its efforts with the local Healthy Start care
coordinator to prevent duplication of services.
	 
	 	(5)	 	Smoking Cessation — The Health Plan shall conduct regularly
scheduled smoking cessation programs as an option for all enrollees, or the
Health Plan shall make a good faith effort to involve enrollees in existing
community smoking cessation programs. The Health Plan shall provide smoking
cessation counseling to enrollees. The Health Plan shall provide participating
PCPs with the Quick Reference Guide to assist in identifying tobacco users and
supporting and delivering effective smoking cessation interventions. (The health
plan can obtain copies of the guide by contacting the DHHS, Agency for Health
Care Research & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or
P.O. Box 8547, Silver Spring, MD 20907.)
	 
	 	(6)	 	Substance Abuse — The Health Plan shall offer annual substance
abuse screening training to its providers.

	 	(a)	 	The Health Plan shall have all PCPs screen enrollees for signs
of substance abuse as part of prevention evaluation at the following times:

	 	(i)	 	Initial contact with a new enrollee;
	 
	 	(ii)	 	Routine physical examinations;
	 
	 	(iii)	 	Initial prenatal contact;

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	 	(iv)	 	When the enrollee evidences serious over-utilization of medical,
surgical, trauma or emergency services; and
	 
	 	(v)	 	When documentation of emergency room visits suggests
the need.

	 	(b)	 	The Health Plan shall offer targeted enrollees either
community or Health Plan-sponsored substance abuse programs.

18. Protective Custody

	 	a.	 	The Health Plan shall provide a physical screening within seventy-two (72)
hours, or immediately if required, for all enrolled children/adolescents taken into
protective custody, emergency shelter or the foster care program by DCF. See
65C-29.008, FAC.
	 
	 	b.	 	The Health Plan shall provide these required examinations, or, if unable to
do so within the required time frames, approve the out-of-network claim and forward
it to the Agency and/or its fiscal agent.
	 
	 	c.	 	For all CHCUP screenings for children/adolescents whose enrollment and
Medicaid eligibility are undetermined at the time of entry into the care and custody
of DCF, and who are later determined to be enrollees at the time the examinations
took place, the Health Plan shall approve the claims and forward them to the Agency
and/or the fiscal agent.

19. Therapy Services

Medicaid therapy services are physical, speech-language (including augmentative and
alternative communication systems), occupational and respiratory therapies. The Health
Plan shall cover therapy services consistent with the Medicaid Therapy Services Coverage
and Limitations Handbook requirements. Therapy services are limited to
children/adolescents under age 21. Adults are covered for physical and respiratory
therapy services under the outpatient hospital services program. The Agency shall
reimburse schools participating in the certified school match program for school-based
therapy services rendered to enrollees. The provision of school-based therapy services to
an enrollee does not replace, substitute or fulfill a service prescription or doctors’
orders for therapy services covered by the Health Plan. The Health Plan shall:

	 	a.	 	Refer enrollees to appropriate providers for further assessment and treatment
of conditions;
	 
	 	b.	 	Offer enrollees scheduling assistance in making treatment appointments and
arranging transportation; and
	 
	 	c.	 	Provide for care management in order to follow the enrollee’s progress from
screening through the course of treatment

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20. Transportation Services (See Attachment I and Attachment II, Exhibit 5)

	 	a.	 	Transportation services include the arrangement and provision of an
appropriate mode of transportation for enrollees to receive medical services.
	 
	 	b.	 	Certain health plans are not authorized to provide transportation services.
Some health plans are required to provide them. The transportation services
requirements for this Contract are detailed in Attachment I and in Attachment II,
Exhibit 5. If the Health Plan does provide transportation, it may do so through its
own network of transportation providers or through a contractual relationship, which
may include the Commission for the Transportation Disadvantaged.
	 
	 	c.	 	If the Health Plan does not provide transportation services, it still must
assist enrollees in arranging transportation to and from medical appointments for
Medicaid- covered services.

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Section VI

Behavioral Health Care

See Attachment I and Attachment II, Exhibit 6

	A.	 	General Provisions

	 	1.	 	Specifics of behavioral health coverage for this Contract are in Attachment II, Exhibit 6.
	 
	 	2.	 	Provision of Behavioral Health Services When Not Covered by the Health Plan:

	 	a.	 	If the Health Plan determines that an enrollee is in need of behavioral
health services that are not covered under the Contract, the Health Plan shall refer
the enrollee to the appropriate provider. The Health Plan may request the assistance
of the Agency’s local field office or the local DCF SAMH Office for referral to the
appropriate service setting.
	 
	 	b.	 	Long-term care institutional services in a nursing facility, an institution
for persons with developmental disabilities, specialized therapeutic foster care,
children’s residential treatment services or state hospital services are not covered
by the Health Plan. For enrollees requiring those services, the Health Plan shall
consult the Medicaid Area Office and/or the local DCF SAMH Office to identify
appropriate methods of assessment and referral.
	 
	 	c.	 	The Health Plan is responsible for transition and referral of the enrollee
to appropriate providers.

	 	3.	 	Substance Abuse Services — Health Plan enrollees will receive Medicaid-funded
substance abuse services through the fee-for-service system. The Health Plan shall
develop methods of coordinating and integrating mental health and substance abuse
services for enrollees. The Health Plan shall be required to use the Florida Supplement
to the American Society of Addictions Medicine Patient Placement Criteria for the
coordination of mental health treatment with substance abuse providers as part of the
integration effort (Second Edition ASAM PPC-2, July 1998). The coordination shall be
reflected in their individualized treatment plans for enrollees with co-occurring
disorder.

	 	4.	 	Drug Utilization Review — The Health Plan shall design and implement a drug
utilization review (DUR) program designed to encourage coordination between an enrollee’s
primary care physician and a prescriber of a psychotropic or similar prescription drug
for behavioral health problems. The Health Plan’s DUR program shall identify those
medications for other serious medical conditions (such as hypertension, diabetes,
neurological disorders, or cardiac problems), where this is a significant risk to the
enrollee posed by potential drug interactions between drugs for these conditions and
behavioral-related drugs. After the Health Plan identifies the potential for such
problems, the Health Plan’s DUR program shall notify all related prescribers that certain
drugs may be contra-indicated due to the potential for drug interactions and shall
encourage the prescribers to coordinate their care. Notice may be provided electronically
or via mail, or by telephonic or direct consultation, as the Health Plan deems
appropriate.

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	 	5.	 	Outreach Program — The Health Plan shall have an outreach program including referral
and other resources designed to assist PCPs in the identification, management and
treatment of:

	 	a.	 	Enrollees with severe and persistent mental illness;
	 
	 	b.	 	Children/adolescents with severe emotional disturbances; and
	 
	 	c.	 	Enrollees with clinical depression.

	 	6.	 	Release of records — The enrollee or authorized representative shall sign and
date a release form before any psychiatric notes can be released to another party.

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Section VII

Provider Network

	A.	 	General Provisions

	 	1.	 	The Health Plan shall have sufficient facilities, service locations and personnel
to provide the covered services described in Attachment II, Section V, Covered
Services, and Section VI, Behavioral Health Care.
	 
	 	2.	 	The Health Plan shall provide BMHC, prior to Contract execution and upon request,
with sufficient evidence that the Health Plan has the capacity to provide covered
services to all enrollees up to the maximum enrollment level in each county, including
evidence that the Health Plan:

	 	a.	 	Offers an appropriate range of services and accessible preventive and
primary care services to meet the needs of the maximum enrollment level in each
county; and
	 
	 	b.	 	Maintains a sufficient number, mix and geographic distribution of
providers, including providers who are accepting new Medicaid patients as
specified in s. 1932(b)(7) of the Social Security Act, as enacted by s. 4704(a) of
the Balanced Budget Act of 1997.

	 	3.	 	Prior to Contract execution and at least monthly thereafter, the Health Plan shall
submit a file of all network providers to the Agency or its agent in the manner and
format determined by the Agency. See Attachment II, Section XII, Reporting
Requirements, Table 1.
	 
	 	4.	 	Each provider shall maintain hospital privileges if hospital privileges are
required for the delivery of covered services. The Health Plan may use admitting panels
to comply with this requirement.
	 
	 	5.	 	The Health Plan shall not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly treatments.
	 
	 	6.	 	When establishing and maintaining the provider network, requesting expansion to
other counties, or requesting enrollment level increases, the Health Plan shall take
the following into consideration as required by 42 CFR 438.206:

	 	a.	 	The anticipated number of enrollees;
	 
	 	b.	 	The expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented;
	 
	 	c.	 	The numbers and types (in terms of training, experience, and
specialization) of providers required to furnish the covered services;
	 
	 	d.	 	The numbers of network providers who are not accepting new enrollees;
	 
	 	e.	 	The geographic location of providers and enrollees, considering distance,
travel time, the means of transportation ordinarily used by enrollees and whether
the location provides physical access for Medicaid enrollees with disabilities.

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	 	7.	 	If the Health Plan is unable to provide medically necessary services to an enrollee,
the Health Plan shall cover these services in an adequate and timely manner by using
providers and services that are not in the Health Plan’s network for as long as the
Health Plan is unable to provide the medically necessary services within its network.
	 
	 	8.	 	The Health Plan shall allow each enrollee to choose among network providers to the
extent possible and appropriate.
	 
	 	9.	 	The Health Plan shall require each provider to have a unique Florida Medicaid
provider number. The Health Plan shall require each provider to have a National
Provider Identifier (NPI) in accordance with s. 1173(b) of the Social Security Act, as
enacted by s. 4707(a) of the Balanced Budget Act of 1997. The provider contract shall
require providers to submit all NPIs to the Health Plan within fifteen (15) business
days of receipt. The Health Plan shall report the providers’ NPIs as part of its
provider network report to the Agency or its agent, as set forth in Attachment II,
Section XII, Reporting Requirements. The Health Plan need not obtain an NPI from the
following providers:

	 	a.	 	Individuals or organizations that furnish atypical or nontraditional
services that are only indirectly related to the provision of health care (examples
include taxis, home and vehicle modifications, insect control, habilitation and
respite services); and
	 
	 	b.	 	Individuals or businesses that only bill or receive payment for, but do not
furnish, health care services or supplies (examples include billing services and
repricers).

	 	10.	 	The Health Plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider, whether participating or
nonparticipating, who is acting within the scope of the provider’s license or
certification under applicable state law, solely on the basis of such license or
certification, in accordance with s.1932(b) (7) of the Social Security Act (as enacted
by s. 4704[a] of the Balanced Budget Act of 1997). The Health Plan is not prohibited
from including providers only to the extent necessary to meet the needs of the Health
Plan’s enrollees or from establishing any measure designed to maintain quality and
control costs consistent with the responsibilities of the Health Plan. If the Health
Plan declines to include individual providers or groups of providers in its network, it
must give the affected providers written notice of the reason for its decision.

	 	11.	 	The Health Plan shall establish and maintain a formal provider relations function
to timely and adequately respond to inquiries, questions and concerns from network
providers.

	B.	 	Network Standards (See Attachment II, Exhibit 7)

	 	1.	 	Primary Care Providers

	 	a.	 	The Health Plan shall enter into provider contracts with a sufficient
number of PCPs to ensure adequate accessibility for enrollees of all ages. The
Health Plan shall select and approve its PCPs and ensure they provide the
following:

	 	(1)	 	The PCP shall provide, or arrange for coverage of services,
consultation or approval for referrals twenty-four hours per day, seven days per
week (24/7) by

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	 	 	 	Medicaid-enrolled providers who will accept Medicaid reimbursement. This coverage
shall consist of an answering service, call forwarding, provider call coverage or
other customary means approved by the Agency. The chosen method of 24/7 coverage
must connect the caller to someone who can render a clinical decision or reach
the PCP for a clinical decision. The after-hours coverage must be accessible
using the medical office’s daytime telephone number; and
	 
	 	(2)	 	The PCP shall arrange for coverage of primary care services during
absences due to vacation, illness or other situations that require the PCP to be
unable to provide services. A Medicaid-eligible PCP must provide coverage.

	 	b.	 	The Health Plan shall provide the following:

	 	(1)	 	At least one (1) FTE PCP per service area including, but not limited
to, the following broad specialty areas:

	 	(a)	 	Family Practice;
	 
	 	(b)	 	General Practice;
	 
	 	(c)	 	Pediatrics; and
	 
	 	(d)	 	Internal Medicine.

	 	(2)	 	At least one (1) FTE PCP per 1,500 enrollees. The Health Plan may
increase the ratio by 750 enrollees for each FTE advanced registered nurse
practitioner (ARNP) or physician’s assistant (PA) affiliated with a PCP.
	 
	 	(3)	 	The Health Plan shall allow pregnant enrollees to choose Health Plan
obstetricians as their PCPs to the extent that the obstetrician is willing to
participate as a PCP.

	 	c.	 	If the enrollee has not selected a provider for a newborn, the Health Plan
shall assign a pediatrician or other appropriate PCP to all pregnant enrollees for
the care of their newborn babies no later than the beginning of the last trimester
of gestation.

	 	2.	 	Specialists and Other Providers (See Attachment II, Exhibit 7)

	 	a.	 	In addition to the above requirements, the Health Plan shall assure the
availability of providers in the following specialty areas, as appropriate for both
adults and pediatric enrollees, on at least a referral basis. The Health Plan shall
use participating specialists with pediatric expertise for children/adolescents
when the need for pediatric specialty care is significantly different from the need
for adult specialty care (for example a pediatric cardiologist for
children/adolescents with congenital heart defects). Specialties below marked with
an asterisk (*) require both adult and pediatric providers.

	 	(1)	 	Allergies,
	 
	 	(2)	 	Anesthesiology,

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	 	(3)	 	Cardiology*,
	 
	 	(4)	 	Chiropractic,
	 
	 	(5)	 	Dermatology,
	 
	 	(6)	 	Endocrinology*,
	 
	 	(7)	 	Gastroenterology,
	 
	 	(8)	 	General Surgery,
	 
	 	(9)	 	Infectious Diseases,
	 
	 	(10)	 	Nephrology*,
	 
	 	(11)	 	Neurology*,
	 
	 	(12)	 	Neurosurgery,
	 
	 	(13)	 	Obstetrics/Gynecology (OB/GYN),
	 
	 	(14)	 	Oncology,
	 
	 	(15)	 	Ophthalmology,
	 
	 	(16)	 	Optometry,
	 
	 	(17)	 	Oral Surgery,
	 
	 	(18)	 	Orthopedics*,
	 
	 	(19)	 	Otolaryngology,
	 
	 	(20)	 	Pathology,
	 
	 	(21)	 	Pediatrics,
	 
	 	(22)	 	Podiatry,
	 
	 	(23)	 	Pulmonology,
	 
	 	(24)	 	Radiology,
	 
	 	(25)	 	Therapy, Physical, Respiratory, Speech and Occupational*,
	 
	 	(26)	 	Urology.

	 	b.	 	If the infectious disease specialist does not have expertise in HIV and its
treatment and care, then the Health Plan shall have another provider with such
expertise.

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	 	c.	 	The Health Plan shall permit female enrollees to have direct access to a women’s
health specialist within the network for covered services necessary to provide
women’s routine and preventive health care services. This is in addition to an
enrollee’s designated PCP, if that provider is not a women’s health specialist.
	 
	 	d.	 	In accordance with s. 641.31, F.S., the Health Plan shall ensure access
to certified nurse midwife services or licensed midwife services for low risk
enrollees, licensed in accordance with Chapter 467, F.S.

	 	3.	 	Public Health Providers

	 	a.	 	The Health Plan shall make a good faith effort to execute memoranda of
agreement with the local CHDs to provide services which may include, but are not
limited to, family planning services, services for the treatment of sexually
transmitted diseases, other public health related diseases, tuberculosis,
immunizations, foster care emergency shelter medical screenings, and services
related to Healthy Start prenatal and post-natal screenings. The Health Plan shall
provide documentation of its good faith effort upon the Agency’s request.
	 
	 	b.	 	A capitated Health Plan shall pay, without prior authorization, at the
contracted rate or the Medicaid fee-for-service rate, all valid claims initiated
by any CHD for office visits, prescribed drugs, laboratory services directly
related to DCF emergency shelter medical screening, and tuberculosis. A capitated
Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and
provides the Health Plan with copies of the appropriate medical records and
provides the enrollee’s PCP with the results of any tests and associated office
visits.
	 
	 	c.	 	The Health Plan shall authorize all claims from a CHD, a migrant health
center funded under Section 329 of the Public Health Services Act or a community
health center funded under Section 330 of the Public Health Services Act, without
prior authorization for the services listed below. Such providers shall attempt to
contact the Health Plan before providing health care services to enrollees and
shall provide the Health Plan with the results of the office visit, including test
results. The Health Plan shall not deny claims for services delivered by these
providers solely based on the period between the date of service and the date of
clean claim submission, unless that period exceeds three-hundred and sixty-five
(365) calendar days, and shall be reimbursed by the Health Plan at the rate
negotiated between the Health Plan and the public provider or the applicable
Medicaid fee-for-service rate.

	 	(1)	 	The diagnosis and treatment of sexually transmitted diseases and
other reportable infectious diseases, such as tuberculosis and HIV;
	 
	 	(2)	 	The provision of immunizations;
	 
	 	(3)	 	Family planning services and related pharmaceuticals;
	 
	 	(4)	 	School health services listed in a, b and c above, and for services
rendered on an urgent basis by such providers; and,

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	 	(5)	 	In the event that a vaccine-preventable disease emergency is declared, the
Health Plan shall authorize claims from the CHD for the cost of the
administration of vaccines.

	 	d.	 	Other clinic-based services provided by a CHD, migrant health center or
community health center, including well-child care, dental care, and sick care
services not associated with reportable infectious diseases, require prior
authorization from the Health Plan in order to receive reimbursement. If prior
authorization is provided, the Health Plan shall reimburse at the entity’s
cost-based reimbursement rate. If prior authorization for prescription drugs is
given and the drugs are provided, the Health Plan shall reimburse the entity at
Medicaid’s standard pharmacy rate.
	 
	 	e.	 	The Health Plan shall make a good faith effort to execute a contract with a
Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic
(RHC).

	 	(1)	 	The capitated Health Plan shall reimburse FQHCs and RHCs at rates
comparable to those rates paid for similar services in the FQHC’s or RHC’s
community.
	 
	 	(2)	 	The capitated Health Plan shall report quarterly to BMHC, the
payment rates and the payment amounts made to FQHCs and RHCs for contractual
services provided by these entities.

	 	f.	 	The Health Plan shall make a good faith effort to execute memoranda of
agreement with school districts participating in the certified match program
regarding the coordinated provision of school-based services pursuant to ss.
1011.70 and 409.908(21), F.S.

	 	4.	 	Facilities and Ancillary Providers

	 	a.	 	Emergency Services and Emergency Services Facilities — The Health Plan
shall ensure the availability of emergency services and care twenty-four hours a
day, seven days a week (24/7).
	 
	 	b.	 	General Acute Care Hospital — The Health Plan shall provide at least one
(1) fully accredited general acute care hospital bed per two-hundred and
seventy-five (275) enrollees.
	 
	 	c.	 	Birth Delivery Facility — The Health Plan shall provide at least one (1)
birth delivery facility, licensed under Chapter 383, F.S., or a hospital with
birth delivery facilities, licensed under Chapter 383, F.S. The birth delivery
facility may be a freestanding facility or part of a hospital. The Health Plan
shall also provide a birthing center, licensed under Chapter 383, F.S. that is
accessible to low-risk enrollees.
	 
	 	d.	 	Regional Perinatal Intensive Care Centers (RPICC) — The Health Plan shall
assure access for enrollees in one (1) or more of Florida’s RPICC, see ss. 383.15
through 383.21, F.S., or a hospital licensed by the Agency for neonatal intensive
care unit (NICU) Level III beds.

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	 	e.	 	Neonatal Intensive Care Unit (NICU) — The Health Plan shall ensure that care for
medically high-risk perinatal enrollees is provided in a facility with a NICU
sufficient to meet the appropriate level of need for the enrollee.
	 
	 	f.	 	Pharmacy — If the Health Plan elects to use a more restrictive pharmacy
network than the Medicaid fee-for-service network, the Health Plan shall provide
at least one (1) licensed pharmacy per 2,500 enrollees. The Health Plan shall
ensure that its contracted pharmacies comply with the Settlement Agreement to
Hernandez et a/. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA).

C. Network Changes

	 	1.	 	The Health Plan shall submit a request for initial or expansion review, including
submission of its provider network, to HSD when it has met the standards in this
section of the Contract. BMHC will not approve the network until credentialing and all
other network requirements have been met.
	 
	 	2.	 	The Health Plan shall provide BMHC and HSD with documentation of compliance with
access requirements at any time there has been a significant change in the Health
Plan’s operations that would affect adequate capacity and services, including, but not
limited to, the following:

	 	a.	 	Changes in Health Plan services or service area; and
	 
	 	b.	 	Enrollment of a new population in the Health Plan.

	 	3.	 	The Health Plan shall notify BMHC within seven (7) business days of any significant
changes to its network. A significant change is defined as:

	 	a.	 	A decrease in the total number of PCPs by more than five percent (5%);
	 
	 	b.	 	A loss of all participating specialists in a specialty where another
participating specialist in that specialty is not available within sixty (60)
minutes;
	 
	 	c.	 	A loss of a hospital in an area where another Health Plan hospital of
equal service ability is not available within thirty (30) minutes; or
	 
	 	d.	 	Other adverse changes to the composition of the network that impair or
deny the enrollee’s adequate access to providers.

	 	4.	 	The Health Plan shall have procedures to address changes in the Health Plan network
that negatively affect the ability of enrollees to access services, including access to
a culturally diverse provider network. Significant changes in network composition that
negatively impact enrollee access to services may be grounds for Contract termination
or sanctions as determined by the Agency and in accordance with Attachment II, Section
XIV, Sanctions.
	 
	 	5.	 	If a PCP ceases participation in the Health Plan’s network, the Health Plan shall
send written notice to BMHC and to the enrollees who have chosen the provider as their
PCP. This notice shall be issued no less than fifteen (15) calendar days after receipt
of the termination notice.

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	 	HMO Contract

	 	a.	 	If an enrollee is in a prior authorized ongoing course of treatment with any
other provider who becomes unavailable to continue to provide services, the Health
Plan shall notify the enrollee in writing within ten (10) calendar days from the
date the Health Plan becomes aware of such unavailability.
	 
	 	b.	 	These requirements to provide notice prior to the effective dates of
termination shall be waived in instances where a provider becomes physically
unable to care for enrollees due to illness, death, or leaving the service area
and fails to notify the Health Plan, or when a provider fails credentialing. Under
these circumstances, notice shall be issued immediately upon the Health Plan’s
becoming aware of the circumstances.

	 	6.	 	The Health Plan shall notify BMHC of any new network providers by the
5th of the month following execution of the provider agreement using the
format provided in the Report Guide referenced in Attachment II, Section XII, Reporting
Requirements.

	D.	 	Provider Contract Requirements

	 	1.	 	The Health Plan shall comply with all Agency procedures for provider contract
review and approval submission.

	 	a.	 	All provider contracts must comply with 42 CFR 438.230, 42 CFR 455.104,
42 CFR 455.105, and 42 CFR 455.106.
	 
	 	b.	 	If the Health Plan is capitated, it shall ensure that all providers are
eligible for participation in the Medicaid program. If a provider was
involuntarily terminated from the Florida Medicaid program, other than for
purposes of inactivity, that provider is not considered an eligible Medicaid
provider. If the Health Plan is not capitated, its providers shall be enrolled as
Florida Medicaid providers.
	 
	 	c.	 	The Health Plan shall not employ or contract with individuals on the
state or federal exclusions list.
	 
	 	d.	 	No provider contract that the Health Plan enters into with respect to
performance under this Contract shall in any way relieve the Health Plan of any
responsibility for the provision of services or duties under this Contract. The
Health Plan shall assure that all services and tasks related to the provider
contract are performed in accordance with the terms of this Contract. The Health
Plan shall identify in its provider contract any aspect of service that may be
subcontracted by the provider.

	 	2.	 	All provider contracts and amendments executed by the Health Plan shall be in
writing, signed, and dated by the Health Plan and the provider, and shall meet the
following requirements:

	 	a.	 	Prohibit the provider from seeking payment from the enrollee for any
covered services provided to the enrollee within the terms of the Contract;
	 
	 	b.	 	Require the provider to look solely to the following for compensation for
services rendered, with the exception of nominal cost sharing, pursuant to the
Medicaid State Plan and the Florida Coverage and Limitations Handbooks:

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	 	HMO Contract

	 	(1)	 	If a capitated Health Plan, then to the capitated Health Plan for compensation;
	 
	 	(2)	 	If a FFS Health Plan, then to the Agency or its Agent, unless the
service is one for which the Health Plan receives a capitation payment from the
Agency. For such capitated services, the Health Plan shall require providers to
look solely to the Health Plan;

	 	c.	 	If there is a Health Plan physician incentive plan, include a statement
that the Health Plan shall make no specific payment directly or indirectly under a
physician incentive plan to a provider as an inducement to reduce or limit,
medically necessary services to an enrollee, and that incentive plans shall not
contain provisions that provide incentives, monetary or otherwise, for withholding
medically necessary care;
	 
	 	d.	 	Specify that any contracts, agreements, or subcontracts entered into by
the provider for purposes of carrying out any aspect of this Contract shall
include assurances that the individuals who are signing the contract, agreement or
subcontract are so authorized and that it includes all the requirements of this
Contract;
	 
	 	e.	 	Require the provider to cooperate with the Health Plan’s peer review,
grievance, QIP and UM activities, and provide for monitoring and oversight,
including monitoring of services rendered to enrollees, by the Health Plan (or its
subcontractor). If the Health Plan has delegated the credentialing to a
subcontractor, the agreement must ensure that all licensed providers are
credentialed in accordance with the Health Plan’s and the Agency’s credentialing
requirements as found in Attachment II, Section VII, Provider Network, Item H.,
Credentialing and Recredentialing;
	 
	 	f.	 	Include provisions for the immediate transfer to another PCP or health
plan if the enrollee’s health or safety is in jeopardy;
	 
	 	g.	 	Not prohibit a provider from discussing treatment or non-treatment
options with enrollees that may not reflect the Health Plan’s position or may not
be covered by the Health Plan;
	 
	 	h.	 	Not prohibit a provider from acting within the lawful scope of practice,
from advising or advocating on behalf of an enrollee for the enrollee’s health
status, medical care, or treatment or non-treatment options, including any
alternative treatments that might be self-administered;
	 
	 	i.	 	Not prohibit a provider from advocating on behalf of the enrollee in any
grievance system or UM process, or individual authorization process to obtain
necessary services;
	 
	 	j.	 	Require providers to meet appointment waiting time standards pursuant to
this Contract;
	 
	 	k.	 	Provide for continuity of treatment in the event a provider contract
terminates during the course of an enrollee’s treatment by that provider;
	 
	 	l.	 	Prohibit discrimination with respect to participation, reimbursement, or
indemnification of any provider who is acting within the scope of his/her license or

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	 	 	 	certification under applicable state law, solely on the basis of such license or
certification. This provision shall not be construed as a willing provider law, as it
does not prohibit the Health Plan from limiting provider participation to the extent
necessary to meet the needs of the enrollees. This provision does not interfere with
measures established by the Health Plan that are designed to maintain quality and
control costs;
	 
	 	m.	 	Prohibit discrimination against providers serving high-risk populations
or those that specialize in conditions requiring costly treatments;
	 
	 	n.	 	Require an adequate record system be maintained for recording services,
charges, dates and all other commonly accepted information elements for services
rendered to the Health Plan;
	 
	 	o.	 	 Require that records be maintained for a period not less than five (5)
years from the close of the Contract, and retained further if the records are
under review or audit until the review or audit is complete. Prior approval for
the disposition of records must be requested and approved by the Health Plan if
the provider contract is continuous;
	 
	 	p.	 	Specify that DHHS, the Agency, MPI and MFCU shall have the right to
inspect, evaluate, and audit all of the following related to this Contract:

	 	(1)	 	Pertinent books,
	 
	 	(2)	 	Financial records,
	 
	 	(3)	 	Medical records, and
	 
	 	(4)	 	Documents, papers, and records of any provider involving financial transactions;

	 	q.	 	Specify covered services and populations to be served under the provider
contract;
	 
	 	r.	 	Require that providers comply with the Health Plan’s cultural competency plan;
	 
	 	s.	 	Require that any community outreach materials related to this Contract
that are displayed by the provider be submitted to the BMHC for written approval
before use;
	 
	 	t.	 	Provide for submission of all reports and clinical information required
by the Health Plan, including Child Health Check-Up reporting (if applicable);
	 
	 	u.	 	Require providers of transitioning enrollees to cooperate in all respects
with providers of other health plans to assure maximum health outcomes for
enrollees;
	 
	 	v.	 	Require providers to submit notice of withdrawal from the network at
least ninety (90) calendar days before the effective date of such withdrawal;
	 
	 	w.	 	Require that all providers agreeing to participate in the network as PCPs
fully accept and agree to responsibilities and duties associated with the PCP
designation;

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	 	x.	 	Require all providers to notify the Health Plan in the event of a lapse in
general liability or medical malpractice insurance, or if assets fall below the
amount necessary for licensure under Florida statutes;
	 
	 	y.	 	Require providers to offer hours of operation that are no less than the
hours of operation offered to commercial Health Plan members or comparable
non-Reform Medicaid recipients if the provider serves only Medicaid recipients;
	 
	 	z.	 	Require safeguarding of information about enrollees according to 42 CFR
438.224; 
	 
	 	aa.	 	Require compliance with HIPAA privacy and security provisions;
	 
	 	bb.	 	Require an exculpatory clause, which survives provider agreement
termination, including breach of provider contract due to insolvency, which assures
that neither Medicaid recipients nor the Agency shall be held liable for any debts
of the provider;
	 
	 	cc.	 	Require that the provider secure and maintain during the life of the
provider contract worker compensation insurance (complying with the Florida worker
compensation law) for all of its employees connected with the work under this
Contract unless such employees are covered by the protection afforded by the Health
Plan;
	 
	 	dd.	 	Make provisions for a waiver of those terms of the provider contract that, as they
pertain to Medicaid recipients, are in conflict with the specifications of this Contract;
	 
	 	ee.	 	Contain no provision that in any way prohibits or restricts the provider
from entering into a commercial contract with any other health plan (see s.
641.315, ES.);
	 
	 	ff.	 	Contain no provision requiring the provider to contract for more than one
(1) Health Plan product or otherwise be excluded (see s. 641.315, F.S.);
	 
	 	gg.	 	Contain no provision that prohibits the provider from providing inpatient
services in a contracted hospital to an enrollee if such services are determined to
be medically necessary and covered services under this Contract;
	 
	 	hh.	 	Require providers to cooperate fully in any investigation by the Agency,
IV1P1, MFCU, or other state or federal entity and in any subsequent legal action
that may result from such an investigation involving this Contract; and
	 
	 	ii.	 	Require providers to submit timely, complete and accurate encounter data to
the Health Plan in accordance with the requirements of Attachment II, Section X,
Administration and Management, Item D., Encounter Data;
	 
	 	jj.	 	Contain a clause indemnifying, defending and holding the Agency and the Health
Plan’s enrollees harmless from and against all claims, damages, causes of action, costs
or expenses, including court costs and reasonable attorney fees, to the extent
proximately caused by any negligent act or other wrongful conduct arising from the
provider agreement. This clause must survive the termination of the agreement, including
breach due to insolvency. The Agency may waive this requirement for itself, but not
Health Plan enrollees, for damages in excess of the statutory cap on damages for public
entities, if the provider is a state agency or subdivision as defined

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	 	 	 	by s. 768.28, F.S., or a public health entity with statutory immunity. All such
waivers shall be approved in writing by the Agency.
	 
	 	kk.	 	Require physicians to immediately notify the Health Plan of an enrollee’s
pregnancy, whether identified through medical history, examination, testing,
claims, or otherwise.
	 
	 	ll.	 	Specify that in addition to any other right to terminate the provider
contract, and notwithstanding any other provision of this Contract, the Agency or
the Health Plan may request immediate termination of a provider contract if, as
determined by the Agency, a provider fails to abide by the terms and conditions of
the provider contract, or in the sole discretion of the Agency, the provider fails
to come into compliance with the provider contract within fifteen (15) calendar
days after receipt of notice from the Health Plan specifying such failure and
requesting such provider abide by the terms and conditions thereof; and
	 
	 	mm.	 	Specify that any provider whose participation is terminated pursuant to the
provider contract for any reason shall utilize the applicable appeals procedures
outlined in the provider contract. No additional or separate right of appeal to the
Agendy or the Health Plan is created as a result of the Health Plan’s act of
terminating, or decision to terminate, any provider under this Contract.
Notwithstanding the termination of the provider contract with respect to any
particular provider, this Contract shall remain in full force and effect with
respect to all other providers.

	E.	 	Provider Termination

	 	1.	 	The Health Plan shall comply with all state and federal laws regarding provider
termination.
	 
	 	2.	 	The Health Plan shall notify enrollees in accordance with the provisions of this
Contract regarding provider termination.
	 
	 	3.	 	In a case in which a patient’s health is subject to imminent danger or a
physician’s ability to practice medicine is effectively impaired by an action by the
Board of Medicine or other governmental agency, notice to both the provider and BMHC
shall be immediate. The Health Plan shall submit a list of terminated providers to
BMHC once a month, in accordance with requirements in Attachment II, Section XII,
Reporting Requirements.
	 
	 	4.	 	The Health Plan shall notify the provider, BMHC and enrollees in active care at
least sixty (60) calendar days before the effective date of the suspension or
termination of a provider from the network. If the termination was for “cause,” the
Health Plan shall provide to BMHC the reasons for termination.

	F.	 	Appointment Waiting Times and Geographic Access Standards

	 	1.	 	The Health Plan must assure that PCP services and referrals to participating
specialists are available on a timely basis, as follows:

	 	a.	 	Urgent Care — within one (1) day,
	 
	 	b.	 	Routine Sick Patient Care — within one (1) week, and

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	 	c.	 	Well Care Visit — within one (1) month.

	 	2.	 	All PCPs, hospital and community mental health services must be available within
an average of thirty (30) minutes’ travel time from an enrollee’s residence. All
participating specialists and ancillary providers must be within an average of sixty
(60) minutes’ travel time from an enrollee’s residence. BMHC may waive this
requirement, in writing, for rural areas and for areas where there are no PCPs,
hospitals or community mental health centers within a thirty (30) minute average
travel time.
	 
	 	3.	 	The Health Plan shall provide a designated emergency services facility within an
average of thirty (30) minutes’ travel time from an enrollee’s residence, that
provides care on a twenty-four hours a day, seven days a week (24/7) basis. Each
designated emergency service facility shall have one (1) or more physicians and one
(1) or more nurses on duty in the facility at all times. BMHC may waive the travel
time requirement, in writing, in rural areas.
	 
	 	4.	 	For rural areas, if the Health Plan is unable to enter into an agreement with
specialty or ancillary service providers within the required sixty (60) minute average
travel time, BMHC may waive, in writing, the requirement.
	 
	 	5.	 	At least one (1) pediatrician or one (1) CHD, FQHC or RHC must be available
within an average of thirty (30) minutes’ travel time from an enrollee’s residence,
provided that this requirement remains consistent with the other minimum time
requirements of this Contract. In order to meet this requirement, the pediatrician(s),
CHD, FQHC, and/or RHC must provide access to care on a twenty-four hour a day, seven
day a week (24/7) basis. BMHC may waive this requirement, in writing, for rural areas
and where there are no pediatricians, CHDs, FQHCs or RHCs within the thirty (30)
minute average travel time.
	 
	 	6.	 	Annually by February 1 of each Contract year, the Health Plan shall review a
statistically valid sample of PCP offices’ average appointment wait times to ensure
services are in compliance with Attachment II, Section VII, Provider Network, Item F.,
Appointment Waiting Times and Geographic Access Standards, and report the results to
BMHC in the format specified, in accordance with Attachment II, Section XII, Reporting
Requirements. (See 42 CFR 438.206(c)(1)(iv),(v) and (vi).)

G. Continuity of Care

	 	1.	 	The Health Plan shall allow enrollees in active treatment to continue care with a
terminated treating provider when such care is medically necessary, through completion
of treatment of a condition for which the enrollee was receiving care at the time of
the termination, until the enrollee selects another treating provider, or during the
next open enrollment period. None of the above may exceed six (6) months after the
termination of the providers contract.
	 
	 	2.	 	The Health Plan shall allow pregnant enrollees who have initiated a course of
prenatal care, regardless of the trimester in which care was initiated, to continue
care with a terminated treating provider until completion of postpartum care.
	 
	 	3.	 	Notwithstanding the provisions in this subsection, a terminated provider may
refuse to continue to provide care to an enrollee who is abusive or noncompliant.

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	 	4.	 	For continued care under this subsection, the Health Plan and the terminated
provider shall continue to abide by the same terms and conditions as existed in the
terminated contract.
	 
	 	5.	 	The requirements set forth in this subsection shall not apply to providers who
have been terminated from the Health Plan for cause.

H. Credentialing and Recredentialing (See Attachment II, Exhibit 7)

	 	1.	 	The Health Plan shall be responsible for the credentialing and recredentialing of
its provider network. Hospital ancillary providers are not required to be
independently credentialed if those providers serve Health Plan enrollees only through
the hospital.
	 
	 	2.	 	The Health Plan shall establish and verify credentialing and recredentialing
criteria for all professional providers that, at a minimum, meet the Agency’s Medicaid
participation standards. The Agency’s criteria include:

	 	a.	 	A copy of each providers current medical license pursuant to s. 641.495, F.S.;
	 
	 	b.	 	No revocation or suspension of the providers state license by the Division
of Medical Quality Assurance, Department of Health;
	 
	 	c.	 	A satisfactory background check with the Florida Department of Law
Enforcement (FDLE) for all treating providers not currently enrolled in Medicaid’s
fee-for-service program;

	 	(1)	 	If exempt from the criminal background screening requirements, a
copy of the screen print of the provider’s current Department of Health
licensure status with the exemption reason included;
	 
	 	(2)	 	The Health Plan shall not contract with any provider who has a
record of illegal conduct; i.e., found guilty of, regardless of adjudication,
or who entered a plea of nolo contendere or guilty to any of the offenses
listed in s. 435.03, F.S.;
	 
	 	(3)	 	Individuals already screened as Medicaid providers or screened
within the past twelve (12) months by another Florida agency or department are
not required to submit fingerprint cards but shall document the results of the
previous screening;
	 
	 	(4)	 	Individuals listed in s. 409.907(8)(a), F.S., for whom criminal
history background screening cannot be documented must provide fingerprint
cards;

	 	d.	 	Disclosure related to ownership and management (42 CFR 455.104), business
transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106);
	 
	 	e.	 	Proof of the provider’s medical school graduation, completion of residency
and other postgraduate training. Evidence of board certification shall suffice in
lieu of proof of medical school graduation, residency and other postgraduate
training;
	 
	 	f.	 	Evidence of specialty board certification, if applicable;

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	 	g.	 	Evidence of the provider’s professional liability claims history;
	 
	 	h.	 	Any sanctions imposed on the provider by Medicare or Medicaid;
	 
	 	i.	 	The provider’s Medicaid ID number, Medicaid provider registration number
or documentation of submission of the Medicaid provider registration form.

	 	3.	 	If behavioral health is a covered service, the Health Plan’s credentialing and
recredentialing files must document the education, experience, prior training and
ongoing service training for each staff member or provider rendering behavioral health
services.
	 
	 	4.	 	The Health Plan’s credentialing and recredentialing policies and procedures shall
be in writing and include the following:

	 	a.	 	Formal delegations and approvals of the credentialing process;
	 
	 	b.	 	A designated credentialing committee;
	 
	 	c.	 	Identification of providers who fall under its scope of authority;
	 
	 	d.	 	A process that provides for the verification of the credentialing and
recredentialing criteria required under this Contract;
	 
	 	e.	 	Approval of new providers and imposition of sanctions, termination,
suspension and restrictions on existing providers;
	 
	 	f.	 	Identification of quality deficiencies that result in the Health Plan’s
restriction, suspension, termination or sanctioning of a provider.

	 	5.	 	The credentialing and recredentialing processes must also include verification of
the following additional requirements for physicians and must ensure compliance with 42
CFR 438.214:

	 	a.	 	Good standing of privileges at the hospital designated as the primary
admitting facility by the PCP or if the PCP does not have admitting privileges,
good standing of privileges at the hospital by another provider with whom the PCP
has entered into an arrangement for hospital coverage;
	 
	 	b.	 	Valid Drug Enforcement Administration (DEA) certificates, where applicable;
	 
	 	c.	 	Attestation that the total active patient load (all populations with
Medicaid FFS, Children’s Medical Services Network, HMO, PSN, Medicare and
commercial coverage) is no more than 3,000 patients per PCP. An active patient is
one that is seen by the provider a minimum of three (3) times per year;
	 
	 	d.	 	A good standing report on a site visit survey. For each PCP,
documentation in the Health Plan’s credentialing files regarding the site survey
shall include the following:

	 	(1)	 	Evidence that the Health Plan has evaluated the provider’s facilities
using the Health Plan’s organizational standards;

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	 	HMO Contract

	 	(2)	 	Evidence that the provider’s office meets criteria for access for persons
with disabilities and that adequate space, supplies, proper sanitation,
smoke-free facilities, and proper fire and safety procedures are in place;
	 
	 	(3)	 	Evidence that the Health Plan has evaluated the providers medical
record keeping practices at each site to ensure conformity with the Health
Plan’s organizational standards;
	 
	 	(4)	 	Evidence that the Health Plan has determined that the following
documents are posted in the provider’s waiting room/reception area: the
Agency’s statewide consumer call center telephone number, including hours of
operation, and a copy of the summary of Florida’s Patient’s Bill of Rights and
Responsibilities, in accordance with s. 381.026, F.S. The provider must have a
complete copy of the Florida Patient’s Bill of Rights and Responsibilities,
available upon request by an enrollee, at each of the provider’s offices;

	 	e.	 	Attestation to the correctness/completeness of the provider’s application;
	 
	 	f.	 	Statement regarding any history of loss or limitation of privileges or
disciplinary activity as described in s. 456.039, F.S.;
	 
	 	g.	 	A statement from each provider applicant regarding the following:

	 	(1)	 	Any physical or mental health problems that may affect the
provider’s ability to provide health care;
	 
	 	(2)	 	Any history of chemical dependency/substance abuse;
	 
	 	(3)	 	Any history of loss of license and/or felony convictions; and
	 
	 	(4)	 	The provider is eligible to become a Medicaid provider;

	 	h.	 	Current curriculum vitae, which includes at least five (5) years of work history.

	 	6.	 	The Health Plan shall recredential its providers at least every three (3) years.
	 
	 	7.	 	The Health Plan shall develop and implement an appeal procedure for providers
against whom the Health Plan has imposed sanctions, restrictions, suspensions and/or
terminations.

I. Provider Services

	 	1.	 	General Provisions

	 	a.	 	The Health Plan shall provide sufficient information to all providers in
order to operate in full compliance with this Contract and all applicable federal
and state laws and regulations.

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	 	b.	 	The Health Plan shall monitor provider knowledge and understanding of provider
requirements, and take corrective actions to ensure compliance with such
requirements.

	 	2.	 	Provider Handbooks (See Attachment II, Exhibit 7)

	 	a.	 	The Health Plan shall issue a provider handbook to all providers at the
time the provider credentialing is complete. The Health Plan may choose not to
distribute the provider handbook via surface mail, provided it submits a written
notification to all providers that explains how to obtain the handbook from the
Health Plan’s website. This notification shall also detail how the provider can
request a hard copy from the Health Plan at no charge. The Health Plan shall keep
all provider handbooks and bulletins up to date and in compliance with state and
federal laws. The provider handbook shall serve as a source of information
regarding Health Plan covered services, policies and procedures, statutes,
regulations, telephone access and special requirements to ensure all Contract
requirements are met. At a minimum, the provider handbook shall include the
following information:

	 	(1)	 	Description of the Medicaid program;
	 
	 	(2)	 	Covered services;
	 
	 	(3)	 	Emergency service responsibilities;
	 
	 	(4)	 	Child Health Check-Up program services and standards;
	 
	 	(5)	 	Policies and procedures that cover the provider complaint system.
This information shall include, but not be limited to, specific instructions
regarding how to contact the Health Plan to file a provider complaint,
including complaints about claims issues, and which individual(s) has
authority to review a provider complaint;
	 
	 	(6)	 	Required procedural steps in the enrollee grievance process,
including the address, telephone number and office hours of the grievance
staff; the enrollee’s right to request continuation of benefits while
utilizing the grievance system; and information about the Subscriber
Assistance Program (SAP, for HMOs only) and the Beneficiary Assistance Program
(BAP, for PSNs only). The Health Plan shall specify telephone numbers to call
to present a complaint, grievance, or appeal. Each telephone number shall be
toll-free within the caller’s geographic area and provide reasonable access to
the Health Plan without undue delays;
	 
	 	(7)	 	Medical necessity standards and practice protocols, including
guidelines pertaining to the treatment of chronic and complex conditions;
	 
	 	(8)	 	PCP responsibilities;
	 
	 	(9)	 	Other provider or subcontractor responsibilities;
	 
	 	(10)	 	Prior authorization and referral procedures, including required forms;
	 
	 	(11)	 	Medical records standards;

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	 	(12)	 	Claims submission protocols and standards, including instructions and all
information necessary for a clean or complete claim;
	 
	 	(13)	 	Protocols for submitting encounter data;
	 
	 	(14)	 	A summary of the Health Plan’s cultural competency plan and how to
get a full copy at no cost to the provider;
	 
	 	(15)	 	Information on the Health Plan’s quality enhancement programs;
	 
	 	(16)	 	Enrollee rights and responsibilities (see 42 CFR 438.100);
	 
	 	(17)	 	Information notifying providers that the Health Plan is authorized to
take whatever steps are necessary to ensure that the provider is recognized by
the state Medicaid program, including its choice counseling/enrollment broker
contractor(s) as a participating provider of the Health Plan and that the
provider’s submission of encounter data is accepted by the Florida MM IS and/or
the state’s encounter data warehouse.

	 	b.	 	The Health Plan shall disseminate bulletins as needed to incorporate any
needed changes to the provider handbook.

	 	3.	 	Education and Training
	 
	 	 	 	The Health Plan shall offer training to all providers and their staff regarding the
requirements of this Contract and special needs of enrollees. The Health Plan shall
conduct initial training within thirty (30) calendar days of placing a newly contracted
provider, or provider group, on active status. The Health Plan also shall conduct
ongoing training, as deemed necessary by the Health Plan or the Agency, in order to
ensure compliance with program standards and this Contract.
	 
	 	4.	 	Toll-Free Provider Help Line

	 	a.	 	The Health Plan shall operate a toll-free telephone help line to respond to
provider questions, comments and inquiries.
	 
	 	b.	 	The Health Plan shall develop telephone help line policies and procedures
that address staffing, personnel, hours of operation, access and response
standards, monitoring of calls via recording or other means, and compliance with
Health Plan standards.
	 
	 	c.	 	The help line shall be staffed twenty-four hours a day, seven days a week
(24/7) to respond to prior authorization requests. This help line shall have staff
to respond to provider questions in all other areas, including the provider
complaint system, provider responsibilities, etc., between the hours of 8 a.m. and
7 p.m. in the provider’s time zone Monday through Friday, excluding state holidays.
	 
	 	d.	 	The Health Plan’s call center systems shall have the capability to track
call management metrics identified in Attachment II, Section IV, Enrollee Services,

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Community Outreach and Marketing, Item A., General Provisions, sub-item 11., Toll-
free Enrollee Help Line.
	 
	 	e.	 	The Health Plan shall ensure that after regular business hours the provider
services line (not the prior authorization line) is answered by an automated system
with the capability to provide callers with information about operating hours and
instructions about how to verify enrollment for an enrollee with an emergency or
urgent medical condition. This requirement shall not be construed to mean that the
provider must obtain verification before providing emergency services and care.

	 	5.	 	Provider Complaint System

	 	a.	 	The Health Plan shall establish and maintain a provider complaint system
that permits a provider to dispute the Health Plan’s policies, procedures, or any
aspect of a Health Plan’s administrative functions, including proposed actions and
claims.
	 
	 	b.	 	The Health Plan shall include its provider complaint system policies and
procedures in its provider handbook as described above.
	 
	 	c.	 	The Health Plan shall also distribute the provider complaint system
policies and procedures, including claims issues, to out-of-network providers upon
request. The Health Plan may distribute a summary of these policies and procedures,
if the summary includes information about how the provider may access the full
policies and procedures on the Health Plan’s website. This summary shall also
detail how the provider can request a hard copy from the Health Plan at no charge.
	 
	 	d.	 	As a part of the provider complaint system, the Health Plan shall:

	 	(1)	 	Have dedicated staff for providers to contact via telephone,
electronic mail, regular mail, or in person, to ask questions, file a provider
complaint and resolve problems;
	 
	 	(2)	 	Identify a staff person specifically designated to receive and
process provider complaints;
	 
	 	(3)	 	Allow providers forty-five (45) calendar days to file a written
complaint for issues that are not about claims;
	 
	 	(4)	 	Thoroughly investigate each provider complaint using applicable
statutory, regulatory, contractual and provider contract provisions,
collecting all pertinent facts from all parties and applying the Health Plan’s
written policies and procedures; and
	 
	 	(5)	 	Ensure that Health Plan executives with the authority to require
corrective action are involved in the provider complaint process.

	 	e.	 	The Health Plan shall provide a written notice of the outcome of the review
to the provider.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

J. Medical Records Requirements

	 	 	The Health Plan shall ensure maintenance of medical records for each enrollee in accordance
with this section and with 42 CFR 456. Medical records shall include the quality, quantity,
appropriateness, and timeliness of services performed under this Contract.

	 	1.	 	The Health Plan shall follow the medical record standards set forth below for each
enrollee’s medical records, as appropriate:

	 	a.	 	Include the enrollee’s identifying information, including name, enrollee
identification number, date of birth, sex and legal guardianship (if any);
	 
	 	b.	 	Each record shall be legible and maintained in detail;
	 
	 	c.	 	Include a summary of significant surgical procedures, past and current
diagnoses or problems, allergies, untoward reactions to drugs and current
medications;
	 
	 	d.	 	All entries shall be dated and signed by the appropriate party;
	 
	 	e.	 	All entries shall indicate the chief complaint or purpose of the visit,
the objective, diagnoses, medical findings or impression of the provider;
	 
	 	f.	 	All entries shall indicate studies ordered (e.g., laboratory, x-ray, EKG)
and referral reports;
	 
	 	g.	 	All entries shall indicate therapies administered and prescribed;
	 
	 	h.	 	All entries shall include the name and profession of the provider
rendering services (e.g., MD, DO, OD), including the signature or initials of the
provider;
	 
	 	i.	 	All entries shall include the disposition, recommendations, instructions
to the enrollee, evidence of whether there was follow-up and outcome of services;
	 
	 	j.	 	All records shall contain an immunization history;
	 
	 	k.	 	All records shall contain information relating to the enrollee’s use of
tobacco products and alcohol/substance abuse;
	 
	 	l.	 	All records shall contain summaries of all emergency services and care and
hospital discharges with appropriate medically indicated follow up;
	 
	 	m.	 	Document referral services in enrollees’ medical records;
	 
	 	n.	 	Include all services provided. Such services must include, but not
necessarily be limited to, family planning services, preventive services and
services for the treatment of sexually transmitted diseases;
	 
	 	o.	 	All records shall reflect the primary language spoken by the enrollee and
any translation needs of the enrollee;

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	p.	 	All records shall identify enrollees needing communication assistance in the
delivery of health care services; and
	 
	 	q.	 	All records shall contain documentation that the enrollee was provided
with written information concerning the enrollee’s rights regarding advance
directives (written instructions for living will or power of attorney) and whether
or not the enrollee has executed an advance directive. Neither the Health Plan,
nor any of its providers shall, as a condition of treatment, require the enrollee
to execute or waive an advance directive. The Health Plan must maintain written
policies and procedures for advance directives;
	 
	 	r.	 	Copies of any advance directives executed by the enrollee.

	 	2.	 	Confidentiality of Medical Records

	 	a.	 	The Health Plan shall have a policy to ensure the confidentiality of
medical records in accordance with 42 CFR, Part 431, Subpart F. This policy shall
also include confidentiality of a minor’s consultation, examination, and treatment
for a sexually transmissible disease in accordance with s. 384.30(2), F.S.
	 
	 	b.	 	The Health Plan shall have a policy to ensure compliance with the privacy
and security provisions of the Health Insurance Portability and Accountability Act
(HIPAA).

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Section VIII

Quality Management

A. Quality Improvement

	 	1.	 	General Requirements

	 	a.	 	The Health Plan shall have an ongoing quality improvement program (QI
program) that objectively and systematically monitors and evaluates the quality
and appropriateness of care and services rendered, thereby promoting quality of
care and quality patient outcomes in service performance to its enrollees. (See 42
CFR 438.204 and 438.240.)
	 
	 	b.	 	The Health Plan shall develop and submit to BMHC a written quality
improvement plan (QI plan) within thirty (30) calendar days from execution of the
initial Contract and resubmit it annually by April 1 of each Contract year for
written approval. The QI plan shall include sections defining how the QI committee
used any of the following programs to develop its performance improvement projects
(PIP): credentialing processes, case management, utilization review, peer review,
review of grievances, and review and response to adverse events. Any
problems/issues identified but not included in a PIP must be addressed and
resolved by the QI committee.
	 
	 	c.	 	The Health Plan’s written policies and procedures shall address
components of effective health care management including, but not limited to,
anticipation, identification, monitoring, measurement, evaluation of enrollee’s
health care needs, and effective action to promote quality of care.
	 
	 	d.	 	The Health Plan shall define and implement improvements in processes that
enhance clinical efficiency, provide effective utilization, and focus on improved
outcome management achieving the highest level of success.
	 
	 	e.	 	The Health Plan and its QI plan shall demonstrate specific interventions
in its care management to better manage the care and promote healthier enrollee
outcomes.
	 
	 	f.	 	The Health Plan shall cooperate with the Agency and the external quality
review organization (EQRO). The Agency will set methodology and standards for
quality improvement (QI) with advice from the EQRO.
	 
	 	g.	 	Prior to implementation, the Agency shall review the Health Plan’s QI plan.

	 	2.	 	Specific Required Components of the QI Program

	 	a.	 	The Health Plan’s governing body shall oversee and evaluate the QI program.
The role of the Health Plan’s governing body shall include providing strategic
direction to the QI program, as well as ensuring the QI plan is incorporated into
operations throughout the Health Plan. The written QI plan shall clearly describe
the mechanism within the Health Plan for strategic direction from the governing
body to be provided to the QI program and for the QI program committee to
communicate with the governing body.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	b.	 	The Health Plan shall have a 01 program committee. The Health Plan’s medical
director shall either chair or co-chair the committee. Other committee
representatives shall be selected to meet the needs of the Health Plan but must
include: 1) the quality director; 2) the grievance coordinator; 3) the utilization
review manager; 4) the credentialing manager; 5) the risk manager/infection control
professional (if applicable); 6) the advocate representative (if applicable); and 7)
provider representation, either through providers serving on the committee or
through a provider liaison position, such as a representative from the network
management department. Individual staff members may serve in multiple roles on the
committee if they also serve in multiple positions within the Health Plan. The
Health Plan is encouraged to include an advocate representative on the 01 program
committee. The committee shall meet no less than quarterly. Its responsibilities
shall include the development and implementation of a written 01 plan, which
incorporates the strategic direction provided by the governing body. The 01 plan
shall contain the following components:

	 	(1)	 	The Health Plan’s guiding philosophy for quality management and
should identify any nationally recognized, standardized approach that is used
(for example, PDCA, Rapid Cycle Improvement, FOCUS-PDCA, Six Sigma, etc.).
Selection of performance indicators and sources for benchmarking also shall be
described;
	 
	 	(2)	 	A description of the Health Plan positions assigned to the 01
program, including a description of why each position was chosen to serve on
the committee and the roles each position is expected to fulfill. The resumes
of 01 program committee members shall be made available upon the Agency’s
request;
	 
	 	(3)	 	Specific training about quality that will be provided by the Health
Plan to staff serving in the 01 program. At a minimum the training shall
include protocols developed by the Centers for Medicare and Medicaid Services
regarding quality. CMS protocols may be obtained from either:

www.cms.hhs.qov/MedicaidManaqCare or www.myfloridaeqro.com
	 
	 	(4)	 	The role of its providers in giving input to the QI program,
whether that is by membership on the committee, its sub-committees, or other
means;
	 
	 	(5)	 	A standard for how the Health Plan shall assure that QI program
activities take place throughout the Health Plan and document results of QI
program activities for reviewers. Protocols for assigning tasks to individual
staff persons and selection of time standards for completion shall be included;
	 
	 	(6)	 	A standard describing the process the QI program will use to review
and suggest new and/or improved QI activities;
	 
	 	(7)	 	The process for selecting and directing task forces, committees, or
other Health Plan activities to review areas of concern in the provision of
health care services to enrollees;
	 
	 	(8)	 	The process for selecting evaluation and study design procedures;

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(9)	 	The process to report findings to appropriate executive authority, staff,
and departments within the Health Plan as well as relevant stakeholders, such as
network providers. The Q1 plan also shall include how this communication will be
documented for Agency review; and
	 
	 	(10)	 	The process to direct and analyze periodic review of enrollee
service utilization patterns.

	 	c.	 	The Health Plan shall maintain minutes of all QI committee and
sub-committee meetings and make the minutes available for Agency review on
request. The minutes shall demonstrate resolution of items or be brought forward
to the next meeting.
	 
	 	d.	 	The Health Plan shall have a peer review process that:

	 	(1)	 	Reviews a provider’s practice methods and patterns,
morbidity/mortality rates, and all grievances filed against the provider
relating to medical treatment;
	 
	 	(2)	 	Evaluates the appropriateness of care rendered by providers;
	 
	 	(3)	 	Implements corrective action(s) when the Health Plan deems it
necessary to do so;
	 
	 	(4)	 	Develops policy recommendations to maintain or enhance the quality
of care provided to enrollees;
	 
	 	(5)	 	Conducts reviews that include the appropriateness of diagnosis and
subsequent treatment, maintenance of a provider’s medical records, adherence to
standards generally accepted by a provider’s peers and the process and outcome
of a provider’s care;
	 
	 	(6)	 	Appoints a peer review committee, as a sub-committee to the QI
program committee, to review provider performance when appropriate. The medical
director or a designee shall chair the peer review committee. Its membership
shall be drawn from the provider network and include peers of the provider
being reviewed;
	 
	 	(7)	 	Receives and reviews all written and oral allegations of
inappropriate or aberrant service by a provider;
	 
	 	(8)	 	Educates enrollees and Health Plan staff about the peer review
process, so that enrollees and the Health Plan staff can notify the peer review
authority of situations or problems relating to providers.

	 	3.	 	Health Plan QI Activities (See Attachment II, Exhibit 8)
	 
	 	 	 	The Health Plan shall monitor, evaluate and improve the quality and appropriateness of
care and service delivery (or the failure to provide care or deliver services) to
enrollees through peer review, performance improvement projects (PIP), medical record
audits, performance measures, surveys, and related activities.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	PIPs — Annually, by January 1 of each Contract year, the Agency shall determine
and notify the Health Plan if there are changes in the number and types of PIPs the
Health Plan shall perform for the coming Contract year. The Health Plan shall
perform four (4) Agency-approved performance improvement projects for each
population (Reform and non-Reform). There must at least one (1) clinical PIP and one
(1) non-clinical PIP per population.

	 	(1)	 	One (1) of the PIPs shall focus on language and culture, clinical
health care disparities, or culturally and linguistically appropriate services.
	 
	 	(2)	 	One (1) of the PIPs shall be the statewide collaborative PIP
coordinated by the EQRO.
	 
	 	(3)	 	One (1) of the clinical PIPs shall relate to behavioral health
services, if the Health Plan covers those services.
	 
	 	(4)	 	One (1) PIP shall be designed to address deficiencies identified by
the Health Plan through monitoring, performance measure results, member
satisfaction surveys, or other similar means.
	 
	 	(5)	 	Each PIP shall include a statistically significant sample of enrollees.
	 
	 	(6)	 	All PIPs shall achieve, through ongoing measurements and
intervention, significant improvement to the quality of care and service
delivery, sustained over time, in areas that are expected to have a favorable
effect on health outcomes and enrollee satisfaction. Improvement must be
measured through comparison of a baseline measurement and an initial
remeasurement following application of an intervention. Change must be
statistically significant at the ninety-five (95%) confidence level and must be
sustained for a period of two (2) additional remeasurements. Measurement
periods and methodologies shall be submitted to BMHC for approval before
initiation of the PIP. PIPs that have successfully achieved sustained
improvement, as approved by the Agency, shall be considered complete and shall
not meet the requirement for one (1) of the four PIPs, although the Health Plan
may wish to continue to monitor the performance indicator as part of its
overall 01 program. In this event, the Health Plan shall select a new PIP and
submit it to BMHC for approval.
	 
	 	(7)	 	Within ninety (90) calendar days after initial Contract execution
and then on June 1 of each subsequent Contract year, the Health Plan shall
submit to BMHC, in writing, a proposal for each planned PIP. The PIP proposal
shall be submitted using the most recent version of the EQRO PIP validation
form. Activities 1 through 6 of the form must be addressed in the PIP proposal.
Annual submissions for ongoing PIPs shall update the form to reflect the Health
Plan’s progress. In the event the Health Plan elects to modify a portion of the
PIP proposal after initial Agency approval, a written request must be submitted
to the BMHC. The EQRO PIP validation report form may be obtained from the
following web site: www.myfloridaecro.com/. Instructions for using the
form to submit PIP proposals and updates may be obtained from the BMHC.
	 
	 	(8)	 	The Health Plan’s PIP methodology must comply with the most recent
protocol set forth by the Centers for Medicare and Medicaid Services,
Conducting

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Performance Improvement Projects, available from the web sites listed in Item A.,
sub-item 2.b.(3), above.
	 
	 	(9)	 	Populations selected for study under the PIP shall be measured and
reported separately for Reform and non-Reform populations, shall be specific to
this Contract and shall exclude non-Medicaid enrollees or Medicaid recipients
from other states. If the Health Plan contracts with a separate entity for
management of particular services, such as behavioral health or pharmacy, PIPs
conducted by the separate entity shall not include enrollees for other Health
Plans served by that entity.
	 
	 	(10)	 	The Health Plan’s PIPs shall be subject to review and validation by
the EQRO. The Health Plan shall comply with any recommendations for improvement
requested by the EQRO, subject to approval by the Agency.

	 	b.	 	Behavioral Health QI Requirements (See Attachment II, Exhibit 6)
	 
	 	c.	 	Performance Measures (PMs)

	 	(1)	 	The Health Plan shall collect data on enrollee PMs, as defined by
the Healthcare Effectiveness Data and Information Set (HEDIS) or otherwise
defined by the Agency and as specified in the Agency’s Report Guide and
Performance Measures Specifications Manual. The Performance Measures
Specifications Manual may be found at 

http://ahca.mvflorida.com/Medicaid/Qualitvmc/index.shtml.
	 
	 	 	 	The Agency may add or remove reporting requirements with sixty (60) days’ advance
notice. By July 1 of each Contract year, the Health Plan shall deliver to the
Bureau of Medicaid Quality Management (BMQM) a report on performance measure data
(including transportation performance measures if transportation is listed as
covered by the Health Plan in Attachment I of this Contract) and a certification
by an Agency-approved independent auditor that the performance measure data
reported for the previous calendar year are fairly and accurately presented. (See
Attachment II, Section XII, Reporting) The report shall be certified by the HEDIS
auditor, and the auditor must certify the actual file submitted to the Agency.
Extensions to the due date may be granted by the Agency for up to thirty (30)
days and require a written request signed by the Health Plan CEO or designee. The
request must be received by BMQM before the report due date, and the delay must
be due to unforeseen and unforeseeable factors beyond the Health Plan’s control.
Extensions will not be granted on oral requests.
	 
	 	(2)	 	A report, certification, or other information required for PM
reporting is incomplete when it does not contain all data required by the
Agency or when it contains inaccurate data. A report or certification is
“false” if done or made with the knowledge of the preparer or a superior of the
preparer that it contains data or information that is not true or not accurate.
A report that contains an “NR” due to bias for any or all measures by the HEDIS
auditor, or is “false,” shall be considered deficient and will be subject to
administrative penalties pursuant to Attachment II, Section XIV, Sanctions.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(3)	 	The Health Plan shall meet Agency-specified performance targets for all
PMs. Where applicable, these targets are the equivalent of the seventy-fifth
(75th) percentile of national Medicaid health plan performance as compiled and
reported in the HEDIS national means and percentiles. For Agency-defined
measures the Agency will establish performance targets. The Agency may change
these targets and/or change the timelines associated with meeting the targets.
The Agency shall make these changes with sixty (60) days’ advance notice to the
Health Plan.
	 
	 	(4)	 	If the Agency determines that the Health Plan performance
relative to the performance targets is not acceptable, the Agency shall
require the Health Plan to submit a performance measure action plan (PMAP)
within thirty (30) calendar days after the notice of the determination in the
format prescribed by the Agency. If the Health Plan fails to provide a PMAP
within the time and format specified by the Agency or fails to adhere to its
own PMAP, the Agency may sanction the Health Plan in accordance with the
provisions of Section XIV, Sanctions, of this attachment. The Health Plan
shall submit reports to the Bureau of Medicaid Quality Management on the
progress of all PMAPs as specified in Attachment II, Section XII, Reporting
Requirements.
	 
	 	(5)	 	If the Agency-defined or HEDIS PMs indicate that the Health
Plan’s performance is not acceptable, the Agency may sanction the Health Plan
in accordance with the provisions of Attachment II, Section XIV, Sanctions.
When considering whether to impose specific sanctions, such as applying civil
monetary penalties or limiting enrollment activities or automatic assignments,
the Agency may consider the Health Plan’s cumulative performance on all
quality and performance measures.

	 	d.	 	Consumer Assessment of Health Plans Survey (CAHPS) — The Agency shall
conduct an annual Consumer Assessment of Health Plans Survey (CAHPS). The Health
Plan shall provide an action plan to address the results of the CAHPS survey
within two (2) months of receipt of the written request from the Agency.
	 
	 	e.	 	Medical Record Review

	 	(1)	 	If the Health Plan is not accredited, the Health Plan shall conduct
reviews of enrollees’ medical records to ensure that PCPs provide high quality
health care that is documented according to established standards, including
subparagraphs (2) through (7) below.
	 
	 	(2)	 	The standards, which must include all medical record documentation
requirements addressed in this Contract, must be distributed to all providers.
	 
	 	(3)	 	The Health Plan shall conduct these reviews at all PCP sites that
serve ten (10) or more enrollees.
	 
	 	(4)	 	Practice sites include both individual offices and large group
facilities.
	 
	 	(5)	 	The Health Plan shall review each practice site at least once every
three years.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(6)	 	The Health Plan shall review a reasonable number of records at each site to
determine compliance. Five (5) to ten (10) records per site is a generally-
accepted target, though additional reviews must be completed for large group
practices or when additional data is necessary in specific instances.
	 
	 	(7)	 	The Health Plan shall submit to BMHC for written approval, and
maintain, a written strategy for conducting medical record reviews. The
strategy must include, at a minimum, the following:

	 	(a)	 	Designated staff to perform this duty;
	 
	 	(b)	 	The method of case selection;
	 
	 	(c)	 	The anticipated number of reviews by practice site;
	 
	 	(d)	 	The tool that the Health Plan will use to review each site; and
	 
	 	(e)	 	How the Health Plan shall link the information compiled
during the review to other Health Plan functions (e.g., QI, credentialing,
peer review, etc.).

	 	4.	 	Cultural Competency Plan

	 	a.	 	In accordance with 42 CFR 438.206, the Health Plan shall have a
comprehensive written cultural competency plan (CCP) describing the Health Plan’s
program to ensure that services are provided in a culturally competent manner to
all enrollees, including those with limited English proficiency. The CCP must
describe how providers, Health Plan employees, and systems will effectively
provide services to people of all cultures, races, ethnic backgrounds, and
religions in a manner that recognizes, values, affirms, and respects the worth of
the individual enrollees and protects and preserves the dignity of each. The CCP
shall be updated annually and submitted to BMHC by October 1 for approval for
implementation by January 1 of each Contract year.
	 
	 	b.	 	The Health Plan may distribute a summary of the CCP to network providers
if the summary includes information about how the provider may access the full CCP
on the web site. This summary shall also detail how the provider can request a
hard copy of the cultural competency plan from the Health Plan at no charge to the
provider.
	 
	 	c.	 	The Health Plan shall complete an annual evaluation of the effectiveness
of its CCP. This evaluation may include results from the CAHPS or other
comparative member satisfaction surveys, outcomes for certain cultural groups,
member grievances, member appeals, provider feedback and Health Plan employee
surveys. The Health Plan shall track and trend any issues identified in the
evaluation and shall implement interventions to improve the provision of services.
A description of the evaluation, its results, the analysis of the results and
interventions to be implemented shall be described in the annual CCP submitted to
the Agency.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	5.	 	EQRO Coordination Requirements

	 	a.	 	The Health Plan shall provide all information requested by the EQRO,
including, but not limited to, quality outcomes concerning timeliness of, and
enrollee access to, covered services.
	 
	 	b.	 	The Health Plan shall cooperate with the EQRO during the external quality
review activities, which may include independent medical record review.
	 
	 	c.	 	If the EQRO indicates the Health Plan’s performance is not acceptable,
the Agency may require the Health Plan to submit a corrective action plan (CAP)
and may restrict the Health Plan’s enrollment activities.

	 	6.	 	Agency Annual Medical Record Audit

	 	a.	 	The Health Plan shall furnish specific data requested in order for the
Agency to conduct the medical record audit.
	 
	 	b.	 	If the medical record audit indicates that quality of care is not
acceptable within the terms of this Contract, the Agency shall sanction the Health
Plan, in accordance with the provisions of Attachment II, Section XIV, Sanctions,
and may immediately terminate all enrollment activities and mandatory assignments,
until the Health Plan attains an acceptable level of quality of care as determined
by the Agency. When considering whether to impose a limitation on enrollment
activities or mandatory assignment, the Agency may take into account the Health
Plan’s cumulative performance on all 01 activities.

B. Utilization Management (UM) (See Attachment II, Exhibit 8)

	 	1.	 	General Requirements

	 	a.	 	The UM program shall be consistent with 42 CFR 456 and include, but not be
limited to:

	 	(1)	 	Procedures for identifying patterns of over-utilization and
under-utilization of services and for addressing potential problems identified
as a result of these analyses.
	 
	 	(2)	 	Reporting fraud and abuse information identified through the UM
program to the Agency’s MPI as described in Attachment II, Section X,
Administration and Management, and referenced in 42 CFR 455.1(a)(1).
	 
	 	(3)	 	A procedure for enrollees to obtain a second medical opinion and
for the Health Plan to authorize claims for such services in accordance with s.
641.51, F.S.
	 
	 	(4)	 	Protocols for prior authorization and denial of services; the
process used to evaluate prior and concurrent authorization; mechanisms to
ensure consistent application of review criteria for authorization decisions;
consultation with the requesting provider when appropriate; hospital discharge
planning; physician profiling; and a retrospective review of both inpatient and
ambulatory claims,

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	 	 	 	meeting the predefined criteria below. The Health Plan shall be responsible for
ensuring the consistent application of review criteria for authorization
decisions and consulting with the requesting provider when appropriate.

	 	(a)	 	The Health Plan shall obtain written approval from BMHC for
its service authorization protocols and any changes.
	 
	 	(b)	 	The Health Plan’s service authorization systems shall provide
the authorization number and effective dates for authorization to providers
and non-participating providers.
	 
	 	(c)	 	The Health Plan’s service authorization systems shall provide
written confirmation of all denials of authorization to providers (See 42
CFR 438.210(c)).
	 
	 	(d)	 	The Health Plan may request to be notified, but shall not deny claims
payment based solely on lack of notification, for the following:

	 	(i)	 	Inpatient emergency admissions (within ten (10)
calendar days);
	 
	 	(ii)	 	Obstetrical care (at first visit);
	 
	 	(iii)	 	Obstetrical admissions exceeding forty-eight (48)
hours for vaginal delivery and ninety-six (96) hours for caesarean
section; and
	 
	 	(iv)	 	Transplants.

	 	(e)	 	The Health Plan shall ensure that all decisions to deny a
service authorization request, or limit a service in amount, duration, or
scope that is less than requested, are made by health care professionals who
have the appropriate clinical expertise in treating the enrollee’s condition
or disease (see 42 CFR 438.210(b)(3)).
	 
	 	(f)	 	Only a licensed psychiatrist may authorize a denial for an
initial or concurrent authorization of any request for behavioral health
services. The psychiatrist’s review shall be part of the UM process and not
part of the clinical review, which may be requested by a provider or the
enrollee, after the issuance of a denial.
	 
	 	(g)	 	The Health Plan shall provide post authorization to CHDs for
emergency shelter medical screenings provided for DCF clients.
	 
	 	(h)	 	Health Plans with automated authorization systems may not
require paper authorization as a condition for providing treatment.
	 
	 	(i)	 	The Health Plan shall not delay service authorization if
written documentation is not available in a timely manner. However, the
Health Plan is not required to approve claims for which it has received no
written documentation.

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	 	b.	 	The Health Plan must provide that compensation to individuals or entities that
conduct UM activities is not structured to provide incentives for the individual or
entity to deny, limit, or discontinue medically necessary services to any enrollee.

	 	2.	 	Care Management
	 
	 	 	 	The Health Plan shall be responsible for the management and continuity of medical care
for all enrollees. The Health Plan shall maintain written case management and continuity
of care protocols that include the following minimum functions:

	 	a.	 	Appropriate referral and scheduling assistance for enrollees needing
specialty health care or transportation services, including those identified
through CHCLIP screenings;
	 
	 	b.	 	Determination of the need for non-covered services and referral of the
enrollee for assessment and referral to the appropriate service setting (to
include referral to WIC and Healthy Start) with assistance, as needed, by the area
Medicaid office;
	 
	 	c.	 	Case management follow-up services for children/adolescents whom the
Health Plan identifies through blood screenings as having abnormal levels of lead;
	 
	 	d.	 	Coordinated hospital/institutional discharge planning that includes
post-discharge care, including short-term, skilled nursing facility care, as
appropriate;
	 
	 	e.	 	A mechanism for direct access to specialists for enrollees identified as
having special health care needs, as appropriate for their conditions and
identified needs;
	 
	 	f.	 	An outreach program and other strategies for identifying every pregnant
enrollee. This shall include case management, claims analysis, and use of health
risk assessment, etc. The Health Plan shall require its participating providers to
notify the plan of any Medicaid enrollee who is identified as being pregnant;
	 
	 	g.	 	Documentation of referral services in enrollee medical records, including
reports resulting from the referral;
	 
	 	h.	 	Monitoring of enrollees with ongoing medical conditions and coordination
of services for high utilizers to address the following, as appropriate: acting as
a liaison between the enrollee and providers, ensuring the enrollee is receiving
routine medical care, ensuring the enrollee has adequate support at home,
assisting enrollees who are unable to access necessary care due to their medical
or emotional conditions or who do not have adequate community resources to comply
with their care, and assisting the enrollee in developing community resources to
manage a medical condition;
	 
	 	i.	 	Documentation of emergency care encounters in enrollee medical records
with appropriate medically indicated follow-up;
	 
	 	j.	 	Coordination of hospital/institutional discharge planning that includes
post-discharge care, including skilled short-term rehabilitation, and skilled
nursing facility care, as appropriate;

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	 	k.	 	Sharing with other Health Plans serving the enrollee the results of its
identification and assessment of any enrollee with special health care needs so that
those activities need not be duplicated;
	 
	 	l.	 	Ensuring that in the process of coordinating care, each enrollee’s privacy
is protected consistent with the confidentiality requirements in 45 CFR parts 160
and 164. 45 CFR Part 164 specifically describes the requirements regarding the
privacy of individually identifiable health information.

	 	3.	 	Practice Protocols

	 	a.	 	The Health Plan shall adopt practice guidelines that meet the following requirements:

	 	(1)	 	Are based on valid and reliable clinical evidence or a consensus of
health care professionals in a particular field;
	 
	 	(2)	 	Consider the needs of the enrollees;
	 
	 	(3)	 	Are adopted in consultation with providers; and
	 
	 	(4)	 	Are reviewed and updated periodically, as appropriate (See 42 CFR
438.236(b)).

	 	b.	 	The Health Plan shall disseminate any revised practice guidelines to all
affected providers and, upon request, to enrollees and potential enrollees.
	 
	 	c.	 	The Health Plan shall ensure consistency with regard to all decisions
relating to UM, enrollee education, covered services and other areas to which the
practice guidelines apply.

	 	4.	 	Changes to Utilization Management Components
	 
	 	 	 	The Health Plan shall provide no less than thirty (30) calendar days’ written notice to
BMHC before making any changes to the administration and/or management procedures and/or
authorization, denial or review procedures, including any delegations, as described in
this section.
	 
	 	5.	 	Disease Management (See Attachment II, Exhibit 8)

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Section IX

Grievance System

A. General Requirements

	 	1.	 	Federal law requires Medicaid managed care organizations to have internal
grievance procedures under which Medicaid enrollees, or providers acting as
authorized representatives, may challenge denial of coverage of, or payment for,
medical assistance. The Health Plan’s grievance system shall comply with the
requirements set forth in s. 641.511, F.S., if applicable, and with all applicable
federal and state laws and regulations, including 42 CFR 431.200 and 42 CFR Part 438,
Subpart F, “Grievance System.”
	 
	 	2.	 	For purposes of this Contract, these procedures must include an opportunity to
file a complaint, a grievance, and/or an appeal and to seek a Medicaid Fair Hearing
through DCF.
	 
	 	3.	 	The Health Plan shall refer all enrollees and/or providers on behalf of the
enrollee (whether participating or non-participating) who are dissatisfied with the
Health Plan or its activities to the Health Plan’s grievance/appeal coordinator for
processing and documentation of the issue.
	 
	 	4.	 	The Health Plan shall include all necessary procedural steps for filing
complaints, grievances, appeals and requests for a Medicaid Fair Hearing in the
enrollee handbook.
	 
	 	5.	 	Where applicable, the Health Plan’s grievance system must include information
for enrollees on seeking a state level appeal through either the Subscriber
Assistance Panel (for HMOs) or the Beneficiary Assistance Panel (for PSNs).
	 
	 	6.	 	The Health Plan shall provide information about the grievance system to all
providers and subcontractors in the provider handbook when they enter into a
contract.
	 
	 	7.	 	The Health Plan must maintain a record of grievances and appeals and submit
reports, as specified in Attachment II, Section XII, Reporting Requirements, to BMHC.
	 
	 	8.	 	The Health Plan must keep a log of complaints that do not become grievances,
including date, name, nature of complaint and disposition. The Health Plan shall
submit this report upon request of the Agency.
	 
	 	9.	 	The Health Plan shall acknowledge in writing receipt of each grievance and
appeal unless the enrollee requests an expedited resolution.
	 
	 	10.	 	The Health Plan shall ensure that decision makers on grievances and appeals
were not involved in previous levels of review or decision making and that all
decision makers are health care professionals with clinical expertise in treating the
enrollee’s condition when deciding the following:

	 	a.	 	Appeal of denial based on lack of medical necessity;
	 
	 	b.	 	Grievance of denial of expedited resolution of an appeal; and

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	 	c.	 	Grievance or appeal involving clinical issues.

	 	11.	 	A Health Plan that covers transportation services through a subcontractor shall
ensure that the subcontractor meets the complaint and grievance system requirements
for problems related to transportation services.

B. Types of Issues

	 	1.	 	A complaint is the lowest level of challenge and provides the Health Plan an
opportunity to resolve a problem without its becoming a formal grievance. Complaints
shall be resolved by close of business the day following receipt or be moved into the
grievance system.
	 
	 	2.	 	A grievance expresses dissatisfaction about any matter other than an action by
the Health Plan.
	 
	 	3.	 	An action is any denial, limitation, reduction, suspension, or termination of
service; denial of payment; or failure to act in a timely manner.
	 
	 	4.	 	An appeal is a request for review of an action.

C. Notices

	 	1.	 	The Health Plan shall provide the enrollee with a written notice of action that
includes the following:

	 	a.	 	The action the Health Plan or its contractor has taken or intends to take;
	 
	 	b.	 	The reasons for the action;
	 
	 	c.	 	The enrollee or provider’s right to file an appeal with the Health Plan;
	 
	 	d.	 	The enrollee’s right to request a Medicaid Fair Hearing;
	 
	 	e.	 	The procedures for exercising the rights specified in the notice;
	 
	 	f.	 	The circumstances under which expedited resolution is available and how
to request it;
	 
	 	g.	 	The enrollee’s right to have benefits continue pending resolution of
the appeal, how to request that benefits be continued, and the circumstances in
which the enrollee must have to pay the cost of those benefits.

	 	2.	 	The Health Plan shall mail the notice as follows:

	 	a.	 	For termination, suspension or reduction of previously authorized
Medicaid-covered services no later than ten (10) calendar days before the action
is to take effect. Certain exceptions apply under 42 CFR 431.213-214;

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	 	b.	 	For denial of payment, at the time of any action affecting the claim;
	 
	 	c.	 	For standard service authorization decisions that deny or limit services
no more than fourteen (14) calendar days following the request for service or
within three (3) business days following an expedited service request;
	 
	 	d.	 	If the Health Plan extends the timeframe for a service authorization
decision, in which case it shall:

	 	(1)	 	Notify the enrollee of the reason for extending the timeframe
and advising of the right to file a grievance if the enrollee disagrees with
the extension of time;
	 
	 	(2)	 	Issue and carry out its determination as expeditiously as
possible and no later than the date the extension expires;
	 
	 	(3)	 	Send notice of the extension to the enrollee within five (5)
business days of determining the need for an extension.

	 	e.	 	For service authorization decisions not reached within required
timeframes, on the date the timeframes expire. Such failures constitute a denial
and are, therefore, an adverse action;
	 
	 	f.	 	For expedited service authorization decisions within the timeframes specified.

D. Filing Grievances and Appeals

	 	1.	 	A grievance may be filed orally or in writing within one (1) year of the
occurrence.
	 
	 	2.	 	An appeal may be filed orally or in writing within thirty (30) calendar days of
the enrollee’s receipt of the notice of action and, except when expedited resolution
is required, must be followed with a written notice within ten (10) calendar days of
the oral filing. The date of oral notice shall constitute the date of receipt.
	 
	 	3.	 	The Health Plan shall provide any reasonable help to the enrollee in completing
forms and following the procedures for filing a grievance or appeal or requesting a
Medicaid Fair Hearing. This includes interpreter services, toll-free calling, and
TTY/TTD
capability.
	 
	 	4.	 	The Health Plan shall handle grievances and appeals as follows:

	 	a.	 	Provide the enrollee a reasonable opportunity to present evidence and
allegations of fact or law in person as well as in writing.
	 
	 	b.	 	Ensure the enrollee understands any time limits that may apply.
	 
	 	c.	 	Provide opportunity before and during the process for the enrollee or
an authorized representative to examine the case file, including medical records,
and any other material to be considered during the process.
	 
	 	d.	 	Consider as parties to the appeal the enrollee or an authorized
representative or, if the enrollee is deceased, the legal representative of the
estate.

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E. Resolution and Notification

	 	1.	 	The Health Plan shall follow Agency guidelines in resolving grievances and
appeals as expeditiously as possible, observing required timeframes and taking into
account the enrollee’s health condition.
	 
	 	2.	 	A grievance shall be reviewed and notice of results sent to the enrollee no later
than ninety (90) calendar days from the date the Health Plan receives it.
	 
	 	3.	 	An appeal shall be heard and notice of results sent to the enrollee no later than
forty-five (45) calendar days from the date the Health Plan receives it.
	 
	 	4.	 	The timeframe for a grievance or appeal may be extended up to fourteen (14)
calendar days if:

	 	a.	 	The enrollee asks for an extension, or the Health Plan documents that
additional information is needed and the delay is in the enrollee’s interest;
	 
	 	b.	 	If the timeframe is extended other than at the enrollee’s request, the
Health Plan shall notify the enrollee within five (5) business days of the
determination, in writing, of the reason for the delay.

	 	5.	 	The Health Plan shall complete the grievance process in time to accommodate an
enrollee’s disenrollment effective date, which can be no later than the first day of
the second month after the filing of a request for disenrollment.
	 
	 	6.	 	The Health Plan shall provide written notice of disposition of an appeal. In the
case of an expedited appeal, the Health Plan also shall provide oral notice by close
of business the day of disposition.
	 
	 	7.	 	Content of notice — The written notice of resolution shall include:

	 	a.	 	The results of the resolution process and the date it was completed;
	 
	 	b.	 	If not decided in the enrollee’s favor, information on the right to
request a Medicaid Fair Hearing and how to do so; the right to request to receive
benefits while the hearing is pending, and how to make the request;
	 
	 	c.	 	The right to appeal an adverse decision on an appeal to the Subscriber
Assistance Program (SAP) for HMOs or the Beneficiary Assistance Program (BAP) for
PSNs, including how to initiate such a review and the following;

	 	(1)	 	Before filing with the SAP or BAP, the enrollee must complete the
Health Plan’s appeal process.
	 
	 	(3)	 	The enrollee must submit the appeal to the SAP or BAP within one
(1) year after receipt of the final decision letter from the Health Plan;
	 
	 	(4)	 	Neither the SAP nor the BAP will consider an appeal that has
already been to a Medicaid Fair Hearing.

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	 	(5)	 	The address and toll-free telephone numbers of the SAP/BAP:
	 
	 	 	 	Agency for Health Care Administration

Subscriber Assistance Program / Beneficiary Assistance Program

Building 1, MS #26

2727 Mahan Drive

Tallahassee, Florida 32308

(850) 921-5458

(888) 419-3456 (toll-free)

	 	d.	 	That the enrollee may have to pay for the cost of those benefits if the
Medicaid Fair Hearing upholds the Health Plan’s action.

F. Expedited Appeals

	 	1.	 	The Health Plan shall have an expedited review process for appeals for use when
taking the time for a standard resolution could seriously jeopardize the enrollee’s
life or health or ability to attain, maintain or regain maximum function.
	 
	 	2.	 	The Health Plan shall resolve each expedited appeal and provide notice to the
enrollee, as quickly as the enrollee’s health condition requires, within state
established time frames not to exceed seventy-two (72) hours after the Health Plan
receives the appeal request, whether the appeal was made orally or in writing.
	 
	 	3.	 	The Health Plan shall ensure that no punitive action is taken against a
provider who requests or supports a request for an expedited appeal.
	 
	 	4.	 	If the Health Plan denies the request for expedited appeal, it shall
immediately transfer the appeal to the timeframe for standard resolution and so
notify the enrollee.

G. Medicaid Fair Hearings (see 65-2.042-2.069, FAC)

	 	1.	 	An enrollee may seek a Medicaid Fair Hearing without having first exhausted the
Health Plan’s grievance and appeal process.
	 
	 	2.	 	An enrollee who chooses to exhaust the Health Plan’s grievance and appeal
process may still file for a Medicaid Fair Hearing within ninety (90) calendar days
of receipt of the Health Plan’s notice of resolution.
	 
	 	3.	 	An enrollee who chooses to seek a Medicaid Fair Hearing without pursuing the
Health Plan’s process must do so within ninety (90) days of receipt of the Health
Plan’s notice of action.
	 
	 	4.	 	Parties to the Medicaid Fair Hearing include the Health Plan as well as the
enrollee or that person’s authorized representative.
	 
	 	5.	 	The address at DCF for the Medicaid Fair Hearing office is:

Office of Public Assistance Appeals Hearings

1317 Winewood Boulevard, Building 5, Room 203

Tallahassee, FL 32399-0700

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H. Continuation of Benefits

	 	1.	 	The Health Plan shall continue the enrollee’s benefits if:

	 	a.	 	The enrollee or the enrollee’s authorized representative files an appeal
with the Health Plan regarding the Health Plan’s decision:

	 	(1)	 	Within ten (10) business days after the notice of the adverse
action is mailed or
	 
	 	(2)	 	Within ten (10) business days after the intended effective date
of the action, whichever is later;

	 	b.	 	The appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment;
	 
	 	c.	 	The services were ordered by an authorized provider;
	 
	 	d.	 	The original period covered by the original authorization has not expired; and
	 
	 	e.	 	The enrollee requests extension of benefits.

	 	2.	 	If, at the enrollee’s request, the Health Plan continues or reinstates the
benefits while the appeal is pending, benefits must continue until one (1) of the
following occurs:

	 	a.	 	The enrollee withdraws the appeal;
	 
	 	b.	 	Ten (10) business days pass after the Health Plan sends the enrollee
the notice of resolution of the appeal against the enrollee, unless the enrollee
within those ten (10) days has requested a Medicaid Fair Hearing with
continuation of benefits;
	 
	 	c.	 	The Medicaid Fair Hearing office issues a hearing decision adverse to the
enrollee;
	 
	 	d.	 	The time period or service limits of a previously authorized service have
been met.

	 	3.	 	If the final resolution of the appeal is adverse to the enrollee and the Health
Plan’s action is upheld, the Health Plan may recover the cost of services furnished to
the enrollee while the appeal was pending to the extent they were furnished solely
because of the continuation of benefits requirement.
	 
	 	4.	 	If the Medicaid Fair Hearing officer reverses the Health Plan’s action and
services were not furnished while the appeal was pending, the Health Plan shall
authorize or provide the disputed services promptly.
	 
	 	5.	 	If the Medicaid Fair Hearing officer reverses the Health Plan’s action and the
enrollee received the disputed services while the appeal was pending, the Health Plan
shall pay for those services in accordance with this Contract.

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Section X

Administration and Management

A. General Provisions

	 	1.	 	The Health Plan’s governing body shall set forth policy and has overall
responsibility for the organization of the Health Plan.
	 
	 	2.	 	The Health Plan shall be responsible for the administration and management of
all aspects of this Contract, including, but not limited to, delivery of services,
provider network, provider education, claims resolution and assistance, and all
subcontracts, employees, agents and services performed by anyone acting for or on
behalf of the Health Plan.
	 
	 	3.	 	The Health Plan shall have a centralized executive administration, which shall
serve as the contact point for the Agency, except as otherwise specified in this
Contract.

B. Staffing

	 	1.	 	The Health Plan shall educate its staff about its policies and procedures and
all applicable provisions of this Contract, including advance directives, situations
in which advance directives may be of benefit to enrollees, and their responsibility
to educate enrollees about this tool and assist them in making use of it.
	 
	 	2.	 	Minimum Staffing Requirements — The positions described below represent the
minimum management staff required for the Health Plan. Within five (5) working days
of any changes in staffing, the Health Plan shall report such changes to BMHC and
HSD.

	 	a.	 	Contract Manager: The Health Plan shall designate a Contract
Manager to work directly with the Agency. The Contract Manager shall be a
full-time employee of the Health Plan with authority to revise processes or
procedures and assign additional resources as needed to maximize the efficiency
and effectiveness of services required under the Contract. The Health Plan shall
meet in person, or by telephone, at the request of Agency representatives to
discuss the status of the Contract, Health Plan performance, benefits to the
state, necessary revisions, reviews, reports and planning.
	 
	 	b.	 	Full-Time Administrator: The Health Plan shall have a full-time
administrator specifically identified to administer the day-to-day business activities of this
Contract. The Health Plan may designate the same person as the Contract Manager,
the full- time administrator, or the medical director, but such person cannot be
designated to any other position in this section, including in other lines of
business within the Health Plan, unless otherwise approved by BMHC.
	 
	 	c.	 	Medical and Professional Support Staff: The Health Plan shall
have medical and professional support staff sufficient to conduct daily business
in an orderly manner, including having enrollee services staff directly available
during business hours for enrollee services consultation, as determined through
management and medical reviews. The Health Plan shall maintain sufficient medical
staff, available twenty-four hours a day, seven days a week (24/7), to handle
emergency services and care

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	 	 	 	inquiries. The Health Plan shall maintain sufficient medical and professional
support staff during non-business hours, unless the Health Plan’s computer system
automatically approves all emergency services and care claims relating to screening
and treatment.
	 
	 	d.	 	Medical Director: The Health Plan shall have a full-time
physician with an active unencumbered license in accordance with Chapter 458 or
459, F.S., to serve as medical director to oversee and be responsible for the
proper provision of covered services to enrollees, the quality management program
and the grievance system. The medical director cannot be designated to serve in
any other non-administrative position.
	 
	 	e.	 	Medical Records Review Coordinator: The Health Plan shall have
a designated person, qualified by training and experience, to ensure compliance
with the medical records requirements as described in this Contract. The medical
records review coordinator shall maintain medical record standards and direct
medical record reviews according to the terms of this Contract.
	 
	 	f.	 	Data Processing and Data Reporting Coordinator: The Health Plan
shall have a person trained and experienced in data processing, data reporting,
and claims resolution, as required, to ensure that computer system reports the
Health Plan provides to the Agency and its agents are accurate, and that computer
systems operate in an accurate and timely manner.
	 
	 	g.	 	Community Outreach Oversight Coordinator: If the Health Plan
engages in community outreach, it shall have a designated person, qualified by training and
experience, to ensure the Health Plan adheres to the community outreach and
marketing requirements of this Contract.
	 
	 	h.	 	QI and UM Professional: The Health Plan shall have a designated
person, qualified by training and experience in QI and UM and who holds the
appropriate clinical certification and/or license.
	 
	 	i.	 	Grievance System Coordinator: The Health Plan shall have a
designated person, qualified by training and experience, to process and resolve
complaints, grievances and appeals, be responsible for the grievance system.
	 
	 	j.	 	Compliance Officer: The Health Plan shall have a designated person
qualified by training and experience in health care or risk management, to oversee
a fraud and abuse program to prevent and detect potential fraud and abuse
activities pursuant to state and federal rules and regulations, and carry out the
provisions of the compliance plan, including fraud and abuse policies and
procedures, investigating unusual incidents and implementing corrective action.
	 
	 	k.	 	Case Management Staff: The Health Plan shall have sufficient case
management staff, qualified by training, experience and certification/licensure to
conduct the Health Plan’s case management functions.
	 
	 	l.	 	Claims/Encounter Manager: The Health Plan shall have a designated
person qualified by training and experience to oversee claims and encounter
submittal and

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	 	 	 	processing, where applicable, and to ensure the accuracy, timeliness and
completeness of processing payment and reporting.

C. Claims (See Attachment II, Exhibits 10 and 13)

	 	1.	 	The Health Plan shall have performance metrics, including those for quality,
accuracy and timeliness, and include a process for measurement and monitoring, and
for the development and implementation of interventions for improvement in regards to
claims processing and claims payment. The Health Plan shall keep documentation of the
above and have these available for Agency review.
	 
	 	2.	 	The Health Plan shall be able to accept electronically-transmitted claims from
providers in HIPAA compliant formats.
	 
	 	3.	 	For purposes of this subsection, electronic transmission of claims, HIPAA
compliant transactions, notices, documents, forms, and payments shall be used to the
greatest extent possible by the Health Plan.
	 
	 	4.	 	The Health Plan shall ensure that claims are processed and comply with the
federal and state requirements set forth in 42 CFR 447.45 and 447.46 and Chapter 641,
F.S., whichever is more stringent.
	 
	 	5.	 	The Health Plan shall have a process for handling and addressing the resolution
of provider complaints concerning claims issues. The process shall be in compliance
with s. 641.3155 F.S.
	 
	 	6.	 	The Health Plan shall not deny claims submitted by an out-of-network provider,
including provision of emergency services and care, solely based on the period
between the date of service and the date of clean claim submission, unless that
period exceeds three- hundred and sixty-five (365) days.
	 
	 	7.	 	Each quarter the Health Plan shall submit an aging claims summary in accordance
with Attachment II, Section XII, Reporting Requirements, Attachment II.

D. Encounter Data

	 	1.	 	Encounter data collection and submission is required from all capitated Health
Plans for all health care services rendered to their enrollees (services for which
the Health Plan is reimbursed by the Agency on a capitated basis) and from all
fee-for-service PSNs for all capitated services. The Health Plan shall submit
encounter data that meets established Agency data quality standards as defined
herein. These standards are defined by the Agency to ensure receipt of complete and
accurate data for program administration and are closely monitored and enforced. The
Agency will revise and amend these standards with ninety (90) calendar days’ advance
notice to the Health Plan to ensure continuous quality improvement. The Health Plan
shall make changes or corrections to any systems, processes or data transmission
formats as needed to comply with Agency data quality standards as originally defined
or subsequently amended.
	 
	 	2.	 	The encounter data submission standards required to support encounter data
collection and submission are defined by the Agency in the Medicaid Encounter Data
System

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	 	 	 	(MEDS) Companion Guide and this section. In addition, the Agency will post encounter
data reporting requirements on its MEDS website: http://ahca.myflorida.com/Medicaid/meds/.
	 
	 	3.	 	The Health Plan shall adhere to the following requirements for the encounter data
submission process:

	 	a.	 	In accordance with the Health Plan’s submission schedule approved by
the Agency, the Health Plan shall submit by October 31, 2009, the historical
encounters for all typical and atypical services with Health Plan paid dates of
January 1, 2007, for Reform populations, and July 1, 2008, for non-Reform
populations, up to the submission start date. The Health Plan shall retain
submitted historical encounter data for a period not less than five (5) years as
specified in the Standard Contract, Section I., Item D., Retention of Records.
	 
	 	b.	 	The Health Plan shall submit encounters for all typical and atypical
services with Health Plan paid dates on or after the submission start date on an
ongoing basis within sixty (60) calendar days following the end of the month in
which the Health Plan paid the claims for services.
	 
	 	c.	 	For all encounters submitted after the submission start date, including
historical and ongoing claims, if the Agency or its fiscal agent notifies the
Health Plan of encounters failing X12 electronic data interface (EDI) compliance
edits or FMMIS threshold and repairable compliance edits, the Health Han shall
remediate all such encounters within sixty (60) calendar days after such notice.
	 
	 	d.	 	There will be no requirement to submit encounters for Health Plan paid
dates prior to January 1, 2007, for Reform populations, and July 1, 2008, for
non-Reform populations.

	 	4.	 	The Health Plan shall have a comprehensive automated and integrated encounter
data system capable of meeting the requirements below:

	 	a.	 	All Health Plan encounters shall be submitted to the Agency in the
standard HIPAA transaction formats, namely the ANSI X12N 837 transaction formats
(P — Professional; I — Institutional; D — Dental), and, for pharmacy services, in
the National Council for Prescription Drug Programs (NCPDP) format. Health Plan
paid amounts shall be provided for non-capitated network providers.
	 
	 	b.	 	The Health Plan shall collect, and submit to the Agency’s fiscal agent,
enrollee service level encounter data for all covered services. The Health Plan
shall be held responsible for errors or noncompliance resulting from their own
actions or the actions of an agent authorized to act on their behalf.
	 
	 	c.	 	The Health Plan shall convert all information that enters its claims
system via hard copy paper claims or other proprietary formats to encounter data
to be submitted in the appropriate HIPAA-compliant formats.
	 
	 	d.	 	The Health Plan shall provide complete and accurate encounters to the
Agency. The Health Plan shall implement review procedures to validate encounter
data submitted by providers.

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	 	HMO Contract

	 	(1)	 	Complete: A Health Plan submitting encounters that represent at least
ninety-five (95%) of the covered services provided by Health Plan providers and
non-participating providers. The Health Plan shall strive to achieve a
one-hundred percent (100%) complete submission rate.
	 
	 	(2)	 	Accurate (X12): ninety-five (95%) of the records in a Health
Plan’s encounter batch submission pass X12 EDI compliance edits and the
FMNIIS threshold and repairable compliance edits. The X12 EDI compliance
edits are established through SNIP levels 1 through 4. FMMIS threshold and
repairable edits that report exceptions are defined in the MEDS X12 Companion
Guide.
	 
	 	(3)	 	Accurate (NCPDP): ninety-five (95%) of the records in a Health
Plan’s encounter batch submission pass NCPDP compliance edits and the
pharmacy benefits system threshold and repairable compliance edits. The NCPDP
compliance edits are described in the National Council for Prescription Drug
Programs Telecommunications Standard Guides. Pharmacy benefits system
threshold and repairable edits that report exceptions are defined in the MEDS
Pharmacy Claims Companion Guide.

	 	5.	 	The Health Plan shall designate sufficient IT and staffing resources to perform
these encounter functions as determined by generally accepted best industry
practices.
	 
	 	6.	 	Where a Health Plan has entered into capitation reimbursement arrangements with
providers, the Health Plan shall comply with sub-item 4 of this section, above. The
Health Plan shall require timely submissions from its providers as a condition of the
capitation payment.
	 
	 	7.	 	The Health Plan shall participate in Agency-sponsored workgroups directed at
continuous improvements in encounter data quality and operations.
	 
	 	8.	 	If the Agency determines that the Health Plan’s MEDS performance is not
acceptable, the Agency shall require the Health Plan to submit a corrective action
plan (CAP). When considering whether to impose a sanction, the Agency will take into
account the Health Plan’s cumulative performance on all NIEDS activities, including
progress toward completeness and accuracy of encounter data, as defined in Item D.,
Encounter Data, above.
	 
	 	9.	 	Encounter data submission time frames specified in this section do not affect
time frames specified in Attachment II, Section XII, Reporting Requirements, for
either pharmacy data encounter reporting, for risk adjustment, or behavioral health
encounters (including pharmacy reporting).

E. Fraud and Abuse Prevention

	 	1.	 	The Health Plan shall establish functions and activities governing program
integrity in order to reduce the incidence of fraud and abuse and shall comply with
all state and federal program integrity requirements, including but not limited to the
applicable provisions of the Social Security Act, ss. 1128, 1902, 1903, and 1932; 42
CFR 431, 433, 434, 435, 438, 441, 447, 455; 45 CFR Part 74; Chapters 409, 414, 458,
459, 460, 461, 626, 641 and 932, F.S., and 59A-12.0073, 59G and 69D-2, FAC.

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	 	HMO Contract

	 	2.	 	The Health Plan shall have adequate staffing and resources to enable the compliance
officer to investigate unusual incidents and develop and implement corrective action
plans relating to fraud and abuse. The compliance officer shall have unrestricted
access to the Health Plan’s governing body for compliance reporting, including fraud
and abuse.
	 
	 	3.	 	The Health Plan’s written fraud and abuse prevention program shall have
internal controls and policies and procedures in place that are designed to prevent,
reduce, detect, correct and report known or suspected fraud and abuse activities.
	 
	 	4.	 	The Health Plan shall submit its compliance plan and its fraud and abuse
policies and procedures to the Bureau of Medicaid Program Integrity (NIPI) for
written approval before those procedures are implemented.

	 	a.	 	At a minimum the compliance plan must include:

	 	(1)	 	Written policies, procedures and standards of conduct that
articulate the Health Plan’s commitment to comply with all applicable federal
and state standards;
	 
	 	(2)	 	The designation of a compliance officer and a compliance
committee accountable to senior management;
	 
	 	(3)	 	Effective training and education of the compliance officer and
the Health Plan’s employees;
	 
	 	(4)	 	Effective lines of communication between the compliance officer
and the Health Plan’s employees;
	 
	 	(5)	 	Enforcement of standards through well-publicized disciplinary
guidelines;
	 
	 	(6)	 	Provision for internal monitoring and auditing; and
	 
	 	(7)	 	Provisions for prompt response to detected offenses and for
development of corrective action initiatives.

	 	b.	 	At a minimum, the Health Plan’s fraud and abuse policies and procedures shall:

	 	(1)	 	Ensure that all officers, directors, managers and employees know
and understand the provisions of the Health Plan’s fraud and abuse policies
and procedures;
	 
	 	(2)	 	Include procedures designed to prevent and detect potential or
suspected fraud and abuse in the administration and delivery of services under
this Contract. Nothing in this Contract shall require that the Health Plan
assure that nonparticipating providers are compliant with this Contract or
state and/or federal law, but the Health Plan is responsible for reporting
suspected fraud and abuse by non-participating providers when detected;
	 
	 	(3)	 	Describe the Health Plan’s organizational arrangement of
anti-fraud personnel, their roles and responsibilities, including a
description of the internal investigational methodology and reporting
protocols;

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	 	HMO Contract

	 	(4)	 	Incorporate a description of the specific controls in place for prevention
and detection of potential or suspected fraud and abuse, including, but not
limited to:

	 	(a)	 	Claims edits;
	 
	 	(b)	 	Post-processing review of claims;
	 
	 	(c)	 	Provider profiling, credentialing, and recredentialing,
including a review process for claims and encounters that shall include
providers and non-participating providers:

	 	(i)	 	Who demonstrate a pattern of submitting falsified
encounter data or service reports;
	 
	 	(ii)	 	Who demonstrate a pattern of overstated reports
or up-coded levels of service;
	 
	 	(iii)	 	Who alter, falsify or destroy clinical record documentation;
	 
	 	(iv)	 	Who make false statements relating to credentials;
	 
	 	(v)	 	Who misrepresent medical information to justify
enrollee referrals;
	 
	 	(vi)	 	Who fail to render medically necessary covered
services they are obligated to provide according to their provider
contracts; and
	 
	 	(vii)	 	Who charge enrollees for covered services.

	 	(d)	 	Prior authorization;
	 
	 	(e)	 	Utilization management;
	 
	 	(f)	 	Subcontract and provider contract provisions;
	 
	 	(g)	 	Provisions from the provider and the enrollee handbooks; and
	 
	 	(h)	 	Standards for a code of conduct;

	 	(5)	 	Contain provisions pursuant to this section for the confidential
reporting of Health Plan violations to MPI and other agencies as required by
law;
	 
	 	(6)	 	Include provisions for the investigation and follow-up of any reports;
	 
	 	(7)	 	Ensure that the identities are protected for individuals reporting
in good faith alleged acts of fraud and abuse;
	 
	 	(8)	 	Require all suspected or confirmed instances of provider or
enrollee fraud and abuse under state and/or federal law be reported to MPI
within fifteen (15) calendar days of detection. Additionally, any final
resolution reached by the Health Plan shall include a written statement that
provides notice to the provider

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	 	 	 	or enrollee that the resolution in no way binds the State of Florida nor
precludes the State of Florida from taking further action for the circumstances
that brought rise to the matter;
	 
	 	(9)	 	Ensure that the Health Plan and all providers and subcontractors,
upon request and as required by state and/or federal law, shall:

	 	(a)	 	Make available to all authorized federal and state
oversight agencies and their agents, including but not limited to the
Agency and the Florida Attorney General, any and all administrative,
financial and medical records and data relating to the delivery of items
or services for which Medicaid monies are expended; and
	 
	 	(b)	 	Allow access to all authorized federal and state
oversight agencies and their agents, including but not limited to the
Agency and the Florida Attorney General, to any place of business and all
medical records and data, as required by state and/or federal law. Access
shall be during normal business hours, except under special circumstances
when the Agency and the Florida Attorney General shall have after-hours
admission. The Agency and the Florida Attorney General shall determine the
need for special circumstances.

	 	(10)	 	Ensure that the Health Plan shall cooperate fully in any
investigation by federal and state oversight agencies and any subsequent legal
action that may result from such an investigation.
	 
	 	(11)	 	Ensure that the Health Plan does not retaliate against any individual
who reports violations of the Health Plan’s fraud and abuse policies and
procedures or suspected fraud and abuse.
	 
	 	(12)	 	Not knowingly have affiliations with individuals debarred or excluded
by federal agencies under ss. 1128 and 1128A of the Social Security Act and 42
CFR 438.610.
	 
	 	(13)	 	Use the federal List of Excluded Individuals and Entities (LEIE), or
its equivalent, to identify excluded parties during the process of engaging the
services of new employees, subcontractors and providers and during renewal of
agreements and recredentialing. The Health Plan shall not engage the services of
an entity that is in nonpayment status or is excluded from participation in
federal health care programs under ss. 1128 and 1128A of the Social Security
Act.
	 
	 	(14)	 	Provide details and educate employees, subcontractors and providers
about the following as required by s. 6032 of the federal Deficit Reduction Act
of 2005:

	 	(a)	 	The False Claim Act;
	 
	 	(b)	 	The penalties for submitting false claims and statements;
	 
	 	(c)	 	Whistleblower protections;
	 
	 	(d)	 	The law’s role in preventing and detecting fraud, waste and abuse;

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	 	HMO Contract

	 	(e)	 	Each person’s responsibility relating to detection and prevention; and
	 
	 	(f)	 	The toll-free state telephone numbers for reporting fraud and abuse.

	 	5.	 	The Health Plan shall query its potential non-provider subcontractors before
contracting to determine whether the subcontractor has any existing or pending
contract(s) with the Agency and, if any, notify MPI.
	 
	 	6.	 	In accordance with s. 6032 of the federal Deficit Reduction Act of 2005, the
Health Plan shall make available written fraud and abuse policies to all employees.
If the Health Plan has an employee handbook, the Health Plan shall include specific
information about s. 6032, the Health Plan’s policies, and the rights of employees to
be protected as whistleblowers.
	 
	 	7.	 	The Health Plan shall comply with all reporting requirements as set forth in
Attachment II, Section XII, Reporting Requirements.
	 
	 	8.	 	The Health Plan shall meet with the Agency periodically, at the Agency’s
request, to discuss fraud, abuse, neglect and overpayment issues.

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	AMERIGROUP Community Care

	 	HMO Contract

Section XI

Information Management and Systems

A. General Provisions

	 	1.	 	Systems Functions. The Health Plan shall have information management processes
and information systems that enable it to meet Agency and federal reporting requirements,
other Contract requirements, and all applicable state and federal laws, rules and
regulations, including HIPAA.
	 
	 	2.	 	Systems Capacity. The Health Plan’s system(s) shall possess capacity sufficient to
handle the workload projected for the begin date of operations and will be scaleable and
flexible so they can be adapted as needed, within negotiated timeframes, in response to
changes in Contract requirements, increases in enrollment estimates, etc.
	 
	 	3.	 	E-Mail System. The Health Plan shall provide a continuously available electronic mail
communication link (e-mail system) with the Agency. This system shall be:

	 	a.	 	Available from the workstations of the designated Health Plan contacts; and
	 
	 	b.	 	Capable of attaching and sending documents created using software products
other than the Health Plan’s systems, including the Agency’s currently installed
version of Microsoft Office and any subsequent upgrades as adopted.

	 	4.	 	Participation in Information Systems Work Groups/Committees. The Health Plan
shall meet as requested by the Agency, to coordinate activities and develop cohesive
systems strategies across vendors and agencies.
	 
	 	5.	 	Connectivity to the Agency/State Network and Systems.
The Health Plan shall be responsible for establishing connectivity to the Agency’s/state’s wide area data
communications network, and the relevant information systems attached to this network, in
accordance with all applicable Agency and/or state policies, standards and guidelines.

B. Data and Document Management Requirements

	 	1.	 	Adherence to Data and Document Management Standards

	 	a.	 	The Health Plan’s systems shall conform to the standard transaction
code sets specified in the Contract.
	 
	 	b.	 	The Health Plan’s systems shall conform to HIPAA standards for data and
document management.
	 
	 	c.	 	The Health Plan shall partner with the Agency in the management of standard
transaction code sets specific to the Agency. Furthermore, the Health Plan shall
partner with the Agency in the development and implementation planning of future
standard code sets not specific to HIPAA or other federal efforts and shall conform to
these standards as stipulated in the plan to implement the standards.

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	 	HMO Contract

	 	2.	 	Data Model and Accessibility. Health Plan systems shall be structured query language
(SQL) and/or open database connectivity (ODBC) compliant. Alternatively, the Health Plan’s
systems shall employ a relational data model in the architecture of its databases in
addition to a relational database management system (RDBMS) to operate and maintain them.
	 
	 	3.	 	Data and Document Relationships. The Health Plan shall house indexed images of
documents used by enrollees and providers to transact with the Health Plan in the
appropriate database(s) and document management systems so as to maintain the logical
relationships between certain documents and certain data.
	 
	 	4.	 	Information Retention. Information in the Health Plan’s systems shall be maintained
in electronic form for three (3) years in live systems and, for audit and reporting
purposes, for five (5) years in live and/or archival systems.
	 
	 	5.	 	Information Ownership. All information, whether data or documents, and reports that
contain or make references to said Information, involving or arising out of this Contract
is owned by the Agency. The Health Plan is expressly prohibited from sharing or publishing
the Agency information and reports without the prior written consent of the Agency. In the
event of a dispute regarding the sharing or publishing of information and reports, the
Agency’s decision on this matter shall be final and not subject to change.

C. System and Data Integration Requirements

	 	1.	 	Adherence to Standards for Data Exchange

	 	a.	 	The Health Plan’s systems shall be able to transmit, receive and process data
in HIPAA-compliant formats that are in use as of the Contract execution date.
	 
	 	b.	 	The Health Plan’s systems shall be able to transmit, receive and process data
in the Agency-specific formats and/or methods that are in use on the Contract
execution date.
	 
	 	c.	 	Health Plan systems shall conform to future federal and/or Agency-specific
standards for data exchange within one-hundred and twenty (120) calendar days of the
standard’s effective date or, if earlier, the date stipulated by CMS or the Agency.
The Health Plan shall partner with the Agency in the management of current and future
data exchange formats and methods and in the development and implementation planning
of future data exchange methods not specific to HIPAA or other federal effort.
Furthermore, the Health Plan shall conform to these standards as stipulated in the
Agency agreed-upon-plan to implement such standards.

	 	2.	 	HIPAA Compliance Checker

All HIPAA-conforming exchanges of data between the Agency and the Health Plan shall be
subjected to the highest level of compliance as measured using an industry-standard HIPAA
compliance checker application.

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	 	HMO Contract

	 	3.	 	Data and Report Validity and Completeness

The Health Plan shall institute processes to ensure the validity and completeness of the
data, including reports, it submits to the Agency. At its discretion, the Agency will
conduct general data validity and completeness audits using industry-accepted statistical
sampling methods. Data elements that will be audited include but are not limited to:
enrollee ID, date of service, assigned Medicaid provider ID, category and subcategory (if
applicable) of service, diagnosis codes, procedure codes, revenue codes, date of claim
processing, and (if and when applicable) date of claim payment. Control totals shall also
be reviewed and verified.

	 	4.	 	State/Agency Website/Portal Integration

Where deemed that the Health Plan’s web presence will be incorporated to any degree to the
Agency’s or the state’s web presence (also known as a portal), the Health Plan shall
conform to any applicable Agency or state standard for website structure, coding and
presentation.

	 	5.	 	Functional Redundancy with FMMIS

The Health Plan’s systems shall be able to transmit and receive transaction data to and
from FMMIS as required for the appropriate processing of claims and any other transaction
that could be performed by either system.

	 	6.	 	Data Exchange in Support of the Agency’s Program Integrity and Compliance Functions

The Health Plan’s systems shall be capable of generating files in the prescribed formats
for upload into Agency systems used specifically for program integrity and compliance
purposes.

	 	7.	 	Address Standardization

The Health Plan’s system(s) shall possess mailing address standardization functionality in
accordance with US Postal Service conventions.

	 	8.	 	Eligibility and Enrollment Data Exchange Requirements

	 	a.	 	The Health Plan shall receive, process and update enrollment files sent daily
by the Agency or its agent.
	 
	 	b.	 	The Health Plan shall update its eligibility/enrollment databases within
twenty-four (24) hours after receipt of said files.
	 
	 	c.	 	The Health Plan shall transmit to the Agency or its agent, in a periodicity
schedule, format and data exchange method to be determined by the Agency, specific data
it may garner from an enrollee including third party liability data.
	 
	 	d.	 	The Health Plan shall be capable of uniquely identifying a distinct Medicaid
recipient across multiple systems within its span of control.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

D. Systems Availability, Performance and Problem Management Requirements

	 	1.	 	Availability of Critical Systems Functions

The Health Plan shall ensure that critical systems functions available to enrollees and
providers, functions that if unavailable would have an immediate detrimental impact on
enrollees and providers, are available twenty-four hours a day, seven days a week (24/7),
except during periods of scheduled system unavailability agreed upon by the Agency and the
Health Plan. Unavailability caused by events outside of a Health Plan’s span of control is
outside the scope of this requirement. The Health Plan shall make the Agency aware of the
nature and availability of these functions prior to extending access to these functions to
enrollees and/or providers.

	 	2.	 	Availability of Data Exchange Functions

The Health Plan shall ensure that the systems and processes within its span of control
associated with its data exchanges with the Agency and/or its agent(s) are available and
operational according to specifications and the data exchange schedule.

	 	3.	 	Availability of Other Systems Functions

The Health Plan shall ensure that at a minimum all other system functions and information
are available to the applicable system users between the hours of 7:00 a.m. and 7:00 p.m.,
in the time zone where the user is located, Monday through Friday.

	 	4.	 	Problem Notification

	 	a.	 	Upon discovery of any problem within its span of control that may jeopardize
or is jeopardizing the availability and performance of all systems functions and the
availability of information in said systems, including any problems affecting
scheduled exchanges of data between the Health Plan and the Agency and/or its
agent(s), the Health Plan shall notify the applicable Agency staff via phone, fax
and/or electronic mail within one (1) hour of such discovery. In its notification the
Health Plan shall explain in detail the impact to critical path processes such as
enrollment management and claims submission processes.

	 	b.	 	The Health Plan shall provide to appropriate Agency staff information on
system unavailability events, as well as status updates on problem resolution. At a
minimum these updates shall be provided on an hourly basis and made available via
electronic mail and/or telephone.

	 	5.	 	Recovery from Unscheduled System Unavailability

Unscheduled system unavailability caused by the failure of systems and telecommunications
technologies within the Health Plan’s span of control will be resolved, and the
restoration of services implemented, within forty-eight (48) hours of the official
declaration of system unavailability.

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	 	HMO Contract

	 	6.	 	Exceptions to System Availability Requirement

The Health Plan shall not be responsible for the availability and performance of systems and
IT infrastructure technologies outside of the Health Plan’s span of control.

	 	7.	 	Information Systems Corrective Action Plan

If at any point there is a problem with a critical systems function, at the request of the
Agency, the Health Plan shall provide to the Agency full written documentation that
includes a corrective action plan (CAP) that describes how problems with critical systems
functions will be prevented from occurring again. The CAP shall be delivered to the Agency
within five (5) business days of the problem’s occurrence. Failure to submit a CAP and to
show progress in implementing the CAP shall make the Health Plan subject to sanctions, in
accordance with Attachment II, Section XIV, Sanctions.

	 	8.	 	Business Continuity-Disaster Recovery (BC-DR) Plan

	 	a.	 	Regardless of the architecture of its systems, the Health Plan shall develop,
and be continually ready to invoke, a business continuity and disaster recovery (BC-DR)
plan that is reviewed and prior-approved by BMHC.

	 	b.	 	At a minimum the Health Plan’s BC-DR plan shall address the following
scenarios: (1) the central computer installation and resident software are destroyed or
damaged; (2) system interruption or failure resulting from network, operating hardware,
software, or operational errors that compromise the integrity of transactions that are
active in a live system at the time of the outage; (3) system interruption or failure
resulting from network, operating hardware, software or operational errors that
compromise the integrity of data maintained in a live or archival system; (4) system
interruption or failure resulting from network, operating hardware, software or
operational errors that do not compromise the integrity of transactions or data
maintained in a live or archival system, but do prevent access to the system, i.e.,
cause unscheduled system unavailability.

	 	c.	 	The Health Plan shall periodically, but no less than annually, by April 30 of
each Contract year, perform comprehensive tests of its BC-DR plan through simulated
disasters and lower level failures in order to demonstrate to the Agency that it can
restore system functions per the standards outlined in the Contract.

	 	d.	 	In the event that the Health Plan fails to demonstrate in the tests of its
BC-DR plan that it can restore system functions per the standards outlined in this
Contract, the Health Plan shall be required to submit to the Agency a corrective action
plan in accordance with Attachment II, Section XIV, Sanctions, that describes how the
failure will be resolved. The corrective action plan shall be delivered within ten (10)
business days of the conclusion of the test.

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

E. System Testing and Change Management Requirements

	 	1.	 	Notification and Discussion of Potential System Changes

The Health Plan shall notify HSD of the following changes to systems within its span of
control at least ninety (90) calendar days before the projected date of the change. If so
directed by the Agency, the Health Plan shall discuss the proposed change with the
applicable Agency staff. This includes: (1) software release updates of core transaction
systems: claims processing, eligibility and enrollment processing, service authorization
management, provider enrollment and data management; (2) conversions of core transaction
management systems.

	 	2.	 	Response to Agency Reports of Systems Problems not Resulting in System
Unavailability

The Health Plan shall respond to Agency reports of system problems not resulting in system
unavailability according to the following timeframes:

	 	a.	 	Within seven (7) calendar days of receipt, the Health Plan shall respond in
writing to notices of system problems.
	 
	 	b.	 	Within twenty (20) calendar days, the correction shall be made or a
requirements analysis and specifications document will be due.
	 
	 	c.	 	The Health Plan shall correct the deficiency by an effective date to be
determined by the Agency.

	 	3.	 	Valid Window for Certain System Changes

Unless otherwise agreed to in advance by the Agency as part of the activities described in
this section, scheduled system unavailability to perform system maintenance, repair and/or
upgrade activities shall not take place during hours that could compromise or prevent
critical business operations.

	 	4.	 	Testing

	 	a.	 	The Health Plan shall work with the Agency pertaining to any testing initiative
as required by the Agency.
	 
	 	b.	 	Upon the Agency’s written request, the Health Plan shall provide details of the
test regions and environments of its core production information systems, including a
live demonstration, to enable the Agency to corroborate the readiness of the Health
Plan’s information systems.

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

F. Information Systems Documentation Requirements

	 	1.	 	Types of Documentation

The Health Plan shall develop, prepare, print, maintain, produce, and distribute distinct
system process and procedure manuals, user manuals and quick-reference guides, and any
updates thereafter, for the Agency and other applicable Agency staff.

	 	2.	 	Content of System Process and Procedure Manuals

The Health Plan shall ensure that written system process and procedure manuals document
and describe all manual and automated system procedures for its information management
processes and information systems.

	 	3.	 	Content of System User Manuals

The system user manuals shall contain information about, and instructions for, using
applicable system functions and accessing applicable system data.

	 	4.	 	Changes to Manuals

	 	a.	 	When a system change is subject to the Agency’s written approval, the Health
Plan shall draft revisions to the appropriate manuals prior to Agency approval of the
change.
	 
	 	b.	 	Updates to the electronic version of these manuals shall occur in real time;
updates to the printed version of these manuals shall occur within ten (10) business
days of the update’s taking effect.

	 	5.	 	Availability of/Access to Documentation

All of the aforementioned manuals and reference guides shall be available in printed form
and/or on-line. If so prescribed, the manuals will be published in accordance with the
appropriate Agency and/or state standard.

G. Reporting Requirements

The Health Plan shall extract and upload data sets, upon request, to a secure FTP site to
enable authorized Agency personnel, or the Agency’s agent, on a secure and read-only basis, to
build and generate reports for management use. The Agency and the Health Plan shall arrange
technical specifications for each data set as required for completion of the request.

H. Community Health Record/Electronic Medical Record and Related Efforts

	 	1.	 	At such times that the Agency requires, the Health Plan shall participate and
cooperate with the Agency to implement, within a reasonable timeframe, secure,
web-accessible, community health records for enrollees.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	2.	 	The design of the vehicle(s) for accessing the community health record, the health
record format and design shall comply with all HIPAA and related regulations.
	 
	 	3.	 	The Health Plan shall also cooperate with the Agency in the continuing development of
the state’s health care data site (www.FloridaHealthFinder.com).

I. Compliance with Standard Coding Schemes

	 	1.	 	Compliance with HIPAA-Based Code Sets

Health Plan systems that are required to or otherwise contain the applicable data type
shall conform to the following HIPAA-based standard code sets; the processes through which
the data are generated should conform to the same standards as needed:

	 	a.	 	Logical Observation Identifier Names and Codes (LOINC);
	 
	 	b.	 	Health Care Financing Administration Common Procedural Coding System
(HCPCS);
	 
	 	c.	 	Home Infusion EDI Coalition (HEIC) Product Codes;
	 
	 	d.	 	National Drug Code (NDC);
	 
	 	e.	 	National Council for Prescription Drug Programs (NCPDP);
	 
	 	f.	 	International Classification of Diseases (ICD-9);
	 
	 	g.	 	Diagnosis Related Group (DRG);
	 
	 	h.	 	Claim Adjustment Reason Codes; and
	 
	 	i.	 	Remittance Remarks Codes.

	 	2.	 	Compliance with Other Code Sets

Health Plan systems that are required to or otherwise contain the applicable data type shall
conform to the following non-HIPAA-based standard code sets:

	 	a.	 	As described in all Agency Medicaid reimbursement handbooks, for all “covered
entities,” as defined under HIPAA, and which submit transactions in paper format
(non-electronic format).
	 
	 	b.	 	As described in all Agency Medicaid reimbursement handbooks for all
“non-covered entities,” as defined under HIPAA.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

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

	 	1.	 	HIPAA-Based Formatting Standards

Health Plan systems shall conform to the following HIPAA-compliant standards for
information exchange effective the first day of operations in the applicable service
region:

	 	a.	 	Batch transaction types

	 	(1)	 	ASC X12N 834 Enrollment and Audit Transaction
	 
	 	(2)	 	ASC X12N 835 Claims Payment Remittance Advice Transaction
	 
	 	(3)	 	ASC X12N 8371 Institutional Claim/Encounter Transaction
	 
	 	(4)	 	ASC X12N 837P Professional Claim/Encounter Transaction
	 
	 	(5)	 	ASC X12N 837D Dental Claim/Encounter Transaction
	 
	 	(6)	 	NCPDP 1.1 Pharmacy Claim/Encounter Transaction

	 	b.	 	Online transaction types

	 	(1)	 	ASC X12N 270/271 Eligibility/Benefit Inquiry/Response
	 
	 	(2)	 	ASC X12N 276 Claims Status Inquiry
	 
	 	(3)	 	ASC X12N 277 Claims Status Response
	 
	 	(4)	 	ASC X12N 278/279 Utilization Review Inquiry/Response
	 
	 	(5)	 	NCPDP 5.1 Pharmacy Claim/Encounter Transaction

	 	2.	 	Methods for Data Exchange

The Health Plan and the Agency and/or its agent shall make predominant use of secure file
transfer protocol (SFTP) and electronic data interchange (EDI) in their exchanges of data.

	 	3.	 	Agency-Based Formatting Standards and Methods

Health Plan systems shall exchange the following data with the Agency and/or its agent in a
format to be jointly agreed upon by the Health Plan and the Agency:

	 	a.	 	Provider network data;
	 
	 	b.	 	Case management fees, if applicable; and
	 
	 	c.	 	Payments.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Section XII

Reporting Requirements

A. Health Plan Reporting Requirements

	 	1.	 	The Health Plan shall comply with all reporting requirements set forth by the Agency in
this Contract. These requirements are summarized in Table 1 in this section.

	 	a.	 	The Health Plan is responsible for assuring the accuracy, completeness,
and timely submission of each report.
	 
	 	b.	 	The Health Plan’s chief executive officer (CEO), chief financial officer
(CFO), or an individual who reports to the CEO or CFO and who has delegated authority
to certify the Health Plan’s reports, shall attest, based on his/her best knowledge,
information, and belief, that all data submitted in conjunction with the reports and
all documents requested by the Agency are accurate, truthful, and complete (see 42 CFR
438.606(a) and (b)).
	 
	 	c.	 	The Health Plan shall submit its certification at the same time it submits
the certified data reports (see 42 CFR 438.606(c)). The certification page shall be
scanned and submitted electronically.
	 
	 	d.	 	Deadlines for report submission referred to in this Contract specify the
actual time of receipt at the Agency bureau or location listed in Table 1 of this
section, not the date the file was postmarked or transmitted.
	 
	 	e.	 	If a reporting due date falls on a weekend or state holiday, the report shall
be due to the Agency on the following business day.
	 
	 	f.	 	All reports filed on a quarterly basis shall be filed on a calendar year quarter.

	 	2.	 	The Health Plan shall use the Health Plan Report Guide in submitting required reports,
including the report formats, templates, instructions, data specifications, submission
timetables and locations, and other materials contained in the guide posted on the
Agency’s web site at:
http://ahca.myflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml.
The Agency shall furnish the Health Plan with appropriate technical
assistance in using the Report Guide.
	 
	 	3.	 	Unless otherwise specified, all reports are to be submitted electronically, as prescribed
in the reporting guidelines.
	 
	 	4.	 	The Agency reserves the right to modify the reporting requirements, with a ninety (90)
calendar day notice to allow the Health Plan to complete implementation, unless otherwise
required by law.
	 
	 	5.	 	The Agency shall provide the Health Plan with written notification of any modifications to
the reporting requirements.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	6.	 	If the Health Plan fails to submit the required reports accurately and within the
timeframes specified, the Agency shall fine or otherwise sanction the Health Plan in
accordance with Attachment II, Section XIV, Sanctions, and 59A-12.0073, FAC.
	 
	 	7.	 	Reports are to be transmitted as described below:

	 	a.	 	If hard copies are required, mail to the following address:

Agency for Health Care Administration

Bureau of Managed Health Care 

2727 Mahan Drive, MS #26

Tallahassee, FL 32308

Or

Transmit electronically to the Agency at the addresses in Table 1.

	 	b.	 	PHI information must be submitted to the Agency SFTP sites.

	 	8.	 	Health Plan reports required by the Agency are as follows as indicated by plan type/
population served. These reports must be submitted as indicated in Table 1 and as specified
in the Health Plan Report Guide.

Table 1

SUMMARY OF REPORTING REQUIREMENTS

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section II

	 	Benefit Maximum Report
	 	Ref HMO; 

Ref FFS PSN;

Ref Cap PSN;
	 	Monthly, fifteen
(15) days after
end of reporting
month once
$450,000 in
enrollee costs
is reached
	 	HSD
Contract
Manager
once
$450,000 is
reached,
and to
BMHC that
initial
month and
monthly
thereafter
through
end of
state fiscal
year
	 
	 	 	 	 	 	 	 	 
	Section III

	 	Newborn Enrollment Report
	 	NR FFS PSN;

Ref FFS PSN;

CCC
	 	Weekly, on Wednesday
	 	Medicaid Area Office

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section III

	 	Involuntary
Disenrollment Report
	 	Ref HMO;

 Ref FFS PSN;

 Ref Cap PSN;

CCC;

HIV/AIDS
	 	Monthly, first
Thursday of month
	 	Choice Counseling
Vendor
	 
	 	 	 	 	 	 	 	 
	Section IV

	 	Medicaid
Redetermination
Notice Summary
Report
	 	All Plans that
participate per
Attachment I
	 	Quarterly, 
forty-five (45)
days after end of
reporting quarter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV

	 	Community Outreach
Health Fairs/Public
Events Notification
	 	All Plans
	 	Monthly, no
later than
20th day
of month before
event month;
amendments two
weeks before event
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV

	 	Community Outreach
Representative
Report
	 	All Plans
	 	Two ( 2) weeks
before activity
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Quarterly, 
forty-five (45)
days
after end of
reporting quarter	 	 
	 
	 	 	 	 	 	 	 	 
	Section V

	 	Customized Benefit
Notifications Report
	 	Ref HMO; Ref Cap PSN
	 	Monthly, fifteen
(15) days after end
of reporting month
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section V

	 	CHCUP (CMS-416) & FL
60% Screening (Child
Health Check Up
report)
	 	All Plans
	 	Annually, unaudited
by January
15th for
prior federal
fiscal year;
Annually, audited
report by October
1st
	 	BMHC

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section V

	 	Inpatient Discharge
Report
	 	NR Ref HMO;

NR Cap PSN;

Ref HMO;

Ref Cap PSN;

HIV/AIDS
	 	Quarterly, thirty
(30) calendar
days after end of
reporting quarter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section V

	 	Hernandez Settlement
Ombudsman Log
	 	NR HMO; 

NR FFS
PSN*;

 NR Cap PSN;

Ref HMO;

Ref FFS PSN*;

Ref Cap PSN;

CCC*;

HIV/AIDS
	 	Quarterly, fifteen
(15) days after end
of reporting
quarter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	* If the FFS
Health Plan has
authorization
requirements
for prescribed
drug services	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Section V

	 	Hernandez Settlement
Agreement Survey
	 	NR HMO;

NR FFS PSN*;

NR Cap PSN;

Ref HMO;

Ref FFS PSN*;

Ref Cap PSN;
	 	Annually, on
August
1st
	 	BMHC
	 

	 	 	 	CCC*;

HIV/AIDS	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	* If the FFS
Health Plan has
authorization
requirements for
prescribed drug
services	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Section V

	 	Quarterly Pharmacy (RX
Quarterly) Encounter
Data Submissions
	 	NR HMO;

NR Cap PSN;

Ref HMO;

Ref Cap PSN;

HIV/AIDS
	 	Quarterly, 30
calendar days
after end of
reporting quarter
	 	MEDS
Team
	 
	 	 	 	 	 	 	 	 
	Section V

	 	Behavioral Health –
Pharmacy Encounter
Data Report
	 	NR HMO;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
	 	Quarterly, forty-five (45) days
after end of
reporting quarter
	 	BMHC

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section V

	 	Pharmacy Navigator
Report
	 	Ref HMO;

 Ref Cap
PSN;

HIV/AIDS
	 	Annually, by
December 1st

	 	Choice Counseling
Vendor
	 
	 	 	 	 	 	 	 	 
	Section V and
Exhibit 4

	 	Enhanced Benefits Report
	 	Ref HMO; 
Ref FFS
PSN; 

Ref Cap PSN;

CCC;

HIV/AIDS
	 	Monthly, ten (10)
days after
end of reporting
month
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health
Annual 80/20
Expenditure Report
	 	NR HMO
	 	Annually, by
April 1st
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health
Critical Incident
Report-Individual
	 	NR HMO;

Ref-HMO;

 Ref. FFS
PSN;

 Ref Cap. PSN;

CCC;

HIV/AIDS
	 	Immediately, no
later than twenty
-four (24) hours
after occurrence or
knowledge of
incident
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health
Critical Incident
Report-Summary
	 	NR HMO;

 Ref HMO;

Ref FFS PSN; 

Ref Cap PSN; 

CCC;

HIV/AIDS
	 	Monthly, on the
15th
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health-Required Staff /Providers Report
	 	NR HMO; 

Ref HMO;

Ref FFS PSN;

 Ref
Cap PSN;

CCC;

 HIV/AIDS
	 	Quarterly,
forty-five (45)
days after end of
reporting quarter
for Health Plans
operating less than
one (1) year;
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Annually, by
August
15th,
for all other
Health Plans	 	 
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health-FARS/CFARS
	 	NR HMO; 

Ref HMO; 

Ref
FFS PSN; 

Ref Cap
PSN; 

CCC;

 HIV/AIDS
	 	Semi-Annually, 
August
15th and
February
15th
	 	BMHC

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section VI, Exhibit
6

	 	Behavioral Health-
Enrollee
Satisfaction Survey
Summary
	 	NR HMO;

Ref HMO; 

Ref FFS
PSN; 

Ref Cap PSN;

CCC;

HIV/AIDS
	 	Annually by
March 1st

	 	BMHC behavioral
health analyst
	 
	 	 	 	 	 	 	 	 
	Section VI, Exhibit
6

	 	Behavioral Health-Stakeholders’
Satisfaction Survey-Summary
	 	NR HMO; 

Ref HMO; 

Ref FFS PSN; 

Ref Cap PSN;

CCC;

 HIV/AIDS
	 	Annually, by
March 1st

	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VI,
Exhibit 6

	 	Behavioral Health-Encounter Data
Report
	 	NR HMO;

 Ref HMO; 

Ref Cap PSN; 

HIV/AIDS
	 	Quarterly, 
forty-five (45)
days after end of
reporting quarter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII

	 	Provider Network File
	 	All Plans
	 	Monthly, First
Thursday of month
(optional weekly
submissions each
Thursday for
remainder of month)
	 	AHCA Choice
Counseling Vendor
for Reform;

For non-Reform, to
Medicaid fiscal
agent and BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII

	 	Provider Termination
and New Provider
Notification Report
	 	All Plans
	 	Monthly, by fifth
calendar day of the
month following the
reporting month
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII

	 	PCP Wait Times Report
	 	ALL Plans
	 	Annually, by
February 1st

	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VIII

	 	Cultural Competency
Plan (and Annual
Evaluation)
	 	All Plans
	 	Annually, October
1st
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IX

	 	Complaints,
Grievance, and
Appeals Report
	 	All Plans
	 	Quarterly, 
fifteen (15) days
after end of
quarter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section X

	 	Performance Measures
	 	All Plans
	 	Annually, on July
1st
	 	BMQM

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section X

	 	MPI — Quarterly Fraud&Abuse Activity Report
	 	All Plans
	 	Quarterly, fifteen (15) days after the end of reporting quarter
	 	MPI
	 
	 	 	 	 	 	 	 	 
	Section X

	 	MPI — Suspected/Confirmed Fraud & Abuse Reporting
	 	All Plans
	 	Within fifteen (15) days of detection
	 	MPI
	 
	 	 	 	 	 	 	 	 
	Section XI

	 	Claims Aging Report & Supplemental Filing Report
	 	All Plans
	 	Quarterly, forty-five
(45) days after end of reporting quarter,
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Capitated Plans, optional
supplemental filing-one-hundred and five (105)
calendar days after end of reporting quarter	 	 
	 
	 	 	 	 	 	 	 	 
	Section XIII

	 	Madicaid Reform Supplemental HIV/AIDS Report
	 	Ref HMO; 
Ref FFS PSN; 

Ref Cap PSN; 

CCC; 

HIV/AIDS
	 	Monthly, by second Thursday of month
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XIII

	 	Catastrophic Component Threshold Report
	 	Ref HMO; 

Ref FFS PSN; 

Ref Cap PSN
	 	Monthly, fifteen (15) days after end of reporting month
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XV

	 	Insolvency Protection Multiple Signatures Agreement Form
	 	NR HMO; 

NR Cap PSN; 

Ref HMO; 

Ref Cap PSN; 

HIV/AIDS
	 	Annually, by April
1st; 

Thirty (30) days after any change
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XV

	 	Audited Annual and Unaudited Quarterly Financial Reports
	 	All Plans except CCC
	 	Audited-Annually April
1st for calendar year;
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Unaudited-Quarterly, forty-five (45) calendar days after end of reporting quarter	 	 

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Report Name	 	Plan Type	 	Frequency	 	Submit To
	Section XVI

	 	Minority Participation Report
	 	All Plans
	 	Monthly, fifteen (15) days after month being reported
	 	BMHC
	 
	 	 	 	 	 	 	 	 

NR HMO = Non-Reform health maintenance organization, includes Health Plans covering

Frail/Elderly Program services as specified in Attachment I

Ref HMO = Reform health maintenance organization

Ref Cap PSN = Reform capitated provider service network

Ref. FFS PSN = Reform Fee-for-Service Provider Service Network

NR Cap. PSN = Non-Reform Capitated Provider Service Network

NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network

CCC = Specialty plan for children with chronic conditions

HIV/AIDS = Specialty plan for recipients living with HIV/AIDS

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Table 2

SUMMARY OF SUBMISSION REQUIREMENTS

2. Other Health Plan submissions (not in Table 1) required by the Agency are as follows:

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Attachment I, Section B., Item3.a.

	 	Increase in enrollment levels
	 	Capitated Health Plans & FFS PSNs
	 	Before increases occur
	 	BMHC and HSD
	 
	 	 	 	 	 	 	 	 
	Attachment I, Section D., Item 3.c.

	 	Changes to optional or expanded services
	 	Capitated Health Plans & FFS PSNs
	 	Annually, by June 15th
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Subsequent references are to Attachment II and its Exhibits

	 
	 	 	 	 	 	 	 	 
	Section II, Item D.4.

	 	Policies, procedures, model provider agreements &
amendments, subcontracts, All materials related to
Contract for distribution to enrollees, providers,
public
	 	All
	 	Before beginning use; whenever changes occur
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section II, Item D.4.a.

	 	Written materials
	 	All
	 	Forty-five (45) calendar days before effective date
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section II, Item D.4.b

	 	Written notice of change to enrollees
	 	All
	 	Thirty (30) calendar days before effective date
	 	Enrollees affected by change
	 
	 	 	 	 	 	 	 	 
	Section II, Item D.6.

	 	Enrollee materials, PDL, provider & enrollee handbooks
	 	All
	 	Available on Health Plan’s web
site without log-in
	 	Plan web site

AHCA Contract No. FA913, Attachment II, Page 154 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section III, Item B.3.c.(1)

	 	Enrollee pregnancy
	 	All
	 	Upon confirmation
	 	DCF & MPI
	 
	 	 	 	 	 	 	 	 
	Section III, 

ltem B.3.c.(3)

	 	Unborn activation notice
	 	All
	 	Presentation for delivery
	 	DCF & MPI
	 
	 	 	 	 	 	 	 	 
	Section III, Item B.3.d.

	 	Birth information if no unborn activation
	 	All
	 	Upon delivery
	 	DCF
	 
	 	 	 	 	 	 	 	 
	Section III, Item C.4.b.

	 	Involuntary disenrollment request
	 	All
	 	Forty-five (45) calendar days before effective date
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section III, Item C.4.e.

	 	Notice that Health Plan is requesting disenrollment in next Contract month
	 	All
	 	Before effective date
	 	Enrollee affected
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A. 1.e.

	 	Notice of reinstatement of enrollee
	 	All
	 	By 1st calendar day of
month after learning of reinstatement or within five (5) calendar days from receipt of enrollment file, whichever is later
	 	Person being reinstated
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.2.a. and Item A.6.a.(17); Section VIII, Item A.4.

	 	How to get Health Plan information in alternative formats
	 	All
	 	Include in cultural competency plan and enrollee handbook, and upon request
	 	Enrolles & potential enrollees
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.2.c.

	 	Right to get information about Health Plan
	 	All
	 	Annually
	 	Enrollees
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.7.c.

	 	Provider directory online file
	 	All
	 	Update monthly & submit attestation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.9.a.

	 	Enrollee assessments
	 	All
	 	Within thirty (30) days of
enrollment notify about pregnancy screening
	 	Enrollees

AHCA Contract No. FA913, Attachment II, Page 155 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section IV, 

Item A.9.c.

	 	Enrollees more than 2 months behind in periodicity screening
	 	All
	 	Contact twice, if needed
	 	Enrollees who meet criteria
	 
	 	 	 	 	 	 	 	 
	Section IV, 

Item A.11.f.

	 	Toll-free help line performance standards
	 	All
	 	Get approval before beginning operation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A. 12. and Item A.,6.a.(17); Section VIII, Item A.4.

	 	How to access translation services
	 	All
	 	Include in cultural competence plan and enrollee handbook
	 	Enrollees
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.14.a.

	 	Incentive program
	 	All
	 	Get approval before offering
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, 

Item A.14.g.

	 	Pre-natal care programs
	 	All
	 	Before implementation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, 
Item A.17.c.

	 	Notice of change in participation
in redetermination notices
	 	All
	 	If Change in participation,
annually, by June 1st
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.17.c.(1)

	 	Redetermination policies & procedures
	 	All
	 	When Health Plan agrees to participate
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item A.17.c.(1)(a)

	 	Notice in writing to discontinue
Medicaid redetermination date data use
	 	All
	 	Thirty (30) calendar days before stopping
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item B.3.c.

	 	Member services phone script responding to community outreach calls and outreach materials
	 	All
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IV, Item B.4.c.

	 	In case of force majeure, notice of participation in health fair or other public event
	 	All
	 	By day of event
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 156 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section IV, Item B.6.f.

	 	Report of staff or community outreach rep. Violations
	 	All
	 	Within fifteen (15) calendar days of knowledge
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section V, Item C.1.

	 	Written details of expanded services
	 	All
	 	Before implementation
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Section V, Item F.

	 	Decision to not offer a service on moral/religious grounds
	 	All
	 	One-hundred and twenty (120) Calendar days before implementation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Thirty (30) calendar days before implementation
	 	Enrollees
	 
	 	 	 	 	 	 	 	 
	Section V, Item H.10.b.2.

	 	UNOS form
& disenrollment request for specified transplants
	 	All
	 	When enrollee listed
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section V, Item H.14.e.

	 	Notice that Health Plan or providers enrolled in VFC program
	 	All
	 	Annually, by October 1st
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section V, Item H.16.a.(4)

	 	PDL update
	 	All
	 	Annually, by October 1st plus thirty-day (30—day) written change notice
	 	BMHC and Bureau of Madicaid Pharmacy Services
	Section VII, Item A.2.

	 	Capacity to provide covered services
	 	All
	 	Before taking enrollment
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII, Item A.3. and Section XII, Table 1

	 	Network provider file
	 	All
	 	Before enrollment and monthly update
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII, Item C.1.

	 	Request for initial or expansion review
	 	All
	 	When requesting initial enrollment or expansion into a county.
	 	BMHC and HSD

AHCA
Contract No. FA913, Attachment II, Page 157 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section VII, Item C.2.

	 	Compliance with access requirements following significant changes in service area or new populations
	 	All
	 	Before expansion
	 	BMHC and HSD
	 
	 	 	 	 	 	 	 	 
	Section VII, Item C.3.

	 	Significant network changes
	 	All
	 	Within seven (7) business days
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII, Item C.5.

	 	When PCP leaves network
	 	All
	 	Within fifteen (15) calendar days of knowledge
	 	BMHC & affected enrollees
	 
	 	 	 	 	 	 	 	 
	Section VII, 
ltem D.2.jj.

	 	Waiver of provider agreement indemnifying clause
	 	All
	 	Approval before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII, Item E.3.

	 	Notice of terminated providers due to imminent danger/impairment
	 	All
	 	Immediate
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VII,

ltem E.4.

	 	Termination or suspension of providers: for “for cause” terminations, include reasons for termination
	 	All
	 	Sixty (60) calendar days before termination effective date
	 	BMHC, affected enrollees, & provider
	 
	 	 	 	 	 	 	 	 
	Section VIII, Item A.1.b.

	 	Written Quality Improvement Plan
	 	All
	 	Within
thirty (30) calendar days of initial Contract execution;
Thereafter, Annually by April 1st
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section Vlll,
Item A.3.a.(6)

	 	Measurement periods and methodologies
	 	All
	 	Any new PIPs before initiation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VIII, Item A.3.a.(7)

	 	Proposal for each planned PIP
	 	All
	 	Ninety (90) calendar days
after Contract execution; Thereafter, Annually by June 1st
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 158 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section VIII, Item A.3.c.(1)

	 	Performance measure data and auditor certification
	 	All
	 	Annually by July 1st
	 	BMQM
	 
	 	 	 	 	 	 	 	 
	Section VIII, 

ltem A.3.c.(4)

	 	Performance measure action plan
	 	All
	 	Within thirty (30) calendar days of determination of unacceptable performance
	 	BMQM
	 
	 	 	 	 	 	 	 	 
	Section VIII,

ltem A.3.e.(7)

	 	Written strategies for medical
record review
	 	All
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VIII, Item A.4.a.

	 	Update cultural competency plan & prior year evaluation
	 	All
	 	Annually, By October 1 for January 1 implementation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VIII, Item B.1.a.(4)(a)

	 	Service authorization protocols & any changes
	 	All
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section VIII, Item B.4.

	 	Changes to UM component
	 	All
	 	Thirty (30) calendar days before effective date
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section IX, Item A.8.

	 	Complaint log
	 	All
	 	Upon request
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section X, Item B.2.

	 	Changes in staffing
	 	All
	 	Five (5) business days of any change
	 	BMHC & HSD
	 
	 	 	 	 	 	 	 	 
	Section X, 

Item B.2.b.

	 	Full-Time Administrator
	 	All
	 	Before designating duties of any other position
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section X, 

Item D.3.a.

	 	Reform and non-Reform historical encounter data for all typical and atypical services
	 	All
	 	According to Agency-approved schedules and no later than 10/31/09
	 	MEDS team & Fiscal Agent

AHCA Contract No. FA913, Attachment II, Page 159 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section X, Item D.3.b.

	 	Encounter data for all typical and atypical services
	 	All
	 	Within sixty (60) calendar days following end of month in which Health Plan paid
claims for services, and as specified in MEDS Companion Guide
	 	MEDS Team & Agency Fiscal Agent
	 
	 	 	 	 	 	 	 	 
	Section X, 

Item E.4.

	 	Fraud & abuse compliance plan & policies & procedures
	 	All
	 	Before implementation
	 	MPI
	 
	 	 	 	 	 	 	 	 
	Section XI, Item D.4.a.

	 	Any problem that threatens system performance
	 	All
	 	Within one (1) hour
	 	Applicable Agency staff
	 
	 	 	 	 	 	 	 	 
	Section XI, Item D.8.a. & Section XVI, Item BB.

	 	Business Continuity-Disaster Recovery Plan
	 	All
	 	Before beginning operation and by May 31 annually thereafter
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XI, Item E.1.

	 	System changes
	 	All
	 	Ninety (90) calendar days before change
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Section XIV, Item A.1.a.

	 	Corrective action plan
	 	All
	 	Within ten (10) business days of notice of violation or non-compliance with Contract
	 	BMHC or MPI if related to fraud/abuse
	 
	 	 	 	 	 	 	 	 
	Section XIV, Item A.1.(b)

	 	Performance measure action plan
	 	All
	 	Within thirty (30) calendar days of notice of failure to meet a performance standard
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XV, Item C.

	 	Proof of working capital
	 	All
	 	Before enrollment
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XV, Item G.2.

	 	Physician incentive plan
	 	All
	 	Written description before use
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 160 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan type	 	Frequency	 	Submit To
	Section XV, Item H.

	 	Third party coverage identified
	 	All
	 	As soon as known
	 	Medicaid Third Party Liability Vendor
	 
	 	 	 	 	 	 	 	 
	Section XV, 

Item I.

	 	Proof of fidelity bond coverage
	 	All
	 	Within sixty (60) calendar
days of Contract execution & before delivering health care
	 	HSD Contract manager
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item C.1.

	 	Assignment of Contract in approved merger/acquisition
	 	All
	 	Ninety (90) days before effective date
	 	BMHC & HSD
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item M.

	 	Use of “Medicaid” or “AHCA”
	 	All
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item O.

	 	All subcontracts for Agency approval
	 	All
	 	Before effective date
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XVI, 

Item O.1.f.

	 	Subcontract monitoring schedule
	 	All
	 	Annually, by December 1
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item V.1.

	 	Ownership & management disclosure forms
	 	All
	 	With initial application; and then annually by September 1
	 	HSD — for initial application; BMHC & HSD for annual
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item V.1.

	 	Changes in ownership & control
	 	All
	 	Within five (5) calendar days of knowledge & sixty (60) days before effective date
	 	BMHC & HSD
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item V.4.

	 	Fingerprints for principals
	 	All
	 	Before Contract execution; Thereafter, annually by September 1
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Section XVI, 

Item V.4.c.

	 	Fingerprints of newly hired principals
	 	All
	 	Within thirty (30) days of hire date
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item V. 5.

	 	Information about offenses listed in 435.03
	 	All
	 	Within five (5) business days of knowledge
	 	HSD

AHCA Contract No. FA913, Attachment II, Page 161 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Section XVI, Item V.6.

	 	Corrective action plan related to principals committing offenses under 435.03
	 	All
	 	As prescribed by the Agency
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item Y.

	 	General insurance policy declaration pages
	 	All
	 	Annually upon renewal
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Section XVI, Item Z.

	 	Workers’ compensation insurance declaration page
	 	All
	 	Annually upon renewal
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 2, Section II, Item D.4.c.

	 	Policies & procedures for screening for clinical eligibility & any changes to them
	 	Specialty Plan for Children with Chronic Conditions
	 	Before implementation
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 3, Section III, Item C.5.

	 	Disenrollment notice
	 	Specialty Plan for Children with Chronic Conditions
	 	Get template approved
before use

 At least
two (2) months before
anticipated effective date
of involuntary
disenrollment
	 	BMHC

 Enrollee
	 
	 	 	 	 	 	 	 	 
	Exhibit 5, Section V, Item A.6.

	 	Letters about exhaustion of benefits under customized benefit package
	 	Reform capitated Health Plans
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 5, Section V, Item H.20.g.

	 	Transportation subcontract
	 	NR HMO offering transportation; Reform Health Plans
	 	Before execution
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 162 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Exhibit 5, Section V, Item H.20.h.

	 	Transportation policies &
procedures
	 	NR HMO offering
transportation; Reform
Health Plans
	 	Before use
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 5, Section V, Item H.20.I.

	 	Transportation adverse incidents
	 	NR HMO offering
transportation; Reform
Health Plans
	 	Within twenty-four (24) hours of occurrence
	 	BMHC & MPI if related to fraud/abuse
	 
	 	 	 	 	 	 	 	 
	Exhibit 5, 

Section V, Item H.20.p.

	 	Performance measures
	 	NR HMO offering
transportation; Reform
Health Plans
	 	By end of
1st month of Contract; Thereafter, annually by August 15
	 	BMQM
	 
	 	 	 	 	 	 	 	 
	Exhibit 5, Section V, Item H.20.q. & r.

	 	Attestation that Health Plan complies with transportation policies & procedures & drivers pass background checks & meet

qualifications
	 	NR HMO offering
transportation; Reform
Health Plans
	 	Annually by January 1
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item A.3.

	 	Review & approval of
behavioral health services staff & sub-contractors for licensure compliance
	 	Reform Health Plans

& NR HMOs
	 	Before providing services
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item B.9.

	 	Model agreement with community mental health centers
	 	Reform Health Plans & NR HMOs
	 	Before agreement is executed
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item M.

	 	Optional services
	 	Plans covering behavioral health
	 	Before offering
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item
R.3.a.

	 	Schedule for administrative and program monitoring and clinical record review
	 	Plans covering behavioral health
	 	Annually by July 1
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 163 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Exhibit 6.

 Item B.12.

	 	Behavioral health staffing

information
	 	Health Plans

covering behavioral

health
	 	Annually, by August
151, if
Health Plan has been
operating twelve
(12) months or more;
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Quarterly if Health
Plan has been
operating less than
twelve (12) months,
due forty-five (45)
days after end of
quarter	 	 
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item C.3.e.

	 	Denied appeals from providers for

emergency services claims
	 	Plans covering

behavioral health
	 	Within ten (10) days
after Health Plan’s
final denial
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item C.5.a.(3)

	 	Medical necessity criteria

for community mental health services
	 	Plans covering

behavioral health
	 	Before use and before
changes implemented
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 
Item L.2.

	 	MBHO staff psychiatrist and model
contracts for each specialty type
	 	Plans covering

behavioral health
	 	Before execution
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6, 

Item M.

	 	Optional services
	 	Plans covering

behavioral health
	 	Before offering
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 6,

 Item R.3.a.

	 	Schedule for administrative and
program monitoring and clinical
record review
	 	Plans covering

behavioral health
	 	Annually by July 1
	 	BMHC

AHCA Contract No. FA913, Attachment II, Page 164 of 186

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 	 	 
	Section	 	Submission	 	Plan Type	 	Frequency	 	Submit To
	Exhibit 8, Section VIII, Item B. 5.

	 	Substitute disease management initiatives
	 	Specialty Plan for

Children with Chronic

Conditions
	 	Within sixty (60) days of Contract execution
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 8, Section VIII, Item A.3.f.

	 	Provider satisfaction survey
	 	All Reform Health Plans
	 	By end of 8th month of Contract
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 8, Section VIII, Item B.5.b.

	 	Policies and procedures and program descriptions for each disease management program
	 	All Reform Heatlh Plans
	 	Annually, by April 1
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 8,
Section VIII, Item B. 1. e. (5)

	 	Caseload maximums for case managers
	 	HIV/AIDS specialty plan
	 	Before providing services
	 	BMHC
	 
	 	 	 	 	 	 	 	 
	Exhibit 10, Section X, Item 

C. 5. a.

	 	Discrepancies in ERV
	 	FFS Health Plans
	 	Within ten (10) business days of discovery
	 	HSD analyst
	 
	 	 	 	 	 	 	 	 
	Exhibit 15, Section XV,
Item A. 1. a.

	 	Plan for
transition from FFS to prepaid capitated plan
	 	FFS PSNs
	 	Last calendar day of 24th month of Health Plan’s initial Reform operation
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Exhibit 15, Section XV, Item A. 1. b.

	 	Conversion application to
capitated health plan
	 	FFS PSNs
	 	By August 1 of 4th year of Reform operation
	 	HSD
	 
	 	 	 	 	 	 	 	 
	Exhibit 15, Section XV, Item I.

	 	Proof of coverage for any non-government subcontractor
	 	Specialty Plan for

Children with Chronic

Conditions
	 	Within sixty (60) days of execution and before delivery of care
	 	BMHC

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	 	HMO Contract

Section XIII

Method of Payment

See Exhibit 13

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	 	HMO Contract

Section XIV

Sanctions

A. General Provisions

	 	1.	 	The Health Plan shall comply with all requirements and performance standards set
forth in this Contract.

	 	(a)	 	In the event the Agency identifies a violation of or other non-compliance
with this Contract, the Health Plan shall submit a corrective action plan (CAP) within
ten (10) business days of the date of receiving notification of the violation or
non-compliance from the Agency.
	 
	 	(b)	 	If the Agency determines that the Health Plan has not met its performance
standards, the Health Plan shall submit a performance measure action plan (PMAP)
within thirty (30) calendar days of receiving notice from the Agency.
	 
	 	(c)	 	In addition to a CAP or PMAP, the Agency may impose sanctions for failure to
follow provisions of this Contract.

	 	2.	 	As allowed in Attachment II, Section XVI, Terms and Conditions, Item I., Disputes,
the Health Plan may appeal any notice of sanction to the Deputy Secretary for Medicaid
(Deputy Secretary) but must do so within twenty-one (21) calendar days from receipt of the
notice of sanction.
	 
	 	3.	 	If monetary sanctions are imposed, they are due from the Health Plan within
twenty-one (21) calendar days from receipt of the notice of sanction and within thirty
(30) days from the date of a final decision rendered by the Deputy Secretary upholding the
sanction.
	 
	 	4.	 	If the Health Plan fails to carry out the substantive terms of the Contract or
fails to meet applicable requirements in ss. 1932 and 1903(m) of the Social Security
Act, the Agency has the authority to terminate the Contract in accordance with 42 CFR
438.708 and may terminate the Contract for violations of 42 CFR 438.700 in addition to
imposing intermediate sanctions.

B. Corrective Action Plans (CAP)

	 	1.	 	The Agency will either approve or disapprove the CAP. If the CAP is disapproved, the
Health Plan shall submit a new CAP within ten (10) business days that addresses the
concerns identified by the Agency.
	 
	 	2.	 	Upon receiving approval of the CAP, the Health Plan shall implement the action steps
set forth in the CAP within the time frames specified by the Agency.
	 
	 	3.	 	If the Health Plan’s CHCUP screening and participation rates are below the eighty
percent (80%) federal goal, the Health Plan shall implement an Agency- accepted CAP that
meets federal requirements. If the Health Plan does not meet the standard established in
the CAP during the time period indicated in the CAP, the Agency may impose sanctions in
accordance with this section.

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	 	4.	 	If the Health Plan’s state-mandated CHCUP screening rate is below sixty percent
(60%), it must implement an Agency-accepted CAP. If the Health Plan does not meet the
standard established in the CAP during the time period indicated in the CAP, the Agency
may impose sanctions in accordance with this section.
	 
	 	5.	 	The Agency shall impose a monetary sanction of $100 per day on the Health Plan for
each calendar day that the approved CAP is not implemented to the satisfaction of the
Agency.

C. Specific Sanctions

	 	1.	 	In accordance with 42 CFR 438.700, the Agency may impose intermediate sanctions
against a Health Plan if it determines that a Health Plan has violated any provision of
this Contract, or any applicable statutes. The Agency may base its determinations on
findings from onsite surveys, enrollee or other complaints, financial status, or any
other source.
	 
	 	2.	 	The Agency determines whether the Health Plan acts or fails to act as follows:

	 	a.	 	Fails substantially to provide medically necessary services the Health Plan
is required to provide, under law or its Contract with the Agency, to an enrollee
covered under the Contract.
	 
	 	b.	 	Imposes on enrollees’ premiums or charges that exceed the premiums or
charges permitted under the Medicaid program.
	 
	 	c.	 	Acts to discriminate among enrollees on the basis of health status or need
for health care services. This includes termination of enrollment or refusal to re-enroll a recipient, except as permitted by the Agency, or any practice that would
reasonably be expected to discourage enrollment by a recipient whose medical condition
or history indicates probable need for substantial future medical services.
	 
	 	d.	 	Misrepresents or falsifies information it furnishes to federal or state officials.
	 
	 	e.	 	Misrepresents or falsifies information it furnishes to an
enrollee, potential enrollee, or provider.
	 
	 	f.	 	Fails to comply with the requirements for physician incentive plans.
	 
	 	g.	 	Distributes directly or indirectly through any agent or independent
contractor, marketing materials that have not been approved by the Agency or contain
false or materially misleading information.
	 
	 	h.	 	Violates any of the other requirements of federal or state law and any
implementing regulations. For a violation under this subparagraph, only the
sanctions specified in Item D., Intermediate Sanctions, sub-items 3., 4., or 5.,
may be imposed.

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D. Intermediate Sanctions

The Agency may impose the following types of intermediate sanctions in accordance with 42 CRF
438.702 for the above violations, including but not limited to:

	 	1.	 	Civil money penalties in the amounts specified below.
	 
	 	2.	 	Appointment of temporary management for the Health Plan in accordance with 42 CFR
438.706.
	 
	 	3.	 	Granting enrollees the right to terminate enrollment without cause and notifying the
affected enrollees of their right to disenroll.
	 
	 	4.	 	Suspension or limitation of all new enrollments, including mandatory enrollments,
after the effective date of the sanction.
	 
	 	5.	 	Suspension of payment for recipients enrolled after the effective date of the
sanction and until CMS or the Agency is satisfied that the reason for imposing the
sanction no longer exists and is not likely to recur.

E. Civil Monetary Penalties

In accordance with 42 CFR 438.704, the Agency may impose the following civil
monetary penalties:

	 	1.	 	For a nonwillful violation, the fine shall not exceed $2,500 per violation and shall
not exceed an aggregate of $10,000 for all nonwillful violations arising out of the same
action.
	 
	 	2.	 	For a willful violation, the Agency may impose a fine not to exceed $20,000 for each
violation not to exceed an aggregate of $100,000 for all knowing and willful violations
arising out of the same action.
	 
	 	3.	 	For purposes of this section, violations involving individual, unrelated recipients
shall not be considered arising out of the same action.
	 
	 	4.	 	For failure to timely and accurately submit data to the Agency as required in this
Contract, the penalty shall be $200 a day beginning on the first day following the due
date. (See 59A-12.0073, FAC.)

F. Notice of Sanction

	 	1.	 	Except as noted in Item D., Intermediate Sanctions, sub-item 2., above, before
imposing any of the sanctions specified in this section, the Agency shall give the Health
Plan timely written notice that explains the basis and nature of the sanction and
applicable due process provisions.
	 
	 	2.	 	Before terminating the Health Plan’s Contract for cause, the Agency shall provide a
pre-termination hearing as follows:

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	 	a.	 	Provide written notice of intent to terminate, the reason, and the time and place
of the hearing;
	 
	 	b.	 	After the hearing, provide written notice of the decision affirming or reversing
the proposed termination of the Contract and, for an affirming decision, the effective
date of termination; and
	 
	 	c.	 	For an affirming decision, notify Health Plan enrollees of the termination along
with information on their options for receiving services following Contract termination.

	 	3.	 	Unless the duration of a sanction is specified, a sanction shall remain in effect until
the Agency is satisfied that the basis for imposing the sanction has been corrected and is
not likely to recur.
	 
	 	4.	 	For FFS PSNs, the Agency reserves the right to withhold all or a portion of the Health
Plan’s monthly administrative allocation for any amount owed pursuant to this section.

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	 	HMO Contract

Section XV 

Financial Requirements

A. Insolvency Protection — See Attachment II, Exhibit 15

B. Insolvency Protection Account Waiver — See Attachment II, Exhibit 15

C. Surplus Start Up Account

All new private entity capitated Health Plans, after initial Contract execution but before
initial enrollment, shall submit to BMHC proof of working capital in the form of cash or
liquid assets excluding revenues from Medicaid payments equal to at least the first three
(3) months of operating expenses or $200,000, whichever is greater. This provision shall
not apply to Health Plans that have been providing services to enrollees for a period
exceeding three (3) continuous months.

D. Surplus Requirement

In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at all times a
surplus amount equal to the greater of $1.5 million, ten percent (10%) of total
liabilities, or two percent (2%) of the annualized amount of the Health Plan’s prepaid
revenues. In the event that the Health Plan’s surplus (as defined in Attachment II, Section
I, Definitions and Acronyms) falls below the amount specified in this paragraph, the Agency
shall prohibit the Health Plan from engaging in community outreach activities, shall cease
to process new enrollments until the required balance is achieved, or may terminate the
Health Plan’s Contract.

E. Interest

Interest generated through investments made by the Health Plan under this Contract shall be
the property of the Health Plan and shall be used at the Health Plan’s discretion.

F. Inspection and Audit of Financial Records

The state, CMS, and DHHS may inspect and audit any financial records of the Health Plan or
its subcontractors. Pursuant to s. 1903(m)(4)(A) of the Social Security Act and state
Medicaid Manual 2087.6(A-B), non-federally qualified Health Plans shall report to the state,
upon request, and to the Secretary and the Inspector General of DHHS, a description of
certain transactions with parties of interest as defined in s. 1318(b) of the Social
Security Act.

G. Physician Incentive Plans

	 	1.	 	Physician incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h), 42
CFR 422.208 and 42 CFR 422.210 and shall not contain provisions that provide
incentives for withholding medically necessary care.

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	 	2.	 	The Health Plan shall disclose information on physician incentive plans listed in 42
CFR 417.479(h)(1) and 42 CFR 417.479(i) at the times indicated in 42 CFR 417.479(d)-(g).
All such arrangements shall be submitted to BMHC for approval, in writing, prior to use.
If any other type of withhold arrangement currently exists, it must be omitted from all
provider contracts.

H. Third Party Resources — See Attachment II, Exhibit 15

The Health Plan shall make every reasonable effort to determine the legal liability of third
parties to pay for services rendered to enrollees under this Contract and notify the Agency’s
third party liability vendor of any third party creditable coverage discovered.

I. Fidelity Bonds — See Attachment II, Exhibit 15

The Health Plan shall secure and maintain during the life of this Contract a blanket fidelity
bond from a company doing business in the State of Florida on all personnel in its employment.
The bond shall be issued in the amount of at least $250,000 per occurrence. Said bond shall
protect the Agency from any losses sustained through any fraudulent or dishonest act or acts
committed by any employees of the Health Plan and subcontractors, if any. Proof of coverage
shall be submitted to the Agency’s Contract Manager within sixty (60) calendar days after
execution of the Contract and prior to the delivery of health care. To be acceptable to the
Agency for fidelity bonds, a surety company shall comply with the provisions of Chapter 624,
F.S.

J. Financial Reporting — Excludes the Specialty Plan for Children with Chronic Conditions

The Health Plan shall submit to BMHC an annual financial report and quarterly unaudited
financial statements in accordance with Attachment II, Section XII, Reporting Requirements, and
with any modification specified in Attachment II, Exhibit 15.

	 	1.	 	The Health Plan shall submit to BMHC the audited financial statements no later than
three (3) calendar months after the end of the Health Plan’s fiscal year, and submit the
quarterly statements no later than forty-five (45) calendar days after each calendar
quarter and shall use generally accepted accounting principles in preparing the
statements.
	 
	 	2.	 	The Health Plan shall submit annual and quarterly financial statements that are
specific to the operations of the Health Plan rather than to a parent or umbrella
organization.

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	 	HMO Contract

Section XVI 

Terms and Conditions

A. Agency Contract Management

	 	1.	 	The Agency’s Division of Medicaid (Division) shall be responsible for management of
the Contract. The Division shall make all statewide policy decisions or Contract
interpretation. In addition, the Division shall be responsible for the interpretation of
all federal and state laws, rules and regulations governing, or in any way affecting,
this Contract. Contract management shall be conducted in good faith, with the best
interest of the state and the Medicaid recipients it serves being the prime
consideration. The Agency shall provide final interpretation of general Medicaid policy.
When interpretations are required, the Health Plan shall submit written requests to the
Agency’s Contract Manager.
	 
	 	2.	 	The terms of this Contract do not limit or waive the ability, authority or
obligation of the Office of Inspector General, MPI, its contractors, or other duly
constituted government units (state or federal) to audit or investigate matters related
to, or arising out of this Contract.
	 
	 	3.	 	The Contract shall be amended only as follows:

	 	a.	 	The parties cannot amend or alter the terms of this Contract
without a written amendment and/or change order to the Contract.
	 
	 	b.	 	The Agency and the Health Plan understand that any such written amendment to
amend or alter the terms of this Contract shall be executed by an officer of each
party, who is duly authorized to bind the Agency and the Health Plan.

B. Applicable Laws and Regulations

	 	1.	 	The Health Plan shall comply with all applicable federal and state laws, rules
and regulations including but not limited to: Title 42 CFR Chapter IV, Subchapter C;
Title 45 CFR Part 74, General Grants Administration Requirements; Chapters 409 and
641, F.S.; all applicable standards, orders, or regulations issued pursuant to the
Clean Air Act of 1970 as amended (42 USC 1857, et seq.); Title VI of the Civil Rights
Act of 1964 (42 USC 2000d) in regard to persons served; Title IX of the education
amendments of 1972 (regarding education programs
and activities); 42 CFR 431, Subpart F; s. 409.907(3)(d), F.S., and Rule 59G-8.100
(24)(b), F.A.C. in regard to the Contractor safeguarding information about enrollees;
Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
applicants for employment; Rule 59G-8.100, F.A.C.; Section 504 of the Rehabilitation
Act of 1973, as amended, 29 USC 794 (which prohibits discrimination on the basis of
handicap in programs and activities receiving or benefiting from federal financial
assistance); the Age Discrimination Act of 1975, as amended, 42 USC 6101 et. seq.
(which prohibits discrimination on the basis of age in programs or activities receiving
or benefiting from federal financial assistance); the Omnibus Budget Reconciliation Act
of 1981, P.L. 97-35, which prohibits discrimination on the basis of sex and religion in
programs and activities

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	 	 	 	receiving or benefiting from federal financial assistance; Medicare — Medicaid Fraud
and Abuse Act of 1978; the federal Omnibus Budget Reconciliation Acts; Americans with
Disabilities Act (42 USC 12101, et seq.); the Newborns’ and Mothers’ Health Protection
Act of 1996, the Balanced Budget Act of 1997, and the Health Insurance Portability and
Accountability Act of 1996.
	 
	 	2.	 	The Health Plan is subject to any changes in federal and state law, rules,
or regulations.

C. Assignment

Except as provided below, or with the prior written approval of the Agency, this Contract
and the monies which may become due are not to be assigned, transferred, pledged or
hypothecated in any way by the Health Plan, including by way of an asset or stock purchase
of the Health Plan, and shall not be subject to execution, attachment or similar process
by the Health Plan.

	 	1.	 	When a merger or acquisition of a Health Plan has been approved, the Agency shall
approve the assignment or transfer of the appropriate Medicaid Health Plan Contract upon
the request of the surviving entity of the merger or acquisition if the Health Plan and
the surviving entity have been in good standing with the Agency for the most recent
twelve month (12-month) period, unless the Agency determines that the assignment or
transfer would be detrimental to Medicaid recipients or the Medicaid program (see s.
409.912, F.S.). The entity requesting the assignment or transfer shall notify the Agency
of the request ninety (90) days before the anticipated effective date.
	 
	 	2.	 	Entities regulated by the Department of Financial Services, Office of Insurance
Regulation (OIR), must comply with provisions of s. 628.4615, F.S., and receive OIR
approval before a merger or acquisition can occur.
	 
	 	3.	 	For the purposes of this section, a merger or acquisition means a change in
controlling interest of a Health Plan, including an asset or stock purchase.
	 
	 	4.	 	To be in good standing, a Health Plan shall not have failed accreditation or
committed any material violation of the requirements of s. 641.52, F.S., and shall meet
the Medicaid Contract requirements.

D. Attorney’s Fees

In the event of a dispute, each party to the Contract shall be responsible for its
own attorneys’ fees, except as otherwise provided by law.

E. Conflict of Interest

This Contract is subject to the provisions of Chapter 112, F.S. The Health Plan shall
disclose to HSD within ten (10) business days of discovery the name of any officer,
director, or agent who is an employee of the State of Florida, or any of its agencies.
Further, the Health Plan shall disclose the name of any state employee who owns, directly
or indirectly, an interest of five percent (5%) or more in the Health Plan or any of its
affiliates. The Health Plan covenants that it presently has no interest and

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shall not acquire any interest, direct or indirect, which would conflict in any manner or
degree with the performance of the services hereunder. The Health Plan further covenants
that in the performance of the Contract no person having any such known interest shall be
employed. No official or employee of the Agency and no other public official of the State of
Florida or the federal government who exercises any functions or responsibilities in the
review or approval of the undertaking of carrying out the Contract shall, prior to
completion of this Contract, voluntarily acquire any personal interest, direct or indirect,
in this Contract or proposed Contract.

F. Contract Variation

If any provision of the Contract (including items incorporated by reference) is declared or
found to be illegal, unenforceable, or void, then both the Agency and the Health Plan shall
be relieved of all obligations arising under such provisions. If the remainder of the
Contract is capable of performance, it shall not be affected by such declaration or finding
and shall be fully performed. In addition, if the laws or regulations governing this
Contract should be amended or judicially interpreted as to render the fulfillment of the
Contract impossible or economically infeasible, both the Agency and the Health Plan shall be
discharged from further obligations created under the terms of the Contract. However, such
declaration or finding shall not affect any rights or obligations of either party to the
extent that such rights or obligations arise from acts performed or events occurring prior
to the effective date of such declaration or finding.

G. Court of Jurisdiction or Venue

For purposes of any legal action occurring as a result of, or under, this Contract, between
the Health Plan and the Agency, the place of proper venue shall be Leon County.

H. Damages for Failure to Meet Contract Requirements

In addition to remedies available through this Contract, in law or equity, the Health Plan
shall reimburse the Agency for any federal disallowances or sanctions imposed on the Agency
as a result of the Health Plan’s failure.

I. Disputes

	 	1.	 	The Health Plan may request in writing an interpretation of the Contract from
the Contract Manager. In the event the Health Plan disputes the interpretation or
any sanction imposed by the Agency, the Health Plan shall request that the dispute be
decided by the Deputy Secretary for Medicaid (Deputy Secretary). The Health Plan
shall submit, within twenty-one (21) days of said interpretation or sanction, a
written request disputing the interpretation or sanction directly to the Deputy
Secretary. The ability to dispute an interpretation does not apply to language in the
Contract that is based on federal or state statute, regulation or case law.
	 
	 	2.	 	The Deputy Secretary shall reduce the decision to writing and serve a copy to
the Health Plan. The written decision of the Deputy Secretary shall be final. The
Deputy Secretary will render the final decision based upon the written

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	 	 	 	submission of the Health Plan and the Agency, unless, at the sole discretion of the
Deputy Secretary, the Deputy Secretary allows an oral presentation by the Health Plan
and the Agency. If such a presentation is allowed, the information presented will be
considered in rendering the decision.
	 
	 	3.	 	In the event the Health Plan challenges the decision of the Deputy Secretary, the
Agency action shall not be stayed except by order of the court.
	 
	 	4.	 	Without limiting the foregoing, the exclusive venue of any legal or equitable action
that arises out of or relates to the Contract, including an appeal of the final decision
of the Deputy Secretary, shall be the appropriate state court in Leon County, Florida; in
any such action, Florida law shall apply and the parties waive any right to a jury trial.
	 
	 	5.	 	Pending final determination of any dispute over an Agency decision, the Health Plan
shall proceed diligently with the performance of the Contract and in accordance with the
direction of the Agency.

J. Force Majeure

The Agency shall not be liable for any excess cost to the Health Plan if the Agency’s
failure to perform the Contract arises out of causes beyond the control and without the
result of fault or negligence on the part of the Agency. In all cases, the failure to
perform must be beyond the control without the fault or negligence of the Agency. The
Health Plan shall not be liable for performance of the duties and responsibilities of the
Contract when its ability to perform is prevented by causes beyond its control. These acts
must occur without the fault or negligence of the Health Plan. These include destruction to
the facilities due to hurricanes, fires, war, riots, and other similar acts.

K. Legal Action Notification

The Health Plan shall give HSD, by certified mail, immediate written notification (no later
than thirty (30) calendar days after service of process) of any action or suit filed or of
any claim made against the Health Plan by any subcontractor, vendor, or other party that
results in litigation related to this Contract for disputes or damages exceeding the amount
of $50,000. In addition, the Health Plan shall immediately advise HSD of the insolvency of
a subcontractor or of the filing of a petition in bankruptcy by or against a principal
subcontractor.

L. Licensing (See Attachment II, Exhibit 16)

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

No person or Health Plan may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication, or a
broadcast, telecast, or other production, alone or with other words, letters, symbols or
emblems the words “Medicaid,” or “Agency for Health Care Administration,” except as
required in the Agency’s Standard Contract, Section I., Item N., Sponsorship, unless prior
written approval is obtained from the Agency. Specific written authorization from the
Agency is required to reproduce, reprint, or distribute

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any Agency form, application, or publication for a fee. State and local governments are
exempt from this prohibition. A disclaimer that accompanies the inappropriate use of
program or Agency terms does not provide a defense. Each piece of mail or information
constitutes a violation.

N. Offer of Gratuities

By signing this agreement, the Health Plan signifies that no member of, or a delegate of,
Congress, nor any elected or appointed official or employee of the State of Florida, the
Government Accountability Office, DHHS, CMS, or any other federal agency has or shall
benefit financially or materially from this procurement. This Contract may be terminated
by the Agency if it is determined that gratuities of any kind were offered to, or received
by, any officials or employees from the state, its agents, or employees.

O. Subcontracts (See Attachment II, Exhibit 16)

The Health Plan shall be responsible for all work performed under this Contract, but may,
with the prior written approval of the Agency, enter into subcontracts for the performance
of work required under this Contract.

	 	1.	 	All subcontracts must comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR 455.105
and 42 CFR 455.106. All subcontracts and amendments executed by the Health Plan shall
meet the following requirements.

	 	a.	 	If the Health Plan is capitated, all subcontractors must be eligible for
participation in the Medicaid program; however, the subcontractor is not required to
participate in the Medicaid program as a provider.
	 
	 	b.	 	If a subcontractor was involuntarily terminated from the Medicaid program
other than for purposes of inactivity, that entity is not considered an eligible
subcontractor.
	 
	 	c.	 	The Agency encourages use of minority business enterprise subcontractors. See
Attachment II, Section VII, Provider Network, Item D., Provider Contract Requirements,
for provisions and requirements specific to provider contracts. See Attachment II,
Section XVI, Terms and Conditions, Item W., Minority Recruitment and Retention Plan,
for other minority recruitment and retention plan requirements. The Health Plan shall
provide a monthly Minority Participation Report (See Attachment II, Section XII,
Reporting Requirements, Table 1), to BMHC summarizing the business it does with minority
subcontractors or vendors.

	 	(1)	 	The Agency will use this information for assessment and evaluation of
the Agency’s Minority Business Utilization Plan. During the term of the Contract,
the Health Plan shall provide this information monthly by the fifteenth
(15th) day after the reporting month.
	 
	 	(2)	 	The Agency may waive this requirement, in writing, if at least one of
the following is true:

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	 	(a)	 	The Health Plan demonstrates that it is at least fifty-one
percent (51%) minority-owned;
	 
	 	(b)	 	At least fifty-one percent (51 %) of its board of directors
belong to a minority;
	 
	 	(c)	 	At least fifty-one percent (51%) of its officers belong to a minority; or
	 
	 	(d)	 	The Health Plan is a not-for-profit corporation and
at least
fifty-one percent (51 %) of the population it serves belong to a minority.

	 	(3)	 	If the Health Plan has been approved by the Agency for a waiver of this
report requirement, it must submit a request for waiver renewal annually, in
writing, to HSD by September 1 of each Contract year.
	 
	 	(4)	 	If this report requirement has not been waived in writing by the Agency,
the Health Plan shall submit a monthly Minority Participation Report to the BMHC and
to the designated HSD Minority Participation Report contact person by the fifteenth
(15th) day of the month following the month being reported.

	 	d.	 	Subcontractors are subject to background checks. The Health Plan shall consider
the nature of the work a subcontractor or agent will perform in determining the level
and scope of the background checks.
	 
	 	e.	 	The Health Plan shall document compliance certification (business-to-business)
testing of transaction compliance with HIPAA for any subcontractor receiving enrollee
data.
	 
	 	f.	 	No subcontract that the Health Plan enters into with respect to performance under
the Contract shall, in any way, relieve the Health Plan of any responsibility for the
performance of duties under this Contract. The Health Plan shall assure that all tasks
related to the subcontract are performed in accordance with the terms of this Contract
and shall provide BMHC with its monitoring schedule annually by December 1 of each
Contract year. The Health Plan shall identify in its subcontracts any aspect of service
that may be further subcontracted by the subcontractor.

	 	2.	 	All model and executed subcontracts and amendments used by the Health Plan under this
Contract shall be in writing, signed, and dated by the Health Plan and
the subcontractor and meet the following requirements:

a. Identification of conditions and method of payment:

	 	(1)	 	The Health Plan agrees to make payment to all subcontractors pursuant to
all state and federal laws, rules and regulations, specifically, s. 641.3155, F.S.,
42 CFR 447.46, and 42 CFR 447.45(d)(2), (3), (d)(5) and (d)(6);
	 
	 	(2)	 	Provide for prompt submission of information needed to make payment;

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	 	(3)	 	Provide for full disclosure of the method and amount of compensation or
other consideration to be received from the Health Plan;
	 
	 	(4)	 	Require an adequate record system be maintained for recording services,
charges, dates and all other commonly accepted information elements for services
rendered to the Health Plan; and
	 
	 	(5)	 	Specify that the Health Plan shall assume responsibility for cost
avoidance measures for third party collections in accordance with Attachment II,
Section XV, Financial Requirements.

b. Provisions for monitoring and inspections:

	 	(1)	 	Provide that the Agency and DHHS may evaluate through inspection or other
means the quality, appropriateness and timeliness of services performed;
	 
	 	(2)	 	Provide for inspections of any records pertinent to the Contract by the
Agency and DHHS;
	 
	 	(3)	 	Require that records be maintained for a period not less than five years
from the close of the Contract and retained further if the records are under review
or audit until the review or audit is complete. (Prior approval for the disposition
of records must be requested and approved by the Health Plan if the subcontract is
continuous.);
	 
	 	(4)	 	Provide for monitoring and oversight by the Health Plan and the
subcontractor to provide assurance that all licensed medical professionals are
credentialed in accordance with the Health Plan’s and the Agency’s credentialing
requirements as found in Attachment II, Section VII, Provider Network, Item H.,
Credentialing and Recredentialing, if the Health Plan has delegated the
credentialing to a subcontractor; and
	 
	 	(5)	 	Provide for monitoring of services rendered to Health Plan enrollees
through the subcontractor.

c. Specification of functions of the subcontractor:

	 	(1)	 	Identify the population covered by the subcontract;
	 
	 	(2)	 	Provide for submission of all reports and clinical information required
by the Health Plan, including CHCUP reporting (if applicable); and
	 
	 	(3)	 	Provide for the participation in any internal and external quality
improvement, utilization review, peer review, and grievance procedures established
by the Health Plan.

d. Protective clauses:

	 	(1)	 	Require safeguarding of information about enrollees according to
42 CFR, Part 438.224.

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	 	(2)	 	Require compliance with HIPAA privacy and security provisions.
	 
	 	(3)	 	Require an exculpatory clause, which survives subcontract termination,
including breach of subcontract due to insolvency, which assures that Medicaid
recipients or the Agency will not be held liable for any debts of the subcontractor.
	 
	 	(4)	 	If there is a Health Plan physician incentive plan, include a statement
that the Health Plan shall make no specific payment directly or indirectly under a
physician incentive plan to a subcontractor as an inducement to reduce or limit
medically necessary services to an enrollee, and affirmatively state that all
incentive plans do not provide incentives, monetary or otherwise, for the
withholding of medically necessary care;
	 
	 	(5)	 	Require full cooperation in any investigation by the Agency, MPI, MFCU or
other state or federal entity or any subsequent legal action that may result from
such an investigation;
	 
	 	(6)	 	Contain a clause indemnifying, defending and holding the Agency and the
Health Plan’s enrollees harmless from and against all claims, damages, causes of
action, costs or expenses, including court costs and reasonable attorney fees, to
the extent proximately caused by any negligent act or other wrongful conduct arising
from the subcontract agreement. This clause must survive the termination of the
subcontract, including breach due to insolvency. The Agency may waive this
requirement for itself, but not Health Plan enrollees, for damages in excess of the
statutory cap on damages for public entities, if the subcontractor is a state agency
or subdivision as defined by s. 768.28, F.S., or a public health entity with
statutory immunity. All such waivers must be approved in writing by the Agency;
	 
	 	(7)	 	Require that the subcontractor secure and maintain, during the life of
the subcontract, workers’ compensation insurance for all of its employees connected
with the work under this Contract unless such employees are covered by the
protection afforded by the Health Plan. Such insurance shall comply with Florida’s
Workers’ Compensation Law;
	 
	 	(8)	 	Specify that if the subcontractor delegates or subcontracts any functions
of the Health Plan, that the subcontract or delegation includes all the requirements
of this Contract;
	 
	 	(9)	 	Make provisions for a waiver of those terms of the subcontract, which, as
they pertain to Medicaid recipients, are in conflict with the specifications of this
Contract;
	 
	 	(10)	 	Provide for revoking delegation, or imposing other sanctions, if the subcontractor’s
performance is inadequate;
	 
	 	(11)	 	Provide that compensation to individuals or entities that conduct utilization
management activities is not structured so as to provide incentives for the

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	 	 	 	individual or entity to deny, limit, or discontinue medically necessary services to
any enrollee; and
	 
	 	(12)	 	Provide details about the following as required by Section 6032 of the
federal Deficit Reduction Act of 2005:

	 	(a)	 	The False Claim Act;
	 
	 	(b)	 	The penalties for submitted false claims and statements;
	 
	 	(c)	 	Whistleblower protections; and
	 
	 	(d)	 	The law’s role in preventing and detecting fraud, waste and
abuse, and each person’s responsibility relating to detection and prevention.

P. Hospital Provider Contracts

All hospital provider contracts must meet the requirements outlined in Attachment II,
Section VII, Provider Network D., Provider Contract Requirements. In addition, hospital
provider contracts shall require that the hospitals notify the Health Plan of enrollee
pregnancies and births where the mother is a Health Plan enrollee. The hospital provider
contract must also specify which entity (Health Plan or hospital) is responsible for
completing the DCF Excel spreadsheet and submitting it to the appropriate DCF Customer Call
Center. The hospital provider contract must also indicate that the Health Plan’s name shall
be indicated as the referring agency when the DCF Excel spreadsheet is completed. (See
Attachment II, Section III, Eligibility and Enrollment)

Q. Termination Procedures

	 	1.	 	In conjunction with the Standard Contract, Section III., Item B., Termination, all
provider contracts and subcontracts shall contain termination procedures. The Health Plan
agrees to extend the thirty (30) calendar-day notice found in the Standard Contract,
Section III., Item B.1., Termination at Will, to one-hundred and twenty (120) calendar
days’ notice. The Health Plan will work with the Agency to create a transition plan,
including the orderly and reasonable transfer of enrollee care and progress whether or not
they are hospitalized. Depending on the volume of Health Plan enrollees affected, the
Agency may require an extension of the
termination date. The party initiating the termination shall render written notice of
termination to the other party by certified mail, return receipt requested, or in person
with proof of delivery, or by facsimile letter followed by certified mail, return receipt
requested. The notice of termination shall specify the nature of termination, the extent to
which performance of work under the Contract is terminated, and the date on which such
termination shall become effective. In accordance with s. 1932(e)(4), Social Security Act,
the Agency shall provide the Health Plan with an opportunity for a hearing prior to
termination for cause. This does not preclude the Agency from terminating without cause.
	 
	 	2.	 	Upon receipt of final notice of termination, on the date and to the extent specified in
the notice of termination, the Health Plan shall:

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	 	HMO Contract

	 	a.	 	Continue work under the Contract until the termination date unless
otherwise required by the Agency;
	 
	 	b.	 	Cease enrollment of new enrollees under the Contract;
	 
	 	c.	 	Terminate all community outreach activities and subcontracts relating
to community outreach;
	 
	 	d.	 	Assign to the state those subcontracts as directed by the Agency’s
contracting officer including all the rights, title and interest of the Health Plan
for performance of those subcontracts;
	 
	 	e.	 	In the event the Agency has terminated this Contract in one or more Agency
areas of the state, complete the performance of this Contract in all other areas in
which the Health Plan’s Contract was not terminated;
	 
	 	f.	 	Take such action as may be necessary, or as the Agency’s contracting officer
may direct, for the protection of property related to the Contract that is in the
possession of the Health Plan and in which the Agency has been granted or may acquire
an interest;
	 
	 	g.	 	Not accept any payment after the Contract ends, unless the payment is for the
time period covered under the Contract. Any payments due under the terms of this
Contract may be withheld until the Agency receives from the Health Plan all written
and properly executed documents as required by the written instructions of the Agency;
	 
	 	h.	 	At least sixty (60) calendar days before the termination effective
date, provide written notification to all enrollees of the following
information: the date on which the Health Plan will no longer participate in the
state’s Medicaid program and instructions on contacting the
Agency’s choice counselor/enrollment broker help line to obtain information on
enrollment options and to request a change in health plans.

R. Waiver

No covenant, condition, duty, obligation, or undertaking contained in or made a part of
the Contract shall be waived except by written agreement of the parties, and
forbearance or indulgence in any other form or manner by either party in any regard
whatsoever shall not constitute a waiver of the covenant, condition, duty, obligation, or
undertaking to be kept, performed, or discharged by the party to which the same may apply.
Until complete performance or satisfaction of all such covenants, conditions, duties,
obligations, or undertakings, the other party shall have the right to invoke any remedy
available under law or equity notwithstanding any such forbearance or indulgence.

S. Withdrawing Services from a County

If the Health Plan intends to withdraw services from a county, the Health Plan shall provide
the Agency with one-hundred and twenty (120) calendar days’ notice and work with the Agency to
develop a transition plan. The Health Plan shall provide

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	 	HMO Contract

written notice to all enrollees in that county at least sixty (60) calendar days before the
last day of service. The notice shall contain the same information as required for a notice
of termination according to Attachment II, Section XVI, Terms and Conditions, Item Q.,
Termination Procedures. The Health Plan shall also provide written notice of the withdrawal
to all providers and subcontractors in the county.

T. MyFloridaMarketPlace Vendor Registration

The Health Plan is exempt under Rule 60A-1.030(3)d(ii), FAC, from being required to register in
MyFloridaMarketPlace for this Contract.

U. MyFloridaMarketPlace Vendor Registration and Transaction Fee Exemption

The Health Plan is exempt from paying the one percent (1%) transaction fee per 60A-1.032(1)(g),
FAC, for this Contract.

V. Ownership and Management Disclosure

The Health Plan shall fully disclose ownership, management and control of disclosing
entities in accordance with state and federal law.

	 	1.	 	Disclosure shall be made on forms prescribed by the Agency for the areas of ownership
and control interest (42 CFR 455.104, Form CMS 1513); business transactions (42 CFR
455.105); conviction of crimes (42 CFR 455.106); public entity crimes (s. 287.133(3)(a),
F.S.); and disbarment and suspension (52 Fed. Reg., pages 20360-20369, and Section 4707 of
the Balanced Budget Act of 1997). The forms are available through the Agency and are to be
submitted to HSD with the initial application for a Medicaid Health Plan and annually to
HSD and BMHC by September 1 of each Contract year thereafter. In addition, the Health Plan
shall submit to the BMHC and HSD full disclosure of ownership and control of the Health
Plan and any changes in management within five calendar days of knowing the change will
occur and at least sixty (60) calendar days before any change in the Health Plan’s
ownership or control takes effect.
	 
	 	2.	 	The following definitions apply to ownership disclosure:

	 	a.	 	A person with an ownership interest or control interest means a person or
corporation that:

	 	(1)	 	Owns, indirectly or directly, five percent (5%) or more of the Health
Plan’s capital or stock, or receives five percent (5%) or more of its profits;
	 
	 	(2)	 	Has an interest in any mortgage, deed of trust, note, or other
obligation secured in whole or in part by the Health Plan or by its property or
assets and that interest is equal to or exceeds five percent of the total property
or assets; or
	 
	 	(3)	 	Is an officer or director of the Health Plan, if organized as a
corporation, or is a partner in the Health Plan, if organized as a partnership.

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	 	b.	 	The percentage of direct ownership or control is calculated by multiplying the
percent of interest that a person owns by the percent of the Health Plan’s assets used
to secure the obligation. Thus, if a person owns ten percent (10%) of a note secured by
sixty percent (60%) of the Health Plan’s assets, the person owns six percent (6%) of the
Health Plan.
	 
	 	c.	 	The percent of indirect ownership or control is calculated by multiplying the
percentage of ownership in each organization. Thus, if a person owns ten percent (10%)
of the stock in a corporation, which owns eighty percent (80%) of the Health Plan’s
stock, the person owns eight percent (8%) of the Health Plan.

	 	3.	 	The following definitions apply to management disclosure:

	 	a.	 	Changes in management are defined as any change in the management control of the
Health Plan. Examples of such changes are those listed below and in Section X,
Attachment II, or equivalent positions by another title.
	 
	 	b.	 	Changes in the board of directors or officers of the Health Plan, medical
director, chief executive officer, administrator, and chief financial officer.
	 
	 	c.	 	Changes in the management of the Health Plan where the Health Plan has decided to
contract out the operation of the Health Plan to a management corporation. The Health
Plan shall disclose such changes in management control and provide a copy of the
contract to the Agency for approval at least sixty (60) calendar days prior to the
management contract start date.

	 	4.	 	By September 1 of each Contract Year, the Health Plan shall conduct an annual background
check with the Florida Department of Law Enforcement on all persons with five percent (5%) or
more ownership interest in the Health Plan, or who have executive management responsibility
for the Health Plan, or have the ability to exercise effective control of the Health Plan
(see ss. 409.912 and 435.03, F.S.).

	 	a.	 	The Health Plan shall submit, prior to execution of this Contract, complete sets
of fingerprints of principals of the Health Plan to HSD for the purpose of conducting a
criminal history record check (see s. 409.907, F.S.).
	 
	 	b.	 	Principals of the Health Plan shall be as defined in s. 409.907, F.S.
	 
	 	c.	 	The Health Plan shall submit to the Agency Contract Manager complete sets of
fingerprints of newly hired principals (officers, directors, agents, and managing
employees) within thirty (30) days of the hire date.

	 	5.	 	The Health Plan shall submit to the Agency, within five (5) business days, any information
on any officer, director, agent, managing employee, or owner of stock or beneficial interest
in excess of five percent of the Health Plan who has been found guilty of, regardless of
adjudication, or who entered a plea of nolo contendere or guilty to, any of the offenses
listed in s. 435.03, F.S. The Health Plan shall submit information to HSD for such persons
who have a record of

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	 	 	 	illegal conduct according to the background check. The Health Plan shall keep a
record of all background checks to be available for Agency review upon request.
	 
	 	6.	 	The Agency shall not contract with a Health Plan that has an officer, director,
agent, managing employee, or owner of stock or beneficial interest in excess of five
percent (5%) of the Health Plan, who has committed any of the above listed offenses
(see ss. 409.912 and 435.03, F.S.). In order to avoid termination, the Health Plan
shall submit a corrective action plan, acceptable to the Agency, which ensures that
such person is divested of all interest and/or control and has no role in the
operation and/or management of the Health Plan.

	W.	 	Minority Recruitment and Retention Plan (See Item 0. Subcontracts, sub-item 1.c.,
above, for other requirements)
	 
	 	 	The Health Plan shall implement and maintain a minority recruitment and retention plan in
accordance with s. 641.217, F.S. The Health Plan shall have policies and procedures for
the implementation and maintenance of such a plan. The minority recruitment and retention
plan may be company-wide for all product lines.
	 
	X.	 	Independent Provider
	 
	 	 	It is expressly agreed that the Health Plan and any agents, officers, and/or employees of
the Health Plan or any subcontractors, in the performance of this Contract shall act in
an independent capacity and not as officers and employees of the Agency or the State of
Florida. It is further expressly agreed that this Contract shall not be construed as a
partnership or joint venture between the Health Plan or any subcontractor and the Agency
and the State of Florida.
	 
	Y.	 	General Insurance Requirements
	 
	 	 	The Health Plan shall obtain and maintain the same adequate insurance coverage including
general liability insurance, professional liability and malpractice insurance, fire and
property insurance, and directors’ omission and error insurance. All insurance coverage
for the Health Plan must comply with the provisions set forth for HMOs in Rule
690-191.069, F.A.C.; excepting that the reporting, administrative, and approval
requirements shall be to the Agency rather than to the Department of Financial Services,
Office of Insurance Regulation (OIR). All insurance policies must be written by insurers
licensed to do business in the State of Florida and in good standing with OIR. All policy
declaration pages must be submitted to BMHC annually upon renewal. Each certificate of
insurance shall provide for notification to the Agency in the event of termination of the
policy.

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	 	HMO Contract

	Z.	 	Workers’ Compensation Insurance
	 
	 	 	The Health Plan shall secure and maintain during the life of the Contract, workers’
compensation insurance for all of its employees connected with the work under this
Contract. Such insurance shall comply with the Florida Workers’ Compensation Law (see
Chapter 440, F.S.). Policy declaration pages shall be submitted to BMHC annually upon
renewal.
	 
	AA.	 	State Ownership
	 
	 	 	The Agency shall have the right to use, disclose, or duplicate all information and data
developed, derived, documented, or furnished by the Health Plan resulting from this
Contract. Nothing herein shall entitle the Agency to disclose to third parties data or
information that would otherwise be protected from disclosure by state or federal law.
	 
	BB.	 	Emergency Management Plan
	 
	 	 	Annually by May 31 of each Contract year, the Health Plan shall submit to BMHC for
approval an emergency management plan specifying what actions the Health Plan shall
conduct to ensure the ongoing provision of health services in a disaster or manmade
emergency including, but not limited to, localized acts of nature, accidents, and
technological and/or attack-related emergencies. If the emergency management plan is
unchanged from the previous year, the Health Plan shall submit a certification to BMHC
that the prior year’s plan is still in place.
	 
	CC.	 	Indemnification (See Attachment H, Exhibit 16; Standard Contract applies unless
indicated otherwise in Exhibit 16)

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	 	HMO Contract

Exhibit 1

Definitions and Acronyms

NOTE: This exhibit provides Health Plan requirements in addition to Attachment II of this
Contract, unless otherwise specified.

N/A

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	 	HMO Contract

Exhibit 2

General Overview

NOTE: This exhibit provides Health Plan requirements in addition to Attachment II of this
Contract, unless otherwise specified.

	 	1.	 	All Health Plans Except Reform HMOs

Section II, General Overview, Item D., General Responsibilities of the Health Plan

A Health Plan shall furnish services in an amount, duration and scope that are no more
restrictive than the services provided in the Medicaid fee-for-service program and may
reasonably be expected to achieve the purpose for which the services are furnished.

	 	2.	 	All Capitated Reform Health Plans

Section II, General Overview, Item D., General Responsibilities of the Health Plan

The Health Plan shall comply with all current Florida Medicaid Handbooks (Handbooks) pursuant
to Attachment II, Section II, General Overview, unless a customized benefit package has been
certified by the Agency. In no instance may the limitations or exclusions imposed by the
Health Plan be more stringent than those specified in the Handbooks, unless authorized in the
customized benefit package by the Agency. The Health Plan may exceed limits in the Handbooks
by offering expanded services, as described elsewhere in this Contract or through its
approved customized benefit package.

	 	3.	 	Capitated Reform Health Plans and FFS PSNs where there is no HMO

Section II, General Overview, Item D., General Responsibilities of the Health Plan

A Health Plan that accepts only the comprehensive component of the capitation rate shall
continue to provide all covered services to each enrollee who reaches the catastrophic
component threshold. The Health Plan shall continue to apply its QM and UM program
components, as well as other administrative policies and protocols to the delivery of care
and services to the enrollees who meet the threshold. The Health Plan shall submit
documentation for reimbursement for covered services costs as outlined in Attachment II,
Exhibit 13.

	 	4.	 	Reform Plans

Section II, General Overview, Item D., General Responsibilities of the Health Plan

	 	1.	 	When the cost of an enrollee’s covered services reaches the benefit maximum of
$550,000 in a fiscal year, the Health Plan shall assist the enrollee in obtaining
necessary health care services in the community. The Health Plan shall continue to
coordinate the care received by the enrollee in the community, and the Health Plan shall
continue to be responsible for emergency services and care. In addition, the Health Plan
shall provide benefit reporting to BMHC, monthly, and HSD in accordance with Attachment
II, Section XII, Reporting Requirements, once the cost of covered services reaches
$450,000.

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	 	HMO Contract

	 	2.	 	The Health Plan may choose to offer a specialty plan only for Medicaid Recipients who are:

	 	a.	 	Children with chronic conditions;
	 
	 	b.	 	Persons diagnosed with HIV/AIDS (HMOs only); or
	 
	 	c.	 	Individuals diagnoses with developmental disabilities or foster care
children, if approved by the Agency.

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	 	HMO Contract

Exhibit 3

Eligibility and Enrollment

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

	1.	 	All Reform Health Plans

Section III, Eligibility and Enrollment, Item C.4., Disenrollment

	 	4.	 	Involuntary Disenrollment Requests

	 	 	 	The Reform Health Plan shall submit involuntary disenrollment requests for the following
reasons to the Agency’s choice counselor/enrollment broker as specified in the Health Plan
Report Guide. In no event shall the Health Plan submit a disenrollment request at such a
date as would cause the disenrollment to be effective later than forty-five (45) calendar
days after the Health Plan’s receipt of the reason for involuntary disenrollment. The Health
Plan shall ensure that involuntary disenrollment documents are maintained in an identifiable
enrollee record.

	 	a.	 	Moved out of Reform Health Plan service area;
	 
	 	b.	 	Enrollee death; and
	 
	 	c.	 	Enrollee ineligible for Health Plan enrollment.

	 	5.	 	Disenrollment Notice
	 
	 	 	 	The Health Plan shall notify enrollees who will be involuntarily disenrolled due to the
reasons above of the following at least two (2) months before the anticipated effective date
of the involuntary disenrollment. The template for such notice must be submitted to and
approved by BMHC before use.

	 	a.	 	The reason for involuntary disenrollment;
	 
	 	b.	 	The telephone number of the choice counselor/enrollment broker; and
	 
	 	c.	 	Transition information.

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	 	HMO Contract

	 	2.	 	Voluntary Populations
	 
	 	 	 	In order to be eligible for the frail/elderly program, enrollees must be:

	 	a.	 	Assessed by CARES as having met a nursing home level of care and in
need of services to live in their homes or in the homes of relatives or
caregivers, as an alternative to being placed in a nursing home facility;
	 
	 	b.	 	Twenty-one (21) years of age or older;
	 
	 	c.	 	An SSI beneficiary including dually-eligible Individuals with Medicare
coverage (dual eligible with either Medicare Part B coverage or Medicare Parts A
and B coverage) who are not enrolled in a Medicare Advantage Plan or a Medicare
Advantage Special Needs Plan and not otherwise ineligible under the terms of this
Contract; and
	 
	 	d.	 	Not ineligible as listed in Section III, Eligibility and Enrollment, Item A.3.
below.

	 	3.	 	Excluded Populations
	 
	 	 	 	A TANF beneficiary or Medicaid recipient in the following programs may not enroll in a
frail/elderly component of a Medicaid HMO:

	 	a.	 	An Aged and Adult disabled Waiver;
	 
	 	b.	 	The Channeling Waiver;
	 
	 	c.	 	Developmental Disabilities Waiver; or
	 
	 	d.	 	The Assisted Living for the Elderly Waiver Section

Section III, Eligibility and Enrollment, Item B., Enrollment

Enrollment in the Frail/Elderly Program. This provision replaces Attachment II, Section
III, Eligibility and Enrollment, Item B.3.b. as follows:

In order for enrollment to occur, the Health Plan must maintain and document the following
information on file and provide it at the Agency’s request:

	 	(1)	 	A current CARES assessment completed within the past twelve (12) months.
	 
	 	(2)	 	An agreement in writing from the recipient’s Medicare or Medicaid PCP,
whichever is applicable, that the provider would participate as part of the
multidisciplinary treatment team and would provide input, review, data etc.
related to the care of the recipient.
	 
	 	(3)	 	A voluntary consent form signed by the recipient documenting the recipients request to enroll
in the frail/elderly program. This form must be approved by BMHC prior to use

AHCA Contract No. FA913, Attachment II, Exhibit 3, Page 5 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Section III, Eligibility and Enrollment, Item C., Disenrollment

The disenrollment requirements listed below must be met in addition to those specified in
Attachment II, Section III, Eligibility and Enrollment, unless otherwise noted below.

	 	a.	 	The Health Plan may request the Agency to disenroll an enrollee if the
enrollee is institutionalized in a long term nursing facility at the conclusion of
the state fiscal year and the Health Plan furnishes written documentation based upon
a CARES assessment or written assurance from the enrollee’s PCP or the administrator
of the nursing facility where the enrollee is placed that the nursing home placement
is permanent and not temporary.
	 
	 	b.	 	All disenrollments for institutionalized enrollees must have prior written
approval by the Agency and be submitted as involuntary disenrollments on the first
available transmission to the fiscal agent after receiving Agency approval of the
request.

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AHCA Contract No. FA913, Attachment II, Exhibit 3, Page 6 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 4

Enrollee Services, Community Outreach and Marketing

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

	1.	 	All Reform Health Plans

Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services

	15.	 	Enhanced Benefit Program

	 	a.	 	The Agency has identified a combination of covered and non-covered services as
healthy behaviors that will earn credits for an enrollee. The Agency shall assign a
specific credit to an enrollee’s account for each healthy behavior service received
and notify each enrollee of the availability of the credits in the account. The
credits in the enrollee’s account shall be available if the enrollee enrolls in a
different health plan and for a period of up to three (3) years after loss of Medicaid
eligibility.
	 
	 	b.	 	The Agency shall administer the program with assistance from the Health Plan.

	 	(1)	 	For covered services identified as healthy behaviors, the Health Plan
shall submit a monthly report to the Medicaid Bureau of Contract Management (MCM)
by the tenth calendar day of the month for the previous month’s paid claims. See
Attachment II, Section XII, Reporting Requirements. A list of procedure codes and
healthy behaviors will be provided in the Agency Report Guide posted on the
Agency’s website at
http://ahca.mvflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml.
	 
	 	(2)	 	For non-Medicaid services, the Health Plan shall assist the enrollee
in obtaining and submitting documentation to MCM to verify participation in a
healthy behavior without a procedure code. A universal form shall be available
with the Agency’s website at
http://ahca.mvflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml and must be
submitted to the Health Plan to document participation in healthy behaviors
without a procedure code.

	 	c.	 	The Agency may add or delete healthy behaviors with thirty (30) calendar days’
written notice.

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AHCA Contract No. FA913, Attachment II, Exhibit 4, Page 7 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 5

Covered Services

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Reform Capitated Health Plans

Section V, Covered Services, Item A., Covered Services

Customized Benefit Packages (See Attachment I)

	 	1.	 	The capitated Health Plan shall submit a customized benefit package (CBP), which may
vary the co-pays or the amount, duration and scope of the following services for
non-pregnant adults: hospital outpatient not otherwise specified (NOS) and hospital
outpatient physical, occupational, respiratory, and speech therapy services; and home
health, dental, pharmacy, chiropractic, podiatry, vision, hearing and durable medical
equipment as specified below.

	 	a.	 	Amount, duration and scope may vary for durable medical supplies (DME) with
the exception of any prosthetic/orthotic supply priced over $3,000 on the Medicaid
fee schedule and except for motorized wheelchairs, which must be covered up to the
Medicaid State Plan (State Plan) limit.
	 
	 	b.	 	Dialysis services, contraceptives, and chemotherapy-related medical and
pharmaceutical services must be covered up to the State Plan limit.
	 
	 	c.	 	Hearing services for non-pregnant adults may vary in amount, duration and
scope except for hearing aid services, which must be covered up to the State Plan
limit.
	 
	 	d.	 	The Health Plan shall provide all medically necessary services up to the State
Plan limit in accordance with the Medicaid Handbook requirements for pregnant women,
children/adolescents, and enrollees with a HIV/AIDS diagnoses as identified by the
Agency.

	 	2.	 	Approved CBPs must comply with the benefit grid plan evaluation tool and
instructions available from HSD. The Agency shall test the Health Plan’s CBP for
actuarial equivalency and sufficiency of benefits, before approving the CBP. Actuarial
equivalency is tested by using a benefit plan evaluation tool that:

	 	a.	 	Compares the value of the level of benefits in the proposed package to the
value of the current Medicaid State Plan package for the average member of the
covered population; and
	 
	 	b.	 	Ensures that the overall level of benefits is appropriate.

	 	3.	 	Sufficiency is tested by comparing the proposed CBP to state-established standards.
The standards are based on the covered population’s historical use of Medicaid State Plan
services. These standards are used to ensure that the proposed CBP is adequate to cover
the needs of the vast majority of the enrollees.
	 
	 	4.	 	If, in its CBP, the Health Plan limits a service to a maximum annual dollar value, the
Health Plan must calculate the dollar value of the service using the Medicaid fee
schedule.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 8 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	5.	 	The CBPs may change on a Contract year basis and only if approved by the Agency in
writing. The Health Plan shall submit to HSD its CBP for recertification of actuarial
equivalency and sufficiency standards no later than June 15"' of each year.
See Attachment I of this Contract.
	 
	 	6.	 	The Health Plan shall incorporate a requirement into its policies and procedures
stating that it will send letters of notification to enrollees regarding exhaustion of
benefits for services restricted by unit amount if the amount is more restrictive than
Medicaid for the following services: pharmacy; DME; hospital outpatient services not
otherwise specified (NOS) and hospital outpatient physical, occupational, respiratory,
and speech therapy services; hearing services; vision services; chiropractic; podiatry;
and home health services. The Health Plan shall send an exhaustion of benefits letter
for any service restricted by a dollar amount. The Health Plan shall implement said
letters upon the written approval of the Agency. The letters of notification include the
following:

	 	a.	 	A letter notifying an enrollee when he/she has reached fifty percent (50%)
of any maximum annual dollar limit established by the Health Plan for a benefit;
	 
	 	b.	 	A follow-up letter notifying the enrollee when he/she has reached
seventy-five (75%) of any maximum annual dollar limit established by the Health Plan
for a benefit; and
	 
	 	c.	 	A final letter notifying the enrollee that he/she has reached the maximum
dollar limit established by the Health Plan for a benefit.

2. Non-Reform Capitated Health Plans

Section V, Covered Services, Item G., Copayments

	 	1.	 	The Health Plan shall not require a copayment or cost sharing for services listed in
Attachment I or Attachment II, Section V, Covered Services, Item A., Covered Services,
including optional services, and Attachment II, Section V, Covered Services, Item B.,
Optional Services, and Attachment II, Section V, Covered Services, Item C., Expanded
Services, nor may the Health Plan charge enrollees for missed appointments. The Health
Plan agrees that the cost of the services and deliverables specified in Section V,
Covered Services, represent the total cost to the state and the Agency for the
contracted services and deliverables and that no additional charges, fees, or costs may
be added to this amount or sought from the state, the Agency or the enrollees.
	 
	 	2.	 	For non-Reform HMOs, paragraph 1. above also applies to covered services listed in
Attachment II, Section VI, Behavioral Health Care.

3. Fee-for-Service PSN and Reform Capitated Health Plans

Section V, Covered Services, Item G., Copayments

The Health Plan may offer to waive copayments or cost sharing for services listed in
Attachment II, Section V, Covered Services, Item A., Covered Services, including optional
services, and Section V, Covered Services, Item B., Optional Services, as an expanded benefit.
See Attachment I of this Contract also.

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AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 9 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

4. Non-Reform Health Plans covering dental as an optional service and Reform Health
Plans

Section V, Covered Services, Item H., Coverage Provisions, sub-item 3., Dental Services

Dental services are defined in the Medicaid Dental Services Coverage and Limitations Handbook.
For enrollees under age 21, the Health Plan shall cover diagnostic services, preventive
treatment, CHCUP dental screening (including a direct referral to a dentist for enrollees
beginning at three years of age or earlier as indicated); restorative treatment, endodontic
treatment, periodontal treatment, surgical procedures and/or extractions, orthodontic
treatment, complete and partial dentures, complete and partial denture relines and repairs,
and adjunctive and emergency services. Adult services include adult full and partial denture
services and medically necessary emergency dental procedures to alleviate pain or infection.
Emergency dental care shall be limited to emergency oral examinations, necessary x-rays,
extractions, and incision and drainage of abscess.

5. All Capitated Health Plans

Section V, Covered Services, Item H., Coverage Provisions, sub-item 8., Out-of-Plan Use of
Non-Emergency Services

	a.	 	Unless otherwise specified in this Contract, where an enrollee uses non-emergency
services available under the Health Plan from a non-participating provider, the Health
Plan shall not be liable for the cost of such services unless the Health Plan referred
the enrollee to the nonparticipating provider or authorized the out-of-network service.
	 
	b.	 	In accordance with s. 409.912, F.S., the Health Plan shall reimburse any hospital or
physician that is outside the Health Plan’s authorized service area for
health-plan-authorized services at a rate negotiated with the hospital or physician or
according to the lesser of the following:

	 	(1)	 	The usual and customary charge made to the general public by the hospital or provider; or
	 
	 	(2)	 	The Florida Medicaid reimbursement rate established for the hospital or provider.

	c.	 	The Health Plan shall reimburse all out-of-network providers as described in s. 641.3155, F.S.

6. Capitated Health Plans

Section V, Covered Services, Item H., Coverage Provisions, sub-item 10., Hospital Services —
Inpatient

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

7. Non-Reform Health Plans not covering transportation as an optional service

Section V, Covered Services, Item H., Coverage Provisions, sub-item 20., Transportation
Services

The Health Plan shall refer enrollees needing transportation to the Agency’s contracted CTD
provider in order to assist them to keep and travel to medical appointments.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 10 of 68

 

 

8. Non-Reform HMOs covering transportation as an optional service and Reform Health Plans

Section V, Covered Services, Item H., Coverage Provisions, sub-item 20., Transportation
Services

The Health Plan shall provide transportation services, including emergency transportation, for
its enrollees who have no other means of transportation available to any Medicaid-compensable,
medically necessary service, including Medicaid services not covered by this Contract such as
prescribed pediatric extended care (this example does not apply to the specialty plan for
children with chronic conditions).

	a.	 	The Health Plan shall comply with provisions of the Medicaid Transportation Services
Coverage and Limitations Handbooks. In any instance when compliance conflicts with the
terms of this Contract, the Contract prevails. In no instance may the limitations or
exclusions imposed by the Health Plan be more stringent than those in the Medicaid
Transportation Services Coverage and Limitations Handbooks.
	 
	b.	 	The Health Plan is not obligated to follow the requirements of the Commission for the
Transportation Disadvantaged (CTD) or the Transportation Coordinating Boards as set forth
in Chapter 427, F.S., unless the Health Plan has chosen to coordinate services with the
CTD.
	 
	c.	 	The Health Plan may provide transportation services directly through its own network
of transportation providers or through a provider contract relationship, which may
include the Commission for the Transportation Disadvantaged. In either case, the Health
Plan is responsible for monitoring provision of services to its enrollees.
	 
	d.	 	The Health Plan shall:

	 	(1)	 	Ensure that all transportation providers comply with standards set forth in
Chapter 427, F.S., and Rules 41-2 and 14-90, FAC. These standards include drug and
alcohol testing, safety standards, driver accountability, and driver conduct.
	 
	 	(2)	 	Ensure that all transportation providers maintain vehicles and equipment in
accordance with state and federal safety standards and the manufacturers’ mechanical
operating and maintenance standards for any and all vehicles used for transportation
of Medicaid recipients.
	 
	 	(3)	 	Ensure that all transportation providers comply with applicable state and
federal laws, including, but not limited to, the Americans with Disabilities Act
(ADA) and the Federal Transit Administration (FTA) regulations.
	 
	 	(4)	 	Ensure that transportation providers immediately remove from service any
vehicle that does not meet the Florida Department of Highway Safety and Motor
Vehicles licensing requirements, safety standards, ADA regulations, or Contract
requirements and re-inspect the vehicle before it is eligible to provide
transportation services for Medicaid recipients under this Contract. Vehicles shall
not carry more passengers than the vehicle was designed to carry. All lift-equipped
vehicles must comply with ADA regulations.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 11 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(5)	 	Ensure transportation services meet the needs of its enrollees including use of
multiload vehicles, public transportation, wheelchair vehicles, stretcher vehicles,
private volunteer transport, over-the-road bus service, or, where applicable,
commercial air carrier transport.
	 
	 	(6)	 	Collect and submit encounter data, as required elsewhere in this Contract;
	 
	 	(7)	 	Ensure a transportation network of sufficient size so that failure of any one
component will not impede the ability to provide the services required in this
Contract;
	 
	 	(8)	 	Ensure that any subcontracts for transportation services meet the
subcontracting requirements detailed in Attachment II, Section XVI, Terms and
Conditions;
	 
	 	(9)	 	Maintain policies and procedures, consistent with 42 CFR 438.12 to ensure there
is no discrimination in serving high-risk populations or people with conditions that
require costly transportation;
	 
	 	(10)	 	Ensure all transportation providers maintain sufficient liability insurance to
meet requirements of Florida law.

	 	e.	 	The Health Plan shall be responsible for the cost of transporting an enrollee from a
nonparticipating facility or hospital to a participating facility or hospital if the
reason for transport is solely for the Health Plan’s convenience.
	 
	 	f.	 	The Health Plan shall approve and process claims for transportation services in
accordance with the requirements set forth in this Contract.
	 
	 	g.	 	If the Health Plan subcontracts for transportation services, it shall provide a copy of
the model subcontract to BMHC for approval before use.
	 
	 	h.	 	Before providing transportation services, the Health Plan shall provide BMHC a copy of
its policies and procedures for approval relating to the following:

	 	(1)	 	How the Health Plan will determine eligibility for each enrollee and what type
of transportation to provide that enrollee;
	 
	 	(2)	 	The Health Plan’s procedure for providing prior authorization to enrollees
requesting transportation services;
	 
	 	(3)	 	How the Health Plan will review transportation providers to prevent and/or
identify those who falsify encounter or service reports, overstate reports or upcode
service levels, or commit any form of fraud or abuse as defined in s. 409.913, F.S.;
	 
	 	(4)	 	How the Health Plan will deal with providers who alter, falsify or destroy
records before the end of the retention period; make false statements about
credentials; misrepresent medical information to justify referrals; fail to provide
scheduled transportation; or charge enrollees for covered services;
	 
	 	(5)	 	How the Health Plan will provide transportation services outside its service area.

	 	i.	 	The Health Plan shall report immediately, in writing to BMHC, any
transportation-related adverse or untoward incident (see s. 641.55, F.S.). The Health
Plan shall also report, immediately upon identification, in writing to MPI, all instances
of suspected enrollee or

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 12 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	transportation services provider fraud or abuse. (As defined in s. 409.913, F.S. See also
Attachment II, Section X, Administration and Management, on fraud and abuse.)
	 
	 	j.	 	The Health Plan shall ensure compliance with the minimum liability insurance
requirement of $100,000 per person and $200,000 per incident for all transportation
services purchased or provided for the transportation disadvantaged through the Health
Plan. (See s. 768.28(5), ES.) The Health Plan shall indemnify and hold harmless the
local, state, and federal governments and their entities and the Agency from any
liabilities arising out of or due to an accident or negligence on the part of the Health
Plan and/or all transportation providers under contract to the Health Plan.
	 
	 	k.	 	The Health Plan shall ensure adequate seating for paratransit services for each
enrollee and escort, child, or personal care attendant, and shall ensure that the
vehicle meets the following requirements and does not transport more passengers than the
registered passenger seating capacity in a vehicle at any time:

	 	(1)	 	Enrollee property that can be carried by the passenger and/or driver, and can
be stowed safely on the vehicle, shall be transported with the passenger at no
additional charge. The driver shall provide transportation of the following items, as
applicable, within the capabilities of the vehicle:

	 	(a)	 	Wheelchairs;
	 
	 	(b)	 	Child seats;
	 
	 	(c)	 	Stretchers;
	 
	 	(d)	 	Secured oxygen;
	 
	 	(e)	 	Personal assistive devices; and/or
	 
	 	(f)	 	Intravenous devices.

	 	(2)	 	Each vehicle shall have posted inside the Health Plan’s toll-free telephone
number for enrollee complaints;
	 
	 	(3)	 	The interior of all vehicles shall be free from dirt, grime, oil, trash, torn
upholstery, damaged or broken seats, protruding metal or other objects or materials
which could soil items placed in the vehicle or cause discomfort to enrollees;
	 
	 	(4)	 	The transportation provider shall provide the enrollee with boarding
assistance, if necessary or requested, to the seating portion of the vehicle. Such
assistance shall include, but not be limited to, opening the vehicle door, fastening
the seat belt or wheelchair securing devices, storage of mobility assistive devices
and closing the vehicle door. In the doorthrough-door paratransit service category,
the driver shall open and close doors to buildings, except in situations in which
assistance in opening and/or closing building doors would not be safe for passengers
remaining in the vehicle. The driver shall provide assisted access in a dignified
manner.
	 
	 	(5)	 	Smoking, eating and drinking are prohibited in any vehicle, except in cases in
which, as a medical necessity, the enrollee requires fluids or sustenance during
transport;
	 
	 	(6)	 	All vehicles must be equipped with two-way communications, in good working
order and audible to the driver at all times, by which to communicate with the
transportation services hub or base of operations;
	 
	 	(7)	 	All vehicles must have working air conditioners and heaters.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 13 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	I.	 	Vehicle transfer points shall provide shelter, security, and safety of enrollees.
	 
	 	m.	 	The transportation provider shall maintain a passenger/trip database for each
enrollee it transports.
	 
	 	n.	 	The Health Plan shall establish a minimum twenty-four (24) hour advance notification
policy to obtain transportation services, and the Health Plan shall communicate that
policy to its enrollees and transportation providers.
	 
	 	o.	 	 The Health Plan shall establish enrollee pick-up windows and communicate those
timeframes to enrollees and transportation providers.
	 
	 	p.	 	The Health Plan shall establish performance measures to evaluate the safety, quality,
timeliness, and adequacy of its transportation services. The transportation performance
measures shall be submitted to the Medicaid Bureau of Quality Management for approval by
the end of the first month of the Contract term and report on those measures to the
Agency as specified in Attachment II, Section VIII, Quality Management, Item A., Quality
Improvement, sub-item 3.c.
	 
	 	q.	 	The Health Plan shall provide an annual attestation to BMHC by January 1 of each
Contract year that it is in full compliance with the policies and procedures relating to
transportation services, and that all vehicles used for transportation services have
received annual safety inspections.
	 
	 	r.	 	The Health Plan shall provide an annual attestation to BMHC by January 1 of each
Contract Year that all drivers providing transportation services have passed background
checks and meet all qualifications specified in law and in rule.

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AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 14 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 6

HMOs & Reform Health Plans

Behavioral Health Care

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Reform Health Plans and Non-Reform HMOs

A. General Provisions

	 	1.	 	The Health Plan shall name a staff member employed by the Health Plan with a
behavioral health-related license or training and experience in behavioral health to
maintain oversight responsibility for behavioral health services and to act as liaison
to the Agency.
	 
	 	2.	 	The Health Plan’s medical director shall appoint a board-certified or
board-eligible Florida- licensed psychiatrist (staff psychiatrist) to oversee the
provision of behavioral health services to enrollees. The Health Plan may delegate
this duty to a third party by a written subcontract.
	 
	 	3.	 	The Agency shall review and approve the Health Plan’s behavioral health services
staff and any subcontracted behavioral health care providers in order to determine the
Health Plan’s compliance with all licensure requirements.
	 
	 	4.	 	The Health Plan shall provide a full range of medically necessary behavioral
health services authorized under the State Plan and specified by this Contract for all
enrollees.

	 	a.	 	Nothing in this Contract shall be construed as preventing the plan from
substituting additional services supported by nationally recognized,
evidence-based clinical guidelines for those provided in the Medicaid handbooks
described below or from using different or alternative services, based on
nationally recognized, evidence-based practices, methods, or approaches to assist
individual enrollees, provided that the net effect of this substitution and these
alternatives is that the overall benefits available to the enrollee are at least
equivalent to those described in the applicable handbooks.
	 
	 	b.	 	Provision of substitution or alternate services shall not supplant or
relieve the Health Plan from providing covered services if needed.

	 	5.	 	The Health Plan shall provide the following services as described in the Mental
Health Targeted Case Management Coverage & Limitations Handbook and the Community
Behavioral Health Services Coverage & Limitations Handbook (the Handbooks). The Health
Plan shall not alter the amount, duration and scope of such services from that
specified in the Handbooks. The Health Plan shall not establish service limitations
that are lower than, or inconsistent with, the Handbooks.

	 	a.	 	Inpatient hospital services for psychiatric conditions (ICD-9-CM codes
290 through 290.43, 290.8, 290.9, 293.0 through 298.9, 300 through 301.9, 302.7,
306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
315.9);
	 
	 	b.	 	Outpatient hospital services for psychiatric conditions (ICD-9-CM codes
290 through 290.43, 290.8, 290.9, 293 through 298.9, 300 through 301.9, 302.7,
306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
315.9);

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 15 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	c.	 	Psychiatric physician services (for psychiatric specialty codes 42, 43, 44 and
ICD-9-CM codes 290 through 290.43, 290.8, 290.9, 293.0 through 298.9, 300 through
301.9, 302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5,
315.8, and 315.9);
	 
	 	d.	 	Community mental health services (ICD-9-CM codes 290 through 290.43,
290.8, 290.9, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through 312.4
and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these
procedure codes H0001, H0001HN; H0001HO, H0001TS; H0031; H0031H0; H0031HN;
H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010H0; H2010HE;
H2010HF; H2010HQ; H2012; H2O12HF; H2017; H2019; H2O19HM; H2O19HN; H2019H0;
H2O19HQ; H2O19HR; T1007; T1007TS; T1015; T1015HE; T1015HF; T1023HE; or T1023HF;
	 
	 	e.	 	Mental Health Targeted Case Management (Children: T1017HA; Adults: T1017);
and
	 
	 	f.	 	Mental Health Intensive Targeted Case Management (Adults: T1017HK).

	 	6.	 	Non-Covered Services

	 	a.	 	The following services are not covered by the Health Plan:

	 	(1)	 	Specialized therapeutic foster care;
	 
	 	(2)	 	Therapeutic group care services;
	 
	 	(3)	 	Behavioral health overlay services;
	 
	 	(4)	 	Community substance abuse services, except as required by this Contract;
	 
	 	(5)	 	Residential care;
	 
	 	(6)	 	Statewide Inpatient Psychiatric Program (SIPP) services;
	 
	 	(7)	 	Clubhouse services; and
	 
	 	(8)	 	Comprehensive behavioral assessment.

	 	b.	 	The Health Plan shall not be responsible for the provision of behavioral
health services to enrollees assigned to a FACT team by the DCF Substance Abuse
and Mental Health Program (SAMH) Office.
	 
	 	c.	 	The Health Plan is not responsible for behavioral health services for
enrollees who are enrolled in the Child Welfare Prepaid Mental Health Plan
(CWPMHP) with the exception of CWPMHP enrollees residing in Area 1 and the
following counties in Area 6: Hardee, Highlands, Manatee and Polk. In Area 1 and
the above listed Area 6 counties, the Health Plan is responsible for providing
behavioral health care services, provided it is approved to cover those counties
as specified in Attachment I of this Contract.

	 	7.	 	If an enrollee makes a request for behavioral health services to the Health Plan,
the Health Plan shall provide the enrollee with the name (or names) of qualified
behavioral health care

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 16 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	providers, and if requested, assist the enrollee with making an appointment with the
provider that is within the required access times indicated in Attachment II, Section
VII, Provider Network, Item F., Appointment Waiting Times and Geographic Access
Standards, and Attachment II, Section VI, Behavioral Health Care.
	 
	 	8.	 	Services available under the Health Plan shall represent a comprehensive range
of appropriate services for both children/adolescents and adults who experience
impairments ranging from mild to severe and persistent. This section outlines the
Agency’s expectations and requirements related to each of the categories of service.

	 	a.	 	(Capitated Health Plans only) — The Health Plan may provide expanded
services under the Contract as a substitution of care or downward substitution.
	 
	 	b.	 	(Capitated Health Plans only) — When the Health Plan intends to provide a
service as a downward substitution, the provider must use clinical rationale for
determining the benefit of the service for the enrollee.

B. Provider Network

	 	1.	 	The Health Plan shall have at least one (1) certified adult psychiatrist and at
least one (1) board-certified child psychiatrist (or one (1) child psychiatrist who
meets all education and training criteria for board certification) that is available
within thirty (30) minutes’ average travel time for urban areas and sixty (60)
minutes’ average travel time for rural areas of all enrollees.
	 
	 	2.	 	For rural areas, if the Health Plan does not have a provider with the necessary
experience, BMHC may waive, in writing, the travel time requirements of paragraph
B.1., above.
	 
	 	3.	 	The Health Plan shall ensure that outpatient staff includes at least one (1)
FTE direct service behavioral health provider per 1,500 enrollees. The Agency expects
the Health Plan’s staffing pattern for direct service providers to reflect the ethnic
and racial composition of the community.
	 
	 	4.	 	The Health Plan’s array of direct service behavioral health providers for
children under age 18 and adults shall include, but not be limited to, providers that
are licensed or eligible for licensure, and demonstrate two (2) years of clinical
experience in the following specialty areas or with the following populations:

	 	a.	 	Adoption/attachment issues;
	 
	 	b.	 	Post traumatic stress syndrome;
	 
	 	c.	 	Dual diagnosis (mental illness/developmental disability);
	 
	 	d.	 	Co-occurring diagnosis (mental illness/substance abuse);
	 
	 	e.	 	Gender/sexual issues;
	 
	 	f.	 	Geriatric/aging issues;
	 
	 	g.	 	Eating disorders;

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	h.	 	Adolescent/children’s issues;
	 
	 	i.	 	Sexual/physical abuse (adult);
	 
	 	j.	 	Sexual/physical abuse (children/adolescents);
	 
	 	k.	 	Separation, grief and loss;
	 
	 	I.	 	Domestic violence/adult;
	 
	 	m.	 	Non-clinical specialties:

	 	(1)	 	Behavioral analysis;
	 
	 	(2)	 	Behavior management/alternative therapies for children/adolescents;
	 
	 	(3)	 	Court-ordered mental health evaluations;
	 
	 	(4)	 	Expert witness testimony;
	 
	 	(5)	 	Child protection or foster care; and
	 
	 	(6)	 	Bi-lingual (English/Spanish, for example).

	 	5.	 	Mental health targeted case managers shall not be counted as direct service
behavioral health providers.
	 
	 	6.	 	The Health Plan shall have access to no fewer than one (1) fully accredited
psychiatric community hospital bed per 2,000 enrollees, as appropriate, for both
children/adolescents and adults. Specialty psychiatric hospital beds may be used to
count toward this requirement when psychiatric community hospital beds are not
available within a particular community. Additionally, the Health Plan shall have
access to sufficient numbers of accredited hospital beds on a medical/surgical unit
to meet the need for medical detoxification treatment.
	 
	 	7.	 	The Health Plan’s facilities must be licensed, as required by law and rule,
accessible to the handicapped, in compliance with federal Americans with Disabilities
Act guidelines, and have adequate space, supplies, good sanitation, and fire, safety,
and disaster preparedness and recovery procedures in operation.
	 
	 	8.	 	The Health Plan shall ensure that it has providers that are qualified to serve
enrollees and experienced in serving severely emotionally disturbed
children/adolescents and severely and persistently mentally ill adults. The Health
Plan shall maintain documentation of its providers’ experience in the providers’
credentialing files. See Section VII, Provider
Network, Item H. Credentialing and Recredentialing, for additional requirements.
	 
	 	9.	 	Before beginning behavioral health services, the Health Plan shall enter into
agreements for coordination of care and treatment of enrollees, jointly or
sequentially served, with community mental health care center(s) that are not a part
of the Health Plan’s provider network. The Health Plan shall enter into similar
agreements with agencies funded pursuant to Chapter 394, F.S. The Agency shall
approve all model agreements between the Health Plan and community mental health
center(s)/agencies before the Health’ Plan enters into the agreement. This
requirement shall not apply if the Health Plan provides the

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	AMERIGROUP Florida, Inc. d/b/a
AMERIGROUP Community Care

	 	Medicaid Non-Reform and Reform
HMO Contract

	 	 	 	Agency with documentation that shows the Health Plan has made a good faith effort to
contract with the center(s)/agencies but could not reach agreement.
	 
	 	10.	 	The Health Plan shall request current behavioral health care provider
information from all new enrollees upon enrollment. The Health Plan shall solicit
these providers to participate in the Health Plan’s network. The Health Plan may
request in writing that the Agency grant exemption to a Health Plan from soliciting a
specific behavioral health services provider on a case-by-case basis.
	 
	 	11.	 	Pursuant to s. 409.912(4)(b)(7), F.S., the Health Plan shall make a good faith
effort to contract for the provision of behavioral health services with all local
community mental health providers designated by the Agency and DCF unless waived by
the Agency.
	 
	 	12.	 	The Health Plan shall submit contracted and subcontracted behavioral health
staffing information to BMHC as follows:

	 	a.	 	Annually for Health Plans providing Medicaid behavioral health services
for more than twelve (12) months. Reports are due no later than August
15th and shall reflect staffing in the month of June;
	 
	 	b.	 	Quarterly for Health Plans providing Medicaid behavioral health services
for twelve (12) months or less. Reports are due forty-five (45) calendar days
following the end of the quarter and shall reflect staffing for the last month of
the quarter.

C. Service Requirements

	 	1.	 	Inpatient Hospital Services

	 	a.	 	Inpatient hospital services are medically necessary behavioral health
services provided in a hospital setting. (See Section V, Covered Services, Item
H., Coverage Provisions, sub-item 10., Hospital Services — Inpatient.) The
inpatient care and treatment services that an enrollee receives must be under the
direction of a licensed physician with the appropriate medical specialty
requirements. Capitated Health Plans may provide inpatient hospital services in a
general hospital psychiatric unit or in a specialty hospital.
	 
	 	b.	 	A hospital’s per diem (daily rate) for inpatient mental health hospital
care and treatment covers all services and items furnished during a twenty-four
(24) hour period. The facilities, supplies, appliances, and equipment furnished by
the hospital during the inpatient stay are included in the per diem as well as the
related nursing, social, and other services furnished by the hospital during the
inpatient stay.
	 
	 	c.	 	For all child/adolescent enrollees (up to age 21) and pregnant adults in
Reform, the Health Plan shall be responsible for the provision of up to
three-hundred and sixty-five (365) days of behavioral health-related hospital
inpatient care for each state fiscal year. For all non-pregnant adults in Reform,
the Health Plan shall be responsible for up to forty-five (45) days of behavioral
health-related inpatient coverage and up to three- hundred and sixty-five (365)
days of behavioral health-related emergency inpatient care, for each state fiscal
year. For non-reform, the Health Plan shall be responsible for providing up to
forty-five (45) days of behavioral health-related hospital inpatient care for each
state fiscal year for all enrollees.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	d.	 	For all enrollees, the Health Plan shall pay for inpatient mental
health-related hospital days determined medically necessary by the Health Plan’s
medical director or designee, up to the maximum number of days required under the
Contract.
	 
	 	e.	 	If an enrollee is admitted to a hospital for a non-psychiatric diagnosis
and during the same hospitalization transfers to a psychiatric unit or receives
treatment for a psychiatric diagnosis, the Health Plan is at risk for the
medically necessary behavioral health treatment inpatient days up to the maximum
number of days required under this Contract.
	 
	 	f.	 	The Health Plan shall cover the cost of all enrollees’ medically
necessary stays resulting from a mental health emergency, until such time as the
Health Plan can safely transport the enrollee to a designated facility.
	 
	 	g.	 	Capitated Health Plans only — Crisis stabilization units (CSU) may be
used as a downward substitution for inpatient psychiatric hospital care when
determined medically appropriate. These bed days are calculated on a two-for-one
basis. Beds funded by the DCF SAMH cannot be used for enrollees if there are
non-funded clients in need of the beds. If CSU beds are at capacity, and some of
the beds are occupied by enrollees, and a non-funded client presents in need of
services, the enrollees must be transferred to an appropriate facility to allow
the admission of the non-funded client. Therefore, the Health Plan shall
demonstrate adequate capacity for inpatient hospital care in anticipation of such
transfers.
	 
	 	h.	 	The Health Plan shall coordinate hospital discharge planning for
psychiatric admissions and substance abuse detoxification to ensure inclusion of
appropriate post-discharge care. This provision does not apply to admissions to
residential settings not covered by the Health Plan.

	 	(1)	 	Enrollees admitted to an acute care facility (inpatient hospital
or CSU) shall receive appropriate services upon discharge from the acute care
facility.
	 
	 	(2)	 	The Health Plan shall have follow-up services available to
enrollees within twenty- four (24) hours of discharge from an acute care
facility, provided the acute care facility notified the Health Plan it had
provided services to the enrollees.

	 	i.	 	BMHC shall sanction the Health Plan, as described in Attachment II,
Section XIV, Sanctions, for any inappropriate over-utilization of state mental
health treatment facility services for its enrollees.

	 	2.	 	Outpatient Hospital Services
	 
	 	 	 	Outpatient hospital services are medically necessary behavioral health services
provided in a hospital setting. The outpatient care and treatment services that an
enrollee receives must be under the direction of a licensed physician with the
appropriate specialty.

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     3. Emergency Services — Behavioral Health Services

	 	a.	 	Crisis Intervention Mental Health Services and Post-Stabilization Care Services

	 	(1)	 	Crisis intervention services include intervention activities of
less than twenty-four (24) hour duration (within a twenty-four (24) hour
period) designed to stabilize an enrollee in a psychiatric emergency.
	 
	 	(2)	 	Post-stabilization care services include any of the mandatory
services that a treating physician views as medically necessary, that are
provided after an enrollee is stabilized from an emergency mental health
condition in order to maintain the stabilized condition, or under the
circumstances described in 42 CFR 438.114(e) to improve or resolve the
enrollee’s condition.

	 	b.	 	An out-of-area, non-participating provider shall notify the Health Plan
within twenty-four (24) hours of the enrollee’s presenting for emergency
behavioral health services. In cases in which the enrollee has no identification,
or is unable to orally identify himself/herself when presenting for behavioral
health services, the out-of-area, nonparticipating provider shall notify the
Health Plan within twenty-four (24) hours of learning the enrollee’s identity.
The out-of-area, non-participating provider shall deliver to the Health Plan the
medical records that document that the identity of the enrollee could not be
ascertained at the time the enrollee presented for emergency behavioral health
services due to the enrollee’s condition.
	 
	 	c.	 	If the out-of-area, non-participating provider fails to provide the
Health Plan with an accounting of the enrollee’s presence and status within
twenty-four (24) hours after the enrollee presents for treatment and provides
identification, the Health Plan shall approve claims only for the time period
required for treatment of the enrollee’s emergency behavioral health services, as
documented by the enrollee’s medical record.
	 
	 	d.	 	The Health Plan shall review and approve or disapprove all out-of-plan
emergency behavioral health service claims within the time frames specified for
emergency claims payment in Attachment II, Section V, Covered Services, Item H.,
Coverage Provisions, sub-item 7., Emergency Services.
	 
	 	e.	 	The Health Plan shall submit to BMHC for review and final determination
all denied appeals from behavioral health care providers and out-of-plan,
non-participating behavioral health care providers for denied emergency
behavioral health service claims. The provider, whether a participating provider
or not, must submit the denied appeal to the BMHC within ten (10) calendar days
after receiving notice of the Health Plan’s final appeal determination.
	 
	 	f.	 	The Health Plan shall not deny emergency services for enrollees
presenting at participating or non-participating receiving facilities for
involuntary examination under the Baker Act. The Health Plan shall evaluate the
need for and authorize or deny any additional services within three (3) hours of
being notified by telephone from the receiving facility.

	 	(1)	 	The receiving facility must notify the Health Plan within four (4)
hours of the enrollee’s presenting. If the receiving facility fails to notify
the Health Plan of the

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	enrollee’s presence and status within four (4) hours, the Health Plan shall pay
for only the first four (4) hours of the enrollee’s treatment, subject to
medical necessity.

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

	 	g.	 	Fee-for-service Health Plans shall follow provisions of subparagraph f.
above for receiving facilities that are not CSUs.

     4. Physician Services

	 	a.	 	Physician services are those services rendered by a licensed physician
who possesses the appropriate medical specialty requirements, when applicable. A
psychiatrist must be Florida licensed and certified as a psychiatrist by the
American Board of Psychiatry and Neurology or the American Osteopathic Board of
Neurology and Psychiatry, or have completed a psychiatry residency accredited by
the Accreditation Council for Graduate Medical Education (ACGME) or the Royal
College of Physicians and Surgeons of Canada.
	 
	 	b.	 	Physician services include specialty consultations for evaluations. A
physician
consultation shall include an examination and evaluation of the enrollee with
information from family member(s) or significant others as appropriate. The
consultation shall include written documentation on an exchange of information with
the attending provider. The components of the evaluation and management procedure
code and diagnosis code must be documented in the enrollee’s medical record. A
hospital visit to an enrollee in an acute care hospital for a behavioral health
diagnosis shall be documented with a behavioral health procedure code and
behavioral health diagnosis code. All procedures with a minimum time requirement
shall be documented in the enrollee’s medical record to show the time spent
providing the service to the enrollee. The Health Plan shall be responsive to
requests for consultations made by the PCP.
	 
	 	c.	 	Physicians are required to coordinate medically necessary behavioral
health services with the PCP and other providers involved with the enrollee’s
care. The Health Plan shall draft and implement a set of protocols that indicate
when such coordination is required.

     5. Community Mental Health Services

	 	a.	 	General Provisions

	 	(1)	 	Community mental health services include behavioral health services
that are provided for the maximum reduction of the enrollee’s behavioral health
disability and restoration to the best possible functional level. Such services
can reasonably be expected to improve the enrollee’s condition or prevent
further regression. The Health Plan shall provide medically necessary community
mental health services rendered or recommended by a physician or psychiatrist
and included in a treatment

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	 		 	plan. Services must be provided to enrollees of all ages. Services should
emphasize the value of early intervention, be age appropriate and be sensitive
to the enrollee’s developmental level. The term “community” is not intended to
suggest that the services must be provided by state-funded facilities or to
preclude state-funded centers from providing these services.

	 	(2)	 	Services shall meet the intent of those covered in the Florida
Medicaid Community Mental Health Services Coverage and Limitations Handbook.
Although the Health Plan can provide flexible services, the service limits and
medical necessity criteria cannot be more restrictive than those in Medicaid
policy as stated in Medicaid Mental Health Targeted Case Management Coverage &
Limitations Handbook and the Community Behavioral Health Services Coverage &
Limitations Handbook (Handbooks) and this Contract.
	 
	 	(3)	 	The Health Plan shall establish medical necessity criteria,
including those for admission, continuing stay, and discharge, for all
mandatory and optional services. Criteria must be specific to enrollee ages
and diagnoses and must account for orders for involuntary outpatient placement
pursuant to s. 394.4655, F.S. These criteria shall be submitted to BMHC for
review and approval when developed and/or when changed.

	 	b.	 	Treatment Plan Development and Modification:

	 	(1)	 	Treatment planning includes working with the enrollee, the
enrollee’s natural support system, and all involved treating providers to
develop an individualized plan for addressing identified clinical needs. A
behavioral health care provider must complete a face-to-face interview with
the enrollee during the development of the plan.
	 
	 	(2)	 	In addition to the Handbook requirements, the individualized
treatment plan shall:

	 	(a)	 	Be recovery-oriented and promote resiliency;
	 
	 	(b)	 	Be enrollee-directed;
	 
	 	(c)	 	Accurately reflect the presenting problems of the enrollee;
	 
	 	(d)	 	Be based on the strengths of the enrollee, family, and
other natural support systems;
	 
	 	(e)	 	Provide outcome-oriented objectives for the enrollee;
	 
	 	(f)	 	Include an outcome-oriented schedule of services that
will be provided to meet the enrollee’s needs;
	 
	 	(g)	 	Include the coordination of services not covered by the
Health Plan such as school-based services, vocational rehabilitation,
housing supports, Medicaid feefor-service substance abuse treatment, and
physical health care; and
	 
	 	(h)	 	For enrollees in the child welfare system the individual
treatment plans shall be coordinated with and complement the goals of the
child welfare case plan.

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(3)	 	Individualized treatment plan reviews shall be conducted at six (6) month
intervals to assure that the services being provided are effective and remain
appropriate for addressing individual enrollee needs. Additionally, a review is
expected whenever clinically significant events occur or when treatment is not
meeting the enrollee’s needs. The provider is expected to use the individualized
treatment plan review process in the utilization management of medically
necessary services. For further guidance see the most recent Community
Behavioral Health Services and Coverage Handbook.

	 	c.	 	Evaluation and Assessment Services

	 	(1)	 	Evaluation and testing services include psychological testing
(standardized tests) and evaluations that assess the enrollee’s functioning in
all areas. Evaluations completed prior to provision of treatment shall include
a holistic view of factors that underlie or may have contributed to the need
for behavioral health services. Diagnostic evaluations are included in this
category. Diagnostic evaluations shall be comprehensive and must be used in
the development of an individualized treatment plan. All evaluations shall be
appropriate to the age, developmental level and functioning of the enrollee.
All evaluations shall include a clinical summary that integrates all the
information gathered and identifies the enrollee’s needs. The evaluation shall
prioritize the clinical needs, evaluate the effectiveness of any prior
treatment, and include recommendations for interventions and mental health
services to be provided. All new enrollees who appear for treatment services
shall receive an evaluation unless there is sufficient collateral information
that a new evaluation would not be necessary.
	 
	 	(2)	 	Evaluation services, when determined medically necessary, shall
include assessment of mutual status, functional capacity, strengths and
service needs by trained mental health staff.
	 
	 	(3)	 	Before receiving any community mental health services, children
ages 0-5 shall have a current assessment (within one (1) year) of presenting
symptoms and behaviors; developmental and medical history; family psychosocial
and medical history; assessment of family functioning; a clinical interview
with the primary caretaker and an observation of the child’s interaction with
the caretaker; and an observation of the child’s language, cognitive, sensory,
motor, self-care, and social functioning.

	 	d.	 	Medical and Psychiatric Services

	 	(1)	 	These services include medically necessary interventions that
require the skills and expertise of a psychiatrist, psychiatric ARNP, or
physician.
	 
	 	(2)	 	Medical psychiatric interventions include the prescribing and
management of medications, monitoring side effects associated with prescribed
medications, individual or group medical psychotherapy, psychiatric evaluation
(for diagnostic purposes and for initiating treatment), psychiatric review of
treatment records for diagnostic purposes, and psychiatric consultation with
an enrollee’s family or significant others, PCPs, and other treatment
providers.
	 
	 	(3)	 	Interventions related to specimen collections, taking vital signs
and administering injections are also a covered service.

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	 	(4)	 	Treatment services are distinguished from the physician services outlined
above in that they are provided through a community mental health provider.
Psychiatric or physician services must be at sites where substantial amounts of
community mental health services are provided.

	 	e.	 	Behavioral Health Therapy Services

	 	(1)	 	Therapy services include individual and family therapy, group
therapy and behavioral health day services. These services may include
psychotherapy or supportive counseling focused on assisting enrollees with the
problems or symptoms identified in an assessment. The focus should be on
identifying and utilizing the strengths of the enrollee, family, and other
natural support systems. Therapy services shall be geared to the individual
needs of the enrollee and shall be sensitive to the age, developmental level,
and functional level of the enrollee.
	 
	 	(2)	 	Family and marital therapy are also included in this category.
Examples of interventions include those that focus on resolution of a life
crisis or an adjustment reaction to an external stressor or developmental
challenge.
	 
	 	(3)	 	Behavioral health day services are designed to enable enrollees
to function successfully in the community in the least restrictive environment
and to restore or enhance ability for social and pre-vocational life
management services. The primary functions of behavioral health day services
are stabilization of the symptoms related to a behavioral health disorder to
reduce or eliminate the need for more intensive levels of care, to provide
transitional treatment after an acute episode, or to provide a level of
therapeutic intensity not possible in a traditional outpatient setting.

	 	f.	 	Community Support and Rehabilitative Services

	 	(1)	 	These services include psychosocial rehabilitation services and
clubhouse services. Clubhouse services are excluded from the Health Plan’s
coverage but are covered under fee-for-service Medicaid. Psychosocial
rehabilitation services may be
provided in a facility, home, or community setting. These services assist
enrollees in functioning within the limits of a disability or disabilities
resulting from a mental illness. Services focus on restoration of a previous
level of functioning or improving the level of functioning. Services must be
individualized and directly related to goals for improving functioning within a
major life domain.
	 
	 	(2)	 	The coverage must include a range of social, educational,
vocational, behavioral, and cognitive interventions to improve enrollees’
potential for social relationships, occupational/educational achievement and
living skills development. Skills training development is also included in
this category and includes activities aimed toward restoration of enrollees’
skills/abilities that are essential for managing their illness, actively
participating in treatment, and conducting the requirements of daily
independent living. Providers must offer the services in a setting best suited
for desired outcomes, i.e., home or community-based settings.
	 
	 	(3)	 	Psychosocial rehabilitative services may also be provided to
assist enrollees in finding or maintaining appropriate housing arrangements or
to maintain employment. Interventions should focus on the restoration of
skills/abilities that are adversely affected by the mental illness and
supports required to manage the enrollee’s housing or employment needs. The
provider must be knowledgeable

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	about TANF and is responsible for medically necessary mental health services
that will assist the individual in finding and maintaining employment.

	 	g.	 	Therapeutic Behavioral On-Site Services (TBOS) for Children and Adolescents

	 	(1)	 	TBOS services are community services and natural supports for
children/adolescents with serious emotional disturbances. Clinical services
include provision of a professional level therapeutic service that may include
teaching problem solving skills, behavioral strategies, normalization
activities and other treatment modalities that are determined to be medically
necessary. These services shall be designed to maximize strengths and reduce
behavior problems or functional deficits stemming from the existence of a
mental health disorder. Social services include interventions designed for the
restoration, modification, and maintenance of social, personal adjustment and
basic living skills.
	 
	 	(2)	 	TBOS services are intended to maintain the child/adolescent in
the home and to prevent reliance upon a more intensive, restrictive, and
costly mental health placement. They are also focused on helping the
child/adolescent possess the physical, emotional, and intellectual skills to
live, learn and work in the home community. Coverage shall include the
provision of these services outside of the traditional office setting. The
services shall be provided where they are needed, in the home, school,
childcare centers or other community sites.

	 	h.	 	Day Treatment Services

	 	(1)	 	Adult day treatment services include therapy, rehabilitation,
social interactions, and other therapeutic services that are designed to
redevelop, maintain, or restore skills that are necessary for enrollees to
function in the community. The provider must have an array of available
services designed to meet the individualized needs of the enrollee, and which
address the following primary functions:

	 	(a)	 	Stabilize symptoms related to a behavioral health
disorder to reduce or eliminate the need for more intensive levels of
care;
	 
	 	(b)	 	Provide a level of therapeutic intensity between
traditional outpatient and an inpatient or partial hospital setting;
	 
	 	(c)	 	Provide a level of treatment that will assist enrollees
in transitioning from an acute care or institutional settings;
	 
	 	(d)	 	Assist enrollees in redeveloping the skills required to
maintain a living environment, use community resources, and conduct
activities of daily living and/or live independently in the community.

	 	(2)	 	Children/adolescent day treatment services include therapy,
rehabilitation and social interactions, and other therapeutic services that are
designed to redevelop, maintain, or restore skills that are necessary for
children/adolescents to function in their community. The approach shall take
into consideration developmental levels and delays in development due to
emotional disorders. If the child/adolescent is school age, the services shall
be coordinated with the school system. All therapeutic day treatment
interventions for children/adolescents shall have a component that addresses
caregiver participation and involvement. Services for all

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	children/adolescents should be coordinated with home care to the greatest extent
possible. Day treatment services shall include an array of programs with the
following functions:

	 	(a)	 	Stabilize the symptoms related to a behavioral health
disorder to reduce or eliminate the need for more intensive levels of
care;
	 
	 	(b)	 	Provide transitional treatment after an acute episode,
admission to an inpatient program, or discharge from a residential
treatment setting;
	 
	 	(c)	 	Provide a therapeutic intensity not possible in a traditional
outpatient setting; and
	 
	 	(d)	 	Assist the child/adolescent in redeveloping
age-appropriate skills required to conduct activities of everyday living
in the community.

	 	(3)	 	Staff providing adult or children/adolescent day treatment services
must have appropriate training and experience. Behavioral health care providers
shall be available to provide clinical services when necessary.

	 	i.	 	Services for Children Ages 0 through 5 Years

	 	(1)	 	Services include behavioral health day services and therapeutic
behavioral on-site services for children ages 0 through 5 years.
	 
	 	(2)	 	Prior to receiving these services, the enrollees in this age group
must have an assessment that meets the criteria in the Medicaid Community
Behavioral Health Services Coverage and Limitations Handbook.

     6. Behavioral Health Targeted Case Management

	 	a.	 	The Health Plan shall provide targeted case management services to
children/adolescents with serious emotional disturbances and adults with a severe
and persistent mental illness as defined below. The Health Plan shall either
develop its own targeted case management certification program or approve a
provider training program that meets the criteria in the Medicaid Targeted Case
Management Coverage and Limitations Handbook.

	 	(1)	 	The Health Plan shall meet the intent of the services and ensure
the qualification and certification of providers as outlined below and in the
Medicaid Targeted Case Management Coverage and Limitations Handbook.
	 
	 	(2)	 	The Health Plan shall set criteria and clinical guidelines for
case management services. Service limits and criteria developed cannot be more
restrictive than those in Medicaid policy.
	 
	 	(3)	 	At a minimum, case management services are to incorporate the
principles of a strengths-based approach. Strengths-based case management
services are an alternative service modality for working with individuals and
families. This method stresses building on the strengths of individuals that
can be used to resolve current problems and issues, countering more
traditional approaches that focus almost exclusively on individual’s deficits
or needs.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	b.	 	Target Populations

	 	(1)	 	Behavioral health targeted case management services shall be available to all
enrollees:

	 	(a)	 	Who require numerous services from different providers and also require
advocacy and coordination to implement or access services;
	 
	 	(b)	 	Who would be unable to access or maintain consistent care within the service
delivery system without case management services;
	 
	 	(c)	 	Who do not possess the strengths, skills, or support system to allow them to
access or coordinate services;
	 
	 	(d)	 	Who may benefit from case management but lack the skills or knowledge
necessary to access services; or
	 
	 	(e)	 	Who do not meet these criteria but may still be eligible for limited targeted
case management services by meeting exception criteria contained in the Medicaid
Targeted Case Management Coverage and Limitations Handbook.

	 	(2)	 	The Health Plan also shall have case management services available to
children/adolescents who have a serious emotional disturbance, which is: a defined mental
disorder; a level of functioning which requires two or more coordinated behavioral health
services to be able to live in the community; and at imminent risk of out-of-home
behavioral health treatment placement.
	 
	 	(3)	 	The Health Plan shall also have case management services available for adults with a
severe and persistent mental illness or who have been denied admission to a long-term
mental health institution or residential treatment facility or have been discharged from a
long-term mental health institution or residential treatment facility.

	 	c.	 	The Health Plan will not be required to seek approval from the SAMH Program Office for client
eligibility or behavioral health targeted case management agency or individual provider
certification.
	 
	 	d.	 	Required Services

	 	(1)	 	Behavioral health targeted case management services include working with the enrollee
and the enrollee’s natural support system to develop and promote a service plan. The
service plan reflects the services or supports needed to meet the needs identified in an
individualized assessment of the following areas: education or employment, physical health,
mental health, substance abuse, social skills, independent living skills, and support
system status. The approach used shall identify and utilize the strengths, abilities,
cultural characteristics, and informal supports of the enrollee, family, and other natural
support systems. Targeted case managers focus on overcoming barriers by collaborating and
coordinating with providers and the enrollee to assist in the attainment of service plan
goals. The targeted case manager takes the lead in both coordinating services/treatment and
assessing the effectiveness of the services provided.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(2)	 	When targeted case management recipients enrolled in the Health
Plan are hospitalized in an acute care setting or held in a county jail or
juvenile detention facility, the Health Plan shall document efforts to ensure
that contact is maintained with the enrollee and shall participate actively in
the discharge planning processes.
	 
	 	(3)	 	Case managers are also responsible for coordination and
collaboration with the parents or guardians of children/adolescents who
receive mental health targeted case management services. The Health Plan shall
monitor case management activities to assure that case managers routinely
include the parents or guardians of enrollees in the process of providing
targeted case management services. Integration of the parent’s input and
involvement with the case manager and other providers shall be reflected in
medical record documentation and monitored through the Health Plan’s quality
of care monitoring activities. Involvement with the
child/adolescent’s school and/or childcare center must also be a component of
case management with children/adolescents.
	 
	 	(4)	 	The Health Plan shall provide behavioral health targeted case
management services to children/adolescents in the care or custody of the
state who need them. The Health Plan shall document efforts to develop a
cooperative agreement with DCF, or its provider of community-based services,
to address how to minimize duplication of case management services and to
promote the establishment of one case manager for the child/adolescent and
family whenever possible.

	 	e.	 	Additional Requirements for Targeted Case Management
	 
	 	 	 	The Health Plan shall have a case management program, including guidelines and
protocols that address:

	 	(1)	 	Caseloads set to achieve the desired results. Size limitations
must clearly state the ratio of enrollees to each individual case manager. The
limits shall be specified for children/adolescents and adults, with a
description of the clinical rationale for determining each limitation. If the
Health Plan permits “mixed” caseloads, i.e., children/adolescents and adults,
a separate limitation is expected along with the rationale for the
determination. Ratios must be no greater than the requirements set forth in
the Medicaid Mental Health Targeted Case Management Coverage and Limitations
Handbook;
	 
	 	(2)	 	A system to manage caseloads when positions become vacant;
	 
	 	(3)	 	A description of the modality of service provision and the
location that services will be provided;
	 
	 	(4)	 	The expected frequency, duration and intensity of the service
with service limits and criteria no more restrictive than those in Medicaid
policy;
	 
	 	(5)	 	Issues related to recovery and self-care, including services to
help enrollees gain independence from the behavioral health and case
management system;
	 
	 	(6)	 	Services based on individual needs of the enrollees receiving the
service. The service system shall also address the changing needs and
abilities of enrollees; and

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(7)	 	Case management staff with expertise and training necessary to competently
and promptly assist enrollees in working with Social Security Administration or
Disability Determination in maintaining benefits from SSI and SSDI. For
enrollees who wish to work, case management staff must have the expertise and
training necessary to help enrollees access Social Security Work Incentives.

     7. Intensive Case Management

	 	a.	 	Intensive case management is intended for highly recidivistic adults
who have a severe and persistent mental illness. The service is intended to help
enrollees remain in the community and avoid institutional care. Care criteria for
this level of case management shall address the same elements required above, as
well as expanded elements related to access and twenty-four (24) hour coverage as
described below. Additionally, the intensive case management team composition
shall be expanded to include members selected specifically to assist with the
special needs of this population.
	 
	 	b.	 	The Health Plan shall provide this service for all enrollees for whom it is determined
to
be medically necessary, to include any enrollee who meets the following criteria:

	 	(1)	 	Has resided in a state mental health treatment facility for at
least six (6) of the past thirty-six (36) months;
	 
	 	(2)	 	Resides in the community and has had two (2) or more admissions
to a state mental health treatment facility in the past thirty-six (36)
months;
	 
	 	(3)	 	Resides in the community and has had three (3) or more admissions
to a crisis stabilization unit, short-term residential facility, inpatient
psychiatric unit, or any combination of these facilities within the past
twelve (12) months; or
	 
	 	(4)	 	Resides in the community and, due to a mental illness, exhibits
behavior or symptoms that could result in long-term hospitalization if
frequent interventions for an extended period of time were not provided.

	 	c.	 	Intensive case management services are frequent and intense and focus
on helping the enrollee attain skills and supports needed for independent living.
Case management services are provided primarily in the enrollee’s residence and
include community- based interventions.
	 
	 	d.	 	The Health Plan shall provide this service in the least restrictive
setting with the goal of improving the enrollee’s level of functioning, and
providing ample opportunities for rehabilitation, recovery, and self-sufficiency.
Intensive case management services shall be accessible twenty-four (24) hours per
day, seven (7) days per week. The Health Plan shall demonstrate adequate capacity
to provide this service for the targeted population within the guidelines
outlined.

     8. Community Treatment of Patients Discharged from State Mental Health Treatment Facilities

	 	a.	 	The Health Plan shall provide medically necessary behavioral health
services to enrollees who have been discharged from any state mental health
treatment facility, including, but not limited to, follow-up services and care.
All enrollees who have

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	previously received services at a state mental health treatment facility must
receive follow-up care.

	 	b.	 	The plan of care shall be aimed at encouraging enrollees to achieve a
high quality of life while living in the community in the least restrictive
environment that is medically appropriate and reducing the likelihood that the
enrollees will be readmitted to a state mental health treatment facility.
	 
	 	c.	 	The Health Plan shall follow the progress of all enrollees enrolled in
the Health Plan prior to admission to a state mental health treatment facility
until the thirtieth day after admission or until disenrollment from the Health
Plan. The Health Plan shall use behavioral health targeted case managers to follow
the progress of enrollees.
	 
	 	d.	 	If the enrollee remains in the state facility more than thirty (30)
calendar days and is disenrolled, the Health Plan shall cooperate with DCF and the
enrollee to ensure that the enrollee is assigned a DCF-funded case management
provider who will bear the responsibility of ongoing monthly follow-up care and
discharge planning until such time that the enrollee is again eligible for, and
enrolled in, a health plan.
	 
	 	e.	 	The Health Plan shall document efforts to develop a cooperative agreement
with the behavioral health care facility.

     9. Community Services for Medicaid Recipients Involved with the Justice System

The Health Plan shall make every effort as follows to provide medically necessary
community-based services for Health Plan enrollees who have justice system involvement:

	 	a.	 	Ensure a linkage to pre-booking sites for assessment, screening or
diversion related to behavioral health services;
	 
	 	b.	 	Provide psychiatric services within twenty-four (24) hours of release
from jail, juvenile detention facility, or other justice facility to assure that
prescribed medications are available for all enrollees;
	 
	 	c.	 	Ensure a linkage to post-booking sites for discharge planning and
assuring that prior Health Plan enrollees receive necessary services upon release
from the facility. Health Plan enrollees shall be linked to services and receive
routine care within seven (7) calendar days from the date they are released;
	 
	 	d.	 	Provide outreach to homeless and other populations of Health Plan
enrollees at risk of justice system involvement, as well as those Health Plan
enrollees currently involved in this system, to assure that services are
accessible and provided when necessary. This activity shall be oriented toward
preventive measures to assess behavioral health needs and provide services that
can potentially prevent the need for future inpatient services or possible deeper
involvement in the forensic or justice system;
	 
	 	e.	 	The Health Plan or its designee shall document efforts to develop a
cooperative agreement with justice facilities to enable the Health Plan to
anticipate enrollees who were Health Plan enrollees prior to incarceration who
will be released from these institutions. The cooperative agreement must address
arrangement for persons who are to be released, but for whom re-enrollment may not
take effect immediately. All enrollees who were Health Plan enrollees prior to
incarceration and Medicaid recipients

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	who are likely to enroll in the Health Plan upon return to the community must
receive a community behavioral health service within twenty-four (24) hours of
discharge from the corrections facility.

     10. Treatment and Coordination of Care for Enrollees with Medically Complex Conditions

	 	a.	 	The Health Plan shall ensure that appropriate resources are available to
address the treatment of complex conditions that reflect both mental health and
physical health involvement. The following conditions must be addressed:

	 	(1)	 	Mental health disorders due to or involving a general medical
condition, specifically ICD-9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89,
and 310.1; and
	 
	 	(2)	 	Eating disorders — ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
307.52.

	 	b.	 	The Health Plan shall provide medically necessary community mental health
services to enrollees who exhibit the above diagnoses and shall develop a plan of
care that includes all appropriate collateral providers necessary to address the
complex medical issues involved. Clinical care criteria shall address modalities
of treatment that are effective for each diagnosis. The Health Plan’s provider
network must include appropriate treatment resources necessary for effective
treatment of each diagnosis within the required access time periods.

     11. Coordination of Children’s Services

	 	a.	 	The delivery and coordination of child/adolescent mental health services
shall be provided for all who exhibit the symptoms and behaviors of an emotional
disturbance. The delivery of services must address the needs of any
child/adolescent served in an SED (severely emotionally disturbed) or EH
(emotionally handicapped) school program. Developmentally appropriate early
childhood mental health services must be available to children from birth to
five(5) years and their families.
	 
	 	b.	 	The Health Plan shall deliver services for all children/adolescents
within a strengths- based, culturally competent service design. The service design
shall recognize and ensure that services are family-driven and include the
participation of family, significant others, informal support systems, school
personnel, and any state entities or other service providers involved in the
child/adolescent’s life.
	 
	 	c.	 	For all children/adolescents receiving services from the Health Plan, the
provider shall work with the parents, guardians, or other responsible parties to
monitor the results of services and determine whether progress is occurring.
Active monitoring of the child/adolescent’s status shall occur to detect potential
risk situations and emerging needs or problems.
	 
	 	d.	 	When the court mandates a parental behavioral health assessment, and the
parent is an enrollee, the provider must complete an assessment of the parent’s
mental health status and the effects on the child. Time frames for completion of
this service shall be determined by the mandates issued by the courts.
	 
	 	e.	 	Evaluation and Treatment Services for Enrolled Children/Adolescents

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(1)	 	The Health Plan shall provide all medically necessary evaluations,
psychological testing and treatment services for children/adolescents referred
to the Health Plan by DCF, DJJ and by schools (elementary, middle, and
secondary schools).
	 
	 	(2)	 	The Health Plan shall provide court-ordered evaluation and
treatment required for children/adolescents who are enrollees. See
specifications in the Medicaid Community Behavioral Health Services Coverage & Limitations Handbook.
	 
	 	(3)	 	The Health Plan or designee shall participate in all DCF or
school staffings that may result in the provision of behavioral health
services to an enrolled child/adolescent.
	 
	 	(4)	 	The Health Plan shall refer children/adolescents to DCF when
residential treatment is medically necessary.

D. Transition Plan

	 	1.	 	A transition plan is a detailed description of the process of transferring
enrollees from nonparticipating providers to the Health Plan’s behavioral health care
provider network to ensure optimal continuity of care. The transition plan shall
include, but not be limited to, a timeline for transferring enrollees, description of
provider clinical record transfers, scheduling of appointments, and proposed
prescription drug protocols and claims approval for existing providers during the
transition period. The Health Plan shall document its efforts relating to the
transition plan in the enrollee’s clinical records.
	 
	 	2.	 	The Health Plan shall minimize the disruption to the enrollee as a result of
any change in behavioral health care providers or case managers that occurs as a
result of this Contract. For enrollees who have received behavioral health services
from a behavioral health care provider, whether the provider is in the Health Plan’s
network or not, the Health Plan shall continue to authorize all valid claims until
the Health Plan has:

	 	a.	 	Reviewed the enrollee’s treatment plan;
	 
	 	b.	 	Developed an appropriate written transition plan; and
	 
	 	c.	 	Implemented the written transition plan.

	 	3.	 	During the first three (3) months that the enrollee receives behavioral health
services under this Contract, the Health Plan shall not deny requests for behavioral
health services outside the network under the following conditions:

	 	a.	 	The enrollee is a patient at a community behavioral health center and the
center has discussed the enrollee’s care with the Health Plan;
	 
	 	b.	 	If, following contact with the Health Plan, there is no behavioral health
care provider readily available and the enrollee’s condition would not permit a
delay in treatment.

	 	4.	 	If the previous treating provider is unable to allow the Health Plan access to
the enrollee’s clinical records because the enrollee refuses to release the records,
then the Health Plan shall approve the provider’s claims for:

	 	a.	 	Four (4) sessions of outpatient behavioral health counseling or therapy;

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	b.	 	One (1) outpatient psychiatric physician session;
	 
	 	c.	 	Two (2) one-hour (1-hour) therapeutic behavioral health on-site sessions; or
	 
	 	d.	 	Six (6) days of behavioral health day services.

	 	5.	 	Any disputes related to coverage of services necessary for the transition of
enrollees from their current behavioral health care provider to a behavioral health
care provider shall follow the process set forth in Attachment II, Section IX,
Grievance System.
	 
	 	6.	 	The Health Plan shall approve claims from providers for authorized out-of-plan
non- emergency services, provided such claims are submitted within twelve (12) months
of the date of service. The Health Plan shall process such claims within the time
period specified in s. 641.3155, F.S.

	E.	 	Psychiatric Evaluations for Enrollees Applying for Nursing Home Admission

The Health Plan shall, upon request from the SAMH offices, promptly arrange for and
authorize psychiatric evaluations for enrollees who are applying for admission to a
nursing facility pursuant to OBRA 1987, and who, on the basis of a screening conducted by
Comprehensive Assessment and Review for Long term Care (CARES) workers, are thought to
need mental health treatment. The examination shall be adequate to determine the need for
“specialized treatment” under OBRA. Evaluations must be completed within five (5) working
days from the time the request from the DCF SAMH office is received. Regulations have been
interpreted by the state to permit any of the mental health professionals listed in s.
394.455, F.S., to make the observations preparatory to the evaluation, although a
psychiatrist must sign such evaluations. The Health Plan will not be responsible for
resident reviews or for providing services as a result of a pre-admission screening and
resident review (PASRR) evaluation.

	F.	 	Assessment and Treatment of Mental Health Residents Who Reside in Assisted Living
Facilities (ALF) that hold a Limited Mental Health License

	 	1.	 	The provider must develop and implement a plan to ensure compliance with s,
394.4574, F.S., related to services provided to residents of licensed assisted living
facilities that hold a limited mental health license. A cooperative agreement, as
defined in s. 429.02, F.S., must be developed by the ALF with the enrollee’s Health
Plan if an enrollee is a resident of an ALF. The provider must ensure that
appropriate assessment services are provided to enrollees and that medically
necessary behavioral health services are available to all enrollees who reside in
this type of setting.
	 
	 	2.	 	A community living support plan, as defined in Attachment II, Section I,
Definitions and Acronyms, shall be developed for each enrollee who is a resident of
an ALF, and it must be updated annually. The Health Plan or its designee’s behavioral
health care case manager is responsible for ensuring that the community living
support plan is implemented as written.
	 
	 	3.	 	Upon request from an ALF, the Health Plan shall provide procedures for the ALF
to follow should an emergent condition arise with an enrollee that resides at the ALF
(see s. 409.912(36), F.S.).

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	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	G.	 	Individuals with Special Health Care Needs

	 	1.	 	The Health Plan shall implement mechanisms for identifying, assessing and ensuring the
existence of an individualized treatment plan for individuals with special health care
needs, as defined in Attachment II, Section I, Definitions and Acronyms. Mechanisms shall
include evaluation of risk assessments, claims data, and CPT/ICD-9 codes. Additionally, the
Health Plan shall implement a process for receiving and considering provider and enrollee
input.
	 
	 	2.	 	In accordance with this Contract and 42 CFR 438.208(c)(3), an individualized treatment
plan for an enrollee determined to need a course of treatment or regular care monitoring
must be:

	 	(a)	 	Developed by the enrollee’s direct service mental health care professional with
enrollee participation and in consultation with any specialists caring for the
enrollee;
	 
	 	(b)	 	Approved by the Health Plan in a timely manner if this approval is required;
and
	 
	 	(c)	 	Developed in accordance with any applicable Agency quality assurance and
utilization review standards.

	 	3.	 	Pursuant to 42 CFR 438.208(c)(4), for enrollees with special health care needs
determined through an assessment by appropriate mental health care professionals
(consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular care
monitoring, the Health Plan shall have a mechanism in place to allow enrollees to directly
access a mental health care specialist (for example, through a standing referral or an
approved number of visits) as appropriate for the enrollee’s condition and identified
needs.

	H.	 	Crisis Support/Emergency Services

	 	1.	 	The Health Plan shall operate, as part of its crisis support/emergency services, a
crisis emergency hotline available to all enrollees twenty-four hours a day, seven days a
week, (24/7).
	 
	 	2.	 	For each county it serves, the Health Plan shall designate an emergency service
facility that operates twenty-four hours a day, seven days a week, (24/7) with Registered
Nurse coverage and on-call coverage by a behavioral health specialist.

	I.	 	Behavioral Health Services Care Coordination and Management

The Health Plan shall be responsible for the coordination and management of behavioral health
services and continuity of care for all enrollees. At a minimum, the Health Plan shall provide
the following services to its enrollees:

	 	1.	 	Document all emergency behavioral health services received by an enrollee, along with
any follow-up services, in the enrollee’s behavioral health medical records. The Health
Plan shall also assure the PCP receives the information about the emergency behavioral
health services for filing in the PCP’s medical record.
	 
	 	2.	 	Document all referral services in the enrollees’ behavioral health clinical records.

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	3.	 	Provide appropriate referral of the enrollee for non-covered services to the
appropriate service setting. The Health Plan shall request referral assistance, as
needed, from the Medicaid Area Office. The Health Plan is encouraged to use the
Florida Supplement to the American Society of Addictions Medicine Patient Placement
Criteria for coordination and treatment of substance abuse related disorders with
substance abuse providers. The Health Plan shall provide coordination of care with
community-based substance abuse agencies as part of its policies and procedures
developed for continuity of care for enrollees who are diagnosed with mental illness
and substance abuse or dependency.
	 
	 	4.	 	Where a SAMH planning process exists, the Health Plan shall participate (see s.
394.75, F.S.).

	J.	 	Discharge Planning
	 
	 	 	Discharge planning is the evaluation of an enrollee’s medical care needs, including
behavioral health service needs, substance abuse service needs, or both, in order to
arrange for appropriate care after discharge from one level of care to another. The Health
Plan shall:

	 	1.	 	Monitor all enrollee discharge plans from behavioral health inpatient
admissions to ensure that they incorporate the enrollee’s needs for continuity in
existing behavioral health therapeutic relationships;
	 
	 	2.	 	Ensure that enrollees’ family members, guardians, outpatient individual
practitioners and other identified supports are given the opportunity to participate
in enrollee treatment to the maximum extent practicable and appropriate, including
behavioral health treatment team meetings and developing the discharge plan. For
adult enrollees, family members and other identified supports may be involved in the
development of the discharge plan only if the enrollee consents to their involvement;
	 
	 	3.	 	Designate staff members who are responsible for identifying enrollees who
remain in the hospital for non-clinical reasons (i.e., absence of appropriate
treatment setting availability, high demand for appropriate treatment setting,
high-risk enrollees and enrollees with multiple agency involvement);
	 
	 	4.	 	Develop and implement a plan that monitors and ensures that clinically
indicated behavioral health services are offered and available to enrollees within
twenty-four (24) hours of discharge from an inpatient setting;
	 
	 	5.	 	Ensure that a behavioral health program clinician provides medication
management to enrollees requiring medication monitoring within twenty-four (24) hours
of discharge from a behavioral health program inpatient setting. The Health Plan
shall ensure that the behavioral health program clinician is duly qualified and
licensed to provide medication management;
	 
	 	6.	 	Upon the admission of an enrollee, the Health Plan shall make its best efforts
to ensure the enrollee’s smooth transition to the next service or to the community
and shall require that behavioral health care providers:

	 	a.	 	Assign a behavioral health care case manager to oversee the care given to
the enrollee;

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	b.	 	Develop an individualized discharge plan, in collaboration with the enrollee
where appropriate, for the next service or program or the enrollee’s discharge,
anticipating the enrollee’s movement along a continuum of services; and
	 
	 	c.	 	Document all significant efforts related to these activities, including
the enrollee’s active participation in discharge planning.

	K.	 	Functional Assessments

	 	1.	 	The Health Plan shall ensure that all behavioral health care providers
administer functional assessments using the functional assessment rating scales
(FARS) for all enrollees over the age of 18 and child functional assessment rating
scale (CFARS) for all enrollees age 18 and under.
	 
	 	2.	 	The Health Plan shall ensure that all behavioral health care providers
administer and maintain the FARS and CFARS for all enrollees receiving behavioral
health services and upon termination of providing such services, as required in the
FARS and CFARS manuals and report templates provided by the Agency.
	 
	 	3.	 	The results of the FARS and CFARS assessments shall be maintained in each
enrollee’s clinical record, including a chart trending the results of the functional
assessments.
	 
	 	4.	 	The Health Plan shall submit the FARS/CFARS reports to BMHC as required in
Attachment II, Section XII, Reporting Requirements.

	L.	 	Behavioral Health Provider Contracts

	 	1.	 	If the Health Plan subcontracts with a managed behavioral health organization
(MBHO) for the provision of behavioral health services, the MBHO must be accredited
by at least one of the recognized national accreditation organizations.
	 
	 	2.	 	The Health Plan shall submit to the BMHC the staff psychiatrist employment
contract, if any, and the model provider contracts for each behavioral health
services specialist type or facility.
	 
	 	3.	 	All subcontracts and provider contracts must adhere to the requirements set
forth in this Contract.

	M.	 	Optional Services
	 
	 	 	The Health Plan is encouraged to provide additional services that will enhance its covered
services. To the degree possible, the Health Plan shall use existing community resources.
Optional services represent a downward substitution for services in the Community
Behavioral Health Services Coverage and Limitations Handbook and are not an expansion of
behavioral health services. The Health Plan shall make information on optional services
available to enrollees and require documentation of enrollee agreement before implementing
such services. The Health Plan shall not require an enrollee to choose an optional service
over a Community Behavioral Health Services Coverage and Limitations Handbook service.
Optional services must be prior approved by BMHC.

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 37 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	N.	 	Community Coordination and Collaboration

The Health Plan shall make every effort to ensure that its providers become a vital part of
the community services and support system. It shall actively participate with and support
community programs and coalitions that promote school readiness, that assist persons to return
to work and provide for prevention programs. The Health Plan shall have linkages with numerous
community programs that will assist enrollees in obtaining housing, economic assistance and
other supports.

	0.	 	Behavioral Health Managed Care Local Advisory Forum

	 	1.	 	There will be one designated Medicaid behavioral health care advisory forum in each
Medicaid Area where managed care organizations are operating. Each forum shall convene no
less than quarterly and report to the Agency on advocacy and programmatic concerns related
to delivery of Medicaid-funded behavioral health services. The local forum is responsible
for gathering information and reporting to the Agency on the provision of managed
behavioral health care services. The forum functions solely as a fact-finder or information
gatherer with no decision-making authority. The forum shall be conducted as an open public
meeting designed to promote the coordination, integration, quality, and efficiency of the
behavioral health system of care.
	 
	 	2.	 	Information is to be presented to keep participants up to date on activities and
contractual responsibilities of each managed care plan. Meeting minutes related to
discussion and activities must be kept and distributed to participants. The local forum is
to be coordinated by Agency staff.
	 
	 	3.	 	The forum is to be facilitated by a volunteer chairperson and vice-chairperson or two
(2) co- chairpersons. Representatives from the Health Plan, behavioral health service
provider agencies or state employees may not hold these voluntary positions.
	 
	 	4.	 	This public forum provides opportunities for beneficiaries, providers, and community
stakeholders to discuss ideas and pose questions to Health Plans and Agency
representatives. Health Plan behavioral health representatives shall attend the forums in
person, participate, and respond to participant questions and inquiries for information
related to Medicaid-funded behavioral health services. Agency representatives also shall be
present and participate appropriately in responding to concerns related to service
delivery, oversight, access, and best practices.
	 
	 	5.	 	Health Plans shall follow up on identified issues of concern related to Medicaid
services or Health Plan administration. On request, Health Plans shall provide pertinent
information about quality improvement findings, access, outreach activities, and best
practices.

	P.	 	Community Behavioral Health Services Annual 80/20 Expenditure Report (HMOs serving non-Reform
populations only)
	 
	 	 	By April 1st of each Contract year, HMOs shall provide a breakdown of expenditures
related to the provision of community behavioral health services to non-Reform populations using
the spreadsheet template provided by the Agency (see Attachment II, Section XII, Reporting
Requirements). For non-Reform HMOs, in accordance with s. 409.912, F.S., 80% of the capitation
rate paid to the Health Plan by the Agency shall be expended for the direct provision of
community behavioral health services. In the event the Health Plan expends less

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	than eighty percent (80%) of the capitation rate, the Health Plan shall return the
difference to the Agency no later than May 1st of each Contract year.

	 	1.	 	For reporting purposes in accordance with this section, “community behavioral
health services” are defined as those services that the Health Plan is required to
provide as listed in the Community Mental Health Services Coverage and Limitations
Handbook and the Mental Health Targeted Case Management Coverage and Limitations
Handbook.
	 
	 	2.	 	For reporting purposes in accordance with this section “expended” means the
total amount, in dollars, paid directly or indirectly to community behavioral health
services providers solely for the provision of community behavioral health services,
not including administrative expenses or overhead of the Health Plan. If the report
indicates that a portion of the capitation payment is to be returned to the Agency,
the Health Plan shall submit a check for that amount with the Behavioral Health
Services Annual 80/20 Expenditure Report that the Health Plan provides to BMHC. See
Attachment II, Section XII, Reporting Requirements, and the Agency’s Report Guide.

	Q.	 	Behavioral Health Clinical Records
	 
	 	 	The Health Plan shall maintain a behavioral health clinical record of services for each
enrollee. Each enrollee’s behavioral health clinical record shall:

	 	1.	 	Include documentation sufficient to disclose the quality, quantity,
appropriateness and timeliness of behavioral health services performed;
	 
	 	2.	 	Be legible and maintained in detail consistent with the clinical and
professional practice that facilitates effective internal and external peer review,
medical audit and adequate follow-up treatment; and
	 
	 	3.	 	For each service provided, clearly identify:

	 	a.	 	The physician or other service provider;
	 
	 	b.	 	Date of service;
	 
	 	c.	 	The units of service provided; and
	 
	 	d.	 	The type of service provided.

	R.	 	Behavioral Health Quality Improvement (QI) Requirements

	 	1.	 	The Health Plan’s QI plan shall include a behavioral health component in order
to monitor and assure that the Health Plan’s behavioral health services are
sufficient in quantity, of acceptable quality and meet the needs of the enrollees.
	 
	 	2.	 	Treatment plans must:

	 	a.	 	Identify reasonable and appropriate objectives;
	 
	 	b.	 	Provide necessary services to meet the identified objectives; and

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 39 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	c.	 	Include retrospective reviews that confirm that the care provided, and its
outcomes, were consistent with the approved treatment plans and appropriate for
enrollee needs.

	 	3.	 	In determining if behavioral health services are acceptable according to current
treatment standards, the Health Plan shall:

	 	a.	 	Submit the annual Contract year schedule for administrative/programmatic monitoring
and clinical record review for approval to BMHC by July 1 St each Contract
year.

	 	(1)	 	A Health Plan that has been in operation less than twelve
(12) months shall perform quarterly administrative monitoring and quarterly
review of a random selection of ten percent (10%) or fifty (50) clinical
records, whichever is less, of enrollees receiving behavioral health
services during the previous quarter.
	 
	 	(2)	 	A Health Plan that has been in operation twelve (12) months
or more shall perform an annual review of a random selection of ten percent
(10%) or seventy-five (75) clinical records, whichever is less, of
enrollees who received behavioral health services during the previous
Contract year.

	 	b.	 	Elements of these reviews shall include, but not be limited to:

	 	(1)	 	Management of specific diagnoses;
	 
	 	(2)	 	Appropriateness and timeliness of care;
	 
	 	(3)	 	Comprehensiveness of, and compliance with, the plan of care;
	 
	 	(4)	 	Evidence of special screening for high risk enrollees and/or conditions;
	 
	 	(5)	 	Evidence of appropriate coordination of care; and
	 
	 	(6)	 	Evidence of compliance with applicable Medicaid Mental
Health Targeted Case Management Coverage & Limitations Handbook and the
Community Behavioral Health Services Coverage & Limitations Handbook.

	S.	 	Behavioral Health Reporting Requirements
	 
	 	 	Behavioral health reporting requirements are also listed in Attachment II, Section
XII, Reporting Requirements and must be submitted as required in the Health Plan
Report Guide.

	T.	 	Enrollee Satisfaction Survey

	 	1.	 	In all service areas in which the Health Plan provides behavioral
health services, the Health Plan shall annually conduct a behavioral health
services enrollee satisfaction survey in both English and Spanish.
	 
	 	2.	 	The Health Plan shall submit the survey tool for approval to BMHC
prior to

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 40 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 		 	use. Any revisions to the tool must also be submitted to BMHC prior to use.

	U.	 	Stakeholder Satisfaction Survey

	 	1.	 	In all service areas in which the Health Plan provides behavioral health
services, the Health Plan shall annually conduct a behavioral health services
stakeholder satisfaction survey in both English and Spanish.
	 
	 	2.	 	The Health Plan shall submit the survey tool for approval to BMHC prior to
use. Any revisions to the tool must also be submitted to BMHC prior to use.

AHCA Contract No. FA913, Attachment II, Exhibit 6, Page 41 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 7

Provider Network

NOTE: This exhibit provides Health Plan requirements in addition to Attachment II of this
Contract, unless otherwise specified.

1. All Reform Health Plans

Section VII Provider Network, Item B., Network Standards

	 	 	In addition to the requirements in Attachment II, Section VII, Provider Network, Item B.
Network Standards, a Health Plan that offers a specialty plan shall ensure that its
provider network meets the following requirements:

	 	1.	 	The provider network will be integrated and consist of PCPs and specialists
who are trained to provide services for a particular condition or population;
	 
	 	2.	 	If the Health Plan has been developed for individuals with a particular
disease state, the network will contain a sufficient number of board certified
specialists in the care and management of the disease. Because individuals have
multiple diagnoses, there should be a sufficient number of specialists to manage
different diagnoses as well;
	 
	 	3.	 	A defined network of facilities used for inpatient care shall be included with
accredited tertiary hospitals and hospitals that have been designated for specific
conditions, appropriate for the Health Plan population (e.g., end stage renal disease
centers, comprehensive hemophilia centers);
	 
	 	4.	 	Specialty pharmacies when appropriate; and
	 
	 	5.	 	A range of community-based care options as alternatives to hospitalization and
institutionalization.

AHCA Contract No. FA913, Attachment II, Exhibit 7, Page 42 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 8

Quality Management

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. All Reform Health Plans

Section VIII, Quality Management, Item A., Quality Improvement, sub-item 3., Health Plan QI
Activities

	 	f.	 	Provider Satisfaction Survey — The Health Plan shall submit a provider
satisfaction survey plan to BMHC for written approval by the end of the eighth month
of this Contract. The plan shall include the questions to be asked. The Health Plan
shall conduct the survey at the end of the first year of this Contract. The results of
the survey shall be reported to BMHC within four (4) months of the beginning of the
second year of this Contract.

2. All Reform Health Plans Except the HIV/AIDS Specialty Plan

Section VIII, Quality Management, Item B. Utilization Management, sub-item 5., Disease
Management

	 	a.	 	The Health Plan shall develop and implement disease management programs for
Reform enrollees living with chronic conditions. The disease management initiatives
shall include, but are not limited to, asthma, HIV/AIDS, diabetes, congestive heart
failure and hypertension. The Health Plan may develop and implement additional
disease
management programs for its enrollees.
	 
	 	b.	 	Each disease management program shall have policies and procedures that follow
the National Committee for Quality Assurance’s (NCQA’s) most recent Disease
Management Standards and Guidelines, which may be accessed online at
http://web.ncqa.orq/tabid/381/Default.aspx. In addition to policies and
procedures, the Health Plan shall have a disease management program description for
each disease state that describes how the program fulfills the principles and
functions of each of the NCQA Disease Management Standards and Guidelines categories.
Each program description should also describe how enrollees are identified for
eligibility and stratified by severity and risk level. The Health Plan shall submit a
copy of its policies and procedures and program description for each of its disease
management programs to BMHC by April 1 of each Contract year.
	 
	 	c.	 	The Health Plan shall have a policy and procedure regarding the transition of
enrollees from disease management services outside the Health Plan to the Health
Plan’s disease management program. This policy and procedure shall include
coordination with the disease management organization (DMO) that provided services to
the enrollee before enrollment in the Health Plan. Additionally, the Health Plan
shall request that the enrollee sign a limited release of information to aid the
Health Plan in accessing the DMO’s information for the enrollee.
	 
	 	d.	 	The Health Plan shall develop and use a plan of treatment for chronic disease
follow-up care that is tailored to the individual enrollee. The purpose of the plan
of treatment is to

AHCA Contract No. FA913, Attachment II, Exhibit 8, Page 43 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	assure appropriate ongoing treatment reflecting the highest standards of medical care
designed to minimize further deterioration and complications. The plan of treatment
shall be on file for each enrollee with a chronic disease and shall contain sufficient
information to explain the progress of treatment. Medication management, the review of
medications that an enrollee is currently taking, should be an ongoing part of the plan
of treatment to ensure that the enrollee does not suffer adverse effects or
interactions from contra-indicated medications. The enrollee’s ability to adhere to a
treatment regimen should be monitored in the plan of treatment as well.

3. Non-Reform Health Plans

Section VIII, Quality Management, Item B., Utilization Management

	 	5.	 	Disease Management — The Agency encourages the Health Plan to develop and
implement disease management programs for enrollees living with chronic conditions.

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AHCA Contract No. FA913, Attachment II, Exhibit 8, Page 44 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 9

Grievance System

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

N/A

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AHCA
Contract No. FA913, Attachment II, Exhibit 9, Page 45 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 10

Administration and Management

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. All Capitated Health Plans

Section X, Administration and Management, Item C., Claims Payment

	 	1.	 	The date of claim receipt is the date the Health Plan receives the claim at its
designated claims receipt location.
	 
	 	2.	 	The date of Health Plan claim payment is the date of the check or other form of payment.
	 
	 	3.	 	For all electronically submitted claims for capitated services, the Health Plan shall:

	 	a.	 	Within twenty-four (24) hours after the beginning of the next business
day after receipt of the claim, provide electronic acknowledgment of the receipt
of the claim to the electronic source submitting the claim.
	 
	 	b.	 	Within twenty (20) calendar days after receipt of the claim, pay the
claim or notify the provider or designee that the claim is denied or contested.
The notification to the provider of a contested claim shall include an itemized
list of additional information or documents necessary to process the claim.
	 
	 	c.	 	Pay or deny the claim within ninety (90) calendar days after receipt
of the claim. Failure to pay or deny the claim within one hundred and twenty
(120) calendar days after receipt of the claim creates an uncontestable
obligation for the Health Plan to pay the claim.

	 	4.	 	For all non-electronically submitted claims for capitated services, the Health Plan shall:

	 	a.	 	Within fifteen (15) calendar days after receipt of the claim, provide
acknowledgment of receipt of the claim to the provider or designee or provide the
provider or designee with electronic access to the status of a submitted claim.
	 
	 	b.	 	Within forty (40) calendar days after receipt of the claim, pay the
claim or notify the provider or designee that the claim is denied or contested.
The notification to the provider of a contested claim shall include an itemized
list of additional information or documents necessary to process the claim.
	 
	 	c.	 	Pay or deny the claim within one hundred and twenty (120) calendar days
after receipt of the claim. Failure to pay or deny the claim within one hundred
and forty (140) calendar days after receipt of the claim creates an uncontestable
obligation for the Health Plan to pay the claim.

	 	5.	 	The Health Plan shall reimburse providers for the delivery of authorized
services as described in s. 641.3155, F.S., including, but not limited to:

	 	a.	 	The provider must mail or electronically transfer (submit) the claim to
the Health Plan within six (6) months after:

AHCA Contract No. FA913, Attachment II, Exhibit 10, Page 46 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(1)	 	The date of service or discharge from an inpatient setting; or
	 
	 	(2)	 	The date that the provider was furnished with the correct name
and address of the Health Plan.

	 	b.	 	When the Health Plan is the secondary payer, the provider must submit the
claim to the Health Plan within ninety (90) calendar days after the final
determination of the primary payer.

	 	6.	 	In accordance with s. 409.912, F.S., the Health Plan shall reimburse any
hospital or physician that is outside the Health Plan’s authorized geographic service
area for Health Plan authorized services provided by the hospital or physician to
enrollees:

	 	a.	 	At a rate negotiated with the hospital or physician; or
	 
	 	b.	 	The lesser of the following:

	 	(1)	 	The usual and customary charge made to the general public by the
hospital or physician; or
	 
	 	(2)	 	The Florida Medicaid reimbursement rate established for the hospital
or physician.

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AHCA Contract No. FA913, Attachment II, Exhibit 10, Page 47 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 11

Information Management and Systems

NOTE: This exhibit provides Health Plan requirements in addition to Attachment II of this
Contract, unless otherwise specified.

N/A

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AHCA Contract No. FA913, Attachment II, Exhibit 11, Page 48 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 12

Reporting Requirements

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

N/A

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AHCA Contract No. FA913, Attachment II, Exhibit 12, Page 49 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 13

CAP-Reform

Method of Payment

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Capitated Reform Health Plans

	A.	 	Payment Overview
	 
	 	 	This is a fixed price (unit cost) Contract. The Agency will manage this fixed price
Contract for the delivery of covered services to enrollees. The Agency or its fiscal agent
shall make payment to the Health Plan on a monthly basis for the Health Plan’s satisfactory
performance of its duties and responsibilities as set forth in this Contract. To
accommodate payments, the Health Plan is enrolled as a Medicaid provider with the fiscal
agent. Payments made to the Health Plan resulting from this Contract include monthly
capitation rate payments for either a comprehensive component or a comprehensive component
and catastrophic component, both of which contain risk adjustments, and were developed for
particular Medicaid populations, and may contain an adjustment to collect amounts for the
enhanced benefit accounts fund. The Agency may also pay Health Plans for obstetrical
delivery and transplant services through kick payments; for covered services that are over
the catastrophic component threshold, if the Health Plan has contracted for the
comprehensive component only; and for CHCUP incentive payments, if any, as specified below.
	 
	B.	 	Capitation Rate Payments 1. The Agency’s capitation rate payments shall
meet the following requirements:

	 	a.	 	Medicaid Reform capitation rates will begin with the September 1, 2009,
capitation rate payments.

	 	(1)	 	For SSI Medicare Part B-only enrollees and SSI Medicare Parts A
and B enrollees, the capitation rates are based on non-Reform capitation rate
methodology for the age groups listed in Attachment I.
	 
	 	(2)	 	The capitation rates for all other enrollees are fully
risk-adjusted.

	 	(a)	 	The Agency will pay the Health Plan the HIV/AIDS
capitation rate only for those enrollees who have been identified and
verified as having an HIV/AIDS diagnosis. The HIV/AIDS capitation rate is
provided in Attachment I.

	 	(i)	 	The Agency will pay the HIV/AIDS capitation rate
for those enrollees who have been identified as having an HIV/AIDS
diagnosis, regardless of whether or not the Health Plan is a specialty
plan.
	 
	 	(ii)	 	Enrollees with an HIV/AIDS diagnosis may be
identified by either the Agency or the Health Plan. For the Health Plan
to identify that an enrollee has an

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 50 of 68

 

 

	 	 	 
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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	HIV/AIDS diagnosis, the Health Plan must have completed lab testing as
interpreted by a licensed physician prior to reporting the enrollee to
the Agency as an identified enrollee with an HIV/AIDS diagnosis. The
Health Plan shall provide the Agency with such enrollee’s test results
upon request.
	 
	 	(iii)	 	The Health Plan shall submit enrollees identified
with an HIV/AIDS diagnosis to BMHC in a format and transmittal method
approved by the Agency as specified in the Agency’s Report Guide. See
Attachment II, Section XII, Reporting Requirements, of this Contract.
	 
	 	(iv)	 	The Agency shall not pay the HIV/AIDS capitation
rate for any enrollee who was not identified as HIV/AIDS prior to
enrollment processing for the month for which the capitation payment is
made, nor shall the Agency make a retroactive capitation payment at the
HIV/AIDS capitation rate if the enrollee was identified as HIV/AIDS
after enrollment processing.

	 	(b)	 	The Agency will pay the Health Plan the capitation rate for
children with chronic conditions only if the enrollee meets the
requirements for children with chronic conditions, as identified by the
Agency, and the enrollee is enrolled in a specialty plan for children with
chronic conditions based on the rates specified in Attachment I.

	 	b.	 	For each eligibility category indicated, and for each age group
indicated, the Agency will make a capitation payment for enrollees as provided for
in the capitation rate tables in Attachment I as follows:

	 	(1)	 	Enrollees who are in the Children and Families and the Aged and
Disabled eligibility categories, not identified as diagnosed with HIV/AIDS and
not enrolled in a specialty plan as identified children with chronic
conditions;
	 
	 	(2)	 	Enrollees who are in the SSI Medicare Part B-only and the SSI
Medicare Parts A and B eligibility categories, and who are not identified as
diagnosed with HIV/AIDS or enrolled in a specialty plan as identified children
with chronic conditions enrollees;
	 
	 	(3)	 	Enrollees who are identified as diagnosed with HIV/AIDS.

	 	c.	 	HIV/AIDS specialty plan enrollees who are family members of enrollees
identified as diagnosed with HIV/AIDS, and who are not identified as diagnosed
with HIV/AIDS, will receive a capitation rate based on their respective
eligibility categories in capitation rate tables in Attachment I. In developing
the capitation rates for these family members, a plan factor of 1.0 will be
assigned until the Agency determines that the Health Plan has enough population of
such enrollees to warrant its own plan factor.
	 
	 	d.	 	The capitation rates for enrollees who are in the children with chronic
conditions specialty plan are provided in Attachment I. Sibling enrollees who are
enrolled in the children with chronic conditions specialty plan, and are not
identified as children with chronic conditions, will receive a capitation rate
based on their respective eligibility

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	categories in capitation rate tables in Attachment I. In developing the capitation
rates for these family members, a plan factor of 1.0 will be assigned until the
Agency determines that the Health Plan has enough population of such enrollees to
warrant its own plan factor.
	 
	 	e.	 	The risk-adjusted capitation rates paid by the Agency are either for the
comprehensive component or comprehensive component and catastrophic component as
specified below.

	 	(1)	 	Health Plans are required to provide the comprehensive component
and the catastrophic component to enrollees in the following manner:

	 	(a)	 	For Contracts serving Broward County and/or Duval County,
Health Plans that are not capitated PSNs are required to provide both the
comprehensive component and catastrophic component. This means that the
Health Plan is responsible for the cost of providing covered services up to
the benefit maximum determined by the Agency for the Contract year.
	 
	 	(b)	 	For Contracts serving Broward County and/or Duval County,
Health Plans that are capitated PSNs must provide the comprehensive
component and may choose to provide the catastrophic component. The
capitated PSN’s choice shall be documented in Attachment I.

	 	i.	 	If the capitated PSN has chosen to provide both the
comprehensive component and the catastrophic component, the Health Plan
is responsible for the cost of providing covered services up to the
benefit maximum determined by the Agency for the Contract year.
	 
	 	ii.	 	If the capitated PSN has chosen to provide the
comprehensive component only, the Health Plan shall be responsible for
the cost of providing covered services up to the catastrophic component
threshold by the Agency for the Contract year. Such a Health Plan will
receive reimbursement from the Agency for its costs beyond the
catastrophic threshold up to the benefit maximum. This reimbursement
shall be based on a percentage of Medicaid fee-for-service payment
levels.

	 	(c)	 	For Contracts serving Baker County, Clay County and/or Nassau
County, the Health Plan is required to provide the comprehensive component
and may choose to provide the catastrophic component to its enrollees in
those counties.

	 	i.	 	If, by this Contract, as specified in Attachment I,
the Health Plan has agreed to provide both the comprehensive component
and the catastrophic component, then the Health Plan is responsible for
the cost of providing the enrollee with covered services up to the
benefit maximum determined by the Agency for the Contract year.
	 
	 	ii.	 	If, by this Contract, as specified in Attachment I,
the Health Plan has agreed to provide the comprehensive component only,
then the Health Plan is

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	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	financially responsible for the provision of covered services up to the
catastrophic component threshold determined by the Agency for the
Contract year.

	 	(2)	 	For purposes of calculating whether an enrollee has met the
catastrophic component threshold and the benefit maximum, a Health Plan’s
costs shall be converted to the Medicaid fee-for-service payment levels. For
services covered by the Health Plan for which there is no Medicaid fee, the
Agency will use the amount the Health Plan paid for the service. Upon the
Agency’s request, the Health Plan shall provide documentation to validate
payment and services rendered. In addition, if the Health Plan receives payment from the Agency for kick payment
services, the kick payment made by the Agency will be included toward the
catastrophic component threshold and toward the benefit maximum.
	 
	 	(3)	 	Health Plans will be paid capitation rates for the comprehensive
component and the catastrophic component or for the comprehensive component
only, in accordance with whether the Health Plan agreed, by this Contract, to
provide both the comprehensive component and catastrophic component or to
provide only the comprehensive component.

	 	2.	 	The Agency’s capitation rates are included as Attachment I, titled “ESTIMATED
HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

	 	a.	 	The Agency may use, or may amend and use these rates, only after
certification by its actuary and approval by the Centers for Medicare and Medicaid
Services. Inclusion of these rates is not intended to convey or imply any rights,
duties or obligations of either party, nor is it intended to restrict, restrain or
control the rights of either party that may have existed independently of this
section of the Contract.
	 
	 	b.	 	By signature on this Contract, the parties explicitly agree that this
section shall not independently convey any inherent rights, responsibilities or
obligations of either party, relative to these rates, and shall not itself be the
basis for any cause of administrative, legal or equitable action brought by either
party. In the event that the rates certified by the actuary and approved by CMS
are different from the rates included in this Contract, the Health Plan agrees to
accept a reconciliation performed by the Agency to bring payments to the Health
Plan in line with the approved rates. The Agency may amend and use the
CMS-approved rates by notice to the Health Plan through an amendment to the
Contract.

	 	3.	 	The Agency shall pay the applicable capitation rate for each eligible enrollee
whose name appears on the HIPAA-compliant X12-820 file for each month, except that the
Agency shall not pay for, and, in accordance with subsections F. and G. of this
exhibit, shall recoup payment for, any part of the total enrollment that exceeds the
maximum authorized enrollment level(s) expressed in this Contract in Attachment I. The
total payment amount to the Health Plan shall depend on the number of enrollees in
each eligibility category and each rate group, and whether the Health Plan is
providing the comprehensive component only or the comprehensive component and the
catastrophic component, and at a rate that has been risk-adjusted pursuant to this
Contract, or as adjusted pursuant to the Contract, where necessary in accordance with
subsection F. of this exhibit.

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 53 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	The Health Plan is obligated to provide services pursuant to the terms
of this Contract for all enrollees for whom the Health Plan has received
capitation payment or for whom the Agency has assured the Health Plan that the
capitation payment is forthcoming.
	 
	 	b.	 	To ensure a seamless health care delivery system for the enrollee, if
the Health Plan contracts for the comprehensive component only, the Health Plan
continues to be responsible for coordinating, managing, and delivering all
enrollee care up to the benefit maximum regardless of whether the cost of the
enrollee’s covered services is above and beyond the catastrophic component
threshold.
	 
	 	c.	 	Regardless of whether the Health Plan is at risk for the comprehensive
component only or for both the comprehensive component and the catastrophic
component, the Health Plan shall continue to be responsible for coordinating and
managing all enrollee care even if the cost of the enrollee’s covered services is
above and beyond the benefit maximum.

	 	4.	 	The capitation rates to be paid specific to the Health Plan shall be as
indicated in the payment tables in Attachment I, and adjusted monthly based on the
Health Plan’s plan factor.
	 
	 	5.	 	Unless otherwise specified in this Contract, the Health Plan shall accept the
capitation payment received each month as payment in full by the Agency for all
services provided to enrollees covered under this Contract and the administrative
costs incurred by the Health Plan in providing or arranging for such services. Any
and all costs incurred by the Health Plan in excess of the capitation payment shall
be borne in total by the Health Plan.
	 
	 	6.	 	The Agency shall pay a retroactive capitation rate for each newborn enrolled in
the Health Plan for up to the first three (3) months of life provided the newborn was
enrolled through the unborn activation process.

	 	a.	 	The Health Plan shall use the unborn activation process to enroll all
babies born to pregnant enrollees as specified in Attachment II, Section III,
Eligibility and Enrollment.
	 
	 	b.	 	The Health Plan is responsible for payment of all covered services
provided to newborns enrolled through the unborn activation process.

C. Kick Payments

	 	1.	 	The Agency shall pay the Health Plan one kick payment for the following covered
services for enrollees who are not also eligible for Medicare:

	 	a.	 	Each obstetrical delivery, and
	 
	 	b.	 	Each covered transplant.

	 	2.	 	The Agency shall make kick payments in the amounts indicated in Attachment I.

	 	a.	 	For Health Plans that provide only the comprehensive component, kick
payment services will be counted toward the catastrophic component threshold. Once
the threshold has been met, the Agency will continue to reimburse the Health Plan
any kick

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 54 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	payment services delivered by the Health Plan at the kick payment amounts specified
in Attachment I of this Contract.
	 
	 	b.	 	For kick payment purposes, an obstetrical delivery includes all births
resulting from the delivery; therefore, if an obstetrical delivery results in
multiple births, the Agency will make only one kick payment. This includes still
births as specified in the Medicaid Physicians Services Handbook.
	 
	 	c.	 	For Health Plans under Contract as specialty plans, reimbursement for
kick payment services will be counted toward the enrollee’s benefit maximum.

	 	3.	 	To receive a kick payment, the Health Plan must adhere to the specific
requirements listed in subsections 4. and 5. below and adhere to the following
requirements:

	 	a.	 	The Health Plan must have provided the covered kick payment service while
the recipient was enrolled in the Health Plan; and
	 
	 	b.	 	The Health Plan shall submit any required documentation to the Agency
upon its request in order to receive the kick payment applicable to the covered
service provided.

	 	4.	 	In addition to subsection 3. above, to receive a kick payment for covered
transplants provided to an enrollee without Medicare, the Health Plan shall also
comply with the following requirements:

	 	a.	 	For each transplant provided, the Health Plan shall submit an accurate
and complete CMS-1500 claim form (CMS-1500) and operative report to the fiscal
agent within the required Medicaid fee-for-service claims submittal timeframes
	 
	 	b.	 	The Health Plan shall list itself as both the pay-to and the treating
provider on the CMS- 1500; and
	 
	 	c.	 	The Health Plan shall use the following list of transplant procedure
codes relative to the type of transplant performed when completing Field 24 D on
the CMS-1500:

	 	 	 
	CPT	 	 
	Code	 	Transplant CPT Code Description
	32851

	 	lung single, without bypass
	 
	 	 
	32852

	 	lung single, with bypass
	 
	 	 
	32853

	 	lung double, without bypass
	 
	 	 
	32854

	 	lung double, with bypass
	 
	 	 
	33945

	 	heart transplant with or without recipient cardiectomy
	 
	 	 
	47135

	 	liver, allotransplantation,
orthotopic, partial or whole from cadaver or living donor
	 
	 	 
	47136

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

	 	5.	 	In addition to subsection 3. above, to receive a kick payment for the covered
obstetrical delivery provided to an enrollee, the Health Plan shall also comply with
the following
requirements:

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 55 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	The Health Plan shall submit an accurate and complete claim form in
sufficient time to be received by the fiscal agent within nine months following
the date of service delivery. The Health Plan shall submit the claim
electronically in a HIPAA compliant X12 837P format;

	 	b.	 	The Health Plan shall list itself as both the pay-to and the treating
provider; and

	 	c.	 	The Health Plan shall use the following list of delivery procedure
codes relative to the type of delivery performed when submitting the X12 837P
transaction:

	 	 	 
	CPT	 	 
	Code	 	Obstetrical Delivery CPT Code Description
	59409

	 	Vaginal delivery only
	 
	 	 
	59410

	 	Vaginal delivery including postpartum care
	 
	 	 
	59515

	 	Cesarean delivery including postpartum care
	 
	 	 
	59612

	 	Vaginal delivery only, after previous cesarean delivery
	 
	 	 
	59614

	 	Vaginal delivery only, after previous cesarean delivery including postpartum care
	 
	 	 
	59622

	 	Cesarean delivery only, following attempted vaginal delivery after previous

cesarean delivery including postpartum care

D. Claims Payment for Health Plans Accepting Financial Risk for the Comprehensive
Component Only

	 	1.	 	In order for Health Plans accepting financial risk for only the comprehensive
component to receive reimbursement from the Agency for incurred expenditures for
covered services for an enrollee who has reached the annual catastrophic component
threshold, the Health Plan shall adhere to the following requirements:

	 	a.	 	The Health Plan shall notify BMHC in writing, in an Agency-specified
format as specified in Attachment II, Section XII, Reporting Requirements, when
expenditures it has paid for an enrollee’s covered services exceed $25,000 prior
to the end of a Contract year.
	 
	 	b.	 	For enrollee’s whose Health Plan expenditures for covered services costs
exceed $25,000, the Health Plan shall update BMHC in writing, as specified in
Section XII, Reporting Requirements, Attachment II, and on a monthly basis, of the
Health Plan’s additional expenditures for covered services for the enrollee until
the enrollee has exceeded the catastrophic component threshold or for the
remainder of the Contract year, whichever occurs first;
	 
	 	c.	 	Once the Agency has reviewed the covered services expenditure information
provided by the Health Plan and has determined that a Health Plan’s expenditures
for an enrollee have exceeded the catastrophic component threshold for the
Medicaid covered services received based on Florida Medicaid’s fee schedules and
as indicated in subsection B.1.c.(2) of this exhibit, and the Health Plan has
received Agency notification that the enrollee has met the catastrophic component threshold, the
Health

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 56 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Plan shall submit the following to the Agency, or its fiscal agent, in order to
receive reimbursement for covered services provided:

	 	(1)	 	An accurate and fully completed claim form in the Agency’s
designated format and within the Medicaid FFS time frames for claims
submission. The Health Plan shall list itself as both the pay-to and treating
provider.
	 
	 	(2)	 	Any specified data requested by the Agency regarding treating
providers unknown to FMMIS.
	 
	 	(3)	 	Health Plan claims data, for an Agency-specified data set in an
Agency-specified format and transmittal method, that documents that the Health
Plan’s expenditures, after conversion to the appropriate Medicaid fee (as
applicable) are an amount equal to the catastrophic component threshold.

	 	2.	 	For Health Plans providing the comprehensive component only, the Agency will be
responsible for payment to the Health Plan for Medicaid-covered services provided in
excess of the catastrophic component threshold up to the enrollee’s benefit maximum.

	 	a.	 	With the exception of kick payment services, such payment will be made at
ninety-five percent (95%) of the Medicaid FFS payment rate, less co-payment or
coinsurance required under the Medicaid fee schedule, for the respective
Medicaid-covered service provided and paid for by the Health Plan.
	 
	 	b.	 	For kick payment services provided by the Health Plan, the Agency’s
payment to the Health Plan will be the kick payment amount specified in Attachment
I.
	 
	 	c.	 	For covered services provided by the Health Ran for which there is not a
Medicaid payment rate, the Agency will pay the actual amount the Health Plan paid
to the provider less five percent (5%).
	 
	 	d.	 	If the Health Plan submits claims to the Agency, or its fiscal agent, for
covered services that are not in excess of the catastrophic component threshold,
or claims for covered services beyond the benefit maximum, and the Agency
reimburses the Health Plan for those claims, the Agency will recoup such
reimbursement or the Health Plan will be responsible for repayment in accordance
with the payment assessments and errors subsections below.

E. Child Health Check-Up (CHCUP) Incentive Payments

Health Plans will be eligible to participate in the CHCUP incentive program when the
Health Plan has exceeded both the sixty percent (60%) state screening rate and the federal
eighty percent (80%) participation and screening ratio goals as outlined in Attachment II,
Section V, Covered Services. The Agency will determine which Health Plans will participate
based upon the audited CHCUP reports submitted.

	 	1.	 	The amount of the incentive payment shall be calculated as follows: the ratio
of a qualified Health Plan’s screenings to the total of all health plans’ screenings
will be multiplied by the total amount in the fund for the incentive payment. The
ratios will be based on the Health Plans’ audited CHCUP reports. The total amount in
the fund will be determined at the

AHCA Contract No. FA913, Attachment II, Exhibit 13-R, Page 57 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	2.	 	Pursuant to 42 CFR 438.6, (5)(iii), the payment to any one health plan shall not be
in excess of five percent (5%) of the capitation amount paid to all health plans for
CHCUP services provided pursuant to this Contract.

F. Payment Assessments

	 	1.	 	Choice Counseling/Enrollment and Disenrollment

In accordance with s 409.912 (29), F.S., at such time as the Agency receives
legislative direction to assess health plans for enrollment and disenrollment services
costs, the Agency shall apply assessments, in quarterly installments each year, against
the Health Plan’s next capitation payment to pay for the enrollment and disenrollment
services costs of the choice counselor/enrollment broker as follows:

	 	a.	 	July 1, for costs estimated for the enrollment and disenrollment services
rendered by the choice counselor/enrollment broker for July and the following two
(2) months;
	 
	 	b.	 	October 1, for costs related to the enrollment and disenrollment services
rendered by the choice counselor/enrollment broker for October and the following
two (2) months;
	 
	 	c.	 	January 1, for costs related to the enrollment and disenrollment services
rendered by the choice counselor/enrollment broker for January and the following
two (2) months; and
	 
	 	d.	 	April 1, for costs related to maintaining the third party enrollment and
disenrollment services contract for April and the following two (2) months.

	 	2.	 	Rate Adjustments

The Health Plan and the Agency acknowledge that the capitation rates paid under this
Contract, as specified in Attachment I of this Contract, are subject to approval by the
federal government.

	 	a.	 	Adjustments to funds previously paid and to be paid may be required.
Funds previously paid shall be adjusted when capitation rate calculations are
determined to have been in error, or when capitation payments have been made for
Medicaid recipients who are determined to be ineligible for Health Plan enrollment
during the period for which the capitation payments were made. In such events, the
Health Plan agrees to refund any overpayment and the Agency agrees to pay any
underpayment.
	 
	 	b.	 	If the Agency receives legislative direction as specified in subsection
F.1., Payment Assessments, Choice Counseling, respectively, the Agency shall
annually, or more frequently, determine the actual expenditures for enrollment and
disenrollment services rendered by the choice counselor/enrollment broker. The
Agency will compare capitation rate assessments to the actual expenditures for
such enrollment and disenrollment services. The following factors will enter into
the cost settlement process:

AHCA
Contract No. FA913, Attachment II, Exhibit 13-R, Page 58 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	(1)	 	If the amount of capitation rate assessments is less than the actual cost
of providing enrollment and disenrollment services rendered by the choice
counselor/enrollment broker, the Health Plan shall pay the difference to the
Agency within thirty (30) calendar days of settlement.
	 
	 	(2)	 	If the amount of capitation assessments exceeds the actual cost
of providing enrollment, and disenrollment services, the Agency will pay the
difference to the Health Plan within thirty (30) calendar days of the
settlement.

	 	c.	 	As the Agency adjusts the plan factor based on updated historical data,
the Health Plan’s capitation rates will be adjusted according to the methodology
indicated in the capitation rate tables.
	 
	 	d.	 	The Agency may adjust the Health Plan’s capitation rates if the
percentage deducted for the enhanced benefit accounts fund is modified due to
program needs.

G. Errors

	 	1.	 	The Health Plan shall carefully prepare all reports and monthly payment
requests for submission to the Agency.
	 
	 	2.	 	If after preparation and electronic submission, either the Health Plan or the
Agency discover an error, including but not limited to errors resulting in incorrect
kick payments, errors resulting in incorrect identification of enrollees (including
but not limited to specific identification of enrollees with HIV/AIDS diagnoses),
errors resulting in incorrect claims payments, and errors resulting in capitation
rate payments above the Health Plan’s authorized enrollment levels, the Health Plan
has thirty (30) calendar days after its discovery of the error, or from its receipt
of Agency notice of the error, to correct the error and re-submit accurate reports
and/or invoices. Failure to respond within the thirty (30) calendar day period shall
result in a loss of any money due the Health Plan for such errors and/or a sanction
against the Health Plan pursuant to Attachment II, Section XIV, Sanctions.

H. Member Payment Liability Protection

Pursuant to s. 1932 (b)(6), Social Security Act (as enacted by section 4704 of the
Balanced Budget Act of 1997), the Health Plan shall not hold members liable for the
following:

	 	1.	 	For debts of the Health Plan, in the event of the Health Plan’s insolvency;
	 
	 	2.	 	For payment of covered services provided by the Health Plan if the Health Plan
has not received payment from the Agency for the covered services, or if the
provider, under contract or other arrangement with the Health Plan, fails to receive
payment from the Agency or the Health Plan; and/or
	 
	 	3.	 	For payments to a provider, including referral providers, that furnished
covered services under a contract, or other arrangements with the Health Plan, that
are in excess of the amount that normally would be paid by the enrollee if the
covered services had been received directly from the Health Plan.

AHCA
Contract No. FA913, Attachment II, Exhibit 13-R, Page 59 of 68

 

 

Exhibit 13

CAP-Non-Reform

Method of Payment

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Non-Reform Capitated Health Plans

A. Fixed Price Unit Contract

This is a fixed price (unit cost) Contract. The Agency or its appointed fiscal agent shall
make payment to the Health Plan on a monthly basis for the Health Plan’s satisfactory
performance of its duties and responsibilities as set forth in this Contract. To
accommodate payments, the Health Plan is capitated with the fiscal agent.

B. Child Health Check-Up (CHCUP) Incentive Program

Health Plans will be eligible to participate in the CHCUP incentive program when the Health
Plan has exceeded both the sixty percent (60%) state screening rate and the federal eighty
percent (80%) participation and screening ratio goals as outlined in Attachment II, Section
V, Covered Services. The Agency will determine which health plans will participate based
upon the audited CHCUP reports submitted each October as set forth in Attachment II,
Section XII, Reporting Requirements.

	 	1.	 	The amount of the incentive payment shall be calculated as follows: The ratio
of a qualified Health Plan’s screenings to the total of all health plans’ screenings
will be multiplied by the total amount in the fund for the incentive payment. The
ratios will be based on the Health Plans’ audited CHCUP reports. The total amount in
the fund will be determined at the discretion of the Agency. In no event shall the
total monies allotted to the incentive program exceed the incentive payment fund.
	 
	 	2.	 	Pursuant to 42 CFR 438.6, (c)(5)(iii), the payment to any one health plan
shall not be in excess of five percent (5%) of the capitation amount paid to all
health plans for CHCUP services provided pursuant to this Contract.

C. Capitation Rates

The Agency shall pay the applicable capitation rate for each eligible enrollee whose name
appears on the HIPAA-compliant X12 820 file for each month, except that the Agency shall
not pay for, and shall recoup, any part of the total enrollment that exceeds the maximum
authorized enrollment level(s) expressed in Attachment I. The total payment amount to the
Health Plan shall depend upon the number of enrollees in each eligibility category and each
rate group, as provided for by this Contract, or as adjusted pursuant to the Contract when
necessary. The Health Plan is obligated to provide services pursuant to the terms of this
Contract for all enrollees for whom the Health Plan has received capitation payment and for
whom the Agency has assured the Health Plan that capitation payment is forthcoming.

	 	1.	 	The Agency’s capitation rates are developed using historical rates paid by
Medicaid fee-forservice for similar services in the same service area, adjusted for
inflation, where applicable, in accordance with 42 CFR 438.6(c). These rates are
included as Attachment I,

AHCA
Contract No. FA913, Attachment II, Exhibit 13-NR, Page 60 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

	 	a.	 	The Agency may use, or may amend and use these rates, only after
certification by its actuary and approval by the Centers for Medicare and Medicaid
Services. Inclusion of these rates is not intended to convey or imply any rights,
duties or obligations of either party, nor is it intended to restrict, restrain or
control the rights of either party that may have existed independently of this
section of the Contract.
	 
	 	b.	 	By signature on this Contract, the parties explicitly agree that this
section shall not independently convey any inherent rights, responsibilities or
obligations of either party, relative to these rates, and shall not itself be the
basis for any cause of administrative, legal or equitable action brought by either
party. In the event that the rates certified by the actuary and approved by CMS
are different from the rates included in this Contract, the Health Plan agrees to
accept a reconciliation performed by the Agency to bring payments to the Health
Plan in line with the approved rates. The Agency may amend and use the
CMS-approved rates by notice to the Health Plan through an amendment to the
Contract.

	 	2.	 	The capitation rates to be paid specific to the Health Plan shall be as
indicated in Attachment I, which indicates the initial and maximum authorized
enrollment levels and capitation rates applicable to each authorized eligibility
category.
	 
	 	3.	 	At such time as the Agency receives legislative direction to assess Health
Plans for enrollment and disenrollment services costs, the Agency shall apply
assessments, in quarterly installments each Contract year, against the Health Plan’s
next capitation payment to pay for the enrollment and disenrollment services
contractor as follows:

	 	a.	 	July 1, for costs estimated for the Agency’s enrollment and disenrollment
services contractor system and Contract for July and the following two (2) months.
	 
	 	b.	 	October 1, for costs related to the third party enrollment and
disenrollment services Contract for October and the following two (2) months.
	 
	 	c.	 	January 1, for costs related to maintaining the third party enrollment
and services Contract for January and the following two (2) months.
	 
	 	d.	 	April 1, for costs related to maintaining the third party enrollment and
disenrollment services contract for April and the following two (2) months.

	 	4.	 	Unless otherwise specified in this Contract, the Health Plan shall accept the
capitation payment received each month as payment in full by the Agency for all
services provided to enrollees covered under this Contract and the administrative
costs incurred by the Health Plan in providing or arranging for such services. Any and
all costs incurred by the Health Plan in excess of the capitation payment shall be
borne in total by the Health Plan.
	 
	 	5.	 	The Agency shall pay a retroactive capitation rate for each newborn enrolled in
the Health Plan for up to the first three (3) months of life, provided the newborn was
enrolled through the unborn activation process.

AHCA
Contract No. FA913, Attachment II, Exhibit 13-NR, Page 61 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	a.	 	The Health Plan shall use the unborn activation process to enroll all babies
born to pregnant enrollees as specified in Section III, Eligibility and Enrollment,
B.3, Unborn Activation and Newborn Enrollment.
	 
	 	b.	 	The Health Plan is responsible for payment of all covered services
provided to newborns enrolled through the unborn activation process.

D. Rate Adjustments and Payment Assessments

	 	1	 	The Health Plan and the Agency acknowledge that the capitation rates paid under
this Contract are subject to approval by the federal government.
	 
	 	2.	 	The Health Plan and the Agency acknowledge that adjustments to funds previously
paid, and to funds yet to be paid, may be required. Funds previously paid shall be
adjusted when capitation rate calculations are determined to have been in error, or
when capitation rate payments have been made for enrollees who are determined not to
have been eligible for Health Plan membership during the period for which the
capitation rate payments were made. In such events, the Health Plan agrees to refund
any overpayment and the Agency agrees to pay any underpayment.
	 
	 	3.	 	The Agency agrees to adjust capitation rates to reflect budgetary changes in
the Medicaid fee-for-service program. The rate of payment and total dollar amount may
be adjusted with a properly executed amendment when Medicaid fee-for-service
expenditure changes have been established through the appropriations process and
subsequently identified in the Agency’s operating budget. Legislatively-mandated
changes shall take effect on the dates specified in the legislation.
	 
	 	4.	 	At such time the Agency receives the appropriate legislative direction as
specified above, the Agency shall annually, or more frequently, determine the actual
expenditures for enrollment and disenrollment services. The Agency will compare
capitation rate assessments to the actual costs for enrollment and disenrollment services. The
following factors will enter into any cost settlement process:

	 	a.	 	If the amount of capitation rate assessments are less than the actual
cost of providing enrollment and disenrollment services, the Health Plan will
return the difference to the Agency within thirty (30) calendar days of
settlement.
	 
	 	b.	 	If the amount of capitation rate assessments exceeds the actual cost of
providing enrollment and disenrollment services, the Agency will make up the
difference to the Health Plan within thirty (30) calendar days of the settlement.

E. Errors

The Health Plan shall carefully prepare all reports and monthly payment requests for
submission to the Agency. If after preparation and electronic submission, the Health Plan
discovers an error, including, but not limited to, errors resulting in capitated payments
above the Health Plan’s authorized levels, either by the Health Plan or the Agency, the
Health Plan has thirty (30) calendar days from its discovery of the error, or thirty (30)
calendar days after receipt of notice by the Agency, to correct the error and re-submit
accurate reports and/or invoices. Failure to respond within the thirty (30) calendar day
period shall result in a loss of any money due to the Health Plan for such errors and/or
sanctions against the Health Plan pursuant to Attachment II, Section XIV, Sanctions.

AHCA Contract No. FA913, Attachment II, Exhibit 13-NR, Page 62 of 68

 

 

F. Member Payment Liability Protection

Pursuant to s. 1932 (b)(6), Social Security Act (as enacted by section 4704 of the
Balanced Budget Act of 1997), the Health Plan shall not hold members liable for the
following:

	 	1.	 	For debts of the Health Plan, in the event of the Health Plan’s insolvency;
	 
	 	2.	 	For payment of covered services provided by the Health Plan if the Health Plan
has not received payment from the Agency for the covered services, or if the
provider, under contract or other arrangement with the Health Plan, fails to receive
payment from the Agency or the Health Plan; and/or
	 
	 	3.	 	For payments to a provider, including referral providers, that furnished
covered services under a contract, or other arrangements with the Health Plan, that
are in excess of the amount that normally would be paid by the enrollee if the
covered services had been received directly from the Health Plan.

G. Transition to Medicaid Reform (Non-Reform Health Plans)

	 	1.	 	The Health Plan understands that the state began Medicaid Reform in Broward
County and Duval County on September 1, 2006, with Baker, Clay, and Nassau Counties
added September 1, 2007, as authorized by the state. As a result, in all areas in
which the state implements Medicaid Reform, the Health Plan’s enrollment will
transition from coverage under this Contract to the Medicaid Reform Contract in
accordance with the Agency’s implementation schedule.
	 
	 	2.	 	When the state authorizes expansion of Medicaid Reform into a new county in
which the Health Plan is currently providing, or will provide, Medicaid services, the
Health Plan acknowledges that it must request an amendment for an expansion of
service under the Contract in order to continue to provide benefits in the new
Medicaid Reform county. Upon implementation of Medicaid Reform, the Health Plan:

	 	a.	 	Shall not engage in marketing or community outreach activities with
regard to the services and/or benefits provided under this Contract; and
	 
	 	b.	 	Shall receive voluntary or mandatory enrollees for the Medicaid Reform
county under this Contract.

H. Cost Effectiveness

The Agency shall ensure that the Health Plan is cost-effective (see s. 409.912(44), F.S.).
The Agency may not renew this Contract if it is not cost-effective.

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AHCA Contract No. FA913, Attachment II, Exhibit 13-NR, Page 63 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 14

Sanctions

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

N/A

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AHCA Contract No. FA913, Attachment II, Exhibit 14, Page 64 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

Exhibit 15

Financial Requirements

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Non-Reform Capitated Health Plans and Reform HMOs

Section XV, Financial Requirements, Item A., Insolvency Protection

	 	1.	 	The Health Plan shall establish a restricted insolvency protection account
with a federally guaranteed financial institution licensed to do business in Florida
in accordance with s. 1903(m)(1) of the Social Security Act (amended by s. 4706 of
the Balanced Budget Act of 1997), and s. 409.912, F.S., and, for capitated PSNs, the
solvency requirements established in approved federal waivers. The Health Plan shall
deposit into that account five percent (5%) of the capitation payments made by the
Agency each month until a maximum total of two percent (2%) of the annualized total
current Contract amount is reached and maintained. No interest may be withdrawn from
this account until the maximum Contract amount is reached and withdrawal of the
interest will not cause the balance to fall below the required maximum amount. This
provision shall remain in effect as long as the Health Plan continues to contract
with the Agency.
	 
	 	2.	 	The restricted Insolvency protection account may be drawn upon with the
authorized signatures of two (2) persons designated by the Health Plan and two (2)
representatives of the Agency. The Multiple Signature Agreement Form shall be
resubmitted to BMHC within thirty (30) calendar days of Contract execution and
resubmitted within thirty (30) calendar days after a change in authorized Health Plan
personnel occurs. If the authorized persons remain the same, the Health Plan shall
submit an attestation to this effect annually by April 1 of each Contract year to
BMHC along with a copy of the latest bank statement. The Health Plan may obtain a
sample Multiple Signature Verification Agreement form from the Agency or its agent or
download from the BMHC website at: http://ahca.myflorida.com/MCHQ/Manaqed Health
Care/MHMO/med prov.shtml All such agreements or other signature cards shall be
approved in advance by BMHC.
	 
	 	3.	 	In the event that a determination is made by the Agency that the Health Plan
is insolvent, as defined in Attachment II, Section I, Definitions, the Agency may
draw upon the amount solely with the two (2) authorized signatures of representatives
of the Agency and funds may be disbursed to meet financial obligations incurred by
the Health Plan under this Contract. A statement of account balance shall be provided
by the Health Plan within fifteen (15) calendar days of request of the Agency.
	 
	 	4.	 	If the Contract is terminated, expired, or not continued, the account balance
shall be released by the Agency to the Health Plan upon receipt of proof of
satisfaction of all outstanding obligations incurred under this Contract.
	 
	 	5.	 	In the event the Contract is terminated or not renewed and the Health Plan is
insolvent, the Agency may draw upon the insolvency protection account to pay any
outstanding debts the Health Plan owes the Agency including, but not limited to,
overpayments made to the Health Plan, and fines imposed under the Contract or, for
HMOs, s. 641.52, F.S., for which a final order has been issued. In addition, if the
Contract is terminated or not renewed and the Health Plan is unable to pay all of its
outstanding debts to health care providers, the

AHCA Contract No. FA913, Attachment II, Exhibit 15, Page 65 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	Agency and the Health Plan agree to the court appointment of an impartial receiver for
the purpose of administering and distributing the funds contained in the Insolvency
protection account. An appointed receiver shall give outstanding debts owed to the
Agency priority over other claims.

2. Reform Capitated PSNs

Section XV, Financial Requirements, Item B., Insolvency Protection Account Waiver

	 	1.	 	A capitated Health Plan is required to assume responsibility for comprehensive
coverage and meet the following financial reserve requirements:

	 	a.	 	The capitated Health Plan shall maintain a minimum surplus in an
amount that is the greater of $1 million or one and one half percent (1.5%) of
projected annual premiums.
	 
	 	b.	 	In lieu of the requirements above, the Agency may consider the following:

	 	(1)	 	If the organization is a public entity, the Agency may take
under advisement a statement from the public entity that a county supports the
Health Plan with the county’s full faith and credit. In order to qualify for
the Agency’s consideration, the county must own, operate, manage, administer,
or oversee the Health Plan, either partly or wholly, through a county
department or agency;
	 
	 	(2)	 	The state guarantees the solvency of the organization;
	 
	 	(3)	 	The organization is a federally qualified health center or is
controlled by one (1) or more federally qualified health centers and meets the
solvency standards established by the state for such organization pursuant to
s. 409.912(4)(c), F.S.; or
	 
	 	(4)	 	The entity meets the financial standards for federally approved
provider-sponsored organizations as defined in 42CFR 422.380 — 422.390 and the
solvency requirements established in approved federal waivers.

	 	2.	 	Capitated PSNs have the option to assume responsibility for catastrophic
coverage, but will be required to meet more stringent financial standards consistent
with licensed HMOs in Chapter 641, F.S. and s. 409.912, F.S. At a minimum, the
capitated Health Plan shall at all times maintain a minimum surplus in an amount that
is the greater $1,500,000, or ten percent (10%) of total liabilities, or two percent
(2%) of total Contract amount.

3. All Capitated Health Plans

Section XV, Financial Requirements, Item H., Third Party Resources

	 	1.	 	The Health Plan shall specify whether it will assume full responsibility for
third party collections in accordance with this section.
	 
	 	2.	 	The Health Plan has the same rights to recovery of the full value of services
as the Agency (See s. 409.910, F.S.) The following standards govern recovery:

	 	a.	 	If the Health Plan has determined that third party liability exists for
part or all of the services provided directly by the Health Plan to an enrollee,
the Health Plan shall make

AHCA Contract No. FA913, Attachment II, Exhibit 15, Page 66 of 68

 

 

	 	 	 
	AMERIGROUP Florida, Inc. d/b/a

	 	Medicaid Non-Reform and Reform
	AMERIGROUP Community Care

	 	HMO Contract

	 	 	 	reasonable efforts to recover from third party liable sources the value of services
rendered.
	 
	 	b.	 	If the Health Plan has determined that third party liability exists for
part or all of the services provided to an enrollee by a subcontractor or referral
provider, and the third party is reasonably expected to make payment within
one-hundred and twenty (120) calendar days, the Health Plan may pay the
subcontractor or referral provider only the amount, if any, by which the
subcontractor’s allowable claim exceeds the amount of the anticipated third party
payment; or, the Health Plan may assume full responsibility for third party
collections for service provided through the subcontractor or referral provider.
	 
	 	c.	 	The Health Plan may not withhold payment for services provided to an
enrollee if third party liability or the amount of liability cannot be determined,
or if payment shall not be available within a reasonable time, beyond one-hundred
and twenty (120) calendar days from the date of receipt.
	 
	 	d.	 	When both the Agency and the Health Plan have liens against the proceeds
of a third party resource, the Agency shall prorate the amount due to Medicaid to
satisfy such liens under s. 409.910, F.S., between the Agency and the Health Plan.
This prorated amount shall satisfy both liens in full.
	 
	 	e.	 	The Agency may, at its sole discretion, offer to provide third party
recovery services to the Health Plan. If the Health Plan elects to authorize the
Agency to recover on its behalf, the Health Plan shall be required to provide the
necessary data for recovery in the format prescribed by the Agency. All
recoveries, less the Agency’s cost to recover, shall be income to the Health Plan.
The cost to recover shall be expressed as a percentage of recoveries and shall be
fixed at the time the Health Plan elects to authorize the Agency to recover on its
behalf.
	 
	 	f.	 	All funds recovered from third parties shall be treated as income for the
Health Plan.

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AHCA Contract No. FA913, Attachment II, Exhibit 15, Page 67 of 68

 

 

Exhibit 16

Terms and Conditions

NOTE: This exhibit provides Health Plan requirements in addition to Attachment ll of this
Contract, unless otherwise specified.

1. Reform and Non-Reform HMOs

Section XVI, Term and Conditions, Item L., Licensing

In accordance with s. 409.912, F.S., all entities that provide Medicaid health care services
must be commercially licensed in accordance with the provisions of Part I and Part III of
Chapter 641, F.S.

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AHCA Contract No. FA913, Attachment II, Exhibit 16, Page 68 of 68

 

 

ATTACHMENT III

BUSINESS ASSOCIATE AGREEMENT

The parties to this Attachment agree that the following provisions constitute a business
associate agreement for purposes of complying with the requirements of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). This Attachment is applicable if the Vendor
is a business associate within the meaning of the Privacy and Security Regulations, 45 C.F.R.
160 and 164.

The Vendor certifies and agrees as to abide by the following:

	1.	 	Definitions. Unless specifically stated in this Attachment, the definition of the
terms contained herein shall have the same meaning and effect as defined in 45 C.F.R. 160
and 164.

	 	1.a.	 	 Protected Health Information. For purposes of this Attachment, protected
health information shall have the same meaning and effect as defined in 45 C.F.R. 160 and 164,
limited to the information created, received, maintained or transmitted by the Vendor
from, or on behalf of, the Agency.
	 
	 	1.b.	 	Security Incident. For purposes of this Attachment, security incident
shall mean any event resulting in computer systems, networks, or data being viewed,
manipulated, damaged, destroyed or made inaccessible by an unauthorized activity. See
National Institute of Standards and Technology (NIST) Special Publication 800-61,
“Computer Security Incident Handling Guide,” for more information.

	2.	 	Use and Disclosure of Protected Health Information. The Vendor shall not use or
disclose protected health information other than as permitted by this Contract or by
federal and state law. The Vendor will use appropriate safeguards to prevent the use or
disclosure of protected health information for any purpose not in conformity with this
Contract and federal and state law. The Vendor will implement administrative, physical, and
technical safeguards that reasonably and appropriately protect the confidentiality,
integrity, and availability of electronic protected health information the Vendor creates,
receives, maintains, or transmits on behalf of the Agency.
	 
	3.	 	Use and Disclosure of information for Management, Administration, and Legal
Responsibilities. The Vendor is permitted to use and disclose protected health
information received from the Agency for the proper management and administration of the
Vendor or to carry out the legal responsibilities of the Vendor, in accordance with 45
C.F.R. 164.504(e)(4). Such disclosure is only permissible where required by law, or where
the Vendor obtains reasonable assurances from the person to whom the protected health
information is disclosed that: (1) the protected health information will be held
confidentially, (2) the protected health information will be used or further disclosed only
as required by law or for the purposes for which it was disclosed to the person, and (3)
the person notifies the Vendor of any instance of which it is aware in which the
confidentiality of the protected health information has been breached.

AHCA Contract No. FA913, Attachment III, Page 1 of 3

 

 

	4.	 	Disclosure to Third Parties. The Vendor will not divulge, disclose, or
communicate protected health information to any third party for any purpose not in
conformity with this Contract without prior written approval from the Agency. The Vendor
shall ensure that any agent, including a subcontractor, to whom it provides protected
health information received from, or created or received by the Vendor on behalf of, the
Agency agrees to the same terms, conditions, and restrictions that apply to the Vendor with
respect to protected health information.
	 
	5.	 	Access to Information. The Vendor shall make protected health information
available in accordance with federal and state law, including providing a right of access
to persons who are the subjects of the protected health information in accordance with 45
C.F.R. 164.524.
	 
	6.	 	Amendment and Incorporation of Amendments. The Vendor shall make protected
health information available for amendment and to incorporate any amendments to the
protected health information in accordance with 45 C.F.R. § 164.526.
	 
	7.	 	Accounting for Disclosures. The Vendor shall make protected health information
available as required to provide an accounting of disclosures in accordance with 45 C.F.R.
§ 164.528. The Vendor shall document all disclosures of protected health information as
needed for the Agency to respond to a request for an accounting of disclosures in
accordance with 45 C.F.R. § 164.528.
	 
	8.	 	Access to Books and Records. The Vendor shall make its internal practices,
books, and records relating to the use and disclosure of protected health information
received from, or created or received by the Vendor on behalf of the Agency, available to
the Secretary of the Department of Health and Human Services or the Secretary’s designee
for purposes of determining compliance with the Department of Health and Human Services
Privacy Regulations.
	 
	9.	 	Reporting. The Vendor shall make a good faith effort to identify any use or
disclosure of protected health information not provided for in this Contract. The Vendor
will report to the Agency, within ten (10) business days of discovery, any use or
disclosure of protected health information not provided for in this Contract of which the
Vendor is aware. The Vendor will report to the Agency, within twenty-four (24) hours of
discovery, any security incident of which the Vendor is aware. A violation of this
paragraph shall be a material violation of this Contract.
	 
	10.	 	Termination. Upon the Agency’s discovery of a material breach of this
Attachment, the Agency shall have the right to terminate this Contract.

	 	10.a.	 	 Effect of Termination. At the termination of this Contract, the Vendor
shall return all protected health information that the Vendor still maintains in any
form, including any copies or hybrid or merged databases made by the Vendor; or with
prior written approval of the Agency, the protected health information may be destroyed
by the Vendor after its use. If the protected health information is destroyed pursuant
to the Agency’s prior written approval, the Vendor must provide a written confirmation
of

MICA Contract No. FA913, Attachment III, Page 2 of 3

 

 

	 	 	 	such destruction to the Agency. If return or destruction of the protected health
information is determined not feasible by the Agency, the Vendor agrees to protect the
protected health information and treat it as strictly confidential.

The Vendor has caused this Attachment to be signed and delivered by its duly authorized
representative, as of the date set forth below.

Vendor Name:

	 	 	 	 	 	 	 
	/s/ William L. McHugh
 

Signature

	 	 
	 	8/31/09
 

Date
	 	 
	 
	 	 	 	 	 	 
	William L. McHugh, CEO
 

Name and Title of Authorized Signer

	 	 	 	 	 	 

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AHCA Contract No. FA913, Attachment III, Page 3 of 3

 

 

ATTACHMENT IV

CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

	(1)	 	No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee
of any agency, a member of congress, an officer or employee of congress, or an employee of a
member of congress in connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any cooperative agreement,
and the extension, continuation, renewal, amendment, or modification of any federal contract,
grant, loan, or cooperative agreement.

	(2)	 	If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
member of congress, an officer or employee of congress, or an employee of a member of congress
in connection with this federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,”
in accordance with its instructions.

	(3)	 	The undersigned shall require that the language of this certification be included in the
award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and
contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall
certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.

	 	 	 	 	 
	/s/ William L. McHugh
 

Signature

	 	                    8/31/09
 

                    Date
	 	 
	 
	 	 	 	 
	William L. McHugh
 

Name of Authorized Individual

	 	  

                    Application
or Contract Number
	 	 
	 
	 	 	 	 
	AMERIGROUP FL, Inc 4200 W. Cypress St. Tampa, FL 33607	 	 
	 	 	 
	Name and Address of Organization
	 	 	 	 

AHCA Contract No. PA913, Attachment IV, Page 1 of 1

 

 

ATTACHMENT V

CERTIFICATION REGARDING 

DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CONTRACTS/SUBCONTRACTS 

This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987, Federal
Register (52 Fed. Reg., pages 20360-20369).

INSTRUCTIONS

	1.	 	Each Vendor whose contract/subcontract equals or exceeds $25,000 In federal monies must sign
this certification prior to execution of each contract/subcontract. Additionally, Vendors who
audit federal programs must also sign, regardless of the contract amount. The Agency for
Health Care Administration cannot contract with these types of Vendors if they are debarred or
suspended by the federal government. 
	 
	2.	 	This certification is a material representation of fact upon which reliance is placed when
this contract/subcontract is entered into. If it is later determined that the signer knowingly
rendered an erroneous certification, the Federal Government may pursue available remedies,
including suspension and/or debarment.
	 
	3.	 	The Vendor shall provide immediate written notice to the contract manager at any time the
Vendor learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
	 
	4.	 	The terms “debarred,” “suspended,” “ineligible,” “person,” “principal,” and “voluntarily
excluded,” as used in this certification, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the contract
manager for assistance in obtaining a copy of those regulations.
	 
	5.	 	The Vendor agrees by submitting this certification that, it shall not knowingly enter into
any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract unless authorized by the Federal
Government.
	 
	6.	 	The Vendor further agrees by submitting this certification that it will require each
subcontractor of this contract/subcontract, whose payment will equal or exceed $25,000 in
federal monies, to submit a signed copy of this certification.
	 
	7.	 	The Agency for Health Care Administration may rely upon a certification of a Vendor that it
is not debarred, suspended, ineligible, or voluntarily excluded from
contracting/subcontracting unless it knows that the certification is erroneous.
	 
	8.	 	This signed certification must be kept in the contract managers contract file.
Subcontractor’s certifications must be kept at the contractors business location.

CERTIFICATION

	(1)	 	The prospective Vendor certifies, by signing this certification, that neither he nor his
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract by any federal department or agency.
	 
	(2)	 	Where the prospective Vendor is unable to certify to any of the statements in this
certification, such prospective Vendor shall attar an explanation to this certification.

	 	 	 	 	 	 	 
	/s/ William L. McHugh
 

Signature

	 	 
	 	8/31/09
 

Date
	 	 
	 
	 	 	 	 	 	 
	William L. McHugh, CEO
	 	 	 	 	 	 
	 	 	 
	Name and Title of Authorized Signer
	 	 	 	 	 	 

AHCA Contract No. FA913, Attachment V, Page 1 of 1

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