Document:

ex10_21.htm

    
      CASH COLLATERAL
AGREEMENT

       

      

      CASH COLLATERAL AGREEMENT
dated as of February 14, 2008 (as amended, restated, supplemented or otherwise
modified from time to time, this “Agreement”)
among each of MORRIS
GAD, an individual residing at 592 5th Avenue,
New York, New York, 10036 (“Pledgor”), PNC BANK, NATIONAL
ASSOCIATION, a national banking association, as depository institution
(the “Bank”) and PNC BANK, NATIONAL
ASSOCIATION, a national banking association as agent for the Lenders (as
defined below) party to the Loan Agreement referred to below (in such capacity,
“Agent”).

       

      WHEREAS, reference is made to
the Revolving Credit, Term Loan and Security Agreement dated as of February 14,
2008 (as amended, modified, supplemented and/or restated from time to time, the
“Loan
Agreement”) among PNC Bank, National Association (“PNC”),
the various financial institutions named in or which hereafter become a party to
the Loan Agreement (PNC and such other various other financial institutions,
collectively, the “Lenders”),
Agent, Hybrook Resources Corp. (to be renamed Best Energy Services, Inc.), a
corporation organized under the laws of the State of Nevada (“Best”),
Bob Beeman Drilling Company, a corporation organized under the laws of the State
of Utah (“BBD”),
and Best Well Service, Inc., a corporation organized under the laws of the State
of Kansas (“BWS”)
(Best, BBD and BWS, each a “Borrower”,
and collectively “Borrowers”).

       

      WHEREAS, as an inducement for
Agent and Lenders to make certain advances to Borrowers under the Loan
Agreement, Pledgor has agreed to enter into this Agreement;

       

      NOW, THEREFORE, in
consideration of the premises and for other good and valuable consideration, the
receipt of which is hereby acknowledged, the parties hereto agree as
follows:

       

      Section
1.  Defined
Terms.  Except as otherwise defined herein, terms defined in
the Loan Agreement are used herein as defined therein.  The following
terms shall have the following meanings for purposes of this
Agreement:

       

      “Account” shall have
the meaning assigned to such term in Section 2 hereof.

       

      “Obligations” shall
mean, collectively, all obligations and liabilities of  Borrowers
under the Loan Agreement, including, without limitation, principal, interest,
expenses relating or incidental to the enforcement or protection of the rights
of Agent and Lenders hereunder or thereunder, and all modifications, amendments,
replacements, extensions and renewals thereof and substitutions therefor,
whether now existing or hereafter at any time created, arising or incurred
without limit to amount, except as expressly stated in the Loan
Agreement.

       

      “Side Collateral”
shall mean cash equal to the Side Collateral Amount, and all interest or other
income with respect to the Side Collateral and all proceeds thereof, deposited
to or for the credit of the Account.

       

      “Side Collateral
Amount” shall mean $2,500,000, less the amount of any Side Collateral
which has been applied to the Obligations or released pursuant to Section 6
hereof.

       

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      
        Section
2.  Establishment and
Maintenance of the Account.

         

        (a)           The
Pledgor shall transfer and deposit, in immediately available funds, an amount
equal to the Side Collateral Amount.   The Side Collateral shall
be transferred to and deposited in immediately available funds in Account No.
31900325348 (the “Account”) in the name
of the Pledgor, which account shall be maintained at the Bank.

         

        (b)           Pledgor,
Agent and the Bank each hereby agree that (i) the Account shall be a segregated
non-demand, interest bearing deposit account used only for the purposes of this
Agreement and all amounts to the credit thereof shall be separate and
identifiable as credited to such Account, (ii) the Account shall at all times be
subject to the exclusive dominion and control of the Agent and (iii) except for
remittances permitted pursuant to Section 6 of this Agreement, the Pledgor shall
have no right or power to withdraw the Side Collateral from the Account and the
Agent is hereby authorized by the Pledgor to provide such instructions, and make
such notations on the records relating to the Account, to give effect to the
foregoing.

         

        Section
3.  Pledge
and Assignment of the Account.  As collateral security for the
prompt payment in full when due (whether at stated maturity, by acceleration or
otherwise) of the Obligations, Pledgor does hereby pledge, grant and assign to
the Agent, for its benefit and for the ratable benefit of Lenders, a security
interest in, to and under, and a continuing lien on, the Side Collateral and the
Account.

         

        Section
4.  Withdrawal of
Deposits.   All amounts and items deposited in the Account
shall remain in the Account until released or withdrawn in accordance with the
terms of this Agreement.

         

        Section
5.  Remedies.   Upon
the occurrence and during the continuance of an Event of Default under the Loan
Agreement:

         

        (a)           The
Agent may, in addition to those rights and remedies which may be available to
the Agent under applicable law, at any time or from time to time, at its option
and without further demand or notice to Pledgor, withdraw or cause to be
withdrawn, charge, set-off or otherwise apply all or any part of the Side
Collateral against the Obligations in such order as it shall determine in its
sole discretion; and

         

        (b)           The
Agent may, in addition to the other rights and remedies provided for herein or
otherwise available to it, exercise all the rights and remedies of a secured
party under the Uniform Commercial Code as in effect in any applicable
jurisdiction.

         

        No
failure on the part of the Agent or any of its agents to exercise, and no course
of dealing with respect to, or delay in exercising, any right, power or remedy
hereunder shall operate as a waiver thereof; nor shall any single or partial
exercise by the Agent or any of its agents of any right, power or remedy
hereunder preclude the exercise of any other right, power or
remedy.  The remedies herein are cumulative and are not exclusive of
any remedies provided by law.

         

        In
furtherance of the foregoing, Pledgor hereby expressly waives diligence,
presentment of payment, protest, demand of performance and all notices
whatsoever, and any requirement that the Agent exhaust any right, power or
remedy under the Loan Agreement or any Other Document, or against any person
under any guarantee of, or security for, any of the
Obligations.  Notwithstanding anything to the contrary contained in
this Agreement, Agent shall use commercially reasonably efforts to notify
Pledgor of any Event of Default under the Loan Agreement, but any failure on the
part of Agent to provide such notice shall not prejudice its rights under this
Agreement.

         

      

    

    
      
        
        

      

      
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        Pledgor
hereby agrees to pay all of the Agent’s expenses (including, without limitation,
reasonable legal fees and disbursements) of every kind directly related to any
dispute with Pledgor arising out of this Agreement, which obligation to
reimburse shall be secured under this Agreement and be deemed to be Obligations
for purposes hereof.

         

        Section
6.   Release of Side Collateral;
Termination.

         

        (a)           Pledgor
shall have to direct Agent from time to time to release any interest that has
accrued on the Side Collateral Amount and that is available for withdrawal from
the Account without penalty by the Bank, and upon receipt of such direction
Agent shall promptly remit or cause to be remitted to the Pledgor, without any
recourse to, or warranty or representation by the Agent whatsoever, any such
interest on the Side Collateral Amount.

         

        (b)           If
as of the date Agent receives the audited financial statements required to be
delivered to Agent and the Lenders pursuant to Section 9.7 of the Loan Agreement
(the “Audited Financial Statements”) for any fiscal year of the Borrowers,
commencing with the fiscal year ending December 31, 2008, (x) no Default or
Event of Default has occurred and is continuing under the Loan Agreement and (y)
such Audited Financial Statements demonstrate to Agent’s reasonably satisfaction
that the net income of the Borrowers on a Consolidated Basis was greater than
$4,000,000, then the Agent shall promptly remit or cause to be remitted to the
Pledgor, without any recourse to, or warranty or representation by the Agent
whatsoever, a portion of the Side Collateral Amount equal to 25% of the
difference between the Borrowers net income for such fiscal year (as
demonstrated by such Audited Financial Statements) and $4,000,000, so long as
after giving effect to the foregoing there shall be Undrawn Availability of not
less than $2,500,000.

         

        (c)           If,
after the Closing Date, Best issues any additional Equity Interests in
accordance with the Loan Agreement such that the aggregate amount of proceeds
received by Best from the issuance of Equity Interests in connection with the
Transactions (whether prior to or after the Closing Date) (such amount, the
“Aggregate Equity Proceeds”) exceeds $9,500,000 (the “Target Amount”), and the
proceeds of such issuance of Equity Interests are utilized to repay the
outstanding Advances under (and as required by) the Loan Agreement, then, so
long as no Default or Event of Default shall have occurred and be continuing,
the Agent shall s promptly (but in no event later than three (3) Business Days
after the repayment of the outstanding Advances under the Loan Agreement with
such proceeds) remit or cause to be remitted to the Pledgor, without any
recourse to, or warranty or representation by the Agent whatsoever, a portion of
the Side Collateral Amount equal to the amount by which the Aggregate Equity
Proceeds exceed the Target Amount.

         

        (d)           Ninety-one
(91) days after the (i) termination or expiration of the Loan Agreement, and
(ii) the payment in full in cash of all Obligations, this Agreement shall
terminate, and the Agent shall promptly remit or cause to be remitted to the
Pledgor, without any recourse to, or warranty or representation by the Agent
whatsoever, all of the Side Collateral in the Account.

         

        Section
7.  Representations and
Warranties.   Pledgor represents and warrants to the Agent
as follows:

         

        (a)           The
execution, delivery and performance of this Agreement are within the capacity of
Pledgor.

         

        (b)           Except
as limited by any applicable bankruptcy, reorganization, insolvency, moratorium,
fraudulent conveyances and other similar laws, this Agreement

         

      

    

    
      
        
        

      

      
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      constitutes
a legal, valid and binding obligation of Pledgor enforceable against Pledgor in
accordance with its terms.

    

    
      
         

        (c)           This
Agreement creates a valid, perfected and first priority security interest in the
Side Collateral, securing the payment of all Obligations.

         

        (d)           Pledgor
is the sole beneficial owner of the Side Collateral and no security interest,
lien, charge, encumbrance or other interest exists in favor of any Person except
for the Agent.

         

        Section
8.  Covenants of the
Pledgors.  Pledgor covenants and agrees for the benefit of the
Agent as follows:

         

        (a)           Pledgor
will not permit any notice creating or otherwise relating to liens on the Side
Collateral and the Account or any portion thereof to exist or be on file in any
public office, except in favor of the Agent.

         

        (b)           Pledgor
will, promptly upon request by the Agent, execute and deliver or use its best
efforts to obtain any document, give any notices, execute and file any financing
statements or other documents (all in form and substance satisfactory to the
Agent), deliver any instruments to the Agent, and take any other actions that
are necessary or, in the opinion of the Agent, desirable to perfect or continue
the perfection and the first priority of the Agent’s security interest in the
Side Collateral and the Account, to protect the Side Collateral and the Account
against the rights, claims or interests of any persons or to effect the intent
and purposes of this Agreement.  The Pledgor will pay all reasonable
costs incurred in connection with any of the foregoing.

         

        (c)           The
Pledgor will not in any way hypothecate or create or permit to exist any lien,
security interest, charge or encumbrance on or other interest in the Side
Collateral or the Account, and the Pledgor will not sell, transfer, assign,
pledge, collaterally assign, exchange or otherwise dispose of the Side
Collateral or the Account.

         

        Section
9.  [Intentionally
Omitted].

        

        Section
10.  Waivers; Other
Agreements.

         

        (a)           Agent
and Lenders are hereby authorized, without notice to or demand upon Pledgor,
which notice or demand is expressly waived hereby, and without discharging or
otherwise affecting the obligations of Pledgor hereunder (which shall remain
absolute and unconditional notwithstanding any such action or omission to act),
from time to time, to:

         

        (i)  supplement,
renew, extend, accelerate or otherwise change the time for payment of, or other
terms relating to, the Obligations, or any portion thereof, or otherwise modify,
amend or change the terms of any promissory note or other agreement, document or
instrument (including, without limitation, the Loan Agreement and the Other
Documents) now or hereafter executed by any Borrower and delivered to Agent or
any Lender, including, without limitation, any increase or decrease of the
principal amount thereof, the rate of interest thereon or fees payable in
connection therewith;

         

        (ii)  waive
or otherwise consent to noncompliance with any provision of any agreement,
document or instrument (including, without limitation, the Loan Agreement and
the Other Documents) evidencing or in respect of the Obligations, or
any

      

       

    

    
      
        
        

      

      
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      part
thereof, now or hereafter executed by any Borrower and delivered to Agent or any
Lender;

       

      (iii)  accept
partial payments on the Obligations;

       

      (iv)  receive,
take and hold security or collateral for the payment or performance of the
Obligations, or any part thereof, or for the payment or performance of any
guaranties of all or any part of the Obligations, and exchange, enforce, waive,
substitute, liquidate, terminate, abandon, fail to perfect, subordinate,
transfer, otherwise alter and release any such security or
collateral;

       

      (v)  apply
any and all such security or collateral and direct the order or manner of sale
thereof as Agent and Lenders may determine in their sole
discretion;

       

      (vi)  settle,
release, compromise, collect or otherwise liquidate the Obligations, or any part
thereof, or accept, substitute, release, exchange or otherwise alter, affect or
impair any security or collateral for the Obligations, or any part thereof, or
any guaranty therefor, in any manner;

       

      (vii)  add,
release or substitute any one or more guarantors, makers or endorsers of all or
any part of the Obligations and otherwise deal with any Borrower, or any
guarantor, maker or endorser as Agent and Lenders may elect in their sole
discretion;

       

      (viii)  apply
any and all payments or recoveries from any Borrower or from any guarantor,
maker or endorser of all or any part of the Obligations in such order as Agent
and Lenders in their sole discretion may determine, whether such Obligations are
secured or unsecured or guaranteed or not guaranteed by others;

       

      (ix)  apply
any and all payments or recoveries from any guarantor, maker or endorser of all
or any part of the Obligations or sums realized from security furnished by any
of them upon any of their indebtedness or obligations to Agent and Lenders as
Agent and Lenders in their sole discretion may determine, whether or not such
indebtedness or obligations relate to the Obligations; and

       

      (x)  refund
at any time, at Agent’s and Lender’s sole discretion, any payment received by
Agent or any Lender in respect of any Obligations, and, even though prior
thereto this Agreement shall have been canceled or surrendered (or any lien,
security interest or other collateral shall have been released or terminated by
virtue thereof), such prior cancellation or surrender (or release or
termination) shall not diminish, release, discharge, impair or otherwise affect
the obligations of Pledgor hereunder in respect of the amount so refunded (and
any lien, security interest or other collateral so released or terminated shall
be reinstated with respect to such obligations), subject, in each case, to other
limitations, if any, set forth herein.

       

      (b)  Pledgor hereby agrees
that its obligations under this Agreement are absolute and unconditional and
shall not be discharged or otherwise affected as a result of:

       

      (i)           the
invalidity or unenforceability of any security for or guaranty of all or any
part of the Obligations or of any promissory note or other agreement, document
or instrument (including, without limitation, the Loan Agreement and the Other
Documents) evidencing or in respect of all or any part of the Obligations, or
the lack of perfection or continuing perfection or failure of priority of any
security for all or any part of the Obligations or any guaranty
therefor;

       

    

    
      
        
        

      

      
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      (ii)           the
absence of any attempt to collect the Obligations, or any portion thereof, from
any Borrower or any guarantor or other action to enforce the same;

       

      (iii)           any
failure by Agent or any Lender to acquire, perfect and maintain any security
interest in, or to preserve any rights to, any security or collateral for all or
any part of the Obligations or any guaranty therefor;

       

      (iv)           any
election by Agent or Lenders in any proceeding instituted under Chapter 11 of
Title 11 of the United States Code (11 U.S.C. § 101 et seq.) (the “Bankruptcy
Code”);

       

      (v)           any
borrowing or grant of a security interest by any Borrower, as
debtor-in-possession, or extension of credit, under the Bankruptcy
Code;

       

      (vi)           the
disallowance, under the Bankruptcy Code, of all or any portion of Agent’s or any
Lender’s claim(s) for repayment of the Obligations;

       

      (vii)           any
use of cash collateral under the Bankruptcy Code;

       

      (viii)                      any
agreement or stipulation as to the provision of adequate protection in any
bankruptcy proceeding;

       

      (ix)           the
avoidance of any lien in favor of Agent for any reason;

       

      (x)           any
bankruptcy, insolvency, reorganization, arrangement, readjustment of debt,
liquidation or dissolution proceeding commenced by or against any Borrower,
Pledgor, or any guarantor, maker or endorser, including without limitation, any
discharge of, or bar or stay against collecting or accelerating, all or any of
the Obligations (or any interest thereon) in or as a result of any such
proceeding;

       

      (xi)           any
failure by Agent or any Lender to file or enforce a claim against any Borrower
or such Person’s estate in any bankruptcy or insolvency case or
proceeding;

       

      (xii)           any
action taken by Agent that is authorized by this Agreement;

       

      (xiii)                      any
election by Agent under Section 9-604(a) of the Uniform Commercial Code as
enacted in any relevant jurisdiction as to any security for the Obligations or
any guaranty of all or any part of the Obligations; or

       

      (xiv)                      any
other circumstance which might otherwise constitute a legal or equitable
discharge or defense of a guarantor (other than payment and performance in full
of the Obligations and the termination of the Loan Agreement and all Other
Documents).

       

      (c)  Until the Obligations
have been paid and performed in full and the Loan Agreement and Other Documents
have been terminated, Pledgor hereby irrevocably agrees that it will not assert,
to the extent permitted by applicable law, any “claim” (as defined in Section
101(5) of the Bankruptcy Code) to which Pledgor is or would at any time be
entitled by virtue of its obligations under this Agreement, including, without
limitation, any right of subrogation (whether contractual, under Section 509 of
the Bankruptcy Code or otherwise), reimbursement, contribution, exoneration or
similar right against any Borrower, or by virtue of any other indebtedness or
obligations of any Borrower to Pledgor now existing or hereafter incurred ;
provided, however, that in any
case under the Bankruptcy Code with respect to any Borrower, Pledgor may file a
proof of contingent claim with respect to any such subrogation or other rights
for the sole purpose of timely asserting such claims in compliance with any bar
order (or standing order or local rule establishing a period of time for the
timely filing of claims in

    

     

    
      
        
        

      

      
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      such
case), provided
further that
(i) Pledgor’s filing such proof of claim shall be without prejudice to Agent’s
and Lenders’ rights under this Agreement and/or under Section 509 of the
Bankruptcy Code and (ii) such proof of claim shall state that Pledgor’s claims
memorialized thereby are subject to the provisions of this
Agreement.  Pledgor further waives, to the extent permitted by
applicable law:

      
         

        (i)  any
requirements of diligence or promptness on the part of Agent or
Lenders;

         

        (ii)  presentment,
demand for payment or performance and protest and notice of protest with respect
to the Obligations or any guaranty with respect thereto;

         

        (iii)  notices
(a) of nonperformance, (b) of acceptance of this Agreement, (c) of default in
respect of the Obligations or any guaranty, (d) of the existence, creation or
incurrence of new or additional indebtedness, arising either from additional
loans extended to any Borrower or otherwise, (e) that the principal amount, or
any portion thereof, and/or any interest on any document or instrument
evidencing all or any part of the Obligations is due, (f) of any and all
proceedings to collect from any Borrower, any maker, endorser or any guarantor
of all or any part of the Obligations, or from anyone else, (g) of the exchange,
sale, surrender or other handling of any security or collateral given to Agent
to secure payment of the Obligations or any guaranty therefor, and (h) of any
action taken by Agent that is authorized by this Agreement;

         

        (iv) any
right to require Agent or Lenders to (a) proceed first against any Borrower or
any other Person whatsoever, (b) proceed against or exhaust any security given
to or held by Agent or Lenders in connection with the Obligations or any
guaranty, or (c) pursue any other remedy in Agent’s or any Lender’s power
whatsoever;

         

        (v)           any
defense arising by reason of (a) any disability or other defense of any Borrower
or any guarantor of all or any portion of the Obligations, (b) the cessation
from any cause whatsoever of the liability of any Borrower or any guarantor of
all or any portion of the Obligations, (c) any act or omission of Agent or any
Lender or others which directly or indirectly, by operation of law or otherwise,
results in or aids the discharge or release of any Borrower or any security
given to or held by Agent or any Lender in connection with the Obligations or
any guaranty;

         

        (vi)           any
and all other suretyship defenses under applicable law (other than payment and
performance in full of the Obligations and the termination of the Loan Agreement
and all Other Documents); and

         

        (vii) the
benefit of any statute of limitations affecting the Obligations or Pledgor’s
liability hereunder or the enforcement hereof.

         

        All
waivers granted by Pledgor hereunder shall be unconditional (except to the
extent expressly provided herein) and irrevocable irrespective of whether the
Obligations have been paid in full by Pledgor or any other party.

         

        (d)  Pledgor
hereby assumes responsibility for keeping itself informed of the financial
condition of each Borrower, of any and all endorsers and/or guarantors of all or
any part of the Obligations and of all other circumstances bearing upon the risk
of nonpayment and nonperformance of the Obligations, or any part thereof, and
Pledgor hereby agrees that neither Agent nor any Lender shall have any duty to
advise Pledgor of information known to Agent or such Lender regarding such
condition or any such circumstances.  In the event Agent or any
Lender, in its sole discretion, undertakes at any time or from time to time to
provide any such information to Pledgor, neither Agent nor such Lender shall not
have any obligation (i) to undertake any investigation, whether or not a part of
its regular business routine, (ii) to disclose

         

      

    

    
      
        
        

      

      
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      any
information which Agent or such Lender wishes to maintain confidential or (iii)
to make any other or future disclosures of such information or any other
information of Pledgor.

      
         

        Section
11.  Continuing Security
Interest; Successors and Assigns.  This Agreement shall create
a continuing security interest in the Side Collateral and the Account and shall
(i) remain in full force and effect until terminated in accordance with its
terms, (ii) be binding upon Pledgor, its heirs, administrators, executors,
successors, and permitted assigns and (iii) inure to the benefit of the Agent
and its successors, transferees and assigns, provided that the
Pledgor shall not have the right to assign this Agreement or any interest herein
or in the Side Collateral and the Collateral.

         

        Section
12. Notices.   All
notices, requests, consents and demands hereunder shall be in writing and
mailed, telecopied or delivered to the intended recipient at the address set
forth on the signature page of this Agreement or such other address as shall be
designated by such party in a written notice to each other party.

         

        Section
13.  Exculpation of Bank;
Indemnification by Company.  Pledgor and Agent agree that Bank
shall have no liability to either of them for any loss or damage that either or
both may claim to have suffered or incurred, either directly or indirectly, by
reason of this Agreement or any transaction or service contemplated by the
provisions hereof, unless occasioned by the gross negligence or willful
misconduct of Bank (as determined by a court of competent jurisdiction in a
final and non-appealable judgment).  In no event shall Bank be liable
for losses or delays resulting from computer malfunction, interruption of
communication facilities, labor difficulties or other causes beyond Bank's
reasonable control or for indirect, special or consequential
damages.  Pledgor agrees to indemnify Bank and hold it harmless from
and against any and all claims, other than those ultimately determined to be
founded on gross negligence or willful misconduct of Bank (as determined by a
court of competent jurisdiction in a final and non-appealable judgment), and
from and against any damages, penalties, judgments, liabilities, losses or
expenses (including reasonable attorney's fees and disbursements) incurred as a
result of the assertion of any claim, by any person or entity, arising out of,
or otherwise related to, any transaction conducted or service provided by Bank
through the use of the Account at Bank pursuant to the procedures provided for
or contemplated by this Agreement.

         

        Section
14.  Amendments and
Waivers.   The terms of this Agreement may be waived,
altered or amended only by an instrument in writing duly executed by the
Pledgor, Agent and the Bank.

         

        Section
15.  Interpretation of
Agreement.  All terms not defined herein or in the Loan
Agreement shall have the meaning set forth in the applicable Uniform Commercial
Code, except where the context otherwise requires.  Acceptance of or
acquiescence in a course of performance rendered under this Agreement shall not
be relevant in determining the meaning of this Agreement even though the
accepting or acquiescing party had knowledge of the nature of the performance
and opportunity for objection.

         

        Section
16.  Survival of
Provisions.  All representations, warranties and covenants of
the Pledgors contained herein shall survive the execution and delivery of this
Agreement, and shall terminate only upon the full and final payment of the
Obligations secured hereby.

         

        Section
17.  Governing
Law.  This Agreement shall be governed by, and construed in
accordance with, the law of the State of New York.

         

        Section
18.  Submission to
Jurisdiction.  Pledgor hereby submits to the nonexclusive
jurisdiction of the federal and state courts located in the State of New York
and the

      

      
         

      

    

    
      
        
        

      

      
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      City of
New York for purposes of all legal proceedings arising out of or relating to
this Agreement or the transactions contemplated hereby.

    

    
       

      Section
19.  WAIVER
OF JURY TRIAL.  PLEDGOR HEREBY KNOWINGLY, VOLUNTARILY AND
INTENTIONALLY WAIVES (TO THE EXTENT PERMITTED BY APPLICABLE LAW) ANY RIGHT IT
MAY HAVE TO A TRIAL BY JURY OF ANY DISPUTE ARISING UNDER OR RELATED TO THIS
AGREEMENT OR ANY OTHER DOCUMENT OR AGREEMENT REFERRED TO HEREIN AND AGREES THAT
ANY SUCH DISPUTE SHALL BE TRIED BEFORE A JUDGE SITTING WITHOUT A
JURY.

       

      Section
20.  Counterparts.   This
Agreement may be executed in any number of counterparts, all of which taken
together shall constitute one and the same instrument and any of the parties
hereto may executed this Agreement by signing any such counterpart.

       

      Section
21.  Severability.   If
any provision hereof is invalid and unenforceable in any jurisdiction, then, to
the fullest extent permitted by law, (i) the other provisions hereof shall
remain in full force and effect in such jurisdiction and shall be liberally
construed in order to carry out the intentions of the parties hereto as nearly
as may be possible and (ii) the invalidity or unenforceability of any provision
hereof in any jurisdiction shall not affect the validity or enforceability of
such provision in any other jurisdiction.

       

      

      [Signature
page follows.]

    

     

    
      
        
        

      

      
        9

        
          

        

      

      
        
        

      

    

    

    IN
WITNESS WHEREOF, the parties hereto have caused this Agreement to be duly
executed and delivered as of the day and year first above written.

     

    
      	/s/
      Morris Gad
	
              Name:
      Morris Gad

               

              Address:  Almod Ltd.

                    592 5th Ave, 8th
      FL
      New York, NY
      10036

              Facsimile:  646-898-4437

            
	 
	
              PNC BANK,
      NATIONAL ASSOCIATION, as Agent

            
	
              By:
      /s/ Jeffrey J.
      Bender

              Name:
      Jeffrey J. Bender

              Title:
      VP

               

              Address: 70
      East 55th Street

                    New York,
      NY  10022

              Attention:  A.
      Roger Craig

              Facsimile:  212-303-0060

            
	 
	PNC BANK, NATIONAL
      ASSOCIATION, as Bank
	
              By:
      /s/ Raymond J.
      DeRiggi

              Name:
      Raymond J. DeRiggi

              Title:
      Senior Vice President

               

              Address:
      265 Millburn Avenue

                      
      Millburn, NJ 07041

              Attention:

              Facsimile:
      973-218-2222

            

    

     

    
      
        
        

      

      
        10

        
          

        

      

      
        
        

      

    

     

    STATE OF
NEW YORK

    COUNTY OF
NEW YORK

    

    On
this 13TH day of February, 2008, before me personally appeared MORRIS GAD
to me known, who, being by me duly sworn, did depose and say that he is the
individual described in and which executed the foregoing
instrument.

     

    /S/
DIANE M. DROBNER

    Notary
Publicexhibit10-1.htm

     

      

    

    Back to Form
8-K

    Exhibit
10.1

    
 

    
      Amendment
001                                                                               Agreement
Number XQ744

    

    
      

      THIS
AMENDMENT, entered into between the State of Florida, Department of Elder
Affairs, hereinafter referred to as the "Department" and the Wellcare. hereinafter
referred to as the "contractor", amends contract number
XQ744.

    

    
      

      The
purpose of this amendment is to amend ATTACHMENTS I, II, EI, and
IV.

    

    
      

      1)           ATTACHMENT
I is hereby replaced with the revised ATTACHMENT I, attached
hereto.

    

    
      2)           ATTACHMENT
H is hereby replaced with the revised ATTACHMENT H, attached
hereto.

    

    
      3)           ATTACHMENT
m is hereby replaced with the revised ATTACHMENT III, attached
hereto.

    

    
      4)           ATTACHMENT
IV is hereby replaced with the revised ATTACHMENT IV, attached
hereto.

    

    
      

      This
amendment shall be effective on the last date that the amendment is signed by
both parties.

    

    
      

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

    

    
      

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

    

    
      

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

    

    
      

      IN
WITNESS WHEREOF, the parties hereto have caused this 107 page amendment to be
executed by their officials thereunto duly authorized.

    

    
      

      

    

    
      	
              CONTRACTOR:   Wellcare

            	
              STATE
      OF FLORIDA, DEPARTMENT OF ELDER AFFAIRS

            
	
              SIGNED
      BY:    /s/   Todd
      Farha

            	
              SIGNED
      BY: /s/  Illegible

              for

            
	
              NAME:
      Todd Farha

            	
              NAME:  E.
      Douglas Beach, PH.D.

            
	
              TITLE:
      President & CEO

            	
              TITLE:
      Secretary

            
	
              DATE:  12/27/07

            	
              DATE:  12/31/07

            
	
              FEDERAL
      ID NUMBER: 592583622 FISCAL YEAR END DATE:

            	 
      

    

    
      

      1

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
       

      LONG-TERM
CARE COMMUNITY DIVERSION PILOT PROJECT 

      Table
of Contents

    

    

    
      	
              SECTION
      1

            	
              GENERAL
      CONTRACT REQUIREMENTS

            	
              5

            
	
              1.1

            	
              Entire
      Agreement; Conflict

            	
              5

            
	
              1.2

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

            	
              5

            
	
              1.3

            	
              Contractor
      Qualifications

            	
              5

            
	
              1.4

            	
              Contract
      Management

            	
              5

            
	
              1.5

            	
              Insolvency
      Protection

            	
              9

            
	
              1.6

            	
              Surplus
      Requirements

            	
              9

            
	
              1.7

            	
              Bonds

            	
              9

            
	
              1.8

            	
              Insurance

            	
              10

            
	
              1.9

            	
              Interest
      and Savings

            	
              10

            
	
              1.10

            	
              Third
      Party Resources

            	
              10

            
	
              1.11

            	
              State
      Ownership

            	
              11

            
	
              1.12

            	
              Ownership
      and Management Disclosure

            	
              11

            
	
              1.13

            	
              Independent
      Provider

            	
              13

            
	
              1.14

            	
              Damages
      from Federal Disallowances

            	
              13

            
	
              1.15

            	
              Offer
      of Gratuities

            	
              13

            
	
              1.16

            	
              Attorneys'
      Fees

            	
              13

            
	
              1.17

            	
              Venue

            	
              13

            
	
              1.18

            	
              Legal
      Action Notification

            	
              13

            
	
              1.19

            	
              Force
      Majeure

            	
              13

            
	
              1.20

            	
              Sanctions

            	
              14

            
	
              1.21

            	
              Additional
      Applicable Laws and Regulations

            	
              15

            
	
              1.22

            	
              Inspection
      and Audit of Financial Records

            	
              15

            
	
              1.23

            	
              Reporting

            	
              15

            
	
              1.24

            	
              Fiscal
      Intermediary

            	
              15

            
	
              1.25

            	
              Subcontracts

            	
              16

            
	
              1.26

            	
              Subcontractor
      Terminations

            	
              20

            
	
              1.27

            	
              Termination

            	
              20

            
	
              1.28

            	
              Assignment

            	
              21

            
	
              SECTION
      2

            	
              RECIPIENT
      ELIGIBILITY TO PARTICIPATE IN THE PROJECT

            	
              21

            
	
              2.1

            	
              Eligibility
      Requirements

            	
              21

            
	
              2.2

            	
              Eligibility

            	
              22

            
	
              2.3

            	
              Persons
      Not Eligible for Enrollment

            	
              22

            
	
              2.4

            	
              Optional
      State Supplementation (OSS)

            	
              22

            
	
              SECTION
      3

            	
              EDUCATIONAL
      MATERIALS AND CHOICE COUNSELING

            	
              23

            
	
              3.1

            	
              Educational
      Materials

            	
              23

            
	
              3.2

            	
              Choice
      Counseling

            	
              23

            
	
              3.3

            	
              Prohibited
      Activities

            	
              23

            
	
              SECTION
      4

            	
              ENROLLMENT
      AND DISENROLLMENT

            	
              24

            
	
              4.1

            	
              Enrollment
      Procedures

            	
              24

            
	
              4.2

            	
              Effective
      Date of Enrollment

            	
              24

            
	
              4.3

            	
              Transition
      Care Planning

            	
              24

            
	
              4.4

            	
              Orientation

            	
              25

            
	
              4.5

            	
              Plan
      of Care

            	
              26

            
	
              4.6

            	
              Integration
      of Care

            	
              28

            
	
              4.7

            	
              Disenrollment

            	
              29

            
	
              4.8

            	
              Disputes
      of Appropriate Enrollments

            	
              31

            
	
              4.9

            	
              Medicaid
      Pending

            	
              31

            
	
              SECTION
      5

            	
              ENROLLEE
      RECORDS

            	
              32

            

    

    
      

      Attachment
I - Page 2

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      	
              SECTION
      6

            	
              SERVICE
      PROVISIONS

            	
              32

            
	
              6.1

            	
              Genera]
      Provisions

            	
              32

            
	
              6.2

            	
              Long-Term
      Care Services

            	
              34

            
	
              6.3

            	
              Minimum
      Long-Term Care Service Provider Qualifications

            	
              37

            
	
              6.4

            	
              Acute-Care
      Services

            	
              39

            
	
              6.5

            	
              Acute
      Care Provider Qualifications

            	
              40

            
	
              6.6

            	
              Optional
      Services

            	
              40

            
	
              6.7

            	
              Expanded
      Services

            	
              40

            
	
              6.8

            	
              Availability/Accessibility
      of Services

            	
              41

            
	
              6.9

            	
              Staffing
      Requirements

            	
              41

            
	
              6.10

            	
              Emergency
      Care Requirements

            	
              42

            
	
              6.11

            	
              Out
      of Network Use of Non-Emergency Services

            	
              42

            
	
              6.12

            	
              Adult
      Protective Services

            	
              43

            
	
              SECTION
      7

            	
              UTILIZATION
      MANAGEMENT

            	
              44

            
	
              SECTION
      8

            	
              QUALITY
      ASSURANCE AND IMPROVEMENT REQUIREMENTS

            	
              45

            
	
              8.1

            	
              General

            	
              45

            
	
              8.2

            	
              Quality
      Assurance Program

            	
              45

            
	
              8.3

            	
              Quality
      Assurance Committee

            	
              46

            
	
              8.4

            	
              Quality
      Improvement Activities and Performance Measures

            	
              46

            
	
              8.5

            	
              Independent
      Medical Review

            	
              47

            
	
              8.6

            	
              Incident
      Reporting

            	
              47

            
	
              SECTION
      9

            	
              GRIEVANCE/APPEALS
      PROCEDURES

            	
              48

            
	
              9.1

            	
              Grievance
      System Requirements

            	
              48

            
	
              9.2

            	
              Appeal
      Process

            	
              49

            
	
              9.3

            	
              Grievance
      Process

            	
              52

            
	
              9.4

            	
              Medicaid
      Fair Hearing System

            	
              52

            
	
              SECTION
      10

            	
              PAYMENT

            	
              53

            
	
              10.1

            	
              Payment
      to Contractor

            	
              53

            
	
              10.2

            	
              Capitation
      Rates

            	
              53

            
	
              10.3

            	
              Payment
      in Full

            	
              54

            
	
              10.4

            	
              Capitation
      Payments

            	
              54

            
	
              10.5

            	
              Payment
      Discrepancies

            	
              54

            
	
              SECTION
      11

            	
              PROGRAM
      REPORTING REQUIREMENTS

            	
              54

            
	
              11.1

            	
              General
      Requirements

            	
              54

            
	
              11.2

            	
              834
      Transactions

            	
              57

            
	
              11.3

            	
              Disenrollment
      Summary Report

            	
              58

            
	
              11.4

            	
              Encounter
      Data Report

            	
              58

            
	
              11.5

            	
              Grievance/Appeals
      Report

            	
              58

            
	
              11.6

            	
              Updated
      Provider Network Listing

            	
              58

            
	
              11.7

            	
              Minority
      Business Enterprise Contract Reporting

            	
              59

            
	
              11.8

            	
              Emergency
      Management Plan

            	
              59

            
	
              11.9

            	
              Enrollee
      Satisfaction Reporting

            	
              59

            
	
              11.10

            	
              Hospice
      Services

            	
              59

            
	
              SECTION
      12

            	
              FINANCIAL
      REPORTING

            	
              59

            
	
              12.1

            	
              General
      Financial Reporting

            	
              59

            
	
              12.2

            	
              Member
      Payment Liability Protection

            	
              59

            
	
              12.3

            	
              Financial
      Reporting Template

            	
              60

            
	
              12.4

            	
              Audited
      Financial Statements

            	
              60

            
	
              12.5

            	
              Unaudited
      Quarterly Financial Statements

            	
              60

            
	
              12.6

            	
              Balance
      Sheet

            	
              61

            
	
              12.7

            	
              Income
      Statement by Category of Service

            	
              65

            
	
              12.8

            	
              Income
      Statement by Line of Business

            	
              74

            
	
              12.9

            	
              Net
      Worth and Working Capital

            	
              75

            
	
              12.10

            	
              Claim
      Lag Reports & Outstanding Claims Liability (OCL)

            	
              76

            
	
              12.11

            	
              Analysis
      of Total Medical Liability to Actual Claims Paid

            	
              76

            
	
              12.12

            	
              Member
      Months

            	
              76

            
	
              12.13

            	
              Notes
      and Other Information

            	
              76

            

    

    
      Attachment
I - Page 3

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

    

    
      	
              SECTION
      12

            	
              FINANCIAL
      REPORTING (cont)

            	 
      
	
              12.14

            	
              Ratio
      Analysis

            	
              76

            
	
              12.15

            	
              Footnote
      Disclosure Requirements

            	
              77

            
	
              SECTION
      13

            	
              DEFINITIONS

            	
              77

            
	
              EXHIBIT
      A

            	
              MULTIPLE
      SIGNATURE VERIFICATION AGREEMENT

            	
              84

            
	
              EXHIBITB

            	
              DISENROLLMENT
      SUMMARY REPORT

            	
              86

            
	
              EXHIBIT
      C

            	
              ENCOUNTER
      DATA REPORTING FORMAT

            	
              87

            
	
              EXHIBIT
      D

            	
              REPORT
      OF GRIEVANCES/APPEALS

            	
              91

            
	
              EXHIBIT
      E

            	
              MINORITY
      BUSINESS ENTERPRISE CONTRACT REPORTING

            	
              92

            
	
              EXHIBITF

            	
              RECONCILIATION
      REPORT

            	
              93

            
	
              EXHIBIT
      G

            	
              DISENROLLMENT
      FORM

            	
              94

            
	
              EXHIBIT
      H

            	
              PROVIDER
      NETWORK AND STAFF LISTING

            	
              96

            
	
              EXHIBIT
      I

            	
              CAPITATION
      RATES

            	
              98

            
	
              EXHIBITJ

            	
              PUBLIC
      ENTITY CRIMES

            	
              99

            
	
              EXHIBIT
      K

            	
              DEBARMENT
      AND SUSPENSION

            	
              101

            
	
              EXHIBIT
      L

            	
              HOSPICE
      ENROLLMENT REPORT

            	
              103

            

    

    
      

    

    
      

    

    
      Attachment
I - Page 4

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

       

    

    
      LONG-TERM
CARE COMMUNITY DIVERSION PILOT PROJECT SECTION l General Contract
Requirements

    

    
      1.1          Conflict

    

    
      

      Correspondence
and project memoranda do not constitute part of this contract. Pending final
determination of any dispute, the contractor must proceed diligently with the
performance of the contract and in accordance with the department's
direction.

    

    
      

      1.2          Misuse
of Symbols, Emblems, or Names in Reference to Medicaid

    

    
      

      No person
or contractor 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 "Department of Elder Affairs," or
"Agency for Health Care Administration," except as required in the
standard-contract unless prior written approval is obtained from the department.
Specific written authorization from the department is required to reproduce,
reprint, or distribute any department or 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 the program
or the department or Agency's terms does not provide a defense. Each piece of
mail or information constitutes a violation.

    

    
      

      1.3          Contractor
Qualifications

    

    
      

      The
long-term care community diversion pilot project contractor
must:

    

    
      
        	
                A.

              	
                Have
      a certificate of authority from the Florida Department of Financial
      Services to  operate as a health maintenance organization (HMO)
      pursuant to Chapter 641 Part I, F.S.,  and have a health care
      provider certificate from the Agency for Health
      Care  Administration (Agency) pursuant to Section 641.49, F.S.,
      for those counties in the  service area in which the applicant
      will apply to provide services or; have a license
      issued  pursuant to Chapter 400 or Chapter 429, F.S., and meet
      the provisions of an "other  qualified provider" set forth in
      Section 430.703(7), F.S. and;

              

      

    

    
      
        	
                B.

              	
                Have
      prior experience in providing home and community-based long-term care
      services  and;

              

      

    

    
      
        	
                C.

              	
                Have
      the capacity to integrate the delivery of acute and long-term care
      services to  enrollees and;

              
	D. 	Meet
      all the requirements to enroll as a Medicaid provider
  and;

      

    

    
      
        	
                E.

              	
                Meet
      all other requirements in the remaining provisions of this contract and
      its  attachments.

              

      

    

    
      

      1.4          Contract
Management

    

    
      

      A.        State
Responsibilities

    

    
      The
Department of Elder Affairs (department) in consultation with the Agency for
Health Care Administration (Agency) will oversee contract management
responsibilities. The department will have the right to approve, disapprove, or
require modification of procedures developed by the contractor under the
contract where necessary to assure compliance with department or Agency rules or
the contract.

    

    
      

      Attachment
I - Page 5

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

      A.  Department
Responsibilities

    

    
      
        	
                1.

              	
                Develop
      or revise policies and procedures for the project in consultation with the
      Agency.

              

      

    

    
      
        	
                2.

              	
                Approve,
      in consultation with the Agency, the contractor's readiness to deliver
      services under the contract.

              

      

    

    
      
        	
                3.

              	
                Determine
      the clinical eligibility of persons applying for Medicaid long-term care
      assistance through the Comprehensive Assessment and Review for Long-Term
      Care Services (CARES)
program.

              

      

    

    
      
        	
                4.

              	
                Provide
      through the CARES program, information regarding long-term care options to
      persons applying for Medicaid long-term care
assistance.

              
	5. 	Provide
      policy and contract clarification, in consultation with the
    Agency.

      

    

    
      
        	
                6.

              	
                Monitor
      with the Agency, the contractor's compliance with the terms of the
      contract and impose appropriate corrective and remedial measures as
      warranted.

              

      

    

    
      
        	
                7.

              	
                Receive
      all materials that must be submitted by the contractor and forward them to
      the appropriate entity except as otherwise stated in the
      contract.

              

      

    

    
      

      C.        Contractor
Responsibilities

    

    
      
        	
                1.

              	
                The
      contractor is responsible for the administration and management of all
      contractor functions, including all subcontracts, employees, agents and
      anyone acting for or on behalf of the contractor. Any delegation of
      activities does not relieve the contractor of this
      responsibility.

              

      

    

    
      
        	
                2.

              	
                If
      the contractor delegates administrative and management functions to a
      third party  administrator (TPA), the TPA must be licensed to do
      business as a TPA in Florida. Such delegation to a TPA does not relieve
      the contractor of responsibility for the administration and management
      required under this contract.

              

      

    

    
      
        	
                3.

              	
                The
      relationship between management personnel and the governing body must be
      set forth in writing, including each person's authority, responsibilities,
      and function.

              

      

    

    
      
        	
                4.

              	
                The
      contractor's governing body shall set policy and has overall
      responsibility for the organization. Pursuant to 42 CFR 438.210(b)(2), the
      contractor is responsible for ensuring consistent application of review
      criteria for authorization decisions and consulting with the requesting
      subcontractor when
appropriate

              

      

    

    
      
        	
                5.

              	
                The
      contractor shall comply with applicable department or agency rules and any
      Agency handbooks relating to the provision of services set forth in
      Section 6, Service Provisions, except where the provisions of the contract
      alter the requirements set forth in the handbooks where applicable.
      Pursuant to 42 CFR 438.210(a) and (a)(3)(i)-(iii), the contractor must
      furnish services up to the limits specified by the Medicaid program. The
      contractor may exceed these limits. However, service limitations shall not
      be more restrictive than the Medicaid fee-for-service
    program.

              

      

    

    
      
        	
                6.

              	
                Pursuant
      to 42 CFR 438.236(b), the contractor shall adopt practice guidelines that
      meet the following
requirements:

              

      

    

    
      
        	
                a)

              	
                Are
      based on valid and reliable clinical evidence or a consensus of
      healthcare  professionals in the particular
    field.

              
	b)	Consider
      the needs of the enrollees.
	c) 	Are
      adopted in consultation with contracting health care
    professionals.
	d)  	Are
      reviewed and updated periodically as
appropriate.

      

    

    
            

    

    
                      The
contractor shall disseminate the guidelines to all affected providers and, upon
request to enrollees and potential enrollees. The decisions for
utilization

    

    
      

      Attachment
I - Page 6

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      management,
enrollee education, coverage of services, and other areas to
which  the guidelines apply shall be consistent with the
guidelines.

    

    
      

        7.          Pursuant
to Section 430.705(2)(b)(3), F.S., the contractor, must have through
performance
or other documented means, the capacity for prompt payment of claims as
specified under Section 641.3155, F.S.

    

    
      

      D. Administrative
Polices and Procedures Section

    

    
      1.  Contractor
will have in place polices and procedures relating to
the  following:

    

    
      a)  Emergency
Management Plan

    

    
      b)  Educational
Materials

    

    
      c)  Initial
enrollment and Ongoing Eligibility

    

    
      d) Transition
Care Planning

    

    
      e) Orientation

    

    
      f)  Disenrollment

    

    
      g) Service
Provisions 

      h)  Network
Adequacy

    

    
      i)   Sufficient
staff available 24 hours per day

    

    
      j)   Credentialing
and Re-Credentialing

    

    
      k)  Plan
for recruiting and retaining minority health vendors

    

    
      I)    Integration
of Care

    

    
      m) 
Plan of Care

    

    
      n)  Out
of network Use of Non-Emergency Services

    

    
      o)   Quality
Assurance Program

    

    
      p)  Quality
Assurance Committee

    

    
      q)  Incident
Reporting

    

    
      r)   Utilization
Management

    

    
      s)   Grievance/Appeals

    

    
      t)   Enrollee
Records

    

    
      u)   Claims

    

    
      v)   Advance
Directives

    

    
      w) 
Payment Discrepancies

    

    
      x)   
Reinstatement

    

    
      y)   
Subcontract

    

    
       

      2.          Fraud
Prevention Polices and Procedures

       

    

    
      
        	
                a)

              	
                The
      policies and procedures for fraud prevention shall provide for use of the
      HHS Office of the Inspector General List of Excluded Individuals /
      Entities Search (http://exclusions.oig.hhs.gov),
      or its equivalent, to identify excluded parties during the process of
      enrolling providers to ensure the contractor providers are not in a
      non-payment status or excluded from participation in federal health care
      programs under Section 1128 or Section 1128A of the Social Security Act.
      The contractor must not employ or contract with excluded providers and
      must terminate providers if they become
  excluded.

              

      

    

    
      
        	
                b)

              	
                The
      contractor must have written policies and procedures for selection and
      retention of providers. These policies and procedures must not
      discriminate against particular providers that serve high-risk populations
      or specialize in conditions that require costly
  treatments.

              

      

    

    
      
        	
                c)

              	
                The
      contractor must develop and maintain written polices and procedures
      to  implement the provision of the
  contract.

              

      

    

    
      

      Attachment
I - Page 7

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

     

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    

    
      

      3.  Credentialing
and Re-Credentialing Policies and Procedures

    

    
      The
contractor's credentialing and re-credentialing policies and procedures shall
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, which provides for verification of the following
core  credential information and the subcontractor's work
history:

        

      

    

    
      
      

    

    
      1.   The
subcontractor's current valid license. 

        
          2.  
The subcontractor's current valid occupational license, where
applicable.

        

      

    

    
      
      

    

    
      3.   Medicaid
provider number, if applicable.

    

    
      4.   Verification
of the following for non-Medicaid providers:

    

    
      
        	
                (a)

              	
                Evidence
      of the subcontractor's professional liability claims
    history.

              

      

    

    
      
        	
                (b)

              	
                Completion
      of a criminal history background check to determine whether subcontactor
      has any history of felony convictions, including adjudication withheld on
      a felony, plea of nolo contendere to a felony, or entry into a pretrial
      for a felony.

              
	(c)	 Any
      sanctions imposed by Medicare or Medicaid in any
  state.

      

    

    
      
        	
                (d)

              	
                Any
      disciplinary action taken against any business or professional license
      held in this or any other state or surrendered a license in this or any
      state.

              

      

    

    
      
        	
                (e)

              	
                Any
      history of loss or limitation of privileges or disciplinary
      activity.

              

      

    

    

    
      
        	
                5.

              	
                Verification
      that the contractor obtained information about the subcontractor on the
      HHS Office of the Inspector General's exclusion website (http://exclusions.oig.hhs.gov).

              

      

    

    
      
        	
                6.

              	
                Verification
      that all subcontractors and their employees with direct contact with
      enrollees have completed Abuse, Neglect, and Exploitation
      Training.

              
	E.	The
      process for periodic re-credentialing shall include the
    following:

      

    

    
      
        	
                1.

              	
                The
      procedure for re-credentialing shall be completed at least every three (3)
      years.

              

      

    

    
      
        	
                2.

              	
                The
      contractor shall verify the current licensure of the subcontractor on an
      annual basis.

              

      

    

    
      
        	
                3.

              	
                The
      contractor shall verify Medicare and Medicaid exclusions on the
      subcontractor on the HHS Office of the Inspector General's website on an
      annual basis.

              

      

    

    
      
        	
                F.

              	
                The
      contractor shall set out in its subcontracts procedures for approval
      of  new providers, and for imposition of sanctions, up to
      termination,
of  contract.

              

      

    

    
      
        	
                G.

              	
                The
      contractor shall develop and implement a mechanism for
      identifying  quality deficiencies that result in the
      contractor's restriction, suspension,  termination, or
      sanctioning of a
subcontractor.

              

      

    

    
      
        	
                H.

              	
                 The
      contractor shall develop and implement an appellate process for sanctions,
      restrictions, suspensions and terminations imposed by the contractor
      against subcontractors.

              

      

    

    
      

      Attachment
I - Page 8

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      4.          Health
Information Systems

    

    
      

      The
contractor shall maintain a health information system that collects, analyzes,
integrates, and reports data and can achieve the objectives of 42 CFR 438.242
and Health Insurance Portability and Accountability Act (HIPAA)
requirements.

    

    
      

      1.5          Insolvency
Protection

    

    
      

      
        	
                A.

              	
                The
      contractor must establish and maintain a restricted insolvency protection
      account in a  bank or savings and loan association located in
      the state of Florida with a balance of at  least $100,000 into
      which monthly deposits equal to at least 5 percent of
      premiums  received under the project are made until the balance
      equals 2 percent of the total contract  amount. The account
      shall be established with such terms as to ensure that funds
      may  only be withdrawn with the signature approval of designated
      department representatives.  A sample form (Signature
      Verification Agreement) can be found in Exhibit
  A.

              

      

    

    
      
        	
                B.

              	
                If
      the contractor's authorized representatives do not change from subsequent
      contract  years, an attestation statement indicating such must
      be submitted to the
department.

              

      

    

    
      
        	
                C.

              	
                In
      the event that a determination is made by the department that the
      contractor is  insolvent as defined in Section 13, the
      department may draw upon the account solely with  the authorized
      signatures of representatives of the department and funds may
      be  disbursed to meet financial obligations incurred by the
      contractor under this contract.  The contractor shall provide a
      statement of account balance upon request by
      the  department.

              

      

    

    
      
        	
                D.

              	
                If
      the contract is terminated, expired, or not continued, the account balance
      shall be  released by the department to the contractor upon
      receipt of proof of satisfaction of all  outstanding obligations
      incurred under this contract.

              

      

    

    
      
        	
                E.

              	
                In
      the event the contract is terminated or not renewed and the contractor is
      insolvent, the  department may draw upon the insolvency
      protection account to pay any outstanding  debts the contractor
      owes the Agency including, but not limited to, overpayments
      made  to the contractor, and fines imposed under the contract or
      Section 641.52, F.S., for which  a final order has been issued.
      In addition, if the contract is terminated or not renewed
      and  the contractor is unable to pay all of its outstanding
      debts to health care providers, the  department, Agency, and the
      contractor agree to the court appointment of an
      impartial  receiver for the purpose of administering and
      distributing the funds contained in the  insolvency protection
      account. A receiver must give outstanding debts owed to
      the  Agency priority over other
  claims.

              

      

    

    
      

      1.6          Surplus
Requirements

    

    
      

      All
contractors shall maintain a surplus of at least $1.5 million as determined by
the department. Each applicant and each provider shall furnish to the department
initial and annual unqualified audited financial statements prepared by a
certified public accountant that expressly confirm that the applicant or
provider satisfies this surplus requirement.

    

    
      

      1.7          Bonds

    

    
      

      The
contractor must secure and maintain during the life of the contract a blanket
fidelity bond from a company doing business in the State of Florida on all
personnel in its employment and its board of directors. The bond must be issued
in the amount of at least $250,000 per occurrence. Said bond must protect the
department and Agency from any losses sustained through any fraudulent or
dishonest act or acts committed by any employees of the provider and
subcontractors, if any. The contractor must submit proof of coverage within 60
calendar days

    

    
      

      Attachment
I - Page 9

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

      after
execution of the contract and prior to the delivery of services. For fidelity
bonds to be acceptable, a surety company must comply with the provisions of
Chapter 624, F.S. The contractor must submit proof of the fidelity bond annually
during the contract renewal period.

    

    
      

      1.8          Insurance

    

    
      

      
        	
                A.

              	
                The
      contractor must obtain and maintain, at all times, adequate insurance
      coverage  including general liability insurance, professional
      liability and malpractice insurance, fire  and property
      insurance, and director's omission and error insurance. All
      insurance  coverage must comply with the provisions set forth in
      Section 690-191.069, Florida  Administrative Code, except that
      the reporting, administrative, and approval requirements  will
      be submitted to the department in addition to the Department of Financial
      Services.  All insurance policies must be written by insurers
      licensed to do business in the State of  Florida and be in good
      standing with the Department of Financial Services,
      unless  coverage is not procurable from authorized insurers, in
      which case the provisions of the  Surplus Lines Law (Section
      626.913 - 626.937, F.S.) shall apply. The contractor
      must  submit all policy declaration pages annually or whenever
      there is a change in insurer or  policy provisions to the
      contract manager. Each certificate of insurance must provide
      for  notification to the department in the event of termination
      of the policy.

              

      

    

    
      
        	
                B.

              	
                The
      contractor must secure and maintain during the life of the contract,
      worker's  compensation insurance for all of its employees
      connected with the work under the contract. Such insurance must
      comply with the Florida Worker's Compensation Law,  Chapter 440,
      F.S. Policy declaration pages must be submitted to the
      department  annually.

              

      

    

    
      

      1.9          Interest
and Savings

    

    
      

      
        	
                A.

              	
                Interest
      generated through investments made by the contractor of funds provided to
      the  contractor pursuant to this contract will be the property
      of the contractor and will be used  at the contractor's
      discretion.

              

      

    

    
      
        	
                B.

              	
                The
      contractor will retain any savings realized under the contract after all
      bills, charges,  and fines are
paid.

              

      

    

    
      

      1.10          Third
Party Resources

       

    

    
      
        	
                A.

              	
                The
      contractor will be responsible for making every reasonable effort to
      determine the  legal liability of third parties to pay for
      services rendered to enrollees under this contract.  The
      contractor has the same rights to recovery of the full value of services
      as the Agency.  (see Section 409.910, F.S.) The following
      standards govern recovery

              

      

    

    
      
        	
                B.

              	
                If
      the contractor has determined that third party liability exists for part
      or all of the  services provided directly by the contractor to
      an enrollee, the contractor must make  reasonable efforts to
      recover from third party liable sources the value of
      services  rendered.

              

      

    

    
      
        	
                C.

              	
                If
      the contractor has determined that third party liability exists for part
      or all of the  services provided to an enrollee by a
      subcontractor or referral provider, and the third  party is
      reasonably expected to make payment within 120 calendar days, the
      contractor  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 contractor may assume full
      responsibility for third party collections for  service provided
      through the subcontractor or referral
provider.

              

      

    

    
      
        	
                D.

              	
                The
      contractor 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

              

      

    

    
      

      Attachment
I - Page 10

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      available
within a reasonable time, beyond 120 calendar days from the date of
receipt.

    

    
      
        	
                E.

              	
                When
      both the Agency and the contractor have liens against the proceeds of a
      third party  resource, the Agency shall prorate the amount due
      to Medicaid to satisfy such liens under  Section 409.910, F.S.,
      between the Agency and the contractor. This prorated
      amount  shall satisfy both liens in full.

              
	F. 	All
      funds recovered from third parties shall be treated as income for the
      contractor.

      

    

    
       

    

    
      1.11          State
Ownership

    

    
      

      The
department and Agency will have the right to use, disclose, or duplicate, all
information and data developed, derived, documented, or furnished by the
contractor resulting from the contract. Nothing herein will entitle the
department and Agency to disclose to third parties data or information, which
would otherwise be protected from disclosure by state or federal
law.

    

    
      

      1.12          Ownership
and Management Disclosure

    

    
      

      
        	
                A.

              	
                Federal
      and state laws require full disclosure of ownership, management and
      control of  managed care organizations, including other
      qualified providers. Disclosure must be made on forms prescribed by the
      department for the areas of ownership and control  interest
      business transactions (42 CFR 455.104), public entity crimes
      (Section  287.133(3)(a), F.S.), and debarment and suspension (52
      Fed. Reg., pages 20360-20369,  and Chapter 4707 of the Balanced
      Budget Act of 1997). The forms are available through  the
      department and are to be submitted to the department with the initial
      application and  then resubmitted on an annual basis. The
      contractor must disclose any changes in  management as soon as
      those occur. In addition, the contractor must submit to
      the  department full disclosure of ownership and control at
      least 60 calendar days before any  change in the contractor's
      ownership or control occurs.

              
	B.  	The
      following definitions apply to ownership
disclosure:

      

    

    
      
        	
                1.

              	
                A
      person with an ownership interest or control interest means a person
      or  corporation
that:

              

      

    

    
      
        	
                a)

              	
                Owns,
      indirectly or directly, five (5) percent or more of the contractor's
      capital or stock, or receives five (5) percent or more of its
      profits;

              

      

    

    
      
        	
                b)

              	
                Has
      an interest in any mortgage, deed of trust, note, or other obligation
      secured in whole or in part by the contractor or by its property or assets
      and that interest is equal to or exceeds five (5) percent of the total
      property or assets; or

              

      

    

    
      
        	
                c)

              	
                Is
      an officer or director of the contractor if organized as a corporation, or
      is a partner in the contractor if organized as a
    partnership.

              

      

    

    
      
        	
                2.

              	
                The
      percentage of direct ownership or control is calculated by multiplying the
      percent of interest that a person owns by the percent of the contractor's
      assets used to secure the obligation. Thus, if a person owns 10 percent of
      a note secured by 60 percent of the contractor's assets, the person owns
      six (6) percent of the
contractor.

              

      

    

    
      
        	
                3.

              	
                The
      percent of indirect ownership or control is calculated by multiplying the
      percentage of ownership in each organization. Thus, if a person owns 10
      percent of the stock in a corporation that owns 80 percent of the
      contractor's stock, the person owns eight (8) percent of the
      contractor.

              

      

    

    
      

      Attachment
I - Page 11

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      
        	
                C.

              	
                Changes
      in management are defined as any change in the management control of
      the  contractor. Examples of such changes are those listed below
      or equivalent positions by  another
  title.

              

      

    

    
      
        	
                1.

              	
                Changes
      in the Board of Directors or Officers of the contractor, Medical Director,
      Chief Executive Officer, Administrator, and Chief Financial
      Officer;

              

      

    

    
      
        	
                2.

              	
                Changes
      in the management of the contractor where the contractor has decided to
      contract out the operation of the contractor to a management
      corporation.

              

      

    

    
       

      The
contractor must disclose such changes in management control and provide a copy
of the contract agreement to the contract manager for approval at least 60
calendar days prior to the management contract start date.

    

    
      
        	
                D.

              	
                In
      accordance with Section 409.912(32), F.S., the contractor must annually
      conduct a  background check with the Florida Department of Law
      Enforcement on all persons with  five (5) percent or more
      ownership interest in the contractor, or who have
      executive  management responsibility for the managed care plan,
      or have the ability to exercise  effective control of the
      contractor. The contractor must submit information to
      the  department for such persons who have a record of illegal
      conduct according to the  background
  check.

              

      

    

    
      
        	
                1.

              	
                In
      accordance with Section 409.907(8)(a), F.S., contractors must submit,
      prior to execution of a contract, complete sets of fingerprints of
      principals of the contractor to the department for the purpose of
      conducting a criminal history record check.

              
	2. 	Principals
      of the contractor are defined in Section 409.907(8)(a),
  F.S.

      

    

    
      
        	
                E.

              	
                The
      contractor must submit to the department, within five (5) working days,
      any  information on any officer, director, agent, managing
      employee, or owner of stock or  beneficial interest in excess of
      five (5) percent of the contractor who has been found  guilty
      of, regardless of adjudication, or who entered a plea of nolo contendere
      or guilty  to, any of the offenses listed in Section 435.03,
      F.S.

              

      

    

    
      
        	
                F.

              	
                In
      accordance with Section 409.912(10), F.S., the department and Agency will
      not  contract with an entity that has an officer, director,
      agent, managing employee, or owner  of stock or beneficial
      interest in excess of five (5) percent of the contractor, who
      has  committed any of the listed offenses as referenced in
      Section 435.03, F.S.  In order to  avoid contract
      termination, the contractor must submit a corrective action plan,
      approved  by the department, that ensures such person is
      divested of all interest and/or control and  has no role in the
      operation and management of the
contractor.

              

      

    

    
      
        	
                G.

              	
                The
      contract is subject to the provisions of Chapter 112 and Section 435.03,
      F.S. The  contractor must disclose the name of any officer,
      director, or agent who is an employee of  the State of Florida,
      or any of its agencies. Further, the contractor must disclose the
      name  of any state employee who owns, directly or indirectly, an
      interest of five (5) percent or  more in the offeror's firm or
      any of its branches. The contractor covenants that it  presently
      has no interest and shall not acquire any interest, direct or indirect,
      which would  conflict in any manner or degree with the
      performance of the services hereunder. The  contractor 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 department or  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
      must, prior to completion of this contract, voluntarily
      acquire  any personal interest, direct or indirect, in this
      contract.

              

      

    

    
      

      Attachment
I - Page 12

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

      1.13          Independent
Provider

    

    
      

      The
contractor and any subcontractors' employees, agents, and officers in the
performance of this contract, shall act in an independent capacity and not as
officers and employees of the department, 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 contractor or any subcontractor and the
department, Agency, or the State of Florida.

    

    
      

      1.14          Damages
from Federal Disallowances

    

    
      

      In
addition to any remedies available through the contract, in law or equity, the
contractor must reimburse the Agency for any federal disallowances or sanctions
imposed on the department or Agency as a result of the contractor's failure to
abide by the terms of the contract.

    

    
      

      1.15          Offer
of Gratuities

    

    
      

      By
signing this agreement, the contractor signifies that no recipient of or a
delegate of Congress, nor any elected or appointed official or employee of the
State of Florida, the General Accounting Office, Department of Health and Human
Services, Centers for Medicare and Medicaid Services, or any other federal
Department has or will benefit financially or materially from this procurement.
The department may terminate the contract if it is determined that gratuities of
any kind were offered to or received by any officials or employees from the
offeror, his agent, or employees.

    

    
      

      1.16          Attorneys'
Fees

    

    
      

      In the
event of a dispute, each party to the contract will be responsible for
attorney's fees except as otherwise provided by law.

    

    
      

      1.17          Venue

    

    
      

      For
purposes of any legal action occurring as a result of or under the contract,
between the contractor and the department or Agency, the place of proper venue
will be Leon County, Florida.

    

    
      

      1.18          Legal
Action Notification

    

    
      

      The
contractor must give the department by certified mail immediate written
notification (no later than 30 calendar days after service of process) of any
action or suit filed or of any claim made against the contractor by any
subcontractor, vendor, or other party which results in litigation related
to this contract for disputes or damages. In addition, the contractor must
immediately advise the department of the insolvency of a subcontractor or of the
filing of a petition in bankruptcy by or against a
subcontractor.

    

    
      

      1.19          Force
Majeure

    

    
      

      The
department and Agency will not be liable for any excess cost to the contractor
if the department's or 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 department or Agency. In all cases, the failure to perform must be
beyond the control without the fault or negligence of the department or Agency.
The contractor will 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 contractor. These include

    

    
      

      Attachment
I-Page 13

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

      destruction
to the facilities due to hurricanes, fires, war, riots, and other similar acts.
Annually by April 30, the contractor must submit to the department for approval
an emergency management plan specifying what actions the contractor must conduct
to ensure the ongoing provisions of health services in a natural disaster or
man-made emergency.

    

    
      

      1.20      Sanctions

    

    
      

      
        	
                A.

              	
                In
      accordance with Section 4707 of the Balanced Budget Act of 1997, and
      Section  409.912(22), F.S, the following sanctions may be
      imposed against the contractor if it is  determined that the
      contractor has violated any provision of this contract, or
      the  applicable statutes or rules governing Medicaid
      HMOs:

              
	1. 	 Suspension
      of the contractor's enrollment.

      

    

    
      
        	
                2.

              	
                Suspension
      or revocation of payments to the plan for Medicaid recipients enrolled
      during the sanction period. If the contractor has violated the contract,
      the contractor may be ordered to reimburse the complainant for
      out-of-pocket medically necessary expenses incurred or order the
      contractor to pay non-network plan providers who provide medically
      necessary services.

              

      

    

    
      
        	
                3.

              	
                Imposition
      of a fine for violation of the contract with the department and Agency,
      pursuant to Section 409.912(22),
F.S.

              

      

    

    
      
        	
                4.

              	
                Termination
      pursuant to paragraph IV B (3) of the standard contract, if the contractor
      fails to carry out substantive terms of its contract or fails to meet
      applicable requirements in sections 1932,1903(m) and 1905(f) of the Social
      Security Act. After the department, in consultation with the Agency,
      notifies the contractor that it intends to terminate the contract, the
      department, in consultation with the Agency, may give the contractor's
      enrollees written notice of the state's intent to terminate the contract
      and allow the enrollees to disenroll immediately without
      cause.

              

      

    

    
      
        	
                B.

              	
                Unless
      the duration of a sanction is specified, a sanction will remain in effect
      until the  department is satisfied that the basis for imposing
      the sanction has been corrected and is  not likely to
      recur.

              

      

    

    
      
        	
                C.

              	
                The
      Agency and/or department may impose intermediate sanctions in accordance
      with 42  CFR 438.702, including:

              
	1.  	Civil
      monetary penalties in the amounts specified in Chapter 409.912(22),
      F.S.

      

    

    
      
        	
                2.

              	
                Appointment
      of temporary management for the contractor. Rules for temporary management
      pursuant to 42 CFR 438.706 are as
follows:

              

      

    

    
      
        	
                a) 

              	
                The
      State may impose temporary management only if it finds (through onsite
      survey, enrollee complaints, financial audits, or any other means)
      that:

              

      

    

    
      
        	
                (1)

              	
                There
      is continued egregious behavior by the contractor, including
      but  not limited to behavior that is described in 42 CFR
      438.700, or that is  contrary to any requirements of Sections
      1903(m) and 1932 of the Social  Security Act;
  or

              
	(2) 	There
      is substantial risk to enrollees' health;
or

      

    

    
      
        	
                (3)

              	
                The
      sanction is necessary to ensure the health of the
      contractor's  enrollees:
      
                  (i)  While
      improvements are made to remedy violations under 42 CFR  438.700;
      or 

                  (ii)
      Until there is an orderly termination or reorganization of the contractor.
      

                

              
	b)	The
      State must impose temporary management (regardless of any other sanction
      that may be imposed) if it finds that, a contractor has repeatedly failed
      to meet substantive requirements in section 1903(m) or section 1932 of the
      Social Security Act or 42 CFR 438.706. The State must also
  grant

      

    

    
       

        Attachment
I - Page 14

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    

    
      

      enrollees
the right to terminate enrollment without cause, as described in 42 CFR
438.702(a)(3), and must notify the affected enrollees of their right to
terminate enrollment.

    

    
      
        	
                c)

              	
                The
      State may not delay imposition of temporary management to provide a
      hearing before imposing this
sanction.

              

      

    

    
      
        	
                d)

              	
                The
      State may not terminate temporary management until it determines that the
      contractor can ensure that the sanctioned behavior will not
      recur.

              

      

    

    

    
      
        	
                3.

              	
                Granting
      enrollees the right to terminate enrollment without cause and notifying
      affected enrollees of their right to
disenroll.

              

      

    

    
      
        	
                4.

              	
                Suspension
      or limitation of all new enrollment, including default enrollment, after
      the effective date of the
sanction.

              

      

    

    
      
        	
                5.

              	
                Suspension
      of payment for beneficiaries enrolled after the effective date of the
      sanction and until CMS, the department, or the Agency is satisfied that
      the reason for imposition of the sanction no longer exists and is not
      likely to recur.

              

      

    

    
      
        	
                6.

              	
                Denial
      of payments provided for under the contract for new enrollees when, and
      for so long as, payment for those enrollees is denied by CMS in accordance
      with 42 CFR 438.730. Before imposing any intermediate sanctions, the state
      must give the contractor timely notice according to 42 CFR
      438.710.

              

      

    

    
      
        	
                7.

              	
                Withholding
      of three (3) percent of the next monthly capitation payment by the Agency
      pending receipt of the
reports.

              

      

    

    
      

      1.21          Additional
Applicable Laws and Regulations

    

    
      

      In
addition to the requirements of Section LB. of the Standard Contract, the
contractor agrees to comply with all applicable federal and state laws, rules
and regulations including but not limited to: Title 42 Code of Federal
Regulations (CFR) Chapter IV, Subchapter C; Chapters 409 and 641, F.S.; 42 CFR
431, Subpart F, Chapter 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C.
in regard to the contractor safeguarding information about beneficiaries; Title
VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
applicants for employment; Chapter 641, parts I and III, F.S., in regard to
managed care; Medicare Medicaid Fraud and Abuse Act of 1978; the federal omnibus
budget reconciliation acts; the Newborns' and Mothers' Health Protection Act of
1996; and the Balanced Budget Act of 1997. The contractor is subject to any
changes in federal and state law, rules, or regulations.

    

    
      

      1.22          Inspection
and Audit of Financial Records

    

    
      

      The state
and DHHS may inspect and audit any financial records of the contractor or its
providers. Pursuant to section 1903(m)(4)(A) of the Social Security Act and
State Medicaid Manual 2087.6(A-B), non-federally qualified contractors must
report to the state, upon request, and to the Secretary and the Inspector
General of DHHS, a description of certain transactions with parties of interest
as defined in section 1318(b) of the Social Security Act.

    

    
      

      1.23          Reporting

    

    
      

      The
contractor is responsible for complying with all the reporting and monitoring
requirements in accordance with the contract. The department will provide the
contractor with the appropriate reporting formats, instructions, submission
timetables, and technical assistance when required. The department reserves the
right to modify the reporting and monitoring requirements to which the
contractor must adhere. Failure of the contractor to submit the required reports
accurately and within the time frames specified may result in sanction in
accordance with Section 1.21.

    

    
      

      1.24          Fiscal Intermediary

    

    
      

      Attachment
I - Page 15

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    
       

      Amendment
001                                                                                    Agreement
Number XQ744

       

    

    
      If the
contractor utilizes a fiscal intermediary service organization as defined in
Chapter 641.316, F.S., such organization must be licensed to do business as a
fiscal intermediary service organization in the state of Florida. Such
delegation does not relieve the contractor of responsibility for the
administration and management required under this contract.

    

    
      

      1.25     Subcontracts

    

    
      

      The
contractor is responsible for all work performed under this contract, but may,
with the written approval of the department, enter into subcontracts for the
performance of work required under this contract. All subcontracts and
amendments thereto executed by the contractor must meet the requirements listed
in this section. All model provider subcontracts must be approved, in writing,
by the department in advance of implementation and execution of subcontracts.
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. Subcontracts are required with all major providers of
services and there shall be no provisions prohibiting service providers from
contracting with other long-term care diversion contractors. All direct service
providers are required to attend and complete Abuse, Neglect & Exploitation
Training. This training can be given by the Department of Children and Families,
the local area agency on aging, the department, and the contractor or be
accommodated through licensing requirements. The contractor's training materials
shall be approved, in advance, by the department.

    

    
      

      Pursuant
to 42 CFR 438.12(a)(1) if a contractor declines to include individual or groups
of providers in its network; it must give the affected providers written notice
of the reason for its decision. Pursuant to 42 CFR 438.12(b) this section may
not be construed to require the contractor to contract with providers beyond the
number necessary to meet the needs of its enrollees and the contract with
department of Elder Affairs, preclude the contractor from using different
reimbursement amounts for different practitioners in the same specialty; or
preclude the contractor from establishing measures that are designed to maintain
quality of services and control costs and is consistent with its
responsibilities to the enrollee

    

    
      

      In all
contracts with health care professionals, the contractor must comply with the
requirements specified in 42 CFR 438.214 which includes but is not limited to
selection and retention of providers, credentialing and re-credentialing
requirements, and nondiscrimination.

    

    
      

      A.          Identification
of conditions and method of payment:

    

    
      All
subcontract and amendments must meet the following
requirements:

    

    
      
        	
                1.

              	
                The
      contractor agrees to make payment to all providers pursuant to 42 CFR
      447.46,42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and
      42 CFR 447.45(d)(6). If third party liability exists, payment of claims
      must be determined in accordance with Section 1.11, Third Party
      Resources.

              
	2.	Provide
      for prompt submission of information needed to make
  payment.

      

    

    
      
        	
                3.

              	
                Make
      full disclosure of the method and amount of compensation or other
      consideration to be received from the contractor. The provider must not
      charge for any service provided to the recipient at a rate in excess of
      the rates established by the contractor's subcontract with the provider in
      accordance with Section 1128B(d)(l), Social Security Act (enacted by
      Section 4704 of the Balanced Budget Act of 1997). The provider may not
      bill the recipient any amount greater than would be owed if the entity
      provided the services
directly.

              

      

    

    
      
        	
                4.

              	
                Require
      an adequate record system be maintained for recording services,
      charges,  dates and all other commonly accepted information
      elements for services  rendered to recipients under the
      contract.

              

      

    

    
      

      Attachment
I - Page 16

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      
        	
                5.

              	
                Physician
      incentive plans must comply with 42 CFR 417.479. The contractor shall make
      no specific payment directly or indirectly under a physician
      incentive  plan to a physician or physician group as an
      inducement to reduce or limit medically necessary services furnished to an
      individual enrollee. Incentive plans must not contain provisions that
      provide incentives, monetary or otherwise, for the withholding of
      medically necessary care. The contractor must disclose information on
      provider 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 must be submitted to the department for approval, in writing,
      prior to use. If any other type of withhold arrangement currently exists,
      it must be omitted from all
subcontracts.

              

      

    

    
      
        	
                6.

              	
                Specify
      whether the contractor will assume full responsibility for third party
      collections in accordance with Section 1.11, Third Party
      Resources.

              

      

    

    
      

      B.          Provisions
for monitoring and inspections:

    

    
      
        	
                1.

              	
                Provide
      that the department, Agency, and Department of Health and Human Services
      (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
      department, Agency, and DHHS.

              

      

    

    
      
        	
                3.

              	
                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 provider
      if the subcontract is
continuous.)

              

      

    

    
      
        	
                4.

              	
                Provide
      for monitoring and oversight by the contractor of the subcontractor to
      provide assurance that all licensed subcontractors are credentialed in
      accordance with Section 1.5.D.3, Credentialing and Re-credentialing
      Policies and Procedures.

              
	5.	Provide
      for monitoring of services rendered to enrollees- by the
      subcontractor.

      

    

    
      
        	
                6.

              	
                Require
      that assisted living facilities and nursing facilities keep a copy of the
      plan of care on file in the residents record and available for inspection
      by the department, Agency and
DHHS.

              

      

    

    
      

      C.          Specification
of functions of the subcontractor:         

    

    
      
        	1. 	 Identify
      the population covered by the subcontract and the counties
    served.
	
                2.

              	
                Specify
      the amount, duration and scope of services to be provided by the
      subcontractor, including a requirement that the subcontractor continue to
      provide services through the term of the capitation period for which the
      Agency has paid the contractor.

              
	3. 	 Provide
      for timely access to appointments and
services.

      

    

    
      
        	
                4.

              	
                Provide
      for submission of all reports and clinical information required by the
      contractor.

              

      

    

    
      
        	
                5.

              	
                Provide
      for the participation in any internal and external quality improvement,
      utilization review, peer review, and grievance procedures established by
      the contractor.

              

      

    

    
      
        	
                6.

              	
                Facility
      and Home Health providers will provide notice to the contractor within 24
      hours when an enrollee dies, leaves the facility, or moves to a new
      residence.

              

      

    

    
      

      Attachment
I - Page 17

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                   Agreement
Number XQ744

    

    
      

      D.          Protective
clauses:

    

    
      
        	
                1.

              	
                Require
      safeguarding of information about enrollees in accordance with 42 CFR
      438.224.

              
	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, that assures the enrollees,
      department, Agency, or DHHS may not be held liable for any debts of the
      subcontractor in accordance with 42 CFR 447.15. In addition, the recipient
      is not liable to the subcontractor for any services for which the
      contractor is liable as specified in Section 641.3154,
  F.S.

              

      

    

    
      
        	
                4.

              	
                Contain
      a clause indemnifying, defending and holding the department, Agency, DHHS,
      and the contractor's enrollees harmless from and against all claims,
      damages, causes of action, costs or expense, including court costs and
      reasonable attorney fees arising from the subcontract agreement. This
      clause must survive the termination of the subcontract, including breach
      due to insolvency. The department may waive this requirement for itself,
      but not the contractor's enrollees, for damages in excess of the statutory
      cap on damages for public entities if the subcontractor is a public health
      entity with statutory immunity. The department must approve all such
      waivers in writing.

              

      

    

    
      
        	
                5.

              	
                Require
      that the subcontractor secure and maintain during the life of the
      subcontract worker's compensation insurance for all of its employees
      connected with the work under this contract unless such employees are
      covered by the protection afforded by the contractor. Such insurance must
      comply with the Florida's Worker's Compensation Law.

              
	6.  	Pursuant
      to Section 641.315(9), F.S., contain no provision that prohibits a physician
      from providing inpatient services in a contracted hospital to an enrollee
      if such services are determined by the organization to be medically
      necessary and covered services under the organization's contract with the
      contract holder.

      

    

    
      
        	
                7.

              	
                Contain
      no provision restricting the subcontractor's ability to communicate
      information to the subcontractor's patient regarding medical care or
      treatment options for the patient when the subcontractor deems knowledge
      of such information by the patient to be in the best interest of the
      health of the patient.

              

      

    

    
      
        	
                8.

              	
                Pursuant
      to Section 641.315(10), contain no provision requiring providers to
      contract for more than one long-term care product or otherwise be
      excluded.

              

      

    

    
      
        	
                9.

              	
                Pursuant
      to Section 641.315(6), F.S., contain no provision that in any way
      prohibits or restricts the health care provider from entering into a
      commercial contract with any other
contractor.

              

      

    

    
      
        	
                10.

              	
                Specify
      that if the subcontractor delegates or subcontracts any functions of the
      contractor, that the subcontract or delegation include all the
      requirements of this section.

              

      

    

    
      
        	
                11.

              	
                Make
      provisions for a waiver of those terms of the subcontract that, as they
      pertain to Medicaid recipients, are in conflict with the specifications of
      this contract.

              

      

    

    
      
        	
                12.

              	
                Specify
      procedures and criteria for extension, renegotiation, and termination of
      the subcontract.

              

      

    

    
      
        	
                13.

              	
                Specify
      that the contractor must give 60 days advance written notice to the
      subcontractor, and department, before canceling the contract with the
      contractor for any reason.

              

      

    

    
      
        	
                14.

              	
                Provisions
      for nonpayment for goods and services rendered by the subcontractor to the
      contractor is not a valid reason for avoiding the 60 day advance notice of
      cancellation pursuant to Section 641.315(2)(a)(2), F.S.

              
	15. 	 Pursuant
      to Section 641.315(2)(b), F.S., specify that the contractor will provide
      60 days advance written notice to the subcontractor and the department
      before canceling, without cause, the contract with the subcontractor.
      However, in a case in which an enrollee'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, notification must be provided to the department
    immediately.

      

    

    
               

    

    
      Attachment
I - Page 18

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

       

    

    
      

      E. The contractor must not discriminate with
respect to participation, reimbursement, or indemnification as to any
subcontractor 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 Section 4704 of the Balanced Budget Act of
1997. This paragraph shall not be construed to prohibit a contractor from
including subcontractors only to the extent necessary to meet the needs of the
contractor's enrollees or from establishing any measure designed to maintain
quality and control costs consistent with the responsibilities of the
organization. If the contractor declines to include individual subcontractors or
groups of subcontractors in its network, it must give the affected
subcontractors written notice of the reason for its decision.

    

    
      

      If the
contractor wishes to terminate a subcontract with an Assisted Living Facility or
a Nursing Facility in which any of its project enrollees are currently residing,
written notice must be provided to the department at least ten (10) calendar
days prior to notifying the subcontractor of its intent to terminate. This
requirement is waived if the facility's license has been revoked or the
department, in consultation with the Agency, waives the notice
period.

    

    
      

      The
department may waive the use of the model subcontract and permit the contractor
to enter into a letter of agreement with certain facilities, licensed under
Chapter 400 and Chapter 429, F.S., and enrolled in the Medicare and Medicaid
programs, when it is determined by the department to be in the best interest of
the enrollee(s) to do so. The letter of agreement shall contain timeframe
provisions for the facility. This exception does not apply for initial network
implementation.

    

    
      

      In
accordance with 42 CFR 438.206(b)(4), if the network is unable to provide
necessary services, covered under the contract to a particular enrollee, the
contractor must adequately and timely cover these services out of the network
for the enrollee, for as long as the contractor is unable to provide them within
the network.

    

    
      

      In
accordance with 42 CFR 438.206(b)(5), out-of-network subcontractors are required
to coordinate with the contractor with respect to payment to ensure that costs
to the enrollee is no greater than it would be if the services were furnished
within the network.

    

    
      

      F.
Network Expansion

    

    
      

      The
contractor may expand into new service areas approved by CMS, by providing the
following information to the plan analyst: letter of expansion request, copies
of the first page and signature page of the executed subcontracts, applicable
licenses, completed provider network template (electronic and hard copy), and
for contractors licensed as a HMO, a copy of the health care provider
certificate for the requested service area.

    

    
      

      Attachment
I - Page 19

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    

    
      1.26          Subcontractor
Termination

    

    
      

      The
contractor must make a good faith effort to give written notification of a
contracted provider termination to each enrollee who has been seen by the
terminated provider on a regular basis within 15 days after receipt or issuance
of the termination notice.

    

    
      

      1.27          Termination

    

    
      

      
        	
                A.

              	
                In
      conjunction with the Standard Contract, Part TV, section B, titled
      "Termination" upon  termination, procedures to ensure services
      to consumers will not be interrupted or  suspended by the
      termination are required (Termination Plan). Such termination
      plan  must be approved by the department and Agency prior to
      notice of termination, and must  provide for an efficient and
      timely transfer and/or relocation of all
  enrollees.

              

      

    

    
      
        	
                B.

              	
                The
      party initiating the termination must render written notice of termination
      to the  department by certified mail, return receipt requested,
      or in person. The notice of  termination required by Part TV,
      Section B of the Standard Contract must specify the  nature of
      termination, the extent to which performance of work under the contract
      is  terminated, the date on which such termination shall become
      effective, and the terms of  the Termination Plan. In accordance
      with section 1932(e)(4), Social Security Act, the  department
      and Agency shall provide the contractor with an opportunity for-a
      hearing  prior to termination for
  cause.

              

      

    

    
      
        	
                C

              	
                In
      the event of a notice of termination and unless a written waiver is
      executed by the department or Agency, the contractor
  must:

              
	1.	Continue
      performance under the terms of the contract until the termination
      date.
	2.	Immediately
      cease enrollment of new enrollees under the contract.
	3.	Immediately
      perform the duties as specified in the approved Termination Plan.
    

      

    

    
      
        	
                4.

              	
                Assign
      to the State those subcontracts as directed by the department's
      contracting officer including all the rights, title and interest of the
      contractor for performance of those
contracts.

              

      

    

    
      
        	
                5.

              	
                At
      least 60 calendar days prior to the effective date of the termination,
      provide written notification to all enrollees of the date on which the
      contractor will no longer participate in the State's Medicaid program and
      instructions on how to contact the department's CARES office for
      information on their long-term care
options.

              

      

    

    
      
        	
                6.

              	
                Take
      such action as may be necessary, or as the department, in consultation
      with the Agency may direct, to protect property related to the contract,
      which is in the possession of the provider, and in which the department
      and Agency have or may acquire an
interest.

              

      

    

    
      
        	
                7.

              	
                Decline
      any prepaid payments for requests for payment submitted after the contact
      ends. Any payments due under the terms of the contract may be withheld
      until the department receives from the contractor all documents as
      required by the written instructions of the
  department.

              

      

    

    
      
        	
                8.

              	
                Continue
      to serve or arrange for provision of services to the enrollees pursuant to
      the contract on a fee-for-service basis for up to 45 days from the
      notification of termination
date.

              

      

    

    
      
        	
                9.

              	
                In
      the event the department has terminated this contract in only one or more
      counties of the state, complete the performance of this contract in all
      other areas in which the contractor's duties have not been
      terminated.

              

      

    

    
      

      Attachment
I - Page 20

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      
        Amendment
001                                                                                    Agreement
Number XQ744

      

    

    
      

      1.28      Assignment

    

    
      

      
        	
                A.

              	
                Except
      as provided below or with the prior written approval of the department,
      which  approval will not be unreasonably withheld, the contract
      and the monies which may  become due are not to be assigned,
      transferred, pledged or hypothecated in any way by  the
      contractor, including by way of an asset or stock purchase of the
      contractor and will  not be subject to execution, attachment or
      similar process by the contractor.

              
	B.	Exceptions
      for HMOs licensed under Chapter 641, F.S., are as
  follows:

      

    

    
      
        	
                1.

              	
                As
      provided by Chapter 409.912(20), F.S., when a merger or acquisition of a
      contractor has been approved by the Office of Insurance Regulation
      pursuant to Chapter 628.4615, F.S., the Office of Insurance Regulation
      shall approve the assignment or transfer of the appropriate Medicaid HMO
      contract upon the request of the surviving entity of the merger or
      acquisition if the contractor and the surviving entity have been in good
      standing with the department and Agency for the most recent 12 month
      period, unless the department determines that the assignment or transfer
      would be detrimental to the Medicaid recipients or the Medicaid
      program.

              

      

    

    
      
        	
                2.

              	
                To
      be in good standing, a contractor must not have failed accreditation or
      committed any material violation of the requirements of Chapter 641.52,
      F.S., and must meet the requirements in this
  contract.

              

      

    

    
      
        	
                3.

              	
                For
      the purposes of this section, a merger or acquisition means a change in
      controlling interest of a contractor, including an asset or stock
      purchase.

              

      

    

    
      
        	
                C.

              	
                Exceptions
      for Other Qualified Providers licensed under Chapter 400 or Chapter
      429,  F.S., are as follows: 

                  In
      determining whether to approve an assignment, the department will consider
      whether the contractor and the surviving entity have been in good standing
      with the department and Agency for the most recent 12 month period and
      will not approve an assignment or transfer that would be detrimental to
      the project enrollees or the Medicaid
  program.

                

              

      

    

     

    
      

      SECTION
2     RECIPIENT ELIGIBILITY TO PARTICIPATE IN THE
PROJECT 

       

      2.1       Eligibility
Requirements

    

    
      Recipients
eligible for project enrollment must be:        

    

    
      
        	A. 	 65
      years of age or older.
	
                B.

              	
                Has
      Medicare Parts A & B as reflected in the Florida Medicaid Management
      Information  System (FMMIS) through the Medicaid Eligibility
      Verification System (MEVS).

              
	C. 	Medicaid
      eligible with incomes up to the Institutional Care Program level
      (ICP).
	D. 	Reside
      in the project service area.

      

    

    
      
        	
                E.

              	
                Determined
      by CARES to be at risk of nursing home placement and meet one or more
      of  the following clinical criteria:

              
	1. 	Require
      some help with five or more activities of daily living (ADLs);
  or
	2.	

                Require
      some help with four ADLs plus requiring supervision or administration of
      medication; or

              
	3. 	Require
      total help with two or more ADLs;
or

      

    

    
      
        	
                4.

              	
                Have
      a diagnosis of Alzheimer's disease or another type of dementia and require
      assistance or supervision with three or more ADLs;
  or

              

      

    

    
      
        	
                5.

              	
                Have
      a diagnosis of a degenerative or chronic condition requiring daily nursing
      services.

              
	F. 	Determined
      by CARES to be a person who, on the effective date of enrollment, can be
      safely served with home and community-based
services.

      

    

    
      

      Attachment
I - Page 21

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      

    

    
      2.2          Eligibility

    

    
      

      
        	
                A.

              	
                The
      Florida Department of Children and Families (DCF) and the federal Social
      Security  Administration determine a person's financial and
      categorical Medicaid eligibility.  Financial eligibility for the
      project will be up to the Medicaid Institutional Care
      Program  (ICP) income and asset
level.

              

      

    

    
      
        	
                B.

              	
                The
      department's CARES program determines a person's clinical eligibility for
      the  project.

              

      

    

    
      
        	
                C.

              	
                The
      contractor shall assist enrollees to ensure continuous eligibility in the
      program. This  includes financial and clinical eligibility as
      part of the case management responsibilities  and a systematic
      process for tracking the eligibility redetermination dates on a
      monthly  basis.

              

      

    

    
      
        	
                D.

              	
                Enrollees
      who lose eligibility and then regain eligibility within 60 days, are
      automatically  reinstated to the contractor during the next
      enrollment cycle. This possible 60 day period  is considered a
      break in service. The enrollee's enrollment eligibility in the plan
      will  remain the same as if they never left the plan. The
      Medicaid fiscal agent will produce two  reinstatement reports -
      one during the monthly enrollment cycle and another the
      first  business day of the month by 12:00
  p.m.

              

      

    

    
      
        	
                E.

              	
                Enrollees
      who lose eligibility between the second to the last Saturday and the end
      of the  month will be identified on the Supplemental HMO
      Disenrollment Report. The Medicaid  fiscal agent produces this
      report on the first business day of the month by 12:00
  p.m.

              

      

    

    
      

      2.3          Persons
Not Eligible for Enrollment

                

    

    
      
        	A.	Persons
      residing outside the project service area.
	
                B.

              	
                Persons
      residing in a state hospital, intermediate care facility for persons
      with  developmental disabilities, or a correctional
      institution.

              
	C.	Persons
      participating in or enrolled in another Medicaid waiver
  project.

      

    

    
      
        	
                D.

              	
                Medicaid
      eligible recipients who are served by the Florida Assertive
      Community  Treatment Team (FACT
team).

              

      

    

    
      
        	
                E.

              	
                Persons
      enrolled in any other Medicaid capitated long-term care program or in
      a  Medicaid HMO or MediPass
program.

              

      

    

    
      

      2.4          Optional
State Supplementation (OSS)

    

    
      

      
        	
                A.

              	
                The
      contractor shall inform and assist enrollees who qualify under Chapter
      409.212, F.S.,  with an application for OSS services. OSS is
      general revenue cash assistance program.  The purpose of the
      program is to supplement the enrollees' income to help pay the cost
      in  an assisted living
facility.

              

      

    

    
      
        	
                B.

              	
                The
      local Department of Children & Families Economic Self-Sufficiency
      office or Audit  Payments Unit will supply the contractor with
      the forms and income
qualifications.

              

      

    

    
      

      Attachment
I - Page 22

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    

    
      

      SECTION
3     EDUCATIONAL MATERIALS AND CHOICE
COUNSELING

    

    
      

      3.1          Educational
Materials

    

    
      

      A.          The
contractor may not market to prospective enrollees
face-to-face.

    

    
      
        	
                B.

              	
                The
      contractor may use mass marketing strategies, approved by the department,
      to  communicate information regarding the project to prospective
      enrollees.

              

      

    

    
      
        	
                C.

              	
                All
      materials including, but not limited to print and media for potential and
      current  enrollees shall be approved by the
      department.

              

      

    

    
      

      3.2          Choice
Counseling

    

    
      

      
        	
                A.

              	
                CARES
      staff will provide prospective enrollees with information regarding
      their  Medicaid long- term care options. These options may
      include: enrolling in the project,  participating in another
      Medicaid home and community-based services waiver
      program,  placement in a nursing home, or declining long-term
      care assistance.

              

      

    

    
      
        	
                B.

              	
                CARES
      staff will also perform a choice counseling function for the project. The
      choice  counseling function includes providing the prospective
      enrollee with contractor prepared,  and department approved,
      educational materials, and explaining the
  following:

              

      

    

    
      
        	
                1.

              	
                The
      concept of managed care and the integrated delivery of acute and long-term
      care.

              

      

    

    
      
        	
                2.

              	
                The
      advantages to the enrollees of the integration and coordination of acute
      and long-term care.

              
	3.	The
      qualifications for enrollment in the
project.

      

    

    
      
        	
                4.

              	
                That
      the enrollee has the right to choose any available contractor in the
      service area and may change contractors if the enrollee is not satisfied
      with his/her initial choice.

              
	5.  	The
      benefits provided under the project.
	6.  	 Pursuant
      to 42 CFR 438.10(g)(3), the contractor shall provide information on the
      contractor's physician incentive plans or on the contractor's structure
      and operation to any Medicaid recipient, upon
request.

      

    

    
       

    

    
      3.3          Prohibited
Activities

    

    
      

      
        	
                A.

              	
                In
      accordance with 42 CFR 438.104(b)(l)(iv), the entity does not seek to
      influence  enrollment in conjunction with the sale or offering
      of any private insurance.

              

      

    

    
      
        	
                B.

              	
                In
      accordance with 42 CFR 438.104(b)(l)(v), the entity does not, directly or
      indirectly,  engage in door-to-door, telephone, or other
      cold-call marketing
activities.

              

      

    

    
      
        	
                C.

              	
                In
      accordance with 42 CFR 43 8.104(b)(2)(i), the entity does not make any
      assertion or  statement (whether written or oral) that the
      beneficiary must enroll with the contractor in  order to obtain
      benefits (Medicaid State Plan benefits) or in order to not lose
      benefits  (Medicaid State Plan
  benefits).

              

      

    

    
      
        	
                D.

              	
                In
      accordance with Section 409.912(2l)(b), F.S., and 42 CFR
      438.104(b)(2)(ii), entity  does not make any inaccurate false or
      misleading claims that the entity is recommended  or endorsed by
      any federal, state or county government, the Agency, CMS,
      department,  or any other organization which has not certified
      its endorsement in writing to
  the  contractor.

              

      

    

    
      

      Attachment
I - Page 23

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      SECTION
4    ENROLLMENT AND DISENROLLMENT

    

    
      

      4.1          Enrollment
Procedures

    

    
      

      
        	
                A.

              	
                When
      a person is determined to be both financially and clinically eligible and
      chooses to  enroll in the Long-Term Care Community Diversion
      Program, CARES staff will  complete a CARES referral package. CARES
      staff will forward the CARES referral  package, with the date of
      enrollment, to the contractor.

              
	B. 	Upon
      receipt, the contractor will log in and date stamp the CARES referral
      package.

      

    

    
      
        	
                C.

              	
                The
      contractor will forward the enrollment information to the Medicaid fiscal
      agent in the  HIPAA approved format. This information must be
      transmitted to the fiscal agent by the  monthly reporting
      deadline in order to be effective for the subsequent
  month.

              

      

    

    
      
        	
                D.

              	
                The
      contractor is responsible to check monthly Medicaid eligibility through
      the Medicaid  Eligibility Verification System (MEVS). This
      includes the following:

              

      

    

    
      
        	
                1.

              	
                Recipient
      address is located in the same county as the contractor's provider service
      area

              
	2.	Recipient
      program codes (should be MS, MMS, or MWA)
	3.  	Residing
      in a nursing home
	4.	Current
      enrollment in a Medicaid HMO
	5.	Current
      enrollment in the MediPass Program
	6.	Has
      presence of Medicare Parts A &B 

                If
      a recipient does not have Medicare Parts A & B on MEVS, then the
      recipient is not eligible for the program. Once the presence of Medicare
      Parts A & B is on MEVS, then the recipient can be submitted for
      electronic enrollment.

              

      

    

    
      
        	E.	The
      contractor shall not deny enrollment to reinstated enrollees.
	
                F.

              	
                The
      contractor accepts individuals eligible for enrollment in the order in
      which they are  received from CARES without restriction (unless
      authorized by the CMS Regional  Administrator), up to the limits
      set under the contract (if applicable). The contractor will  not
      discriminate against individuals eligible to enroll on the basis of race,
      color, or  national origin, and will not use any policy or
      practice that has the effect of  discriminating on any basis
      including but not limited to race, color, or national
    origin.

              

      

    

    
      

      4.2          Effective
Date of Enrollment

    

    
      

      Enrollment
is effective at 12:01 a.m. on the first day of the calendar month that the
enrollee's name appears on the report for payment issued by the Medicaid fiscal
agent. Enrollment is in whole months. Retroactive disenrollment will be
considered by the Agency, in consultation with the department for those
enrollees who have moved out of the service area into an area where the
contracted services are unavailable, deceased enrollees prior to the initial
enrollment effective date, and potential enrollees who decided to remain in the
skilled nursing facility for long term care prior to the initial enrollment
effective date.

    

    
      

      4.3          Transition
Care Planning

    

    
      

      
        	
                A.

              	
                Transition
      care services are those services necessary in order to safely maintain a
      person  in the community both prior to and after the effective
      date of their enrollment in the  project up until the time the
      Plan of Care is implemented. For recipients who
      are  transferring from another home and community based service
      waiver program, the  contractor shall ensure continuation of
      needed services during the transition
phase.

              

      

    

    
      
        	
                B.

              	
                CARES
      staff will notify the contractor, the lead agency, and when appropriate,
      hospital  discharge planning staff regarding the need for a
      transition care plan. CARES staff
will

              

      

    

    
      

      Attachment
I - Page 24

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      forward,
to each of these entities, any information collected during the clinical
eligibility determination process related to the person's health status,
functional status, caregiver, social support system, living environment and how
current service needs are being met. By the first date of enrollment, (1) the
contractor must provide transition care services in collaboration with CARES
staff and (2) assume responsibility for meeting the enrollee's care needs. The
contractor must ensure that enrollment in the project does not interrupt or
delay the delivery of services needed by the enrollee.

    

    
      

      4.4       Orientation

    

    
      

      
        	
                A.

              	
                Prior
      to or upon enrollment the contractor must provide each new enrollee or
      their  representative with a written notice of the effective
      date of enrollment, a plan ID card  which includes the
      contractor's name, address, the member services telephone
      number,  an enrollee handbook, and a provider
      directory.

              

      

    

    
      
        	
                B.

              	
                The
      contractor must complete face-to-face project orientation within five (5)
      business  days of enrollment for those enrollees in a community
      setting (document any exceptions  beyond this timeframe). The
      contractor must complete face-to-face project
      orientation  within 7 business days of enrollment for those
      enrollees residing in a
facility.

              

      

    

    
      
        	
                C.

              	
                The
      enrollee handbook must be written so it can be read and understood by the
      enrollees  or their representatives at or below an eighth grade
      reading level. The following items  must be
      included:

              
	1. 	 Terms
      and conditions of enrollment including the reinstatement
  process.
	2.	 An
      explanation of the role of the case
manager.

      

    

    
      
        	
                3.

              	
                Procedures
      for obtaining required and/or covered services, including second opinions
      in accordance with Section 641.51 (5)(c), F.S., and 42 CFR
      438.206(b)(3).

              

      

    

    
      
        	
                4.

              	
                The
      toll-free telephone number of the Agency for Health Care Administration
      Consumer Hotline (888)
419-3456.

              

      

    

    
      
        	
                5.

              	
                The
      toll-free telephone number of the statewide Abuse Hotline (800) 96ABUSE or
      (800) 962 2873.

              

      

    

    
      
        	
                6.

              	
                Instructions
      on how enrollees obtain access to the services included in their care
      plans.

              
	7. 	The
      consequences of obtaining care from out-of-network
  providers.

      

    

    
      
        	
                8.

              	
                Information
      regarding the enrollee's right to disenroll at any time and instructions
      to initiate the disenrollment process. Information must explain that if
      voluntary disenrollment is requested prior to the fiscal agent's monthly
      processing deadline, disenrollment will be effective the first of the
      following month.

              
	9.	Information
      regarding the enrollee's rights and responsibilities.
	10.	Grievance
      and appeals process.
	11.	Information
      regarding the confidentiality of enrollee
records.

      

    

    
      
        	
                12.

              	
                Notification
      to the enrollee that the following items are available to them upon
      request:

              

      

    

    
      
        	
                a)

              	
                A
      detailed description of the contractor's authorization and referral
      process for services.

              

      

    

    
      
        	
                b)

              	
                A
      detailed description of the contractor's process used to determine whether
      services are medically necessary.

              
	c) 	A
      detailed description of the contractor's quality assurance
    program.
	d)	A
      detailed description of the contractor's credentialing
  process.

      

    

    
      
        	
                e)

              	
                The
      policies and procedures relating to the contractor's prescription drug
      benefits program.

              
	f)	The
      policies and procedures relating to the confidentiality and disclosure of
      the
      enrollee's medical records. g)  Information that enrollees may
      obtain from the contractor regarding quality performance indicators,
      including aggregate enrollee satisfaction
data

      

    

    
           

    

    
      Attachment
I - Page 25

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001            Agreement
Number XQ744

    

     

    
      
        	
                13.

              	
                Information
      that interpretation services for all non-English languages and alternative
      communication systems are available, free of charge and how to access
      these services.

              

      

    

    
      
        	
                14.

              	
                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).

              

      

    

    
      
        	
                15.

              	
                Information
      that services will continue upon appeal of a suspended authorization and
      that the enrollee may have to pay in case of an adverse
      ruling.

              
	16. 	Information
      regarding the health care advanced directives pursuant to Chapter 765,
      F.S.. Written information regarding advance directives provided by the
      contractor must reflect changes in state law as soon as possible, but no
      later than 90 days after the effective date of the
  change.

      

    

    
      
        	
                17.

              	
                The
      contractor will provide enrollee information in accordance with 42
      CFR  438.10(f). In accordance with 42 CFR 438.10(f)(2), the
      contractor must notify  enrollees at least on an annual basis of
      their right to request and
  obtain  information.

              

      

    

    
      
        	
                D.

              	
                The
      provider directory must list the providers sorted by county and then by
      service, and  contain the following: 

                  
                    1.          Provider
      name

                  

                  
                    2.          Service(s)
      provided

                  

                  
                    3.          Provider
      location

                  

                  
                    4.          Provider
      telephone number

                  

                

              

      

    

    
      
        	
                E.

              	
                The
      contractor shall assure that appropriate non-English language versions of
      all  materials are developed and available to members and
      potential members. The contractor  shall provide interpreter
      services in person where practical, but otherwise by
      telephone,  for applicants or members whose primary language is
      not English. Non-English versions  of materials are required if,
      as provided annually by the Agency, the population speaking  a
      non-English language in a county is greater than five (5)
      percent.

              

      

    

    
      
        	
                F.

              	
                All
      materials including, but not limited to print and media for potential and
      current  enrollees shall be approved by the
      department.

              

      

    

    
      

      4.5       Plan
of Care

    

    
      

      
        	
                A.

              	
                The
      contractor is required to develop an individualized written plan of care,
      in a format  approved by the department, for every new enrollee
      within five (5) business days of the  effective date of
      enrollment for those enrollees in a community setting (document
      any  exceptions beyond this timeframe). The contractor must
      develop an individualized  written plan of care, in a format
      approved by the department within seven (7) business  days of
      enrollment for those enrollees residing in a
  facility.

              

      

    

    
      
        	
                B.

              	
                This
      does not relieve the contractor of its obligation as set forth in Section
      4.3 of  Attachment I to this
contract.

              

      

    

    
      
        	
                C.

              	
                Services
      included in the plan of care will be determined by the contractor in
      conjunction  with the initial assessment information provided by
      the CARES office, in consultation  with the enrollee or their
      representative and be necessary to address all health and
      social  service needs of the enrollee identified through an
      assessment.

              

      

    

    
      
        	
                D.

              	
                The
      plan of care must be based on a comprehensive assessment of the enrollee's
      health  status, physical and cognitive functioning, environment,
      social supports, and end-of-life  decisions. The plan of care
      must clearly identify barriers to the enrollee and caregivers,
      if  applicable. The case manager must discuss barriers and
      explore potential solutions
with

              

      

    

    
      

      Attachment
I - Page 26

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      the
enrollee, and caregivers when applicable. The plan of care must detail all
interventions designed to address specific barriers to independent functioning.
The plan may include services provided through the enrollee's own informal
network or by volunteers from community social service agencies or other
organizations such as churches and synagogues.

    

    
      
        	
                E.

              	
                The
      Plan of Care or Plan of Care summary given to the enrollee or the
      enrollee's  caregiver must include at minimum the following
      components as specified in
  42CFR.  441.351(f):

              

      

    

    
      a.          The
enrollee's name

    

    
      b.          The
enrollee's Medicaid ID number

    

    
      c.          Plan
of Care effective date

    

    
      d.          Plan
of care review date

    

    
      e.          Covered
services provided including routine medical and HCBS services

    

    
      f.          Begin
date and end date

    

    
      g.          Providers

    

    
      h.          Amount
and frequency

    

    
      i.          Case
manager's signature

    

    
      j.          Enrollee
or the enrollee's authorized representative's signature and
date

    

    
      F.          In
developing the plan of care, the contractor must:

    

    
      
        	
                1.

              	
                Assess
      the immediacy of the new enrollee's services needs and include a
      description of the project participant's condition (e.g., ADL and LADL
      limitations, incontinence, cognitive impairment, arthritis, high blood
      pressure), as identified through an appropriate comprehensive assessment
      and a medical history review.

              

      

    

    
      
        	
                2.

              	
                Identify
      any existing care plans and service providers and assess the adequacy of
      current services.

              

      

    

    
      
        	
                3.

              	
                Provide
      for continuous care to the new enrollee if the enrollee is receiving
      active treatment prior to the effective date of
  enrollment.

              

      

    

    
      
        	
                4.

              	
                Pursuant
      to 42 CFR 43 8.208(c)(3) and (c)(4), the contractor must produce a plan of
      care that addresses the health, social service, and special health care
      needs of the enrollee identified through an assessment. The plan of care
      must be:

              

      

    

    
      
        	
                a)

              	
                Developed
      by the enrollee's primary care provider with enrollee participation, and
      in consultation with any specialists caring for the
    enrollee.

              

      

    

    
      
        	
                b)

              	
                Approved
      by the managed care provider in a timely manner, if the managed care
      provider requires an
approval.

              

      

    

    
      
        	
                c)

              	
                In
      accordance with any applicable state quality assurance and utilization
      review standards.

              

      

    

    
      
        	
                5.

              	
                Ensure
      that the care plan contains, at a minimum, information about the
      enrollee's medical condition, the type of services to be furnished, the
      amount, frequency and duration of each service, and the type of provider
      to furnish each service.

              

      

    

    
      
        	
                6.

              	
                Ensure
      that treatment interventions address identified problems, needs, and
      conditions. In consultation with the enrollee and, as appropriate, the
      enrollee's representative or caregiver, the plan of care must specify the
      long-term care service interventions, and when such services are the
      responsibility of the contractor, the medical interventions for the
      enrollee.

              

      

    

    
      

      Attachment
I - Page 27

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    
      

      
        	
                7.

              	
                Ensure
      that review of the care plan is performed through face-to-face contact
      with the enrollee at least every third month to determine the
      appropriateness and adequacy of services and to ensure that the services
      furnished are consistent with the nature and severity of the enrollee's
      needs.

              

      

    

    
      
        	
                8.

              	
                Ensure
      that the care plan is reviewed sooner than the minimum required time frame
      if in the opinion of any person or person(s) involved in the care of the
      enrollee there is reason to believe significant changes have occurred in
      the enrollee's condition or in the services the enrollee receives, or an
      enrollee or an enrollee's representative requests another review due to
      the changes in the enrollee's physical or mental
  condition.

              

      

    

    
      
        	
                9.

              	
                Ensure
      the maintenance or creation of an enrollee's informal network of
      caregivers and services providers. Primary caregivers, family, neighbors
      and other volunteers will be integrated into an enrollee's plan of care
      when it is determined through multi-disciplinary assessment and care
      planning that these services would improve the enrollee's capability to
      live safely in the home setting and are agreed to by the
      enrollee.

              

      

    

    
      
        	
                10.

              	
                Implement
      a systematic process for determining whether enrollees have advance
      directives, health care powers of attorney, do not resuscitate orders, or
      a legally appointed guardian if applicable. This information will become
      part of the enrollee's medical record and these orders and preferences
      will be integrated into the care coordination process. The contractor
      shall include a copy of the enrollee's health care powers of attorney or
      the legally appointed guardian documents in the enrollee's file. The
      contractor will discuss with the enrollee the importance of advance
      directives and do not resuscitate orders and note the enrollee's response
      in the case file.

              

      

    

    
      
        	
                G.

              	
                A
      copy of the plan of care must be forwarded to the enrollee's primary care
      physician within ten (10) days of
development.

              

      

    

    
      
        	
                H.

              	
                A
      copy of the plan of care must be forwarded to the department's CARES
      office within ten (10) days of
development.

              

      

    

    
      
        	
                I.

              	
                If
      the enrollee resides in an assisted living facility or a nursing facility
      a copy of the plan of care must be forwarded to the facility within ten
      (10) days of development.

              

      

    

    
      
        	
                J.

              	
                Revisions
      to the plan of care must be done in consultation with the enrollee, the
      caregiver, and when feasible, the primary care physician. If the primary
      care physician is not under contract with the contractor to deliver
      services to the enrollee, an effort must be made by the case manager to
      obtain physicians input regarding plan of care revisions. Changes in
      service provision resulting from a plan of care review must be implemented
      within five (5) business days of the review
  date.

              

      

    

    
      
        	
                K.

              	
                The
      contractor will send a Form 2515 to the local CARES office and DCF
      informing them of any changes in an enrollee's
  address.

              

      

    

    
      

      4.6           Integration
of Care

    

    
      

      
        	
                A.

              	
                Project
      case managers are responsible for long-term care planning and at least
      annual  assessments, for developing and carrying out strategies
      to coordinate and integrate the  delivery of all acute and
      long-term care services to
enrollees.

              

      

    

    
      
        	
                B.

              	
                For
      those persons enrolled in the contractor's Medicare Advantage plan
      (where  applicable), the contractor must have protocols to
      ensure that all acute care services and  long-term care services
      are coordinated. The enrollee's case manager must
      coordinate  with the primary care physician, as well as the
      enrollee or other appropriate person, in the  development of
      acute and long-term care plans. The contractor must ensure that
      all  subcontractors, delivering services covered by the
      contract, agree to cooperate with the  goal of an integrated and
      coordinated service delivery system for the
  enrollee.

              

      

    

    
      

      Attachment
I - Page 28

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001

    

    
      

      Agreement
Number XQ744

    

    

    
      

      
        	
                C.

              	
                When
      contract enrollees elect to remain in the Medicare fee-for-service system,
      the  contractor must establish protocols to ensure that services
      are coordinated to the  maximum extent feasible. The case
      manager must actively pursue coordination with the  enrollee's
      primary care physician and other care
providers.

              

      

    

    
      
        	
                D.

              	
                In
      addition, the contractor will be responsible for the following activities
      to facilitate care  coordination and continuity of
      care:

              

      

    

    
      
        	
                1.

              	
                The
      contractor must implement a systematic process for generating or receiving
      referrals and with the enrollee's written consent, sharing clinical and
      treatment plan information, including management of
      medications.

              

      

    

    
      
        	
                2.

              	
                The
      contractor must implement a systematic process for obtaining consent from
      enrollees or their representatives to share confidential medical and
      treatment-planning information with
providers.

              

      

    

    
      
        	
                3.

              	
                The
      contractor must implement a systematic process for coordinating care with
      organizations which are not part of the contractor's network of providers
      but are otherwise important to the health and well being of
      enrollees.

              

      

    

    
      
        	
                4.

              	
                For
      enrollees in an assisted living or nursing facility, the contractor will
      ensure coordination with the medical, nursing, or administrative staff
      designated by the facility to ensure that the enrollees have timely and
      appropriate access to the contractor's providers and to coordinate care
      between those providers and the facility's
  providers.

              

      

    

    
      
        	
                5.

              	
                The
      contractor must implement a systematic process for tracking the Medicaid
      eligibility redetermination dates on a monthly basis to ensure continuity
      of care without a break in
eligibility.

              

      

    

    
      
        	
                E.

              	
                Pursuant
      to 42 CFR 438.208(b), the contractor must implement procedures to
      coordinate  health care service for all enrollees
      that:

              

      

    

    
      
        	
                1.

              	
                Ensure
      each enrollee has an ongoing source of primary care appropriate to his/her
      needs and a person or entity formally designated as primarily responsible
      for coordinating the health care services furnished to the
      enrollee.

              

      

    

    
      
        	
                2.

              	
                Coordinate
      the services the contractor furnishes to the enrollee with services the
      enrollee receives from any other managed care entity during the same
      period of enrollment.

              

      

    

    
      
        	
                3.

              	
                Share
      with other managed care organizations serving the enrollee with special
      health care needs the results of its identification and assessment of the
      enrollee's needs to prevent duplication of those
    activities.

              

      

    

    
      
        	
                4.

              	
                Ensure
      in the process of coordinating care, each enrollee's privacy is protected
      in accordance with the privacy requirements in 45 CFR Part 160 and 164
      Subparts A and E, to the extent that they are
  applicable.

              

      

    

    
      

      4.7           Disenrollment

    

    
      

      
        	
                A.

              	
                Enrollees
      must be allowed to voluntarily disenroll at any time. If voluntary
      disenrollment  is requested prior to the fiscal agent's monthly
      processing deadline, disenrollment will be  effective the first
      of the following month. If voluntary disenrollment is requested
      after  the fiscal agent's monthly processing deadline,
      disenrollment will not take place until the  first of the month
      subsequent to the next month.

              

      

    

    
      
        	
                B.

              	
                The
      contractor must ensure that it does not restrict the enrollee's right to
      voluntarily  disenroll in any way, and that it does not deter
      the enrollee's contact with the State.  Disenrollment shall be
      in accordance with 42 CFR 438.56(b)(3) and
  (d)(3).

              

      

    

    
      
        	
                C.

              	
                Immediately
      upon receiving a voluntary request for disenrollment, the contractor
      must  inform the enrollee of disenrollment
      procedures.

              

      

    

    
      
        	
                D.

              	
                The
      contractor must make disenrollment assistance available during business
      hours. This  assistance must be available through a toll-free
      telephone number or face-to-face
contact.

              

      

    

    
      

      Attachment
I - Page 29

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      The
contractor's written disenrollment procedure must list the staff responsible for
this type of assistance.

    

    
      
        	
                E.

              	
                The
      contractor must keep a daily log of all verbal and written disenrollment
      requests and  the disposition of such requests. The contractor
      must ensure that disenrollment request  logs are maintained in
      an identifiable manner, and enrollees who wish to file a
      grievance  are afforded appropriate notice and opportunity to do
      so.

              

      

    

    
      
        	
                F.

              	
                The
      contractor shall assure that appropriate non-English language versions of
      all  disenrollment materials are developed and available to
      members. The contractor shall  provide interpreter services in
      person where practical, but otherwise by telephone, for  members
      whose primary language is not English. Non-English language versions
      of  disenrollment materials are required if, as provided
      annually by the Agency, the  population speaking a particular
      non-English language in a county is greater than five
      (5)  percent.

              
	G. 	
                 Involuntary
      disenrollments are limited to the following reasons:

                1.          Enrollee
      death.

                
                  2.          Ineligibility
      for Medicaid.

                

                
                  3.          Ineligibility
      for the project.

                

                
                  4.          Moving
      outside the contractor's service area.

                

                
                  5.          Fraudulent
      use of the enrollee's Medicaid ID card.

                

                
                  6.          Incarceration.

                

                
                  7.          Non-cooperation,
      subject to department
approval.

                

              

      

    

    
      
        	
                H.

              	
                After
      providing at least one verbal and at least one written warning of the full
      implications of failure to follow a recommended plan of care, the
      contractor may submit an involuntary disenrollment request to the
      department for an enrollee who continues not to comply. The
      department may approve such a request provided that a written explanation
      of reason for disenrollment is given to the enrollee prior to the
      effective date and provided that the enrollee's actions are not related to
      the enrollee's medical or mental condition. Enrollees must be given a
      reasonable opportunity to comply with the plan of care subsequent to each
      verbal and written warning before disenrollment is made effective except
      in instances where the enrollee's actions threaten the health, safety, or
      well being of service providers or contractor's staff or representatives.
      Enrollees who are disenrolled through this section are not eligible for
      re-enrollment without the permission of the contractor.

              
	I.  	The
      contractor may also submit an involuntary disenrollment request for an
      enrollee whose
      behavior is disruptive, unruly, abusive, or uncooperative to the extent
      that his or her enrollment with the contractor seriously impairs the
      contractor's ability to furnish services to either the enrollee or other
      enrollees. The contractor must provide at least one verbal and one written
      warning to the enrollee regarding the implications of his or her actions.
      A written explanation of the reason for disenrollment must be given to the
      enrollee prior to submitting the disenrollment request. The department
      will approve, such requests in writing, provided the contractor has
      documented the actions described above and the enrollee's actions are not
      related to the enrollee's medical or mental condition, involuntary
      disenrollment documents are maintained in an identifiable enrollee record,
      and enrollees who are disenrolled through this action are not eligible for
      re-enrollment without the permission of the contractor. The contractor
      shall be prohibited from requesting a disenrollment based on a change in
      the enrollee's health status pursuant 42 CFR 438.56(b)(2). Involuntary
      disenrollments without the department's consent will be considered an
      express or intentional violation of the contract. Repeated occurrences
      will be considered a cause for termination as specified in Section
      1.28.

      

    

    
      
        	
                 
      

              	
                J.

              	
                Disenrollment
      request forms must be completed in their entirety whether completed by the
      contractor or the enrollee,, and submitted on DOEA Form LTCD-002, Exhibit
      G.

              

      

    

    
      

      Attachment
I - Page 30

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001.                                Agreement
Number XQ744

    

    
      

      
        	
                K.

              	
                All
      disenrollments, including those subject to prior approval, shall be
      completed through the submission of the HIPAA approved format to the
      Medicaid fiscal agent.

              

      

    

    
      
        	
                L.

              	
                The
      contractor must provide disenrollment data via the HIPAA approved format
      on the first available transmission to the Medicaid fiscal agent after the
      date of receipt of the disenrollment request. In no event will the
      contractor submit a disenrollment with an effective date later than 49
      calendar days after the contractor's receipt of a voluntary disenrollment
      request.

              

      

    

    
      
        	
                M.

              	
                A
      copy of the disenrollment form will be sent to the CARES office within 48
      hours of receipt and a copy will be placed in the contractor's case
      management file.

              

      

    

    
      

      4.8          Disputes
of Appropriate Enrollments

    

    
      

      Disputes
relating to the appropriateness of enrollments authorized by CARES staff
pursuant to section 2.1 of Attachment I to this contract, will be decided by the
department in consultation with the Agency. This provision excludes matters
brought forth by enrollees. The department must reduce its decision to writing
and serve a copy on the contractor. The decision of the department will be final
and conclusive.

    

    
      

      4.9          Medicaid
Pending

    

    
      

      
        	
                A.

              	
                Section
      430.705(5), F.S., designates Medicaid Pending as individuals who apply for
      the  Long-Term Care Community Diversion Pilot Project and are
      determined medically  eligible by CARES, but have not been
      determined financially eligible for Medicaid by the  Department
      of Children and Families
(DCF).

              

      

    

    
      
        	
                B.

              	
                Individuals
      will be offered the option to receive services under the Medicaid
      Pending  initiative.

              

      

    

    
      
        	
                C.

              	
                Contractors
      may elect to provide the Medicaid Pending option by completing
      and  returning Attachment Number IV to the
      department.

              

      

    

    
      
        	
                D.

              	
                CARES
      staff will refer individuals identified as Medicaid Pending, and who
      choose to  receive Medicaid Pending services, to the chosen
      contractor. Included with the referral  will be the Freedom of
      Choice Form, 701B Assessment, Level of Care, 3008, and  Informed
      Consent.

              

      

    

    
      
        	
                E.

              	
                If
      individuals are determined financially eligible by DCF, the contractor
      will be  reimbursed a capitated rate for services rendered
      retroactive to the first of the month  following the CARES
      medical eligibility
determination.

              

      

    

    
      
        	
                F.

              	
                If
      the individual is not financially eligible for Medicaid as determined by
      DCF, the  contractor may terminate services and seek
      reimbursement from the individual. The  contractor may seek
      reimbursement from the individual in accordance with the
      Medicaid  Coverage and Limitations Handbooks and the associated
      fee schedules.

              

      

    

    
      
        	
                G.

              	
                The
      contractor will assist Medicaid Pending individuals in submitting the
      ACCESS  Florida Application (on-line or hard copy)f www.mvflorida.com/accessflorida) to
      DCF.  Additionally, the contractor must forward, at a minimum,
      the following documentation to  DCF: Financial Release (CF FS
      2613, Notification of Level of Care (DOEA-CARES  603), and the
      Certification of Enrollment Status (HCBS)(CF-AA
  2515).

              

      

    

    
      
        	
                H.

              	
                Once
      the individual is determined financially eligible, the contractor must
      notify CARES and provide a copy of the Notice of Case Action or
      verification of Medicaid eligibility within two (2) business days of
      receipt.

              

      

    

    
      
        	
                 
      

              	
                I.

              	
                The
      contractor will submit 834 enrollment transactions for the Medicaid
      Pending individuals to the Medicaid fiscal agent one week prior to the
      monthly submission date. Additionally, the Florida Medicaid Management
      Information System (FMMIS) is designed to process the enrollment date
      retroactive up to a maximum of four (4) months prior to the first of the
      month following the CARES eligibility determination.
  If

              

      

    

    
      

      Attachment
I - Page 31

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      circumstances
require a determination of Medicaid eligibility by DCF for a Medicaid Pending
individual that exceeds four months, the request for enrollment must be
submitted via the manual enrollment process.

    

    
      

      SECTION
5  ENROLLEE RECORDS

    

    
      

      
        	
                A.

              	
                The
      contractor is responsible for a complete long-term care record for each
      enrollee.

              

      

    

    
      
        	
                B.

              	
                The
      contractor must use procedures that promote the development of a
      centralized,  comprehensive long-term care record for enrollees.
      The contractor must ensure, with  written consent of the
      enrollee or their representative, all providers involved in
      the  enrollee's care have access to the enrollee's record for
      the purpose of providing
care.

              

      

    

    
      
        	
                C.

              	
                The
      contractor must maintain an enrollee records system, which is consistent
      with  professional standards and permits the prompt retrieval of
      information. Each record must  include timely and accurately
      documented information and must be readily available to  all
      appropriate and authorized practitioners involved in the integration and
      coordination  of
care.

              

      

    

    
      
        	
                D.

              	
                The
      contractor will ensure all subcontracted long term care providers-properly
      document  the care provided to
  enrollees.

              

      

    

    
      
        	
                E.

              	
                The
      contractor will ensure enrollee record information is accessible only to
      authorized persons in accordance with written consent or an executed
      authorization granted by the enrollee or the enrollee's representative and
      with all applicable federal and state laws, rules and
      regulations.

              

      

    

    
      
        	
                F.

              	
                The
      contractor must disclose enrollee records, including enrollee and
      caregiver  identifying information, to the department and
      Agency. It is the department and Agency's  obligation to oversee
      the performance or to conduct assessment, investigation,
      or  evaluation of this contract. Not withstanding provisions to
      the contrary, release of  material to the department and Agency
      will not be construed as public disclosure of  confidential
      information.

              

      

    

    
      
        	
                G.

              	
                All
      records must contain documentation that the member was provided written
      information concerning the member's rights regarding advanced directives,
      and whether  or not the member has executed an advance
      directive. The contractor shall not, as a  condition of
      treatment, require the member to execute or waive an advance directive
      in  accordance with Section 765.110, F.S. The contractor must
      comply with the  requirements of 42 CFR 422.128 for maintaining
      written policies and procedures for  advance
      directives.

              

      

    

    
      

      SECTION
6     SERVICE PROVISION

      

    

    
      6.1
General Provisions

    

    
      
        	
                (a)

              	
                The
      contractor must bear the underwriting risk of all services covered under
      this contract. The contractor shall establish and maintain a network in
      conformance with 42 CFR
438.206

              

      

    

    
      
        	
                (b).

              	
                Services
      are to be provided in accordance with an individualized plan of care. The
      plan of care is developed by the contractor in consultation with the
      enrollee and must include those services that are determined through
      assessment to be necessary to address the health and social service needs
      of the enrollee.

              

      

    

    
      
        	
                (c)

              	
                The
      contractor must directly provide case management services as listed in
      Section 6.2.

              

      

    

    
      
        	
                (d)

              	
                The
      contractor may provide services, beyond those required in this contract
      providing such services are safe, legal, medically prudent, and provided
      equally to any enrollee with similar needs without discrimination. Such
      extra contractual services must be paid
from

              

      

    

    
      

      Attachment
I - Page 32

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      program
cost savings and may not be included in encounter data as reported under Section
11.4.

    

    
      
        	
                E.

              	
                The
      contractor must not require any co-payment or cost sharing from the
      enrollees except  where the Florida Department of Children and
      Families has assessed a patient  responsibility amount for
      financial contributions by the enrollee toward nursing
      facility  and assisted living services.

              
	F. 	The
      contractor must not allow enrollees to be charged for missed
      appointments.

      

    

    
      
        	
                G.

              	
                The
      contractor is responsible for Medicare co-insurance and deductibles for
      contractor  covered services. The contractor shall reimburse
      providers or enrollees for Medicare  deductibles and
      co-insurance payments made by the providers or enrollees, according
      to  Medicaid guidelines or the rate negotiated with the
      provider.

              

      

    

    
      
        	
                H.

              	
                All
      services delivered by the contractor to enrollees, either directly or
      through a subcontract, must be guided by the following service delivery
      principles:

              

      

    

    
      
        	
                1.

              	
                Services
      must be individualized as a result of a competent, comprehensive
      understanding of an enrollee's multiple
needs.

              

      

    

    
      
        	
                2.

              	
                Services
      must be delivered in a timely fashion in the least restrictive,
      cost-effective, and appropriate
setting.

              

      

    

    
      
        	
                3.

              	
                The
      contractor must allow each enrollee to choose his or her service delivery
      provider. The contractor assures that each enrollee will be given free
      choice of all qualified providers of each service included in his or her
      written plan of care.

              

      

    

    
      
        	
                4.

              	
                Each
      contractor shall provide the department with documentation of compliance
      with access requirements no less frequently than the
      following:

              
	a) 	At
      the time it enters into a contract with the
  department.

      

    

    
      
        	
                b)

              	
                At
      any time there has been a significant change in the contractor's
      operations that would affect adequate capacity and services, such as
      contractor services, benefits, or geographic service
  area.

              

      

    

    
      
        	
                5.

              	
                Long-term
      care services must be based upon an enrollee's plan of care and include
      goals, objectives, and specific treatment strategies. Any limitations on
      amount, duration, and scope may be offset by alternative services to
      address the health and social services needs of an
    enrollee.

              

      

    

    
      
        	
                6.

              	
                Services
      must be coordinated to address comprehensive needs and provide continuity
      of care.

              

      

    

    
      
        	
                7.

              	
                Services
      must be delivered regardless of geographic location within the service
      area, level of functioning, cultural heritage, or degree of illness of the
      enrollee.

              

      

    

    
      
        	
                8.

              	
                The
      project's administration and service delivery system must ensure the
      participation of the enrollee in care planning and delivery, as
      appropriate, allow for the participation of the family, significant
      others, and caregivers.

              

      

    

    
      
        	
                9.

              	
                The
      contractor shall provide interpreter services in person where practical,
      but otherwise by telephone, for applicants or enrollees whose primary
      language is not English. Non-English versions of materials are required
      if, the population speaking a particular non-English language in a county
      is greater than five (5) percent, as determined annually by the
      Agency.

              

      

    

    
      
        	
                10.

              	
                Services
      must be delivered by qualified providers as defined in Sections 6.4, 6.5,
      6.6, and 6.7. The contractor must have a credentialing system approved by
      an accreditation organization that has been approved by the Agency
      pursuant to Chapter 641.512, F.S. The system must include procedures for
      credentialing long-term care
providers.

              

      

    

    
      
        	
                11.

              	
                The
      contractor must be approved by an accreditation organization that has been
      approved by the Agency pursuant to Chapter 641.512,
  F.S.

              

      

    

    
      
        	
                12.

              	
                All
      facilities providing services to enrollees must be accessible to persons
      with disabilities, be smoke-free, and have adequate space, supplies, good
      sanitation, and fire and safety
procedures.

              

      

    

    
      

      Attachment
I - Page 33

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                13.

              	
                For
      contractor performance that is not in compliance with the contract, the
      department shall require a corrective action plan. Failure to provide a
      corrective action plan within the time specified shall result in penalties
      or sanctions as specified by the contract or governing statutes and
      federal regulations.

              

      

    

    
      

      
        	
                6.2

              	
                Long-Term
      Care Services

              

      

    

    
      

      
        	
                 
      

              	
                With
      the exception of nursing facility services, the long-term care services in
      this section are authorized under the Medicaid home and community-based
      waiver. As required by Section 430.705(2)(b)2., F.S., the contractor shall
      have at least two (2) subcontractors for each service as listed below
      (with the exception of case management services, which are directly
      provided by the contractor):

              

      

    

    
      
        	
                A.

              	
                Adult
      Companion Services: Non-medical care, supervision and socialization
      provided to  a functionally impaired adult. Companions assist or
      supervise the enrollee with tasks  such as meal preparation or
      laundry and shopping, but do not perform these activities
      as  discrete services. The provision of companion services does
      not entail hands-on nursing  care. This service includes light
      housekeeping tasks incidental to the care and supervision of the
      enrollee.

              

      

    

    
      
        	
                B.

              	
                Adult
      Day Health Services: Services provided pursuant to Chapter 429, Part HI,
      F.S. For  example, services furnished in an outpatient setting,
      encompassing both the health and  social services needed to
      ensure optimal functioning of an enrollee, including
      social  services to help with personal and family problems, and
      planned group therapeutic  activities. Adult day health services
      include nutritional meals. Meals are included as a  part of this
      service when the patient is at the center during meal times. Adult day
      health  care provides medical screening emphasizing prevention
      and continuity of care including  routine blood pressure checks
      and diabetic maintenance checks. Physical, occupational  and
      speech therapies indicated in the enrollee's plan of care are furnished as
      components  of this service. Nursing services which include
      periodic evaluation, medical supervision  and supervision of
      self-care services directed toward activities of daily living
      and  personal hygiene are also a component of this service. The
      inclusion of physical,  occupational and speech therapy services
      and nursing services as components of adult  day health services
      does not require the contractor to contract with the adult day
      health  provider to deliver these services when they are
      included in an enrollee's plan of care.  The contractor may
      contract with the adult day health provider for the delivery of
      these  services or the contractor may contract with other
      providers qualified to deliver these  services pursuant to the
      terms of this contract.

              

      

    

    
      
        	
                C.

              	
                Assisted
      Living Services: Personal care services, homemaker services, chore
      services,  attendant care, companion services, medication
      oversight, and therapeutic social and  recreational programming
      provided in a home-like environment in an assisted
      living  facility licensed pursuant to Chapter 429 Part I, F.S.,
      in conjunction with living in the  facility. This service does
      not include the cost of room and board furnished in  conjunction
      with residing in the facility. This service includes 24-hour on-site
      response  staff to meet scheduled or unpredictable needs in a
      way mat promotes maximum dignity  and independence, and to
      provide supervision, safety and security. Individualized care
      is  furnished to persons who reside in their own living units
      (which may include dual  occupied units when both occupants
      consent to the arrangement) which may or may not  include
      kitchenette and/or living rooms and which contain bedrooms and toilet
      facilities.  The resident has a right to privacy. Living units
      may be locked at the discretion of the  resident, except when a
      physician or mental health professional has certified in
      writing  that the resident is sufficiently cognitively impaired
      as to be a danger to self or others if  given the opportunity to
      lock the door. The facility must have a central dining
      room,  living room or parlor, and common activity areas, which
      may also serve as living
rooms

              

      

    

    
      
         

        Attachment
I - Page 34

      
      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    Amendment
001            Agreement Number
XQ744

     

    
      

      
        	
                 
      

              	
                or
      dining rooms. The resident retains the right to assume risk, tempered only
      by a person's ability to assume responsibility for that risk. Care must be
      furnished in a way that fosters the independence of each consumer to
      facilitate aging in place. Routines of care provision and service delivery
      must be consumer-driven to the maximum extent possible, and treat each
      person with dignity and respect. Assisted living services may also
      include: physical therapy, occupational therapy, speech therapy,
      medication administration, and periodic nursing evaluations. The
      contractor may arrange for other authorized service providers to deliver
      care to residents of assisted living facilities in the same manner as
      those services would be delivered to a person in their own home. The
      contractor shall be responsible for placing enrollees in the appropriate
      Assisted Living Facility setting.  Note: Assistive Care Services
      are covered under this contract and cannot be billed separately by the
      Assisted Living Facility.

              

      

    

    
      
        	
                D.

              	
                Case
      Management Services: Services which facilitate enrollees gaining access to
      other needed medical, social, and educational services regardless of the
      funding source for the services, and which contribute to the coordination
      and integration of care delivery. Case management services contribute to
      the coordination and integration of care delivery through the ongoing
      monitoring of services as prescribed in each enrollee's plan of care. The
      contractor will provide this service directly and the ratio of enrollees
      to case managers shall be appropriate to support the needs of the
      enrollees.

              

      

    

    
      
        	
                E.

              	
                Chore
      Services: Services needed to maintain the home as a clean, sanitary and
      safe living environment. This service includes heavy household chores such
      as washing floors, windows and walls, tacking down loose rugs and tiles,
      and moving heavy items of furniture in order to provide safe entry and
      exit.

              

      

    

    
      
        	
                F.

              	
                Consumable
      Medical Supply Services: The provision of disposable supplies used by the
      enrollee and care giver, which are essential to adequately care for the
      needs of the enrollee. These supplies enable the enrollee to perform
      activities of daily living or stabilize or monitor a health condition.
      Consumable medical supplies include adult disposable diapers, tubes of
      ointment, cotton balls and alcohol for use with injections, medicated
      bandages, gauze and tape, colostomy and catheter supplies, and other
      consumable supplies. Not included are items covered under the Medicaid
      home health service, personal toiletries, and household items such as
      detergents, bleach, and paper towels, or prescription
    drugs.

              

      

    

    
      
        	
                G.

              	
                Environmental
      Accessibility Adaptation Services: Physical adaptations to the home
      required by the enrollee's plan of care which are necessary to ensure the
      health, welfare and safety of the enrollee or which enable the enrollee to
      function with greater independence in the home and without which the
      enrollee would require institutionalization. Such adaptations may include
      the installation of ramps and grab-bars, widening of doorways,
      modification of bathroom facilities, or installation of specialized
      electric and plumbing systems to accommodate the medical equipment and
      supplies which are necessary for the welfare of the enrollee. Excluded are
      those adaptations or improvements to the home that are of general utility
      and are not of direct medical or remedial benefit to the enrollee, such as
      carpeting, roof repair, or central air conditioning. Adaptations which add
      to the total square footage of the home are not included in this benefit.
      All services must be provided in accordance with applicable state and
      local building codes.

              

      

    

    
      
        	
                H.

              	
                Escort
      Services: Personal escort for enrollees to and from service providers. An
      escort may provide language interpretation for people who have hearing or
      speech impairments or who speak a language different from that of the
      provider. Escort providers assist enrollees in gaining access to services.
      This service does not include
transportation.

              

      

    

    
      
        	
                I.

              	
                Family
      Training Services: Training and counseling services for the families of
      enrollees served under this contract. For purposes of this service,
      "family" is defined as the individuals who live with or provide care to a
      person served by the contractor and may include a parent, spouse,
      children, relatives, foster family, or in-laws. "Family" does not include
      persons who are employed to care for the enrollee. Training includes
      instruction and updates about treatment regimens and use of equipment
      specified in the plan of care to safely maintain the enrollee at
      home.

              

      

    

    
      

      Attachment
I - Page 35

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

     

    
      
        	
                J.

              	
                Financial
      Assessment/Risk Reduction Services:    Assessment and
      guidance to the caregiver and enrollee with respect to financial
      activities. This service provides instruction for and/or actual
      performance of routine, necessary, monetary tasks for financial management
      such as budgeting and bill paying. In addition, this service also provides
      financial assessment to prevent exploitation by sorting through financial
      papers and insurance policies and organizing them in a usable manner. This
      service provides coaching and counseling to enrollees to avoid financial
      abuse, to maintain and balance accounts that directly relate to the
      enrollees living arrangement at home, or to lessen the risk of nursing
      home placement due to inappropriate money
  management.

              

      

    

    
      
        	
                K.

              	
                Home
      Delivered Meals: Nutritionally sound meals to be delivered to the
      residence of an enrollee who has difficulty shopping for or preparing food
      without assistance. Each meal is designed to provide 1/3 of the
      Recommended Dietary Allowance (RDA). Home delivered meals may be hot,
      cold, frozen, dried, canned or a combination of hot, cold, frozen, dried,
      or canned with a satisfactory storage life. These meals must comply with
      all federal and state requirements for procurement, preparation,
      transportation and storage. Religious preferences in the selection and
      preparation of menu items shall be given consideration and accommodated,
      if available.

              

      

    

    
      
        	
                L.

              	
                Homemaker
      Services: General household activities (meal preparation and routine
      household care) provided by a trained
homemaker.

              

      

    

    
      
        	
                M.

              	
                Nutritional
      Assessment/Risk Reduction Services: An assessment, hands-on care, and
      guidance to caregivers and enrollees with respect to nutrition. This
      service teaches caregivers and enrollees to follow dietary specifications
      that are essential to the enrollee's health and physical functioning, to
      prepare and eat nutritionally appropriate meals and promote better health
      through improved nutrition. This service may include instructions on
      shopping for quality food and on food
  preparation.

              

      

    

    
      
        	
                N.

              	
                Personal
      Care Services: Assistance with eating, bathing, dressing, personal
      hygiene, and other activities of daily living. This service includes
      assistance with preparation of meals, but does not include the cost of the
      meals. This service may also include housekeeping chores such as bed
      making, dusting and vacuuming, which are incidental to the care furnished
      or which are essential to the health and welfare of the enrollee, rather
      than the enrollee's family.

              

      

    

    
      
        	
                O.

              	
                Personal
      Emergency Response Systems (PERS): The installation and service of an
      electronic device which enables enrollees at high risk of
      institutionalization to secure help in an emergency. The PERS is connected
      to the enrollee's telephone jack or electrical receptacle and programmed
      to signal a response center once a "help" button is activated. The
      enrollee may also wear a portable "help" button to allow for mobility.
      PERS services are generally limited to those enrollees who live alone or
      who are alone for significant parts of tire day and who would otherwise
      require extensive
supervision.

              

      

    

    
      
        	
                P.

              	
                Respite
      Care Services: Services provided to enrollees unable to care for
      themselves furnished on a short-term basis due to the absence or need for
      relief of persons normally providing the care. Respite care does not
      substitute for the care usually provided by a registered nurse, a licensed
      practical nurse or a therapist. Respite care is provided in the home/place
      of residence, licensed hospital, nursing facility, or assisted living
      facility.

              

      

    

    
      
        	
                Q.

              	
                Occupational
      Therapy: Treatment to restore, improve or maintain impaired functions
      aimed at increasing or maintaining the enrollee's ability to perform tasks
      required for independent functioning when determined through a
      multi-disciplinary assessment to improve an enrollee's capability to live
      safely in the home setting.

              

      

    

    
      
        	
                R.

              	
                Physical
      Therapy: Treatment to restore, improve or maintain impaired functions by
      using

              

      

    

    
      
         

        Attachment
I - Page 36

    

    
      
      

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      activities
and chemicals with heat, light, electricity or sound, and by massage and active,
resistive, or passive exercise when determined through a multi-disciplinary
assessment to improve an enrollee's capability to live safely in the home
setting.

    

    
      
        	
                S.

              	
                Speech
      Therapy: The identification and treatment of neurological deficiencies
      related to feeding problems, congenital or trauma-related maxillofacial
      anomalies, autism, or neurological conditions that effect oral motor
      functions. Therapy services include the evaluation and treatment of
      problems related to an oral motor dysfunction when determined through a
      multi-disciplinary assessment to improve an enrollee's capability to live
      safely in the home setting.

              

      

    

    
      
        	
                T.

              	
                Nursing
      Facility Services: Services furnished in a health care facility licensed
      under Chapter 395 or Chapter 400,
F.S.

              

      

    

    
      

      6.3       Minimum
Long-Term Care Service Provider Qualifications

    

    
      

      The
long-term care services authorized in this project must be provided in
accordance with the following requirements.

    

    
      
        	
                A.

              	
                Adult
      Companion Services: Providers must be employed by a licensed home
      health  agency pursuant to Chapter 400, Part III, F.S., or
      organizations having a certificate of  registration issued by
      the Agency for Health Care Administration pursuant to
      Section  400.509, F.S., or be a Community Care for the Elderly
      (CCE) provider as defined in  Section 430.203, F.S., and
      registered in accordance with Section 400.509, F.S.,
      or  individuals contracted by a nurse registry pursuant to
      Sections 400.462(18) and
  400.506,  F.S.

              

      

    

    
      
        	
                B.

              	
                Adult
      Day Health Services: Providers must be licensed by the Agency for Health
      Care  Administration as an adult day care center pursuant to
      Chapter 429, Part III, F.S., or meet  the adult day care center
      exemption requirements in Section 429.905,
F.S.

              

      

    

    
      
        	
                C.

              	
                Assisted
      Living Facility Services: Providers must be licensed pursuant to Chapter
      429,  Part I, F.S.

              

      

    

    
      
        	
                D.

              	
                Case
      Management Services: Case managers must be a registered nurse; or have
      a  Bachelor's Degree in Social Work, Sociology, Psychology,
      Gerontology or a related  field; or have a Bachelor's Degree in
      an unrelated field and at least two (2) years of
      case  management experience; or be a Licensed Practical Nurse
      (LPN) with four (4) years of  geriatric experience. Case
      managers must attend and complete the following
      training  annually: four (4) hours of in-service training,
      Abuse, Neglect and Exploitation training,  and Alzheimer's
      disease and related disorders continuing
  education.

              

      

    

    
      
        	
                E.

              	
                Chore
      Services: Providers must be a lead agency as defined in Section
      430.203(9), F.S.;  or a home health agency licensed in
      accordance with Chapter 400, Part III, F.S.; or a pest  control
      business licensed pursuant to Section 482.071, F.S.; or a contractor
      licensed to do  home repair; or a person, employed by or under
      the supervision of the contractor, who is  qualified by training
      or experience to provide chore
services.

              

      

    

    
      

      Attachment
I - Page 37

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                F.

              	
                Consumable
      Medical Supply Services: Providers must be pharmacies permitted
      under  Section 465.022, F.S.; or home medical equipment
      providers licensed pursuant to  Chapter 400, Part VII, F.S.; or
      home health agencies licensed pursuant to Chapter 400,  Part
      III, F.S.; or be a licensed
vendor.

              

      

    

    
      
        	
                G.

              	
                Environmental
      Accessibility Adaptation Services: Providers must be properly
      licensed  pursuant to state and local building requirements, and
      be confirmed by the provider to  have knowledge and experience
      needed to satisfactorily perform the
service.

              

      

    

    
      
        	
                 
      

              	
                H.

              	
                Escort
      Services: Providers must be a lead agency as defined in Section
      430.203(9), F.S.; or home health agencies licensed pursuant to Chapter
      400, Part III, F.S.; or an individual contracted by a nurse registry
      pursuant to Section 400.506, F.S.; or persons employed by the contractor
      and trained in the following areas: communication arid assistance with
      hearing and visually impaired patients; emergency procedures; and enrollee
      confidentiality.

              

      

    

    
      
        	
                 
      

              	
                I.

              	
                Family
      Training Services: Providers must be a home health agency licensed
      pursuant to Chapter 400, Part III, F.S.; or a lead agency as defined in
      Section 430.203(9), F.S.; or a medical practitioner licensed under Chapter
      464 or 491, F.S., providing training or counseling within the scope of
      their practice.

              

      

    

    
      
        	
                 
      

              	
                J.

              	
                Financial
      Assessment/Risk Reduction Services: Providers must be home health agencies
      licensed pursuant to Chapter 400, Part III, F.S.; or a lead agency as
      defined in Section 430.203(9), F.S.; or persons confirmed to be qualified
      to perform the service by experience and training, such as certified
      financial planners, bank employees, or individual bookkeepers; or
      qualified persons employed or contracted by the
  contractor.

              

      

    

    
      
        	
                 
      

              	
                K.

              	
                Home
      Delivered Meal Providers: Providers must be a lead agency as defined in
      Section 430.203(9), F.S., with a contract or referral agreement for the
      preparation of meals; employed by or under contract with the contractor
      and meet the food service standards as defined in Chapters 500 and 509,
      F.S.; Older American's Act providers as defined in Chapter 58A-1, Florida
      Administrative Code (FAC).

              

      

    

    
      
        	
                 
      

              	
                L.

              	
                Homemaker
      Service Providers: Services must be provided by a home health agency
      licensed pursuant to Chapter 400, Part III, F.S.; or a lead agency as
      defined in Section 430.203(9), F.S.; or individuals contracted by a nurse
      registry pursuant to Sections 400.462(18) and 400.506, F.S.; or have a
      certificate of registration issued by the Agency pursuant to Section
      400.509, F.S.

              

      

    

    
      
        	
                 
      

              	
                M.

              	
                Nutritional
      Assessment Risk Reduction Services: Services must be provided by
      Registered Licensed Dietitians or other health professionals functioning
      in their legal scope of practice. A dietetic technician (DTR) may,
      according to the American Dietetic Association, assist a dietitian and
      assume full responsibility under supervision of a Registered Licensed
      Dietitian for a wide range of duties including counseling enrollees on
      specific diets. Nutritional education materials must be approved by a
      Registered Licensed Dietitian. Providers may include lead agencies as
      defined in Section 430.203(9),
F.S.

              

      

    

    
      
        	
                 
      

              	
                N.

              	
                Nursing
      Facility Services: Providers must be licensed under Chapter 395 or Chapter
      400, F.S.

              

      

    

    
      
        	
                 
      

              	
                O.

              	
                Personal
      Care Providers: Providers must be lead agencies as defined in Section
      430.203(9), F.S.; Certified Nursing Assistants or home health aides
      contracted under Nurse Registries licensed pursuant to Section 400.506,
      F.S.; or home health agencies licensed pursuant to Chapter 400, Part III,
      F.S.

              

      

    

    
      
        	
                 
      

              	
                P.

              	
                Respite
      Care Providers: Providers must be employed by a licensed home health
      agency pursuant to Chapter 400, Part III, F.S.; or be a lead agency as
      defined in Section 430.203(9), F.S.; or be an Adult Day Care Center
      licensed pursuant to Chapter 429, Part HI, F.S.; or be an Assisted Living
      Facility licensed pursuant to Chapter 429, Part I, F.S.; or be a Nursing
      Facility licensed pursuant to Chapter 400, Part I, F.S.; or be individuals
      contracted by a nurse registry pursuant to Section 400.506, F.S.; or be a
      hospice licensed pursuant to Chapter 400, Part IV,
  F.S.

              

      

    

    
      
         

        Attachment
I - Page 38

      
      

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

     

    
      
        	
                 
      Q.   

              	
                Occupational,
      Physical, and Speech Therapy Providers: Providers must be home health
      agencies licensed pursuant to Chapter 400, Part III, F.S., or providers
      holding current registration, certification, or licenses pursuant to
      Chapters 455,468, and 486,
F.S.

              

      

    

    
      

      
        	
                 
      R. 

              	
                Personal
      Emergency Response System Service Providers: Providers must meet the
      requirements as set forth in Section 489.505(15) or (16),
    F.S.

              

      

    

    
      

      6.4           Acute-Care
Services

    

    
      

      The
following services are covered for Medicaid recipients based on the Medicaid
state plan approved by the federal Centers for Medicare and Medicaid Services.
These services are covered in the project to the extent that they are not
covered by Medicare or are reimbursed by Medicaid pursuant to Medicaid's
Medicare cost-sharing policies.

    

    
      
        	
                A.

              	
                Community
      Mental Health Services: Community-based rehabilitative services, which
      are  psychiatric in nature, recommended or provided by a
      psychiatrist or other physician.  Such services must be provided
      in accordance with the policy and service provisions  specified
      in the Medicaid
      Community Mental Health Coverage and Limitations  Handbook
      except that the provider need not be a community mental health
      center.

              

      

    

    
      
        	
                B.

              	
                Dental
      Services: Medically necessary emergency dental care limited to emergency
      oral  examination, necessary radiographs, extractions, incision
      and drainage of abscess and full  or partial dentures. Dentures
      are limited to one set of full or partial dentures a
      lifetime.  Such services must be provided in accordance with the
      policy and service provisions  specified in the Medicaid Dental Services
      Coverage and Limitations Handbook, and must  be provided
      by providers licensed under Chapter 466,
F.S.

              

      

    

    
      
        	
                C.

              	
                Hearing
      Services: Medically necessary hearing evaluations and diagnostic testing
      for  hearing aid candidacy every three (3) years. A hearing aid
      fitting and dispensing for each  ear every three (3) years.
      Three (3) hearing aid repairs a year outside the
      warranty  period. One cochlear implant for either ear, but not
      both, if medical criterion is met  through prior authorization.
      Prior authorization may be granted for cochlear implant  repairs
      outside the warranty period. Such services must be provided in accordance
      with  the policy and service provisions specified in the Medicaid Hearing Services
      Coverage  and Limitations Handbook, and must be provided
      by providers licensed under Chapter  484, Part II,
      F.S.

              

      

    

    
      
        	
                D.

              	
                Home
      Health Care Services: Intermittent or part-time nursing services provided
      by a  registered nurse or licensed practical nurse, or personal
      care services provided by a  licensed home health aide, with
      accompanying necessary medical supplies, appliances,  and
      durable medical equipment. Such services must be provided in accordance
      with the  policy and service provisions specified in the Medicaid Home Health Coverage
      and  Limitations
      Handbook.

              

      

    

    
      
        	
                E.

              	
                Independent
      Laboratory and Portable X-ray Services: Medically necessary
      and  appropriate diagnostic laboratory procedures and portable
      x-rays ordered by a physician  or other licensed practitioner of
      the healing arts as specified in the Independent  Laboratory and Portable X-ray
      Services Coverage and Limitations
  Handbook.

              

      

    

    
      
        	
                F.

              	
                Inpatient
      Hospital Services: Medically necessary services, including ancillary
      services,  furnished to inpatient enrollees, 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. Such services must be provided in
      accordance with the policy and   service provisions
      specified in the Medicaid Hospital Coverage and
      Limitations  Handbook.

              

      

    

    
      
        	
                G.

              	
                Outpatient
      Hospital/Emergency Medical Services: Outpatient preventive,
      diagnostic,  therapeutic, or palliative care provided under the
      direction of a physician at a licensed hospital. Such services include
      emergency room, dressings, splints, oxygen, physician ordered services and
      supplies necessary for the clinical treatment of a specific diagnosis or
      treatment as specified in the Medicaid Hospital Coverage and
      Limitations Handbook.

              

      

    

    
      

      Attachment
I - Page 39

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744 

    

    
       

    

    
      
        	
                H.

              	
                Physician
      Services: Those services and procedures rendered by a licensed physician
      at a physician's office, patient's home, hospital, nursing facility or
      elsewhere when dictated by the need for preventive, diagnostic,
      therapeutic or palliative care, or for the treatment of a particular
      injury, illness, or disease as specified in the Medicaid Physicians Coverage
      and Limitations
      Handbook.

              
	L. 	Prescribed
      Drug Services: Prescribed drug services for dual eligible Medicaid beneficiaries
      are covered as per the Medicare Modernization Act (MMA). However, Section
      103(c) of the MMA added §1935(d)(2) to the Social Security Act to allow
      State Medicaid programs to continue to provide and receive Federal
      Financial Participation (FFP) for certain drugs not included in the
      Medicare Prescription Drug benefit (Part D). Drugs excluded from Part D
      coverage are listed in § 1927(d)(2) of the Act. Contractors shall provide
      certain drugs not included in Part D as described in the Medicaid Prescribed Drugs Services and
      Limitations Handbook.  The contractor's pharmacy benefits
      management program must comply with all applicable federal and state
      laws.
	J.	Vision
      Services: Medically necessary eye examinations. Eyeglass repairs and
      adjustments. Eyeglasses are limited to two pair every 365 days. Such
      services must be provided in accordance with the policy and service
      provisions specified in the Medicaid Vision Services Coverage and
      Limitations Handbook, and must be provided by providers licensed
      under Chapter 484, Part I, or 463, F.S..
	K. 	 Hospice
      Services: End of life services provided to enrollees electing hospice
      services. Services will be provided in accordance with the policy and
      services provisions specified in the Hospice Services Coverage and
      Limitations Handbook.

      

    

    
       

    

    
      6.5          Acute
Care Provider Qualifications

    

    
      

      For the
acute care services that are covered under the contract and are also covered by
Medicare, the provider qualifications will be those of the Medicare
program.

    

    
      

      For the
acute care services covered under the contract that are not covered by Medicare,
the contractor must meet the provider requirements of the Medicaid programs
except that provider type limitations associated with certain services will not
apply when other provider types can legally perform the
service.

    

    
      

      6.6          Optional
Services

    

    
      

      Transportation
Services may be rendered within Medicaid guidelines at the option of the
contractor. These services are the arrangement and provision of an appropriate
mode of transportation for enrollees to receive necessary medical services.
Types of transportation services include: ambulance, non-emergency medical
vehicles, public and private transportation vehicles, and air ambulances as
specified in the Medicaid
Transportation Coverage and Limitations
Handbook.

    

    
      

      6.7          Expanded
Services

    

    
      

      The
contractor may offer incentive programs for enrollees. The contractor shall
receive written approval from the department prior to the use of any special
incentives for enrollees. Any incentive program offered must be provided to all
eligible individuals and will not be used to direct individuals to select a
specific contractor.

    

    
      

      Attachment
I - Page 40

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      6.8          Availability/Accessibility
of Services

    

    
      

      The
contractor must make available and accessible sufficient facilities, service
locations, service sites, and personnel to provide the services. The
contractor's network of providers must be accessible to the enrollees in its
service area. Services covered under this contract must be available to
enrollees to the same extent that such services are available in the project
service area to persons with comparable functional impairment and health
conditions that are not served under this contract.

    

    
      

      The
contractor must establish appropriate scheduling guidelines for service
delivery. These guidelines must be communicated in writing to providers in the
contractor's network. The contractor must develop a process for monitoring the
scheduling of service delivery and the actual time enrollees must wait to
receive the service. "When the service delivery scheduling or waiting times are
excessive, the contractor must take appropriate action to ensure adequate
service delivery.

    

    
      

      The
contractor must arrange for a 24-hour on-call system for each enrollee. The
system may vary by enrollee and should be reflected in the enrollee's plan of
care. The system should provide for the availability of a qualified person with
information regarding the enrollee's plan of care.

    

    
      

      6.9          Staffing
Requirements

    

    
      

      The
contractor is responsible for the following staffing
requirements:

    

    
      
        	
                A.

              	
                A
      full time administrator designated to be responsible for the
      administration of the day-  to-day business activities of the
      contract.

              

      

    

    
      
        	
                B.

              	
                A
      licensed physician, with demonstrated experience in geriatric medicine, to
      serve as a  medical director to oversee and be responsible for
      the proper provisions of covered  services for the
      contract.

              

      

    

    
      
        	
                C.

              	
                A
      person, qualified by training, to be responsible for the contract's
      quality assurance and  improvement
  systems.

              

      

    

    
      
        	
                D.

              	
                A
      person designated to be responsible for the contractor's orientation,
      outreach and  educational activities who is qualified by
      training and experienced in working with
      frail  elders.

              

      

    

    
      
        	
                E.

              	
                A
      person designated to be responsible for the health information and/or the
      enrollee  records
system.

              

      

    

    
      
        	
                F.

              	
                A
      person designated to be responsible for the processing and resolution
      of  grievances/appeals.

              

      

    

    
      
        	
                G.

              	
                Sufficient
      support staff 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.

              
	H.	The
      contractor must maintain sufficient staff available 24 hours per day to
      handle care inquiries.
	I.	A
      person designated to be responsible for the contractor's utilization
      control.

      

    

    
      
        	
                 
      

              	
                J.

              	
                A
      person designated to be responsible for case management and qualified case
      managers in sufficient numbers to ensure that the case management
      requirements are met.

              

      

    

    
      
        	
                K

              	
                A
      person, graduated from a four-year program, designated on a full-time
      basis, to be responsible for the data needs of the program, including but
      not limited to, enrollment and disenrollment transactions, HIPAA
      compliance transactions, report reconciliations, data collection, and
      reporting.

              

      

    

    
      
        	
                 
      

              	
                L.

              	
                A
      plan for recruiting and retaining health care practitioners who are
      minority persons as defined in Section 288.703(3), F.S., as required by
      Section 641.217, F.S.

              

      

    

    
      

      Attachment
I - Page 41

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      6.10          Emergency
Care Requirements

    

    
      

      In
accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the contractor must also
cover post-stabilization services without authorization, regardless of whether
the enrollee obtains the service within or outside the contractor's network, for
the following situations:

    

    
      
        	
                A.

              	
                Post-stabilization
      care services that were pre-approved by the contractor, or were not
      pre-approved by the contractor because the contractor did not respond to
      the treating  provider's request for pre-approval within one (1)
      hour after being requested to approve  such care, or could not
      be contacted for
pre-approval.

              

      

    

    
      
        	
                B.

              	
                Post-stabilization
      services are services subsequent to an emergency that a treating physician
      views as medically necessary after an emergency medical condition has
      been  stabilized. These are not emergency services, but are
      non-emergency services that the  contractor could choose not to
      cover out-of-contractor except in the circumstances  described
      above.

              

      

    

    
      

      6.11          Out
of Network Use of Non-Emergency Services

    

    
      

      Unless
otherwise specified in this document, when an enrollee uses non-emergency
services available under the project from a non-subcontracted provider, the
contractor is not liable for the cost of such utilization unless the contractor
referred the enrollee to the non-subcontracted provider or authorized such
out-of-network utilization. The contractor must provide timely approval or
denial of authorization of out-of-network use through the assignment of a prior
authorization number that refers to and documents the approval. A contractor may
not require paper authorization as a condition of an enrollee receiving
treatment if the contractor has an automated authorization system. Written
follow-up documentation of the approval must be provided to the out-of-network
provider within one business day from the request for approval. The enrollee is
liable for the cost of such unauthorized use of contract-covered services from
non-subcontracted providers.

    

    
      

      However,
in accordance with the Balanced Budget Act of 1997, and pursuant to 42 CFR
422.100(b)(l)(iii), the plan must also cover post-stabilization services without
authorization, regardless of whether the enrollee obtains the service within or
outside the plan's network, for the following situations:

    

    
      
        	
                A.

              	
                Post-stabilization
      care services that were pre-approved by the plan; or were not
      pre-  approved by the plan because the plan did not respond to
      the treating provider's request  for pre-approval within one
      hour after being requested to approve such care, or could
      not  be contacted for
pre-approval.

              

      

    

    
      
        	
                B.

              	
                Post-stabilization
      services are services subsequent to an emergency that a
      treating  physician views as medically necessary after an
      emergency medical condition has been  stabilized. These are not
      emergency services, but are non-emergency services that
      the  plan chooses not to cover out-of-plan except in the
      circumstances described
above.

              

      

    

    
      

      Attachment
I - Page 42

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement Number
XQ744

    

    
      

      6.12     Adult
Protective Services

    

    
      

      The
Department of Elder Affairs and the Department of Children and Families (DCF)
have defined processes for ensuring elderly victims of abuse, neglect or
exploitation in need of home and community-based services are referred to the
aging network, tracked, and served in a timely manner. Requirements for serving
elderly victims of abuse, neglect and exploitation can be found in Section
430.205 (5)(a), F.S.

    

    
      

      
        	
                A.

              	
                DCF
      assigns a risk-level designation of "low," "intermediate" or "high" for
      each referral.  If the individual needs immediate protection
      from further harm, which can be  accomplished completely or in
      part with the provision of home and community-based  services,
      the referral is designated "high" risk. Individuals designated "high" risk
      must  be served within 72 hours after being referred to the AAA
      or lead agency, as mandated  by Florida
  statute.

              

      

    

    
      
        	
                1.

              	
                Reports
      of abuse, neglect and exploitation begin with the DCF-administered Florida
      Abuse Hotline. Victims aged 60 and older in need of home and
      community-based services are referred to the appropriate Area Agency on
      Aging (AAA) or Community Care for the Elderly (CCE) lead
      agency.

              

      

    

    
      
        	
                2.

              	
                Reports
      received on individuals determined to be enrolled in the diversion program
      will be referred to the appropriate
contractor.

              

      

    

    
      
        	
                B.

              	
                Upon
      receipt of a referral, the AAA or CCE lead agency will contact the
      contractor via  the telephone using the contact information
      provided. Any changes to the names or  phone numbers of the
      primary, secondary or 24-hour contacts must be sent to
      your  contract manager at the Department of Elder Affairs. Once
      the contractor is contacted  and provides assurance that the
      enrollee's needs will be met, the AAA or CCE lead  agency will
      fax or hand-deliver to the contractor the DCF referral packet, which
      contains  the following:

              
	1.  	Adult
      Protective Services Referral Form,
	2.	Adult
      Safety Assessment of Safety
Factors,

      

    

    
      
        	
                3.

              	
                Capacity
      to Consent Form (if the referral has the capacity to consent) OR Provision
      of Voluntary Protective Services Form (required if consent is provided by
      the caregiver/guardian),

              
	4.	Court
      Order, if services were court
ordered,

      

    

    
      
        	
                A.

              	
                The
      contractor is responsible for contacting the AAA or CCE lead agency once
      the crisis  is resolved. All contact and discussions with AAA or
      CCE lead agency staff must be  included in the contractor's case
      manager's notes. In addition, a copy of the referral  packet
      must be kept in the case file for each
referral.

              

      

    

    
      
        	
                B.

              	
                When
      contacted by the AAA or CCE lead agency in regard to a high-risk referral,
      the contractor will be required to provide assurance that the crisis will
      be addressed. If the CCE lead agency or AAA attempts to contact the
      contractor during business hours and  the contractor cannot be
      contacted or cannot provide assurance that the crisis will be addressed,
      the CCE lead agency is required to provide the crisis resolving services
      until  such assurance is received. If contacted by the AAA or
      lead agency after business hours  (including evenings, weekends
      and holidays), assurance that the crisis will be addressed  must
      be provided to the AAA or lead agency within 24 hours. The cost of the
      crisis  resolving services provided by the CCE lead agency while
      awaiting assurance outside of  the allowable delay will be
      reimbursed by the contractor.

              

      

    

    
      

      Attachment
I - Page 43

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      SECTION
7    UTILIZATION MANAGEMENT

    

    
      

      The
contractor's service authorization systems shall provide authorization numbers,
effective dates for the authorization, and written confirmation to the
contractor of denials, as appropriate. Pursuant to 42 CFR 438.210(b)(3), any
decision to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested, must be made by a health
care professional who has appropriate clinical expertise in treating the
enrollee's condition or disease. Pursuant to 42 CFR 438.210(c), the contractor
must notify the requesting provider of any decision to deny a service
authorization request or to authorize a service in an amount, duration, or scope
mat is less than requested. The notice to the provider need not be in writing.
The contractor must notify the enrollee in writing 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. Pursuant to 42 CFR 438.210(e), the
contractor must provide that compensation to individuals or entities that
conduct utilization management activities is not structured to provide
incentives for the individual or entity, or deny, limit, or discontinue
medically necessary services to any enrollee.

    

    
      

      Pursuant
to 42 CFR 438.404(a), 42 CFR 438.404(c) and 42 CFR 438.210(b) and (c), the
contractor must give the enrollee written notice of any "action" as defined in
Section 13, Definitions, within the time frames for each type of action.
Pursuant to 42 CFR 43 8.404(b) and 42 CFR 438.210(c), the notice must
explain:

    

    
      

      1.          The
action the contractor has taken or intends to take.

    

    
      2.          The
reasons for the action.

    

    
      3.          The
enrollee's or the provider's right to file a
grievance/appeal.

    

    
      4.          The
enrollee's right to request a Medicaid Fair Hearing.

    

    
      5.          Procedures
for exercising enrollee rights to appeal or grieve.

    

    
      6.          Circumstances
under which expedited resolution is available and how to request
it.

      
        7.    Enrollee rights to
request that benefits continue pending the resolution of the appeal, how to
request that benefits be continued, and the circumstances under which the
enrollee may be required to pay the costs of these
services.

      

    

    
      
      

    

    
      

      Pursuant
to 42 CFR 438.404 (a) and (c), the notice must be in writing and must meet the
language and format requirements of 42 CFR 438.10(c) and (d) to ensure ease of
understanding.

    

    
      

      The
contractor must mail the notice within the following time
frames:

    

    
      
        	
                1.

              	
                For
      termination, suspension, or reduction of previously authorized
      Medicaid-covered services, within the time frames specified in 42 CFR
      431.211,431.213, and 42 CFR 431.214.

              
	2. 	For
      denial of payment, at the time of any action affecting the
  claim.

      

    

    
      
        	
                3.

              	
                For
      standard service authorization decisions that deny or limit services,
      within the time frame specified in 42 CFR
  438.210(d)(1).

              

      

    

    
      
        	
                4.

              	
                If
      the contractor extends the time frame in accordance with 42 CFR
      438.210(d)(1), it must:

              

      

    

    
      
        	
                a)

              	
                Give
      the enrollee written notice of the reason for the decision to extend the
      time frame and inform the enrollee of the right to file a grievance if he
      or she disagrees with that
decision.

              

      

    

    
      
        	
                b)

              	
                Issue
      and carry out its determination as expeditiously as the enrollee's health
      condition requires and no later than the date the extension
      expires.

              

      

    

    
      
        	
                5.

              	
                For
      service authorization decisions not reached within the time frames
      specified in 42  CFR 438.210(d) (which constitutes a denial and
      is thus an adverse action), on the date  that the time frames
      expire.

              

      

    

    
      

      Attachment
I - Page 44

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      6.          For
expedited service authorization decisions, within the time frames specified in
42 CFR

    

    
      438.210(d).

    

    
      

      SECTION
8    QUALITY ASSURANCE AND IMPROVEMENT
REQUIREMENTS

    

    
      

      8.1           General

    

    
      

      The
contractor's quality assurance program must address the needs of enrollees,
promote improved clinical outcomes and quality of life, identify and address
service delivery issues, and monitor the quality and appropriateness of care
furnished to enrollees with special health care needs. The quality assurance
program required by this section must comply with applicable provisions of
Section 409.912(27), F.S., and Section 641.51, F.S., and be incorporated into an
existing quality improvement system.

    

    
      

      8.2           Quality
Assurance Program

    

    
      

      The
contractor must formally adopt a quality assurance program for enrollees. The
quality assurance program must include written goals, policies, and procedures
that ensure enhancement of quality of life for enrollees, emphasize quality
patient outcomes, and to promote the coordination of acute and long-term care
services. The quality assurance program must have a system to identify and
prioritize problem areas for resolution and a process to design and implement
strategies to resolve identified problems. The system must include: a process
for changing the current quality assurance program as needed; a protocol that
dictates the active involvement of the medical director, the quality assurance
director, medical/clinical providers, and the director of the program; and a
description of the mechanism for measuring the success of quality assurance
strategies and for providing feedback to all providers involved in the program.
Specifically, the contractor must have a quality assurance program that includes
the following:

    

    
      A. A
written description of the quality assurance program.

      
        B. Written
responsibilities of the governing body for monitoring, evaluating, and
improving  care.

      

    

    
      
      

    

    
      C.  A
procedure for quality assurance program supervision.

      
        D. Assurance
of adequate resources to carry out the program's specified
activities  effectively.

      

    

    
      
      

    

    
      E. A
protocol for provider participation in the quality assurance
program.

    

    
      F. A
procedure for delegation of quality assurance responsibilities to designated
personnel.

    

    
      G. A
procedure for credentialing and re-credentialing providers.

    

    
      H. A
procedure for informing enrollees about their rights and
responsibilities.

    

    
      I.  Assurance
of availability of and accessibility to services and care.

    

    
      J.  A
procedure to ensure the accessibility and availability of medical and long-term
care records,
as well as proper record keeping, and a process for record
review.

    

    
      K. A
procedure for utilization review.

    

    
      L.  A
procedure for quality assurance program documentation.

    

    
      M.  A
procedure for coordination of quality assurance activities with other management
activities.

    

    
      N. A
continuity of care system.

    

    
      O. An
active quality assurance committee.

    

    
      

      Attachment
I - Page 45

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      8.3          Quality
Assurance Committee

    

    
      

      The
contractor must have a quality assurance committee that is either a separate
mechanism for addressing the quality assurance concerns of eligible frail
enrollees, or incorporated into an existing quality assurance
committee.

    

    
      

      The
quality assurance committee must:

    

    
      
        	
                A.

              	
                Oversee
      quality of life indicators such as, but not limited to, the degree of
      personal  autonomy, provision of services and supports to assist
      people in exercising medical and  social choices, self-direction
      of care and maximum use of natural support
  networks.

              

      

    

    
      
        	
                B.

              	
                Review
      grievances and appeals identified through the contractor's policies
      and  procedures and through external
  oversight.

              

      

    

    
      
        	
                C.

              	
                Review
      case records of all fair hearings and document internal
      complaint/grievance steps  involved in the fair hearing, as well
      as other pertinent information for the
enrollee.

              

      

    

    
      
        	
                D.

              	
                Review
      quality assurance policies, standards, and written procedures to ensure
      that the  needs of the enrollees are adequately
      addressed.

              
	E.	Review
      utilization of services with adverse or unexpected outcomes for
      enrollees.

      

    

    
      
        	
                F.

              	
                Develop
      and periodically review written guidelines, procedures and protocols on
      areas of  concern in the care of the frail elderly; for example:
      falls, incontinence, dementia,  depression, congestive heart
      failure, inadequate family care, family caregiver
      stress,  family conflict, out-of-home placements, alcohol
      problems, and problems of compliance  in procedures of medical
      treatment.

              

      

    

    
      
        	
                G.

              	
                Develop
      an ethics committee to review ethical questions such as end-of-life
      decisions and  advance directives.

              
	H.	Develop
      a system of peer review by physicians and other service
    providers.

      

    

    
                 

    

    
      8.4          Quality
Improvement Activities and Performance Measures

    

    
      

      The
contractor 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 performance improvement projects, performance
measures, surveys, and related activities in accordance with Section
409.912(27)(b) F.S.

    

    
      

      A.         Performance
Improvement Projects 

      The
contractor shall perform two (2) performance improvement projects (PIPs) that
have been approved by the department in consultation with the
Agency.

    

    
                

    

    
      
        	1.	Each
      PIP must include a statistically significant sample of
  Enrollees.
	
                2.

              	
                One
      of the PIPs must be the statewide collaborative PIP coordinated by the
      External Quality Review
Organization.

              

      

    

    
      
        	
                3.

              	
                One
      PIP must be designed to address deficiencies identified by the plan
      through monitoring, performance measure results, member satisfaction
      surveys, or other similar
means.

              

      

    

    
      
        	
                4.

              	
                All
      PIPs must 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 95% confidence level and must be
      sustained for a period of two additional remeasurements. Measurement
      periods and methodologies shall be approved in advance by the department
      prior to initiation of the
PIP.

              

      

    

    
      

      Attachment
I - Page 46

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                5.

              	
                PIPs
      that have successfully achieved sustained improvement as defined in A.4
      and as approved by the department shall be considered complete and shall
      not meet the requirement for one of the two PIPs, although the contractor
      may wish to continue to monitor the performance indicator as part of the
      overall quality management program. A new PIP shall be selected and
      submitted to the department for
approval.

              

      

    

    
      
        	
                6.

              	
                Within
      30days of the execution of this amendment and annually within 30 days of
      the execution of this contract thereafter, the contractor shall submit to
      the department, in writing, a proposal for each planned
      PIP.  The PIP proposal shall be submitted using the most recent
      version of the External Quality Review PIP Validation Report
      Form.  Activities 1 through 6 of the Form must be addressed in
      the PIP proposal.   Subsequent annual submissions shall be
      updated to reflect the contractor's progress. In the event that the
      contractor elects to modify a portion of the PIP proposal subsequent to
      initial department approval, a written request may be submitted to the
      department. The External Quality Review PIP Validation Report Form may be
      obtained from the following website:www.myfloridaeqro.com

              

      

    

    
      
        	
                7.

              	
                The
      contractor's PEP methodology must comply with the most recent protocol set
      forth by the Centers for Medicare and Medicaid Services, Conducting Performance Improvement
      Projects. This protocol may be obtained from either of the
      following websites: http://www.cms.hhs.gov/MedicaidManagCare/ or www.mvfloridaeqro.com

              

      

    

    
      
        	
                8.

              	
                The
      contractor's PIPs shall be subject to review and validation by the
      External Quality Review Organization. The contractor shall comply with any
      recommendations for improvement requested by the External Quality Review
      Organization, subject to approval by the
  department.

              

      

    

    
      
        	
                9.

              	
                The
      contractor shall submit a quarterly report no less than 45 days following
      the last day of the quarter describing the activities that have occurred
      during the quarter related to the
PIPs.

              

      

    

    
      
        	
                10.

              	
                Populations
      selected for study under the PIP must be specific to this contract and
      shall not include non-Medicaid enrollees or Medicaid beneficiaries from
      other states. In the event that the contractor contracts with a separate
      entity for management of particular services, such as behavioral health or
      pharmacy, PEPs conducted by the separate entity shall not include
      enrollees for other health plans served by the
  entity.

              

      

    

    
      

      8.5          Independent
Medical Review

    

    
      

      In
accordance with 42 CFR 438.204(d), the Agency shall provide for an independent
review of all Medicaid services provided or arranged by the contractor. The
contractor shall provide information necessary for the review based upon the
requirements of the Agency or the Agency's independent peer review contractor.
The information shall include quality outcomes concerning timeliness of, and
access to, services covered under the contract. The review shall be performed at
least annually by an entity outside state government. If the medical audit
indicates that quality of care is unacceptable pursuant to contractual
requirements, the Agency and the department may restrict the contractor's
enrollment activities pending attainment of acceptable quality of
care.

    

    
      

      8.6          Incident
Reporting

    

    
      

      The
contractor shall implement a systematic process for Incident Reporting in
accordance with Section Q. Incident Reporting of the Standard
Agreement.

    

    
      

      Attachment
I - Page 47

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      The
contractor is required to maintain an incident log which shall be submitted to
the department within 30 days of the file closure date via e-mail to DiversionReports@elderaffairs.org
with password protection for HIPAA related information or via U.S.
mail.

    

    
      

      SECTION
9    GRIEVANCE/APPEALS PROCEDURES

    

    
      

      9.1        Grievance
System Requirements

    

    
      

      The
contractor must have a grievance system in place for enrollees that includes a
grievance process, an appeal process, and access to the Medicaid fair hearing
system. The contractor must develop, implement and maintain a grievance system
mat complies with the requirements in s. 641.511, F.S., and with federal laws
and regulations, including 42 CFR 431.200 and 438, Subpart F, "Grievance
System." The system must include written policies and procedures that are
approved by the department. The contractor shall refer all enrollees and
providers who are dissatisfied with the contractor or its action to the
grievance/appeal coordinator for processing and documentation in accordance with
this contract and the approved policies and procedures. The nature of the
complaint, using the definitions in this contract, determines which of the two
processes the contractor must follow. The grievance process is the procedure for
addressing enrollee grievances, which are expressions of dissatisfaction about
any matter other than an action, as "action" is defined in Section 13,
Definitions. The appeal process is the procedure for addressing enrollee
appeals, which are requests for review of an action, as "action" is defined in
Section 13, Definitions.

    

    
      

      The
contractor must give enrollees reasonable assistance in completing forms and
other procedural steps, and must provide interpreter services and toll-free
numbers with TTY/TDD and interpreter capability. The contractor must acknowledge
receipt of each grievance and appeal in writing. The contractor must ensure that
decision makers on grievances and appeals were not involved in previous levels
of review or decision-making. The decision makers must be health care
professionals with clinical expertise in treating the enrollee's condition or
disease when deciding any, of the following:

    

    
      1. An
appeal of a denial based on lack of medical necessity.

    

    
      2. A
grievance regarding denial of expedited resolution of an
appeal.

    

    
      3. A
grievance or appeal involving clinical issues.

    

    
      

      The
contractor must provide information on grievance, appeal, and fair hearing, and
its respective policies, procedures, and time frames, to all providers at the
time they enter into a contract. Procedural steps must be clearly specified in
the member handbook for members and the provider manual for providers, including
the address, telephone number, and office hours of the grievance coordinator.
The information must include:

    

    
      

      Attachment
I - Page 48

    

    
      

    

    
      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      

    

    
      

    

    
      Amendment
001        Agreement Number
XQ744

    

    
      

    

    
      1.   Enrollee
rights to Medicaid fair hearing, the method for obtaining a hearing, the rules
that govern representation at the hearing, and the DCF address for pursuing a
fair hearing, which is:

    

    
      

    

    
      Office
of Public Assistance Appeals Hearings

    

    
       1317
Winewood Boulevard, Building 5, Room 203

    

    
      Tallahassee,
Florida 32399-0700

    

    
      

    

    
      2.
Enrollee rights to file grievances and appeals, and the requirements and time
frames for filing.

    

    
      3. The
availability of assistance in the filing process.

    

    
      4. The
toll-free numbers to file oral grievances and appeals.

    

    
      5.
Enrollee rights to appeal to the Agency and the Subscriber Assistance Program
(SAP) if enrolled with contractors licensed under 641, F.S.  The
contractor's appeal or grievance process must be exhausted in accordance with s.
408.7056 and 641.511, F.S., with the following exception: a grievance or appeal
taken to Medicaid fair hearing will not be considered by the SAP. The
information must explain that a request for SAP review must be made by the
enrollee within one year of receipt of the final decision letter from the
contractor. The information must explain how to initiate such a review and
include the SAP's address and telephone number as follows:

    

    
      

    

    
      Agency
for Health Care Administration

    

    
      Bureau
of Managed Health Care, Building 1, Room 339

    

    
      2727
Mahan Drive, Tallahassee, Florida 32308

    

    
      1-888-419-3456

    

    
      

    

    
      (6)
Notice that the contractor must continue enrollee benefits
if:

    

    
      (a) The
appeal is filed timely, meaning on or before the later of the
following:

    

    
      (1)
Within ten (10) days of the date on the notice of action (or 15 days if the
notice is sent via U.S. mail).

    

    
      (2) The
intended effective date of the contractor's proposed action.

    

    

    
      (b) The
appeal involves the termination, suspension, or reduction of a previously
authorized course of treatment;

    

    
      (c) The
services were ordered by an authorized contractor;

    

    
      (d) The
authorization period has not expired; and

    

    
      (e) The
enrollee requests extension of benefits.

    

    
      

      The
contractor must maintain records of grievances and appeals in accordance with
the terms of this contract.

    

    
      

      9.2       Appeal
Process

    

    
      

      An appeal
is a request for review of an "action" as defined in Section 13, Definitions.
An

    

    
      enrollee
may file an appeal, and a provider, acting on behalf of the enrollee and with
the

    

    
      enrollee's
written consent, may file an appeal. The appeal procedure must be the same for
all

    

    
      enrollees.

    

    
      A.        Filing
Requirements

    

    
      
        	
                1.

              	
                The
      enrollee or provider may file an appeal within 30 days of the date of the
      notice of action. If the contractor does not issue a written notice of
      action, the enrollee or provider may file an appeal within one year of the
      action.

              

      

    

    
      
        	
                2.

              	
                The
      enrollee or provider may file an appeal either orally or in writing and
      must follow an oral filing with a written? signed appeal. For oral
      filings, time frames for resolution begin on the date the contractor
      receives the oral filing.

              

      

      

    

    
      B.          Contractor
Duties

    

    
      

      Attachment
I - Page 49

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001

    

    
      

      Agreement
Number XQ744

    

    

    
      

      The
contractor must:

    

    
      
        	
                1.

              	
                Ensure
      enrollee oral inquiries seeking to appeal an action are treated as appeals
      and confirm those inquiries in writing, unless the enrollee or the
      provider requests expedited
resolution.

              

      

    

    
      
        	
                2.

              	
                Provide
      a reasonable opportunity to present evidence and allegations of fact or
      law, in person, as well as in
writing.

              

      

    

    
      
        	
                3.

              	
                Allow
      the enrollee and representative an opportunity before and during the
      appeals process to examine the enrollee's case file, medical records, and
      any other documents and
records.

              

      

    

    
      
        	
                4.

              	
                Consider
      the enrollee, representative, or estate representative of a deceased
      enrollee as parties to the
appeal.

              

      

    

    
      
        	
                5.

              	
                Resolve
      each appeal and provide notice, as expeditiously as the enrollee's health
      condition requires, within State-established time frames not to exceed 45
      days from the day the contractor receives the appeal.

              
	6. 	Continue
      the enrollee's benefits if:
	a) 	The
      appeal is filed timely on or before the later of the
  following:

      

    

    
      
        	
                (1)

              	
                Within
      ten (10) days of the date on the notice of action (or 15 days if the
      notice is sent via U.S. mail).

              
	(2)	The
      intended effective date of the contractor's proposed
  action.

      

    

    
      
        	
                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
      authorization period has not expired; and
	e)	The
      enrollee requests extension of
benefits.

      

    

    
      
        	
                7.

              	
                Provide
      written notice of disposition that includes the results and date of
      appeal  resolution, and for decisions not wholly in the
      enrollee's favor, that includes:    

              

      

    

    
      
        	a)	Notice
      of the right to request a Medicaid fair hearing.
	
                b) 

              	
                Information
      about how to request a Medicaid fair hearing, including the DCF address
      for pursuing a fair hearing, which
is:

              

      

    

    
      Office
of Public Assistance Appeals Hearings

    

    
      1317
Winewood Boulevard, BIdg. 5, Room 203,

    

    
      Tallahassee,
Florida 32399-0700

    

    
                

    

    
      
        	c)	Notice
      of the right to continue to receive benefits pending a
  hearing.
	d)  	Information
      about how to request the continuation of benefits.
	
                e)

              	
                Notice
      that if the contractor's action is upheld in a hearing, the enrollee may
      be liable for the cost of any continued
  benefits.

              

      

    

    
      
        	
                f)

              	
                Notice
      that if the appeal is not resolved to the satisfaction of the enrollee,
      the enrollee has one year in which to request review of the contractor's
      decision concerning the appeal by the Subscriber Assistance Program, as
      provided in Chapter 408.7056, F.S. The notice must explain how to initiate
      such a review and must include the addresses and toll-free telephone
      numbers of the Agency and the Subscriber Assistance
    Program.

              

      

    

    
      
        	
                8.

              	
                Provide
      the department with a copy of the written notice of disposition upon
      request.

              

      

    

    
      
        	
                9.

              	
                Ensure
      punitive action is not taken against a provider who files an appeal on an
      enrollee's behalf or supports an enrollee's
  appeal.

              

      

    

    
      
        	
                10.

              	
                The
      contractor may extend the resolution time frames by up to 14 calendar days
      if the enrollee requests the extension or the contractor documents there
      is a need for additional information and the delay is in the enrollee's
      interest. If the extension is not requested by the enrollee, the
      contractor must give the enrollee written notice of the reason for the
      delay.

              
	11. 	If
      the contractor continues or reinstates enrollee benefits while the appeal
      is

      

    

    
              

    

    
      Attachment
I - Page 50

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    Amendment
001            Agreement
Number XQ744

    

    
      

      pending,
the benefits must be continued until one of following occurs:

    

    
      a)   The
enrollee withdraws the appeal.

    

    
      b)  Ten
days pass from the date of the contractor's adverse contractor decision and the
enrollee has not requested a Medicaid fair hearing with continuation of benefits
until a Medicaid fair hearing decision is reached, (or 15 days if the notice is
sent via U.S. mail.)

    

    
      c)    A
Medicaid fair hearing decision adverse to the enrollee is
made.

    

    
      d)    The
authorization expires or authorized service limits are met.

    

    

    
      
        	
                12.

              	
                If
      the final resolution of the appeal is adverse to the enrollee, the
      contractor may recover the cost of the services furnished while the appeal
      was pending, to the extent that they were furnished solely because of the
      requirements of this section.

              

      

    

    
      
        	
                13.

              	
                The
      contractor must authorize or provide the disputed services promptly, and
      as expeditiously as the enrollee's health condition requires, if the
      services were not furnished while the appeal was pending and the
      disposition reverses a decision to deny, limit, or delay
      services.

              

      

    

    
      
        	
                14.

              	
                The
      contractor must pay for disputed services, in accordance with State policy
      and regulations, if the services were furnished while the appeal was
      pending and the disposition reverses a decision to deny, limit, or delay
      services.

              

      

    

    
      

      C.        Expedited
Process

    

    
      

      Each
contractor must establish and maintain an expedited review process for appeals
when the contractor determines or the provider indicates that taking the time
for a standard resolution could seriously jeopardize the enrollee's life or
health or ability to attain, maintain, or regain maximum
function.

    

    
      

      The
enrollee or provider may file an expedited appeal either orally or in writing.
The contractor must:

    

    
      
        	
                1.

              	
                Inform
      the enrollee of the limited time available for the enrollee to present
      evidence and allegations of fact or law, in person and in
      writing.

              

      

    

    
      
        	
                2.

              	
                Resolve
      each expedited appeal and provide notice, as expeditiously as the
      enrollee's health condition requires, within State-established time frames
      not to exceed 72 hours after the contractor receives the
      appeal.

              
	3.	Provide
      written notice of disposition.
	4. 	Make
      reasonable efforts to also provide oral notice of
  disposition.

      

    

    
      
        	
                5.

              	
                Ensure
      that punitive action is not taken against a provider who requests ah
      expedited resolution on the enrollee's behalf or supports an enrollee's
      request for expedited
resolution.

              

      

    

    
      
        	
                6.

              	
                The
      contractor may extend the resolution time frames by up to 14 calendar days
      if the enrollee requests the extension or the contractor documents that
      there is a need for additional information and that the delay is in the
      enrollee's interest. If the extension is not requested by the enrollee,
      the contractor must give the enrollee written notice of the reason for the
      delay.

              

      

    

    
      

      If the
contractor denies a request for expedited resolution of an appeal, the
contractor must:

    

    
      

      
        	
                1.

              	
                Transfer
      the appeal to the standard time frame of no longer than 45 days from the
      day the contractor receives the appeal with a possible 14-day
      extension.

              
	2. 	Make
      reasonable efforts to provide prompt oral notice of the
  denial.

      

    

    
       

    

    
      Attachment
I - Page 51

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      3.          Provide
written notice of the denial within two (2) calendar days.

    

    
      4.          Fulfill
all contractor duties listed above.

    

    
      

      9.3          Grievance
Process

    

    
      

      A
grievance is an expression of dissatisfaction about any matter other than an
action, as "action" is defined in Section 13, Definitions. A grievance may be
filed by an enrollee or a provider acting on behalf of the enrollee and with the
enrollee's written consent.

       

    

    
      A.          Filing
Requirements

    

    
      
        	
                1.

              	
                The
      enrollee or provider may File a grievance within one (1) year after the
      date of occurrence that initiated the
grievance.

              

      

    

    
      
        	
                2.

              	
                The
      enrollee or provider may file a grievance either orally or in writing. An
      oral request may be followed up with a written request, but the time frame
      for resolution begins the date the contractor receives the oral
      filing.

              

      

    

    
      

      B.          Contractor
Duties

    

    
      The
contractor must:         

    

    
      
        	1. 	Resolve
      each grievance, and provide notice, as expeditiously as the enrollee's
      health
      condition requires, within State established time frames not to exceed 90
      days from the day the contractor receives the
  grievance.
	
                2.

              	
                Provide
      written notice of this disposition including the results and date of
      grievance resolution.

              

      

    

    
      
        	
                3.

              	
                Provide
      the department with a copy of the written notice of disposition upon
      request.

              

      

    

    
      
        	
                4.

              	
                Ensure
      punitive action is not taken against a provider who files a grievance on
      an enrollee's behalf or supports an enrollee's
  grievance.

              

      

    

    
      

      The
contractor may extend the resolution time frames by up to 14 calendar days if
the enrollee requests the extension or the contractor documents there is need
for additional information and the delay is in the enrollee's interest. If the
extension is not requested by the enrollee, the contractor must give the
enrollee written notice of the reason for the delay.

    

    
      

      9.4          Medicaid
Fair Hearing System

    

    
      

      The
Medicaid fair hearing policy and process is detailed in Rule 65-2.042, F.A.C.
The contractor's grievance system policy and appeal and grievance processes
shall state the enrollee has the right to request a Medicaid fair hearing at any
time, in addition to, pursuing the contractor's grievance process. A
provider-acting on behalf of the enrollee and with the enrollee's written
consent may request a Medicaid fair hearing. Parties to the Medicaid fair
hearing include the contractor, as well as the enrollee and his or her
representative or the representative of a deceased enrollee's
estate.

    

    
      

               

    

    
      
        	A.	Request
      Requirements
	
                1.

              	
                The
      enrollee or provider may request a Medicaid fair hearing within 90 days of
      the date of the notice of
action.

              

      

    

    
      
        	
                2.

              	
                The
      enrollee or provider may request a Medicaid fair hearing by contacting DCF
      at the Office of Public Assistance Appeals Hearings, 1317 Winewood
      Boulevard, Building 5, Room 203, Tallahassee, Florida
      32399-0700.

              

      

    

    
      
        	
                B.

              	
                Contractor Duties  The
      contractor must:

              
	1.	Continue
      the enrollee's benefits while Medicaid fair hearing is pending
    if:

      

    

    
                

    

    
      

      Attachment
I - Page 52

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                a)

              	
                The
      Medicaid fair hearing is filed timely on or before the later of
      the  following:

              

      

    

    
      
        	
                (1)

              	
                Within
      10 days of the date on the notice of action (or 15 days if the notice is
      sent via U.S. mail).

              
	(2)   	The
      intended effective date of the plan's proposed
action.

      

    

    
      
        	
                b)

              	
                The
      Medicaid fair hearing involves the termination, suspension, or
      reduction  of a previously authorized course of
      treatment;

              
	c)	The
      services were ordered by an authorized provider;
	d)  	The
      authorization period has not expired; and
	e)	The
      enrollee requests extension of benefits.
	2. 	Ensure
      punitive action is not taken against a provider who requests a Medicaid
      fair hearing on the enrollee's behalf or supports an enrollee's request
      for a Medicaid fair hearing.

      

    

    
      
        	
                C.

              	
                If
      the contractor continues or reinstates enrollee benefits while the
      Medicaid fair hearing is pending, the benefits must be continued until one
      of following occurs:

              
	1.  	 The
      enrollee withdraws the request for Medicaid fair
  hearing.

      

    

    
      
        	
                2.

              	
                Ten
      days pass from the date of the contractor's adverse decision and the
      enrollee has not requested a Medicaid fair hearing with continuation of
      benefits until a Medicaid fair hearing decision is reached (or 15 days if
      the notice is sent via U.S. mail.)

              
	3.   	A
      Medicaid fair hearing decision adverse to the enrollee is
  made.
	4.  	The
      authorization expires or authorized service limits are
  met.

      

    

    
       

    

    
      The
contractor must authorize or provide the disputed services promptly, and as
expeditiously as the enrollee's health condition requires, if the services were
not furnished while the Medicaid fair hearing was pending and the Medicaid fair
hearing officer reverses a decision to deny, limit, or delay
services.

    

    
      

      The
contractor must pay for disputed services, in accordance with State policy and
regulations, if the services were furnished while the Medicaid fair hearing was
pending and the Medicaid fair hearing officer reverses a decision to deny,
limit, or delay services.

    

    
      

      SECTION
10   PAYMENT

    

    
      

      10.1          Payment
to Contractor

    

    
      

      The
Agency, through the Medicaid fiscal agent, will make a payment to the contractor
on a monthly basis for the contractor's satisfactory performance of its duties
and responsibilities as set forth in this contract and its
attachments.

    

    
      

      10.2          Capitation
Rates

    

    
      

      
        	
                A.

              	
                The
      capitation rate paid to the contractor is indicated in Exhibit I. The
      Agency and  department, working in conjunction with a licensed
      actuary, shall review and, if  necessary, recalculate the
      capitation rate. Legislatively mandated changes in
      Medicaid  services will also be considered in reviewing the
      capitation rate. If as a result of the  review, the capitation
      rate is recalculated, notice shall be provided to the contractor.
      The  contractor shall have 30 days from the date of the notice
      to provide written comments to  the department on the proposed
      recalculated capitation rate.

              

      

    

    
      
        	
                B.

              	
                The
      contractor, department, and the Agency acknowledge that the capitation
      rate paid  under this contract as specified in Exhibit I of this
      contract is subject to approval by the  federal
      government.

              

      

    

    
      

      Attachment
I - Page 53

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                 
      

              	
                C.        In
      accordance with 42 CFR 438.6(c)(l)(i), capitation rates are to be
      developed and certified as actuarially sound, appropriate for the
      populations to be covered, and the services to be furnished under the
      contract.

              

      

    

    
      

      10.3          Payment
in Full

    

    
      

      The
contractor must accept the capitation payment received each month as payment in
full for all services provided to enrollees covered under this contract and the
administrative costs incurred by the contractor in providing or arranging for
such services.

    

    
      

      10.4          Capitation
Payments

    

    
      

      
        	
                A.

              	
                Adjustments
      to funds previously paid and to be paid may be required.
      Funds  previously paid will be adjusted when capitation
      payments) are determined to have  been in error, or an error is
      made in enrolling an ineligible person. In such events,  the
      contractor agrees to refund any overpayment and the Agency agrees to pay
      any  underpayment.

              

      

    

    
      
        	
                B.

              	
                The
      Agency agrees to reflect 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
      will take effect on the  dates specified in the
      legislation.

              

      

    

    
      

      10.5          Payment
Discrepancies

    

    
      

      
        	
                A.

              	
                If
      after an enrollment and disenrollment submission, a discrepancy is
      discovered either by  the contractor, the Agency, or the
      department, the contractor has five (5) business days to  submit
      correct detailed information on the Reconciliation Form (Exhibit F) to
      the  department.

              

      

    

    
      
        	
                B.

              	
                After
      receipt of the fiscal agent remittance vouchers, the contractor has ten
      (10) business  days to submit correct detailed information on
      the Reconciliation Form (Exhibit F) to
      the  department.

              

      

    

    
      
        	
                C.

              	
                Failure
      to respond within the above time periods may result in a loss and/or
      forfeiture of  any money due the
  contractor.

              

      

    

    
      

      SECTION
11   PROGRAM REPORTING REQUIREMENTS

    

    
      

      11.1      General
Requirements

    

    
      

      The
contractor is responsible for complying with all reporting requirements
established by the department and Agency. The contractor will be responsible for
assuring the accuracy and completeness of all required reports as well as the
timely submission of each report. The contractor will be furnished with the
appropriate reporting formats, instructions, submission timetables and technical
assistance as required. The contractor shall review all monthly reports, as well
as remittance vouchers, received from the fiscal agent for accuracy and will
notify the department and Agency if discrepancies are found. The discrepancies
shall be reported as specified in Attachment I, Section 10.5.

    

    
      

      
        	
                 
      

              	
                A.        Level
      of Analysis: The following levels of analysis will be used, as indicated,
      for the required reports:

              

      

    

    
      1.          Individual
Level - One report is required for each enrollee, e.g., one
grievance

    

    
      record
for each grievance, one record per long-term care service.

    

    
      

      Attachment
I - Page 54

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      
        	
                2.

              	
                Location
      Level - One report required for each nine-digit Medicaid provider number
      the contractor has under
contract.

              

      

    

    
      
        	
                3.

              	
                Contractor
      Level - One report is required for each seven-digit Medicaid provider
      number the contractor has under
contract.

              

      

    

    
      Example:
ABC Health Plan, Medicaid Provider Number 1234567, operates three locations: ABC
of Palm Beach (123456701), ABC of Indian River (123456702), and ABC of Martin
(123456703). A contractor level report would be summarized over all plans with
the seven-digit Medicaid Provider number (1234567). A location level report
would have one report for each nine-digit provider number (123456701,123456702,
and 123456703).

    

    
      

      The
following table summarizes the required data reporting for the
project:

    

    

    
      	
              
                Report
      Name

              

            	
              
                Level
      of Analysis

              

            	
              
                Reporting
      Frequency

              

            	
              
                Submission
      Method

              

            	
              
                Reporting
      Location

              

            
	
              
                834
      Transactions

              

            	
              
                Location

              

            	
              
                Monthly,
      by 4:00 PM on the

              

              
                Wednesday
      preceding the second to last Saturday.

              

            	
              
                Secured
      Internet website supplied by the fiscal agent; file upload and download on
      secured website

              

            	
              
                Fiscal
      Agent

              

            
	
              
                Supplemental
      834 Transaction

              

            	
              
                Location

              

            	
              
                Monthly,
      by 4:00 PM on the

              

              
                Wednesday
      prior to 834 transactions

              

            	
              
                Secured
      Internet website supplied by the fiscal agent; file upload and download on
      secured website

              

            	
              
                Fiscal
      Agent

              

            
	
              
                Disenrollment
      Summary Report

              

            	
              
                Location

              

            	
              
                Monthly
      within 5 calendar days after the

              

              
                beginning
      of the reporting month

              

            	
              
                Electronic
      Mail (with password protection for HEPAA related information)
      to

              

              
                DiversionReports@elderaffairs.org or mail
      via a compact disk (with password protection for HEPAA related
      information)

              

            	
              
                Department

              

            

    

    
      

      Attachment
I - Page 55

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      	
              
                Report
      Name

              

            	
              
                Level
      of Analysis

              

            	
              
                Reporting
      Frequency

              

            	
              
                Submission
      Method

              

            	
              
                Reporting
      Location

              

            
	
              
                Encounter
      Data Report

              

            	
              
                Individual

              

            	
              
                Quarterly,
      within 3 months of the end of reporting calendar
    quarter

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@elderaffairs.org or mail
      via a compact disk (with password protection for HIPAA related
      information)

              

            	
              
                Department

              

            
	
              
                Grievance/Appeals
      Report

              

            	
              
                Individual

              

            	
              
                Quarterly
      within 5 calendar days of end or reporting calendar
      quarter

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@elderaffairs.org or mail
      via a compact disk (with password protection for EQPAA related
      information)

              

            	
              
                Department

              

            
	
              
                Updated
      Provider Network and Staff Listing

              

            	
              
                Location

              

            	
              
                Quarterly,
      within 5 calendar days of end of reporting calendar
      quarter

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@elderaffairs.org or mail
      via a compact disk (with password protection for HIPAA related
      information)

              

            	
              
                Department

              

            
	
              
                Minority
      Business Enterprise Contract Reporting

              

            	
              
                Contractor

              

            	
              
                April
      15, July 5, October 15, January 15

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@eIderaffairs.org or mail
      via a compact disk (with password protection for HIPAA related
      information)

              

            	
              
                Department

              

            
	
              
                Financial
      Statements

              

            	
              
                Contractor

              

            	
              
                Quarterly,
      within 45 days of end of reporting quarter

              

            	
              
                Agency
      Supplied Template on Compact Disc, Electronic Mail or Hard
      Copy

              

            	
              
                Department

              

            
	
              
                Audited
      Financial Statement

              

            	
              
                Contractor

              

            	
              
                Annually,
      within 120 days of end ofcontractor's
      fiscal year

              

            	
              
                Electronic
      Mail, Compact Disc or Hard Copy

              

            	
              
                Department

              

            
	
              
                Emergency
      Management Plan

              

            	
              
                Contractor

              

            	
              
                Annually,
      April 30

              

            	
              
                Electronic
      Mail, Compact Disc, or Hard Copy

              

            	
              
                Department

              

            
	
              
                Enrollee
      Satisfaction Survey

              

            	
              
                Contractor

              

            	
              
                Annually,
      May 15

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@eIderaffairs.org or mail
      via a compact disk (with password protection for HIPAA related
      information)

              

            	
              
                Department

              

            

    

    
      

      Attachment
I - Page 56

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                     Agreement
Number XQ744

    

    

    
      	
              
                Report
      Name

              

            	
              
                Level
      of Analysis

              

            	
              
                Reporting
      Frequency

              

            	
              
                Submission
      Method

              

            	
              
                Reporting
      Location

              

            
	
              
                Insolvency
      Fund Statements

              

            	
              
                Contractor

              

            	
              
                Monthly
      Statements

              

            	
              
                Electronic
      Mail or Hard Copy

              

            	
              
                Department

              

            
	
              
                Reconciliation
      Report

              

            	
              
                Individual

              

            	
              
                Within
      ten (10) days of receipt of remittance vouchers

              

            	
              
                Electronic
      Mail (with password protection for HIPAA related information)
      to

              

              
                DiversionReports@elderaffairs.org or mail
      via a compact disk (with password protection for BDDPAA related
      information)

              

            	
              
                Department

              

            
	
              
                Hospice
      Report

              

            	
              
                Contractor

              

            	
              
                15
      days after the reporting month

              

            	
              
                Electronic
      Mail

              

            	
              
                Department

              

            

    

    
      

      11.2      834
Transactions

    

    
      

      
        	
                A.

              	
                These
      reports are to be submitted monthly to the Florida Medicaid fiscal agent.
      These  reports shall be transmitted to the Medicaid fiscal agent
      using the communications  protocol through the secured Internet
      site supplied by the fiscal agent. The contractor is  required
      to submit the report for every person who is to be enrolled or disenrolled
      during  the reporting
period.

              

      

    

    
      
        	
                B.

              	
                The
      fiscal agent is authorized to process the enrollment input data as an
      electronic  transaction in which payment is generated for each
      enrollee according to the established  capitation rate. On
      specified dates each month the contractor will receive the
      remittance  invoice accompanied by a payment warrant, in hard
      copy or contract format. The amount  of payment is determined by
      the number of enrollees enrolled in each capitation
      category  and any adjustments that may
  apply.

              

      

    

    
      
        	
                C.

              	
                Contractors
      must comply with all the federal requirements of
      administrative  simplification, as documented in the National
      Electronic Data Interchange Transaction Set Implementation Guide for the
      Benefit Enrollment and Maintenance ASC X12N 834 Transaction, as well as
      the ACS/AHCA ANSI ASC XI2N 834 Companion
Guide.

              

      

    

    
      
        	
                A.

              	
                The
      monthly transmission shall be sent to the fiscal agent the Wednesday
      preceding the  second to the last Saturday of each
      month.  The enrollment transactions will include
      all  enrollments submitted from the CARES office and
      disenrollment requested by enrollees  or their representative.
      These enrollments and disenrollments will be effective the first
      of  the next month.

              

      

    

    
      
        	
                B.

              	
                The
      supplemental transmission shall be sent to the fiscal agent the Wednesday
      prior to  the monthly transaction. The supplemental transactions
      will include Medicaid pending,  referrals from the CARES office
      received after the monthly cutoff date, and enrollments  that
      did not process the previous
month.

              

      

    

    
      

      Attachment
I - Page 57

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      11.3          Disenrollment
Summary Report

    

    
      

      This
report provides a uniform means of reporting each contractor's monthly
disenrollments. The report is required to assess the reasons for each
disenrollment and to ensure that disenrollments' are in compliance with contract
guidelines.

    

    
      

      This
report must be provided as a Microsoft Excel spreadsheet in the format specified
in Exhibit B of this contract. Disenrollments shall be numbered, and information
shall be listed in alphabetized ascending order by enrollee last name, then by
enrollee first name. Information shall pertain only to disenrollments that are
effective for the month being reported. A report will be required if there are
no disenrollments filed during the given month. For example, the November 2002
report of disenrollments would include information on an enrollee that expired
on October 28,2002. October 28, 2002, would be provided as the Disenrollment
Reason Occurrence Date for that enrollee in the Disenrollment Summary
Report.

    

    
      

      11.4          Encounter
Data Report

    

    
      

      The
contractor shall provide encounter level service utilization data as specified
in Exhibit C of this contract. The services reported represent the comprehensive
array of services that might be necessary to maintain a member at home while
avoiding nursing home placement, including acute and long-terms care
services.

    

    
      

      The
contractor shall resubmit files with more current data during the subsequent
reporting quarter to replace the data previously submitted. The previously
submitted data will be discarded, and the more recent data will be
utilized.

    

    
      

      11.5          Grievance/Appeals
Report

    

    
      

      This
report provides a uniform means of reporting each contractor's quarterly
grievances/appeals, and is needed in order to track the number of
grievances/appeals, as well as the reason and disposition of grievances/appeals.
Grievance/appeals reporting provides a method by which to assess the
contractor's ability to manage formal grievances/appeals through its internal
grievance/appeals process.

    

    
      

      The
Grievance/Appeals Report must be provided as a Microsoft Excel spreadsheet in
the format specified in Exhibit D of this contract. The Grievance/Appeals Report
shall be submitted by the contractor to report all grievances, appeals or
updates to previously reported grievances, appeals, or to report whether there
have been any new grievances/appeals during the reporting
quarter.

    

    
      

      11.6          Updated
Provider Network and Staff Listing

    

    
      

      This
updated listing provides current information on the contractor's provider
network and staffing to ensure that adequate resources are available to
enrollees at all times.

    

    
      

      The
Provider Network and Staff Listing shall be provided electronically in a format
specified by the department. The network listing shall be submitted to the
department via Electronic Mail (with password protection for HIPAA related
information) to DiversionReports@elderaffairs.org
or mail via a compact disk (with password protection for HIPAA related
information). The Provider Network Listing shall be updated to include
information on providers who joined the contractor's provider network, or who
were terminated from the contractor's provider network during the reporting
quarter. The terminated providers shall be indicated by a strikethrough and a
termination date. The first page and signature page of the subcontract will be
submitted for each new provider added to the network.

    

    
      

      If the
contractor has not added or terminated a subcontract to its provider network
within the

    

    
      

      Attachment
I - Page 58

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      reporting
quarter, a statement to that effect shall be provided to the department in lieu
of an updated Provider Network and Staff Listing.

    

    
      

      11.7          Minority
Business Enterprise Contract Reporting

    

    
      

      This
report will be submitted in accordance with the Standard Contract Section J.3,
Equity in Contracting. This format is specified in Exhibit E.

    

    
      

      11.8          Emergency
Management Plan

    

    
      

      The
contractor must submit an emergency management plan to the department for
approval specifying what actions the contractor must conduct to ensure the
ongoing provisions of health services in a natural disaster or man-made
emergency. This plan shall also address service delivery post disaster or
emergency, i.e. shelf-stable meals for those affected enrollees whose care plan
includes home delivered meals. This plan is due annually April
30.

    

    
      

      11.9          Enrollee
Satisfaction Reporting

    

    
      The
contractor shall conduct the enrollee satisfaction survey by March 1st of each
year. A copy of the survey shall be sent to the Department for approval by
November 1st of the state fiscal year. The contractors shall report the survey
results to the department by May 15th of each year. This survey shall be
conducted in English or in an alternative language, if the population speaking a
particular non-English language in a county is greater than five (5) percent.
The sampling for the survey shall be a statistically significant sample for
members having received long term care services during the period reflected in
the report.

    

    
      

      The
enrollee satisfaction survey results submitted to the department shall include
an attestation statement signed by an authorized representative that addresses
the validity, reliability, and unbiasedness of the survey. The attestation must
describe how the validity and reliability was statistically or otherwise
established. The attestation of unbiasedness must include the measures the
provider took to ensure the independence of the survey and the trust of the
respondent.

    

    
      

      11.10     Hospice
Services

    

    
      

      Hospice
Services shall be submitted monthly on the Hospice Enrollment Report (Exhibit
L), indicating enrollees electing hospice services the prior
month.

    

    
      

      SECTION
12   FINANCIAL REPORTING

    

    
      

      12.1          General

    

    
      

      The
reporting requirements outlined in this section are designed in accordance with
the department and Agency's Medicaid prepaid plan contract financial reporting
requirements.

    

    
      

      12.2          Member
Payment Liability Protection

    

    
      

      The
contractor shall not hold members liable for the following in accordance with
Section 1932 (b)(6), Social Security Act (enacted by Section 4704 of the
Balanced Budget Act of 1997):

    

    
               

    

    
      
        	A. 	For
      debts of the contractor, in the event of the contractor's
      insolvency.
	
                B.

              	
                For
      payment of covered services provided by the contractor if the contractor
      has not  received payment from the Agency for the services, or
      if the provider, under contract or other
      arrangement with the contractor, fails to receive payment from the Agency
      or the contractor.

              

      

    

    
      

      Attachment
I - Page 59

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    
      

      
      

    

    
      

      
        	
                C.

              	
                For
      payments to the providers that furnished covered services under a
      contract, or other arrangement with the contractor, that are in excess of
      the amount that normally would be paid by the member if the service had
      been received directly from the
contractor.

              

      

    

    
      

      12.3          Financial
Reporting Template

    

    
      

      The
contractor will be supplied with a template for financial
reporting that can be used with Excel spreadsheet applications. The spreadsheets
are to be completed and either electronically transmitted or on a compact disk
mailed to the department.

    

    
      
        	
                A.

              	
                Master
      financial sheet - This is the balance sheet, Income statements and Net
      Worth  and Working Capital that reflects four (4) quarters plus
      the contractor's fiscal year  totals. Variances have been placed
      within the quarters to track fluctuations on a line-  item
      basis. Ratios have been created to monitor or detect material weaknesses
      in the  contractor.

              

      

    

    
      
        	
                B.

              	
                Enrollment
      sheet - Consists of quarterly summaries of enrollment detailed by
      county  penetration. Indicators have been placed to reflect
      potential over or under
  enrolling  practices.

              

      

    

    
      
        	
                C.

              	
                Income
      Statement By Lines of Business- Contains a sheet to track
      individual  performance by commercial, Medicare, and Medicaid
      product lines.

              

      

    

    
      
        	
                D.

              	
                Balance
      Sheet Write-ins - This sheet tracks any information recorded on the
      balance  sheet, which needs further
  explanation.

              

      

    

    
      
        	
                E.

              	
                Certification
      page - Showing the contractor's name, address, telephone number,
      and  other
elements.

              

      

    

    
      

      12.4          Audited
Financial Statements

    

    
      

      The
contractor must submit annual audited financial statements prepared by a
certified public accountant that expressly confirm that the contractor satisfies
the surplus requirements as per Section 430.705(b)(5) and summarizes the
contractor's financial activities for the contract period. In addition, the
contractor must annually send a statement, signed by the president of the
organization, attesting that no assets of the contractor have been pledged to
secure personal loans. The financial statements must be submitted to the
department no later than four calendar months after the end of the contractor's
fiscal year and must be prepared by an independent certified public accountant
on the accrual basis of accounting in accordance with generally accepted
accounting principles as established by the American Institute of Certified
Public Accountants (AICPA). Audits performed to meet the requirements of OMB
Circular 128 satisfy this requirement. For government owned and operated
facilities operating on a cash method of accounting, data based on such a method
of accounting will be acceptable. The certified public accountant (CPA)
preparing the financial statements must sign statements as the preparer and in a
separate letter state the scope of his work and opinion in conformity with
generally accepted auditing standards and AICPA statements on auditing
standards. The annual audited report will be for the contractor unless prior
approval is obtained from the department for some other
alternative.

    

    
      

      If the
period covered by this contract is less than six months, the contractor may
request of the department's contract manager, in writing, an exemption from the
requirements of this section for this contract period. The department's contract
manager will grant, the exception provided that all other performance measures
are satisfactory and the contractor provides a complete set of financial
statements accompanied by an attestation of accuracy signed by a corporate
officer.

    

    
      

      12.5          Unaudited
Quarterly Financial Statements

    

    
      

      The
contractor must submit the following unaudited quarterly financial statements^
Balance Sheet, Income Statements and Net Worth and Working
Capital.

    

    
      

      Attachment
1 - Page 60

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                A.

              	
                These
      statements must be filed, on a compact disk or electronically transmitted
      using the  supplied spreadsheet template and are due 45 days
      after the end of each quarter in a  contractor's fiscal year.
      Quarterly financial reports are to be specific to the operation
      of  the contractor rather than to a parent or umbrella
      organization.

              

      

    

    
      
        	
                B.

              	
                The
      reporting date, and the name of the provider, roust be plainly written or
      stamped on  the certification page, along with the Chief
      Executive Officer's (CEO)
signature.

              

      

    

    
      
        	
                C.

              	
                Do
      not leave blanks. If no entry is to be made, write ANONE, @ not applicable
      (N/A) or  "-0-" in the space provided. Any item that cannot be
      readily classified under one of the  printed items should be
      entered as an aggregated item and adequately
  described.

              

      

    

    
      
        	
                D.

              	
                If
      additional supporting statements or schedules are added in connection with
      providing  information on the financial statement, the additions
      should be properly keyed to the item  being
      answered.

              

      

    

    
      E.          One
copy of the financial template is required to be filed with the quarterly
submission.

    

    
      

      12.6      Balance
Sheet

    

    
      

      The
balance sheet is to report all assets and liabilities of the Contractor in total
and does not relate to the NHD Program specifically. This is a Contractor wide
Balance Sheet (i.e. should represent the entire legal reporting
entity).

    

    
      

      A.      Current
Assets

    

    
      Assets
that can be converted into cash or consumed within one year from the balance
sheet date. Restricted assets are not to be included as current
assets.

    

    
      

      100 -
Cash and Cash Equivalents

    

    
      Include:   Cash
and cash equivalents, available for current use. Cash

    

    
      equivalents
are investments maturing 90 days or less from the date of
purchase.

    

    
      

      
        	
                 
      

              	
                Exclude:
      Restricted cash (and equivalents) and any cash (and equivalents) pledged
      by the Contractor to satisfy insolvency and surplus
      requirements.

              

      

    

    
      

      102 -
Short-term Investments

    

    
      
        	
                 
      

              	
                Include:   Investments
      that are readily marketable or that are to be redeemed or sold within one
      year of the balance sheet
date.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Investments maturing 90 days or less from the date of purchase and
      restricted securities. Also exclude investments pledged by the Contractor
      to satisfy insolvency and surplus
requirements.

              

      

    

    
      

      104 -
Premium/Capitation Receivable

    

    
      
        	
                 
      

              	
                Include:   Net
      amounts receivable for premiums and capitation payments as of the balance
      sheet date.

              

      

    

    
      

      106-
Interest Receivable

    

    
      
        	
                 
      

              	
                Include:   Interest
      income earned but not yet received from cash equivalents, investments,
      on-balance sheet performance bonds, and short and long-term
      investments.

              

      

    

    
      

      108 -
Other Receivables

    

    
      Include:   Any
amount due to contractor not included in accounts 104 or 106.

    

    
      

      Attachment
I - Page 61

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                            Agreement
Number XQ744

    

    
      

      110-
Prepaid Expenses

    

    
      
        	
                 
      

              	
                Include:   Any
      amount paid by the contractor in advance for expenses not yet
      incurred.

              

      

    

    
      

      112-
Other Aggregate Write-ins

    

    
      
        	
                 
      

              	
                Include:   Other
      current assets that are not accounted for elsewhere in accounts
      100,102,104,106,108, or 110. These other current assets should be recorded
      in Tab 1-Balance Sheet Write-ins. Due from Affiliates, Provider
      Advances/Receivables, and Tax Receivables are accounted for in this line
      item. Provider Advances/Receivables should be accounted for in this line
      item, and should not be netted against Claims Payables and/or IBNRs.
      Please provide a detail description of other write-ins for those that
      comprise at least 5 percent of total current
  assets.

              

      

    

    
      

      Exclude:
Amounts due to affiliates.

    

    
      

      B.        Other
Assets

    

    
      

      120 -
Restricted Funds (NHD Surplus)

    

    
      
        	
                 
      

              	
                Include:   All
      cash and investments pledged to meet the NHD Surplus
      requirement.

              

      

    

    
      

      122-
Restricted Funds (NHD Insolvency)

    

    
      
        	
                 
      

              	
                Include:   All
      cash and investments pledged to meet the NHD Insolvency
      requirement.

              

      

    

    
      

      124 - All
Other Restricted Funds

    

    
      Include:   Cash,
securities, receivables, etc., whose use is restricted.

    

    
      

      126 -
Long-term Investments

    

    
      Include:   Investments
that are to be held longer than one year.

    

    
      

      
        	
                 
      

              	
                Exclude:
      Investments pledged by the Contractor to satisfy insolvency and surplus
      requirements

              

      

    

    
      

      128-
Intangibles/Goodwill

    

    
      Include:   The
net amount of intangible assets and/or goodwill.

    

    
      

      130 -
Other Aggregate Write-ins

    

    
      
        	
                 
      

              	
                Include:   Other
      assets that are not accounted for elsewhere in accounts 120, 122,124,126,
      and 128. These other assets should be recorded in Tab 1-Balance Sheet
      Write-ins. Security Deposits, Due from Affiliates, and Tax Receivables are
      accounted for in this line item. Please provide a detail description of
      other write-ins for those that comprise at least 5 percent of total other
      assets.

              

      

    

    
      

      C.        Property,
Plant & Equipment (Net of depreciation)

    

    
      

      140-
Land

    

    
      Include:   Real
estate owned by the Contractor.

    

    
      

      Attachment
I - Page 62

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      142 -
Buildings & Improvements (Net of Depreciation)

    

    
      
        	
                 
      

              	
                Include:   Buildings
      owned by the Contractor, including buildings under a capital lease, and
      improvements to buildings owned by the Contractor. All amounts are
      reported net of accumulated depreciation

                 

                Exclude:
      Improvements made to leased or rented buildings or
  offices.

              

      

    

    
       

      144-
Construction in Progress (Net of Depreciation)

    

    
      
        	
                 
      

              	
                Include:   All
      building and other major construction projects not completed. All amounts
      are reported net of accumulated
depreciation.

              

      

    

    
      

      146-
Furniture & Equipment (Net of Depreciation)

    

    
      
        	
                 
      

              	
                Include:
      Medical equipment, office equipment, data processing hardware and software
      (where permitted), and furniture owned by the Contractor, as well as
      similar assets held under capital leases. All amounts are reported net of
      accumulated depreciation.

              

      

    

    
      

      148 -
Leasehold Improvements (Net of Depreciation)

    

    
      
        	
                 
      

              	
                Include:   Capitalized
      improvements made to facilities not owned by the
    Contractor.

              

      

    

    
      

      150-
Other Aggregate Write-ins

    

    
      
        	
                 
      

              	
                Include:   All
      other tangible assets that are not accounted for elsewhere in accounts
      140,142,144,146, and 148. These assets should be recorded in Tab 1-Balance
      Sheet Write-ins. Computer Software and Vehicles are accounted for in this
      line item. Please provide a detail description of other write-ins for
      those that comprise at least 5 percent of total Property, Plant &
      Equipment.

              

      

    

    
      

      D.      Current
Liabilities

    

    
      Obligations
that are reasonably expected to be paid within one year from the balance sheet
date.

    

    
      

      200-
Accounts Payable

    

    
      
        	
                 
      

              	
                Include:   Amounts
      due to creditors for the acquisition of goods and services (trade and
      administrative vendors) on a credit
basis.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Amounts due to providers related to the delivery of health care
      services.

              

      

    

    
      

      202 -
Outstanding Claims Liability (OCL)

    

    
      Include:   The
total amount of received but unpaid claims of the Contractor.

    

    
      This
represents the claims that have been received by the Contractor but as of the
date of the report have not been paid. In addition, this includes all estimated
amounts for claims incurred by the Contractor that have not been reported
(D3NR).

    

    
      

      204 -
Accrued Provider Incentive Pool

    

    
      
        	
                 
      

              	
                Include:   The
      estimated payable to providers for incentives that have been earned by the
      providers but not yet paid.

              

      

    

    
      

      206 -
Capitation Payable

    

    
      

      Attachment
I - Page 63

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      Include:   Net
amounts owed to providers for monthly capitation.

    

    
      

      
        	
                 
      

              	
                Exclude:
      Capitation amounts payable as a result of an underpayment or unearned
      premiums.

              

      

    

    
      

      208 -
Unearned Premiums

    

    
      
        	
                 
      

              	
                Include:   The
      total portion of premiums received by the Contractor for which the revenue
      will be recorded/earned in a subsequent
period.

              

      

    

    
      

      210 -
Current Portion of Loans & Notes Payable

       

    

    
      
        	
                 
      

              	
                Include:   The
      total current portion from the principal amount on loans, notes, and
      capital lease obligations due within one year of the balance sheet
      date.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Long-term portion of and accrued interest on loans, notes, and capital
      lease obligations.

              

      

    

    
      

      212-
Other Aggregate Write-ins

       

    

    
      
        	
                 
      

              	
                Include:   All
      other current liabilities that are not accounted for elsewhere in accounts
      200, 202, 204, 206, 208, 210, and 212. These current liabilities should be
      recorded in Tab 1-Balance Sheet Write-ins. Accrued Salaries, Taxes
      Payable, and due to Affiliates are accounted for in this line item. Please
      provide a detail description of other write-ins for those that comprise at
      least 5 percent of total current
liabilities.

              

      

    

    
      

      E.        Other
Liabilities

    

    
      Obligations
that are reasonably expected to be paid more than one year from the date of the
balance sheet.

    

    
      

      220 -
Long-Term Portion of Loans & Notes Payable

    

    
      
        	
                 
      

              	
                Include:   The
      total non-current portion of the principal on loans, notes, and capital
      lease obligations.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Current portion of long term debt and accrued interest on loans, notes,
      and the current portion of capital lease
  obligations.

              

      

    

    
      

      222 -
Statutory Liabilities

    

    
      Include:   The
total amount of any Statutory Liabilities.

    

    
      

      224 -
Other Aggregate Write-ins

    

    
      
        	
                 
      

              	
                Include:   All
      other liabilities that are not accounted for elsewhere in accounts 220 and
      222. These liabilities should be recorded in Tab 1-Balance Sheet
      Write-ins. Due to Affiliates and Other Contingencies are accounted for in
      this line item. Please provide a detail description of other write-ins for
      those that comprise at least 5 percent of total other
      liabilities.

              

      

    

    
      

      F.          Equity/Net
Assets (Liabilities)

    

    
      Includes
preferred stock, common stock, treasury stock, additional paid-in capital,
contributed capital, restricted net assets, unrestricted net assets, unrealized
gains and losses on investments, and retained earnings/fund
balance.

    

    
      

      Attachment
I - Page 64

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

       300-
Contributed Capital

    

    
      Include:   Capital
paid or donated to the Contractor.

    

    
      

      302 -
Common Stock

    

    
      
        	
                 
      

              	
                Include:   Total
      par value of Common Stock or in the case of no-par shares, the stated or
      liquidation value.

              

      

    

    
      

      304-
Preferred Stock

    

    
      
        	
                 
      

              	
                Include:   Total
      par value of Preferred Stock or in the case of no-par shares, the stated
      or liquidation value.

              

      

    

    
      

      306 -
Paid in Surplus

    

    
      
        	
                 
      

              	
                Include:   Amounts
      paid and contributed in excess of the par or stated value of shares
      issued.

              

      

    

    
      

      308-
Surplus Notes

    

    
      Include:   Amounts
designated as Surplus Notes to the Contractor.

    

    
      

      310
-      Unassigned Surplus-Retained
Earnings

    

    
      Include:   Accumulated
earnings of the Contractor.

    

    
      

      312-
Other Aggregate Write-ins

    

    
      Include:   All
equity items that are not accounted for elsewhere in accounts 300, 302,
304, 306, 308, and 310. These items should be recorded in Tab 1-Balance Sheet
Write-ins. Non-Admitted Assets are accounted for in this line item. Please
provide a detail description of other write-ins for those that comprise at least
5 percent of total Equity.

    

    
      

      12.7     Income
Statement by Category of Service

    

    
      

      Report 2
should be reported at the NHD Program level by applicable Category of Service.
All medical expenses must be reported net of Medicare/Other Payor reimbursement.
The medical expenses should be reported in the applicable Category of Service
for the NHD Program only. This report is not a Contractor-wide Income
Statement. In addition to completing this report, a Contractor-wide Income
Statement by Line of Business will be completed in Report 2A.

    

    
      

      A.        Member
Months

    

    
      

      300 -
Nursing Home Diversion Member Months

    

    
      
        	
                 
      

              	
                Include:   All
      member months for the Nursing Home Diversion Program. The total reported
      here will be consistent with the total reported on Report 6 Member Months.
      A member month is equivalent to one person for whom the Contractor has
      received capitation revenue for one
month.

              

      

    

    
      

      B.        Revenues

    

    
      

      302-
Capitation Premium

    

    
      Include:   Revenue
recognized on a prepaid basis for eligible enrollees.

    

    
      

      Exclude:
Premiums and co-payments from enrollees.

    

    
      

      Attachment
I - Page 65

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      304-
Other Premiums

    

    
      
        	
                 
      

              	
                Include:   Premiums
      received by the Contractor that are paid for by the Contractor's
      enrollees.

              

      

    

    
      

      Exclude:
Co-payments from enrollees.

    

    
      

      306-
Co-payments

    

    
      
        	
                 
      

              	
                Include:
      The revenue earned from co-payments paid by the Contractor's enrollees to
      receive covered services. Only include co-payments actually received by
      the Contractor.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Co-payments collected by contracted providers from enrollees to receive
      covered services.

              

      

    

    
      

      308 -
Investment/Interest Income

    

    
      
        	
                 
      

              	
                Include:   All
      investment income earned during the period. Interest income and interest
      expense should not be netted
together.

              

      

    

    
      

      310-  Net
Reinsurance Recovery/Expense

    

    
      
        	
                 
      

              	
                Include:   The
      net amount of reinsurance earned over premiums (or premiums over
      reinsurance earned) as of the statement
date.

              

      

    

    
      

      312-   Third
Party Liability/Coordination of Benefits Recoveries

    

    
      
        	
                 
      

              	
                Include:   Revenue
      from the settlement of accident claims or other third party
      sources.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      TPL/COB recoveries collected by the contracted providers. These amounts
      should be netted against claims
expenses.

              

      

    

    
      

      314-   Other
Income

    

    
      
        	
                 
      

              	
                Include:   Revenue
      from sources not identified in other revenue categories for NHD Program
      only.

              

      

    

    
      

      
        	
                C.

              	
                Facility
      Care Expenses

              

      

    

    
      Report
expenses for Facility Care Services. Expense must be reported net of patient SOC
contributions, if collected by the nursing facilities. Included in these
expenses are therapeutic leave and bed hold days.

    

    
      

      400-   Skilled
Nursing Facility

    

    
      
        	
                 
      

              	
                Include:   Services
      furnished in a health care facility licensed under Chapter 395 or Chapter
      400, Florida Statutes.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Non-SNF services delivered in the SNF, such as physician services
      etc.

              

      

    

    
      

      402-   Bed
Holds

    

    
      
        	
                 
      

              	
                Include:   Expenses
      incurred for therapeutic leave and bed hold days in a skilled nursing
      facility. Medicaid limits bed holds due to hospitalization to 8 days per
      occurrence and therapeutic leave for family setting visits to 16 days per
      state fiscal year. Due to hospitalization policy, Florida Medicaid has no
      upper limit per year for
      bed holds. Nursing facilities must have less than 95 percent occupancy in
      Medicaid certified beds on the date claimed for the bed hold to be
      reimbursed for bed
holds.

              

      

    

    
      

      Attachment
I - Page 66

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

     

    Amendment 001        Agreement
Number XQ744

    
       

    

    
      404-  Assisted
Living Facility Services

    

    
      
        	
                 
      

              	
                Include:   Personal
      care services, homemaker services, chore services, attendant care,
      companion services, medication oversight, and therapeutic social and
      recreational programming provided in a home-like environment in an
      assisted living facility licensed pursuant to Chapter 429 Part I, Florida
      Statutes, in conjunction with living in the facility. This service does
      not include the cost of room and board furnished in conjunction with
      residing in the facility. This service includes 24-hour on-site response
      staff to meet scheduled or unpredictable needs in a way that promotes
      maximum dignity and independence, and to provide supervision, safety and
      security.

              

      

    

    
      

      D.           Long-Term
Care Support Services

    

    
      

      410-   Hospice

    

    
      
        	
                 
      

              	
                Include:   Expenses
      incurred for palliative and support care for terminally ill members and
      their family, or caregivers.

              

      

    

    
      

      412-   Occupational/Physical/Other
Therapies

    

    
      
        	
                 
      

              	
                Include:   Physical,
      occupational, respiratory, audiology and speech therapy expenses incurred
      for outpatient services.

              

      

    

    
      

      414-   Respite
Care Services

    

    
      Include:   Services
provided to enrollees unable to care for themselves furnished
on a short-term basis due to the absence or need for relief of persons normally
providing the care. Respite care does not substitute for the care usually
provided by a registered nurse, a licensed practical nurse or a therapist.
Respite care is provided in the home/place of residence, Medicaid licensed
hospital, nursing facility, or assisted living facility.

    

    
      

      416-   Personal
Care Services

    

    
      
        	
                 
      

              	
                Include:   Assistance
      with eating, bathing, dressing, personal hygiene, and other activities of
      daily living. This service includes assistance with preparation of meals,
      but does not include the cost of the meals. This service may also include
      housekeeping chores such as bed making, dusting and vacuuming, which is
      incidental to the care furnished or which are essential to the health and
      welfare of the enrollee, rather than the enrollee's
  family.

              

      

    

    
      

      418-   Homemaker
Services

    

    
      
        	
                 
      

              	
                Include:   General
      household activities (meal preparation and routine household care)
      provided by a trained
homemaker.

              

      

    

    
      

      420-   Consumable
Medical Supplies

    

    
      
        	
                 
      

              	
                Include:   The
      provision of disposable supplies used by the enrollee and care giver,
      which are essential to adequately care for the needs of the enrollee.
      These supplies enable the enrollee to perform activities of daily living
      or stabilize or monitor a health condition. Consumable medical supplies
      include adult disposable diapers, tubes of ointment, cotton balls and
      alcohol for use with injections, medicated bandages, gauze and tape,
      colostomy and catheter supplies, and other consumable supplies. Not
      included are items covered under the Medicaid home health service,
      personal toiletries, and household items such as detergents, bleach, and
      paper towels, or prescription
drugs.

              

      

    

    
      

      Attachment
I - Page 67

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001         Agreement
Number XQ744

    

    
      

       

    

    
      

      422-  Adult
Day Health Services

    

    
      
        	
                 
      

              	
                Include:   Services
      provided pursuant to Chapter 400, Part V, Florida Statutes. For example,
      services furnished in an outpatient setting, encompassing both the health
      and social services needed to ensure optimal functioning of an enrollee,
      including social services to help with personal and family problems, and
      planned group therapeutic activities. Adult day health services include
      nutritional meals. Meals are included as a part of this service when the
      patient is at the center during meal times. Adult day health care provides
      medical screening emphasizing prevention and continuity of care including
      routine blood pressure checks and diabetic maintenance checks. Physical,
      occupational and speech therapies indicated in the enrollee's plan of care
      are furnished as components of this service. Nursing services which
      include periodic evaluation, medical supervision and supervision of
      self-care services directed toward activities of daily living and personal
      hygiene are also a component of this service. The inclusion of physical,
      occupational and speech therapy services and nursing services as
      components of adult day health services does not require the contractor to
      contract with the adult day health provider to deliver these services when
      they are included in an enrollee's plan of care. The contractor may
      contract with the adult day health provider for the delivery of these
      services or the contractor may contract with other providers qualified to
      deliver these services pursuant to the terms of this
    contract.

              

      

    

    
      

      424-  Adult
Companion Services

    

    
      
        	
                 
      

              	
                Include:   Non-medical
      care, supervision and socialization provided to a functionally impaired
      adult. Companions assist or supervise the enrollee with tasks such as meal
      preparation or laundry and shopping, but do not perform these activities
      as discreet services. The provision of companion services does not entail
      hands-on nursing care. This service includes light housekeeping tasks
      incidental to the care and supervision of the
  enrollee.

              

      

    

    
      

      426-   Home
Delivered Meals

    

    
      Include:   Nutritionally
sound meals to be delivered to the residence of an enrollee
who has difficulty shopping for or preparing food without assistance. Each meal
is designed to provide 1/3 of the Recommended Dietary Allowance (RDA). Home
delivered meals may be hot, cold, frozen, dried, canned or a combination of hot,
cold, frozen, dried, canned with a satisfactory storage life.

    

    
      

      428-   Chore
Services

    

    
      

      Attachment I
- Page 68

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                 
      

              	
                Include:   Services
      needed to maintain the home as a clean, sanitary and safe living
      environment. This service includes heavy household chores such as washing
      floors, windows and walls, tacking down loose rugs and tiles, and moving
      heavy items of furniture in order to provide safe entry and
      exit.

              

      

    

    
      

      430-  Environmental
Accessibility/Adaptation Services

    

    
      
        	
                 
      

              	
                Include:   Physical
      adaptations to the home required by the enrollee's plan of care which are
      necessary to ensure the health, welfare and safety of the enrollee or
      which enable the enrollee to function with greater independence in the
      home and without which the enrollee would require institutionalization.
      Such adaptations may include the installation of ramps and grab-bars,
      widening of doorways, modification of bathroom facilities, or installation
      of specialized electric and plumbing systems to accommodate the medical
      equipment and supplies which are necessary for the welfare of the
      enrollee. Excluded are those adaptations or improvements to the home that
      are of general utility and are not of direct medical or remedial benefit
      to the enrollee, such as carpeting, roof repair, or central air
      conditioning. Adaptations which add to the total square footage of the
      home are not included in this benefit. All services must be provided in
      accordance with applicable state and local building
  codes.

              

      

    

    
      

      432-  Escort
Services

    

    
      
        	
                 
      

              	
                Include:   Personal
      escort for Enrollees to and from service Providers. An escort may provide
      language interpretation for people who have hearing or speech impairments
      or who speak a language different from that of the Provider. Escort
      Providers assist Enrollees in gaining access to
  services.

              

      

    

    
      

      434-   Family
Training Services

    

    
      
        	
                 
      

              	
                Include:   Training
      and counseling services for the families of enrollees served under this
      contract. For purposes of this service, "family" is defined as the
      individuals who live with or provide care to a person served by the
      contractor and may include a parent, spouse, children, relatives, foster
      family, or in-laws. "Family" does not include persons who are employed to
      care for the enrollee. Training includes instruction and updates about
      treatment regimens and use of equipment specified in the plan of care to
      safely maintain the enrollee at
home.

              

      

    

    
      

      436-   Financial
Assessment/Risk Reduction Services

    

    
      
        	
                 
      

              	
                Include:   Assessment
      and guidance to the caregiver and enrollee with respect to financial
      activities. This service provides instruction for and/or actual
      performance of routine, necessary, monetary tasks for financial management
      such as budgeting and bill paying. In addition, this service also provides
      financial assessment to prevent exploitation by sorting through financial
      papers and insurance policies and organizing them in a usable manner. This
      service provides coaching and counseling to enrollees to avoid financial
      abuse, to maintain and balance accounts that directly relate to
      the

              

      

    

    
      

      Attachment
I - Page 69

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      enrollees
living arrangement at home, or to lessen the risk of nursing home placement due
to inappropriate money management.

    

    
      

      438-  Nutritional
Assessment/Risk Reduction Services

    

    
      Include:   An
assessment, hands-on care, and guidance to caregivers and

    

    
      enrollees
with respect to nutrition. This service teaches caregivers and enrollees to
follow dietary specifications that are essential to the enrollee's health and
physical functioning, to prepare and eat nutritionally appropriate meals and
promote better health through improved nutrition. This service may include
instructions on shopping for quality food and on food
preparation.

    

    
      

      440-  Personal
Emergency Response Systems (PERS)

    

    
      
        	
                 
      

              	
                Include:   The
      installation and service of an electronic device which enables enrollees
      at high risk of institutionalization to secure help in an emergency. The
      PERS is connected to the person's phone and programmed to signal a
      response center once a "help" button is activated. The enrollee may also
      wear a portable "help" button to allow for mobility. PERS services are
      generally limited to those enrollees who live alone or who are alone for
      significant parts of the day and who would otherwise require extensive
      supervision.

              

      

    

    
      

      442-  Other
Long-Term Care Support Services

    

    
      
        	
                 
      

              	
                Include:   All
      other long-term care support services that can not be classified within
      one of the previous categories of
service.

              

      

    

    
      

      E.      Acute
Care Services

    

    
      

      444-   Inpatient
Hospital Services (Hospitalization)

    

    
      
        	
                 
      

              	
                Include:
      Medically necessary services, including ancillary services, furnished to
      inpatient enrollees, provided under the direction of a physician or
      dentist, in a hospital maintained primarily for the care and treatment of
      patients.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Services provided in a facility by a separate registered provider such as
      a physician.

              

      

    

    
      

      446-   Outpatient
Facility Services

    

    
      
        	
                 
      

              	
                Include:   Outpatient
      facility expenses incurred for outpatient services, including ambulatory
      surgical centers.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Services provided in a facility by a separate registered provider such as
      a physician.

              

      

    

    
      

      448-   Emergency
Services

    

    
      
        	
                 
      

              	
                Include:
      Those expenses relating to emergency room services provided on an
      outpatient basis, including any facility
fee.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Services provided in a facility by a separate registered provider such as
      a physician.

              

      

    

    
      

      450-   Primary
Care/Physician Services

    

    
      

      Attachment
I - Page 70

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                       Agreement
Number XQ744

    

    
      

      
        	
                 
      

              	
                Include:   All
      forms of compensation for primary care delivery, including salary,
      capitation, and
fee-for-service.

              

      

    

    
      

      452-  Referral/Specialty
Physician Services

    

    
      
        	
                 
      

              	
                Include:   All
      forms of compensation paid for referral (specialist) physician
      services.

              

      

    

    
      

      454-   Other
Professional Services

    

    
      
        	
                 
      

              	
                Include:   All
      forms of compensation paid for non-physician professional services,
      including advanced registered nurse practitioner services, chiropractic
      services, physician assistant services, registered nurse first assistant
      services, etc.

              

      

    

    
      

      456-  Prescription
Drug

    

    
      
        	
                 
      

              	
                Include:   Prescribed
      drug services for dual eligible Medicaid beneficiaries are covered per the
      Medicare Modernization Act (MMA). However, Section 103(c) of the MMA added
      § 1935(d)(2) to the Social Security Act to allow State Medicaid programs
      to continue to provide and receive Federal Financial Participation (FFP)
      for certain drugs not included in the Medicare Prescription Drug benefit
      (Part D). Drugs excluded from Part D coverage are listed in § 1927(d)(2)
      of the Act. Contractors shall provide certain drugs not included in Part D
      as described in the Medicaid Prescribed Drugs Services and Limitations
      Handbook.

              

      

    

    
      

      458-   Independent
Lab/Radiology/X-Ray

    

    
      
        	
                 
      

              	
                Include:   Medically
      necessary and appropriate diagnostic laboratory procedures and portable
      x-rays ordered by a physician or other licensed practitioner of the
      healing arts as specified in the Independent Laboratory and Portable X-ray
      Services Coverage and Limitations
Handbook.

              

      

    

    
      

      460-   Community
Mental Health Services

    

    
      
        	
                 
      

              	
                Include:   Community-based
      rehabilitative services, which are psychiatric in nature, recommended or
      provided by a psychiatrist or other physician. Such services must be
      provided in accordance with the policy and service provisions specified in
      the Medicaid Community Mental Health Coverage and Limitations Handbook
      except that the provider need not be a community mental health
      center.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Inpatient behavioral health expenses, lab, radiology and psychotropic
      medications and monitoring.

              

      

    

    
      

      462-  Home
Health Care Services

    

    
      
        	
                 
      

              	
                Include:   Intermittent
      or part-time nursing services provided by a registered nurse or licensed
      practical nurse, or personal care services provided by a licensed home
      health aide, with accompanying necessary medical supplies, appliances, and
      durable medical equipment.

              

      

    

    
      

      464-   Vision/Optometric
Services

    

    
      
        	
                 
      

              	
                Include:   Medically
      necessary eye examinations and Eyeglass repairs and adjustments.
      Eyeglasses are limited to two pair every 365
  days.

              

      

    

    
      

      Attachment
I - Page 71

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      Such
services must be provided in accordance with the policy and service provisions
specified in the Medicaid Vision Services Coverage and Limitations
Handbook.

    

    
      

      466-  Durable
Medical Equipment & Supplies

    

    
      
        	
                 
      

              	
                Include:   Medical
      supplies, medical equipment, prosthetic devices, and oxygen expenses
      incurred for outpatient
services.

              

      

    

    
      

      468-   Dialysis

    

    
      Include:   All
expenses incurred for the provision of dialysis services.

    

    
      

      470-   Transportation

    

    
      
        	
                 
      

              	
                Include:   Medically
      necessary transportation expenses incurred for inpatient and outpatient
      services.

              

      

    

    
      

      472-   Dental
Services

    

    
      Include:   Dental
expenses incurred for outpatient services, including outpatient
surgery, prescription drugs, lab, and radiology specifically related to a dental
diagnosis.

    

    
      

      474-  Hearing
Services

    

    
      Include:   Hearing
expenses incurred for outpatient services, including outpatient
surgery, hearing exams, corrective hearing devices, and other services related
to hearing services.

    

    
      

      476-  Home
Health Services

    

    
      
        	
                 
      

              	
                Include:   Expenses
      incurred for medically supervised and physician ordered intermittent
      health maintenance, continued treatment or monitoring of a health
      condition and supporting care with activities of daily living in a home
      and community based setting.

              

      

    

    
      

      478-   Home
Diversion Provider Services

    

    
            Include:   Expanded
services paid by the Contractor on a case-by-case basis.

    

    
      

      480-   Other
Acute Services

    

    
      
        	
                 
      

              	
                Include:   Those
      outpatient expenses not specifically identified in one of the categories
      defined above.

              

      

    

    
      

      F.         Prior
Year OCL Adjustments in Current Year

    

    
      

      482-   Prior
Year OCL Adjustments in Current Year (Prior Period Claim Liability
Adjustment)

    

    
      
        	
                 
      

              	
                Include:   Adjustments
      made within the current year's medical expense for over/under estimation
      of D3NR expenses for prior
years.

              

      

    

    
      

      G.         Case
Management Expense

    

    
      

      490 -
Case Management

    

    
      Include:   Services
which facilitate enrollees gaining access to other needed services
regardless of the funding source for the services, and which contribute to the
coordination and integration of care delivery.

    

    
      

      Attachment
I - Page 72

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                                                                    Agreement
Number XQ744

    

    
      

      H.    Administrative
Expense

    

    
      Those
costs associated with the overall management and operation of the
Contractor.

    

    
      

      500 -
Compensation

    

    
      
        	
                 
      

              	
                Include:   All
      forms of compensation, including employee benefits and taxes, to
      administrative personnel. This includes medical director compensation,
      whether on salary or
contract.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Compensation classified as case management and of any physician or
      contracted provider that bills independently for
  services.

              

      

    

    
      

      502- Data
Processing

    

    
      
        	
                 
      

              	
                Include:   Costs
      for outside data processing services during the period as well as internal
      data processing expenses, other than
  compensation.

              

      

    

    
      

      
        	
                 
      

              	
                Exclude:
      Compensation for any internal data processing personnel as this is
      reported in 500-Compensation.

              

      

    

    
      

      504-   Management
Fees

    

    
      
        	
                 
      

              	
                Include:   Management
      fees paid or payable by the Contractor for the current period to a parent
      or an outside management
company.

              

      

    

    
      

      506 -
Interest Expense

    

    
      Include:   Interest
expense incurred on outstanding debt during the period. Interest income and
interest expense should not be netted together.

    

    
      

      508 -
Occupancy

    

    
      
        	
                 
      

              	
                Include:   Occupancy
      expenses incurred, such as rent and utilities, on facilities that are not
      used to deliver health care services to
members.

              

      

    

    
      

      510-   Marketing

    

    
      
        	
                 
      

              	
                Include:
      Those activities whose intent is to increase membership.  This
      requirement also applies to any marketing costs included in an allocation
      from a parent or other related
corporation.

              

      

    

    
      

      512-
Depreciation

    

    
      
        	
                 
      

              	
                Include:   Depreciation
      on those assets that are not used to deliver health care services to
      members.

              

      

    

    
      

      514-
Other Administration

    

    
      
        	
                 
      

              	
                Include:   Administration
      expenses not specifically identified in the categories
    above.

              

      

    

    
      

      I.      Other Items

    

    
      

      520-  Non-operating
Income (Loss)

    

    
      
        	
                 
      

              	
                Include:   Gains
      and losses on sale of investments and fixed assets during the period and
      any other non-operating income or
loss.

              

      

    

    
      

      530-   Provision
for Income Taxes and/or Premium Taxes

    

    
      Include:   Income
taxes (Federal and State) and premium taxes for the period.

    

    
      

      Attachment
I - Page 73

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      12.8      Income
Statement by Line of Business

    

    
      

      Report 2A
should be reported by each of the requested lines of business: Nursing Home
Diversion, All Other Medicaid, Medicare, and All Other. This report is a
Contractor-wide Income Statement.

    

    
      

      A.        Member
Months

    

    
      

      300-
Member Months

    

    
      
        	
                 
      

              	
                Include:   All
      member months for each line of business. A member month is equivalent to
      one person for whom the Contractor has received capitation revenue for one
      month.

              

      

    

    
      

      B.        Revenues

    

    
      

      310 - Net
Capitation and Premium Revenue

    

    
      
        	
                 
      

              	
                Include:   Revenue
      recognized on a prepaid basis for eligible enrollees and premiums paid by,
      or for, eligible members for covered
services.

              

      

    

    
      

      312-
Fee-For-Service Revenue

    

    
      
        	
                 
      

              	
                Include:   Revenue
      received by the Contractor that are paid for by enrollees or others on a
      fee-for-service basis.

              

      

    

    
      

      314-
Other Health Care Related Revenue

    

    
      
        	
                 
      

              	
                Include:   Revenue
      received by the Contractor for the provision of health care services that
      has not been included in Net Capitation and Premium Revenue or
      Fee-For-Service Revenue.

              

      

    

    
      

      316-   Net
Reinsurance Recovery/Expense

    

    
      
        	
                 
      

              	
                Include:   The
      net amount of reinsurance earned over premiums (or premiums over
      reinsurance earned) as of the statement
date.

              

      

    

    
      

      318 -
Investment/Interest Income

    

    
      
        	
                 
      

              	
                Include:   All
      investment income earned during the period. Interest income and interest
      expense should not be netted
together.

              

      

    

    
      

      320-   All
Other Income and Revenue

    

    
      Include:   Revenue
from sources not identified in other revenue categories.

    

    
      

      C.        Medical
Expense

    

    
      

      330-   Inpatient
and Outpatient Facility Expense

    

    
      
        	
                 
      

              	
                Include:
      All forms of compensation for hospital inpatient, as well as outpatient
      facility expenses incurred for outpatient services, including ambulatory
      surgical centers.

              

      

    

    
      

      332-   Professional
Services

    

    
      Include:   All
forms of compensation for primary care/physician services, referral
(specialist) physician services, an all forms of compensation paid for
professional services, including advanced registered nurse practitioner
services, chiropractic services, physician assistant services, registered nurse
first assistant services, etc

    

    
      

      Attachment
I - Page 74

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      334-  Emergency
Room

    

    
      
        	
                 
      

              	
                Include:   Those
      expenses relating to emergency room services provided on an outpatient
      basis, including any facility
fee.

              

      

    

    
      

      336-  Prescription
Drug

    

    
      Include:   Retail
and mail order pharmacy expenses incurred for outpatient services.

    

    
      

      338-  Long-Term
Care Services

    

    
      Include:   All
services designated as Long-Term Care in Report 2.

    

    
      

      340-   Other
Medical Expense

    

    
      
        	
                 
      

              	
                Include:   Those
      medical expenses that are not specifically identified in one of the
      categories defined above.

              

      

    

    
      

      D.        Case
Management Expense

    

    
      

      350- Case
Management

    

    
      
        	
                 
      

              	
                Include:   Case
      management expenses, including salaries, benefits, travel and training
      expenses for case managers, and case management
    supervisors.

              

      

    

    
      

      E.        Administrative
Expense

    

    
      

      360-
Administration

    

    
      
        	
                 
      

              	
                Include:   All
      costs associated with the overall management and operation of the
      Contractor including: compensation, data processing, management fees,
      interest expenses, occupancy, marketing, depreciation, and other
      administration expenses.

              

      

    

    
      

      F.   Other
Items

    

    
      

      372-   Non-operating
Income (Loss)

    

    
      
        	
                 
      

              	
                Include:   Gains
      and losses on sale of investments and fixed assets during the period and
      any other non-operating income or
loss.

              

      

    

    
      

      374-  Provision
for Income Taxes and/or Premium Taxes

    

    
      Include:   Income
taxes (Federal and State) and premium taxes for the period.

    

    
      

      12.9      Net
Worth and Working Capital

    

    
      

      The Net
Worth (Changes to Equity/Net Assets) Report shows changes to the Contractor's
net assets on a quarterly and annual basis. This report is completed on a
Contractor-Wide basis and not NHD Program Specific. The design of the report is
self-explanatory and serves as the instructions. As indicated on the report,
please provide description to any amounts entered as "other".

    

    
      

      The
Working Capital Analysis section reports the entity's cash flows during the
reporting period. This report is completed on a Contractor-Wide basis and not
NHD Program Specific. The Working Capital Analysis is segregated by sources and
uses of funds. The design of the report is self-explanatory and serves as the
instructions. As indicated on the report, please provide description to any
amounts entered as "other".

    

    
      

      Attachment
I - Page 75

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    
       

    

    
      12.10           Claims
Lag Reports & Outstanding Claims Liability (OCL)

    

    
      This
report should be completed for the NHD Program ONLY.

    

    
      

      The
schedules are arranged with dates of service horizontally and quarter of payment
vertically. Therefore, payments made during the current quarter for services
rendered during the current quarter are reported on row 1, column 3, while
payments made during the current quarter for services rendered in prior quarters
are reported on row 1, columns 4 through 9. Do not include risk pool
distributions or sub-capitation as payments in this schedule. Include these
payments in row 12.

    

    
      

      Payments
and expenses should be reported in this Report consistent with the major expense
categories in Report 2 (Facility Care Expenses, Long-Term Care Support Services,
and Acute Care Services). For example, Facility Care payments and expenses
should include all payments and expenses adjustments for Report 2 account 400
(Skilled Nursing Facility), account 402 (Bed Holds), and account 404 (Assisted
Living Facility Services). As a result the total expense reported for Facility
Care Expenses, row 14, for a given quarter should tie to the expense reported on
Report 2 as Total Facility Care Expenses.

    

    
      

      The
schedules allow for the inclusion of an adjustment (e.g., for provider refunds)
amount to the lag schedule. A general explanation of any adjustments should be
included in the footnotes as well as additional detail if any adjustment is
greater than 10 percent of total medical claims payable.

    

    
      

      12.11           Analysis
of Total Medical Liability to Actual Claims Paid

    

    
      

      This
report should be completed for the NHD Program ONLY.

    

    
      

      Using
tire Contractor's Lag Reports from Report 4, complete the schedule for the
current and previous seven quarters. The report is arranged to illustrate the
difference between the original OCL at the end of the quarter to the claims
subsequently paid for that quarter.

    

    
      

      12.12           Member
Months

    

    
      

      This
report details the member months associated with the NHD Program and All Other
Lines of Business by county. Provide total member months by county for the NHD
Program column and the All Other column (include all other lines-of-business)
for the current quarter and contract year-to-date. The total column will
calculate automatically. A member month is equivalent to one person for whom
tire Contractor has received capitation revenue for one
month.

    

    
      

      12.13           Notes
and Other Information

    

    
      

      Utilize
the Notes and Other Information tab to indicate and provide information that can
not be reported within the main context of the required reports. Please provide
the specific report number and reference of the additional information being
provided.

    

    
      

      12.14           Ratio
Analysis

    

    
      

      This
report summarizes specific ratios utilized by the State to monitor the
Contractor. All information is automatically calculated and no input is required
by the Contractor. The information will not calculate for all ratios if the
Contractor is not required to complete all reports.

    

    
      

      Attachment
I - Page 76

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      12.15    Footnote
Disclosure Requirements

    

    
      

      A.        Footnote
Disclosures

    

    
      

      Footnote
disclosures are required in order to supplement the financial reporting
template. The following list represents expected items that should be disclosed
and included in the Notes and Other Information tab, but is not intended to be
all-inclusive.

    

    
      

      
        	
                1)

              	
                Contractor's
      Organizational Structure: Discuss changes in the organization structure
      and/or location of its
headquarters.

              

      

    

    
      

      
        	
                2)

              	
                Summary
      of Significant Accounting Policies: Discuss changes in accounting policies
      relating to significant balance sheet line items such as, but not limited
      to, cash and cash equivalents, investments and medical claims
      payable.

              

      

    

    
      

      
        	
                3)

              	
                Pledges/Assignments
      and Guarantees: Describe any pledges, assignments, or collateralized
      assets and any guaranteed liabilities not disclosed on the balance
      sheet.

              

      

    

    
      

      
        	
                4)

              	
                Material
      Adjustments: Disclose and describe any material adjustments made during
      the current reporting period, including those adjustments that may relate
      to a prior period, specifically BBNR adjustments, that affect the
      financial statements.

              

      

    

    
      

      
        	
                5)

              	
                Claims
      Payable Analysis: Explain large fluctuations and/or revisions in estimates
      and the factors that contributed to the change in D3NR and RBUC balances
      from the prior quarter. Specifically, address changes in IBNRs and/or Rubs
      of more than 10 percent (on an EBNR or RBUC per member basis).
      Explanations should detail the amount of the adjustments by quarter and by
      county.

              

      

    

    
      

      
        	
                6)

              	
                Contingent
      Liabilities: Provide details of any malpractice or other claims asserted
      against the Contractor, as well as the status of the case, potential
      financial exposure and expected
resolution.

              

      

    

    
      

      
        	
                7)

              	
                Due
      from/to Affiliates (Current and Non-current): Describe, in detail, the
      composition of the due to/from affiliates including the name of the
      affiliate, a description of the affiliation, amount due to/from the
      affiliate and a description of any significant changes to the line
      item.

                 

              
	8) 	 Equity
      Activity:   Disclose all activity in equity, other than net
      income or net loss.

      

    

    
        

    

    
      
        	
                9)

              	
                Prior
      Period Adjustments: Disclose and describe any adjustments made to
      previously submitted financial statements including those adjustments that
      affect the current quarter's financial
  statements.

              

      

    

    
      

      SECTION
13   DEFINITIONS

    

    
      

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

    

    
      

      Action - 42 CFR 438.400 - 1.
The denial or limited authorization of a requested service, including the type
or level of service. 2. The reduction, suspension, or termination of a
previously authorized service: 3. The denial, in whole or in part, of payment
for a service. 4. The failure to provide services in a timely

    

    
      

      Attachment
I - Page 77

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      manner,
as defined by the state. 5. The failure of the plan to act within the timeframes
provided in 42 CFR 438.408(b). 6. For a resident of a rural area with only one
managed care entity, the denial of a Medicaid enrollee's request to exercise his
or her right, under 42 CFR 438.52(b)(2)(h), to obtain services outside the
network

    

    
      

      APL
- Activities of Daily Living; include, dressing, grooming, bathing, eating,
transferring in and out of bed or a chair, walking, climbing stairs, toileting,
bladder/bowel control, and the wearing and changing of incontinent
briefs.

    

    
      

      Advance
Directives- refers to oral and written instructions authorizing another
to act as one's agent or attorney regarding future medical care. (Examples:
Living Will and Durable Power of Attorney)

    

    
      

      Adverse
Determination - Adverse determination
means any instance in which coverage for the requested service is denied,
reduced, or terminated. The contractor's decision to deny, reduce or terminate
coverage must be based on the review of whether an admission, availability of
care, continued stay, or other service required in accordance with this contract
meets the contractor's requirements for medical necessity, appropriateness,
health care setting, level of care, or effectiveness.

    

    
      

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

    

    
      

      Ancillary
Services - Services provided at a hospital include, but are not limited
to, radiology, pathology, neurology, and anesthesiology as specified in the
Hospital Coverage and Limitations Handbook.

    

    
      

      Appeal - 42 CFR 438.400 - A request
for review of action.

    

    
      

      Area
Agency on Aging
- an agency designated by the department to develop and administer a plan
for a comprehensive and coordinated system of services for older
persons.

    

    
      

      Assessment -an individualized
comprehensive appraisal of an individual's medical, developmental, mental,
social, financial, and environmental status conducted by a qualified individual
for the purpose of determining the need for long term care
services.

    

    
      

      Benefits - a schedule of medical or
social services to be delivered to enrollees covered under this
contract.

    

    
      

      CMS - Centers for Medicare and
Medicaid Services.

    

    
      

      Capitation
Rate - the monthly fee paid by the Agency to the contractor for each
enrollee enrolled under the contract for the provision of services during the
payment period.

    

    
      

      Care
Plan - See Plan of Care.

    

    
      

      CASES
- Comprehensive Assessment and Review for Long Term Care Services. A nursing
home pre-admission assessment program, which provides a comprehensive, on-site
assessment of individuals seeking admission to a nursing home under a state
assisted program. The program explores all available options to nursing home
placement and recommends, and may facilitate alternative placements for
individuals who are determined able to remain in the
community.

    

    
      

      CFR - Code of Federal
Regulations.

    

    
      

      Cold-call
marketing -
Any unsolicited personal contact by the contractor or subcontractors with a
potential enrollee for the purpose of marketing.

    

    
      

      Complaints - See
Grievance

    

    
      

      Contractor - the organizational entity
serving as the primary contractor and with whom tins agreement is executed. The
term contractor shall include all employees, subcontractors, agents, volunteers,
and anyone acting on behalf of, in the interest of, or for a
contractor.

    

    
      

      Covered
Services -
see Benefits.

    

    
      

      Attachment
I - Page 78

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001.        Agreement
Number XQ744

    

    

    
      

      Department - Department of Elder
Affairs.

    

    
      DCF- Department of Children
and Families

    

    
      DHHS - United States
Department of Health and Human Services.

    

    
      Disenrollment - the discontinuance of
an enrollee's membership in the contractor's plan.

    

    
      

      Durable
Medical Equipment - medical equipment
that can withstand repeated use; is primarily and 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 recipient's home.

    

    
      

      Emergency
Medical Condition - according to 42 CFR
438.114(a) means a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in the
following:

    

    
      
        	
                (1)

              	
                Placing
      the health of the individual (or, with respect to a pregnant woman, the
      health of the woman or  her unborn child) in serious
      jeopardy.

              
	(2)	Serious
      impairment to bodily functions.
	(3)	Serious
      dysfunction of any bodily organ or
part.

      

    

    
                     

    

    
      Emergency
Services -
according to 42 CFR 438.114(a) means covered inpatient and outpatient services
that are as follows:

    

    
      (1)        Furnished
by a provider that is qualified to furnish these services under this title.

    

    
      (2)        Needed
to evaluate or stabilize an emergency medical condition. 

    

    
      

      Enrollee - according to 42 CFR
438.10(a) means a Medicaid recipient who is currently enrolled in a MCO as
defined in 42 CFR 438.10(a). See "Member."

    

    
      

      Enrollment - the process by which
an eligible Medicaid recipient becomes an enrollee in the Long Term Care
Community Diversion Pilot Project.

    

    
      

      Existing
diversion provider - an entity that is approved by the department on or
before June 30,2007, to provide services to consumers through any Long-Term Care
Community Diversion Pilot Project authorized under Chapter 430.701- 430.709,
F.S..

    

    
      

      Extraordinary
Reporting - reporting of
awareness or discovery of conditions that may materially affect the contractor's
ability to perform services under this contract.

    

    
      

      Facility - any
premises (a) owned, leased, used or operated directly or indirectly by or for
the contractor or its affiliates for purposes related to this contract; or (b)
maintained by a sub-contractor to provide services on behalf of the
contractor.

    

    
      

      Fair
Hearing -
the opportunity to present one's case to a reviewing authority in accordance
with the terms and conditions in 42 CFR Part 431, State Organization and General
Administration, Subpart E, and 59G-1.030, Florida Administrative
Code.

    

    
      

      Fiscal
Agent - any
corporation or other legal entity that has contracted with the Agency to
receive, process and adjudicate claims under the Medicaid
program.

    

    
      

      FMMIS- Florida Medicaid Management
Information System, Medicaid fiscal agent utilizes this system for all Medicaid
related data and information.

    

    
      

      Furnished
- means supplied, given, prescribed, ordered, provided, or directed to be
provided in any manner.

    

    
      

      Grievance - means an expression of
dissatisfaction about any matter other than an action, as "action" is defined in
this section. The term is also used to refer to the overall system that includes
grievances and appeals handled at the contractor level and access to the
Medicaid fair hearing process. (Possible subjects for grievances include, but
are not limited to, the quality of care or services provided, and aspects
of

    

    
      

      Attachment
I - Page 79

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                           Agreement
Number XQ744

    

    
      

      interpersonal
relationships such as rudeness of a contractor or employee, or failure to
respect the enrollee's rights.) (42 CFR 438.2)

    

    
      

      Grievance
Procedure -
the procedure for addressing enrollees' grievances. A grievance is an enrollee's
expression of dissatisfaction with any aspect of their care other than the
appeal of actions (which is an appeal).

    

    
      

      Grievance
System - the
system for reviewing and resolving enrollee grievances or appeals. Components
must include a grievance process, an appeal process, and access to the Medicaid
fair hearing system.

    

    
      

      Grievant - an enrollee,
subcontractor, or other service provider that files a grievance with the
contractor.

    

    
      

      Health
Care Professional - means a physician or
any of the following: a 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), licensed certified
social worker, registered respiratory therapist, and certified respiratory
therapy technician.

    

    
      

      HMO - Health Maintenance
Organization as certified pursuant to Chapter 641, F.S..

    

    
      

      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.

    

    
      

      IADL - Instrumental
Activities of Daily Living; include making and answering telephone calls,
shopping, transportation ability, preparing meals, laundry, light housekeeping,
heavy chores, taking medication, and managing money.

    

    
      

      ICP - The Medicaid
Institutional Care Program.

    

    
      

      Ineligible
Recipient -
a Medicaid recipient that does not qualify for enrollment in the Long Term Care
Community Diversion Program.

    

    
      

      Insolvency/Insolvent - 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.

    

    
      

      Lead
Agency -
means an entity designated by an area agency on aging and given the authority
and responsibility to coordinate services for functionally impaired elderly
persons.

    

    
      

      Long-Term
Care Record - a record that includes
information regarding the medical and long-term care services an enrollee is
receiving including the plan of care and documentation of case management
activities including efforts to coordinate and integrate the delivery of all
services to the enrollee.

    

    
      

      Marketing - any activity conducted
by or on behalf of the contractor where information regarding the services
offered by the contractor is disseminated in order to encourage eligible
enrollees to enroll or accept any application for enrollment in the Long Term
Care Community Diversion Program developed under this
contract.

    

    
      

      Medicaid - the medical assistance
program authorized by Title XIX of the federal Social Security Act, 42 U.S.C.
s.1396 et seq., and regulations there under, as administered in this state by
the Agency under Chapter 409.901 et seq., F.S.

    

    
      

      Medicaid
HMO - an HMO
as defined in the Medicaid State Plan.

    

    
      

      Medically
Necessary or Medical Necessity - services provided in
accordance with 42 CFR 438.210(a)(4) and as defined in Section 59G-1.010(166),
F.A.C., to include that medical or allied care, goods, or services furnished or
ordered must: A. Meet the following conditions:

    

    
      

      Attachment
I - Page 80

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      
        	
                1.

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

              

      

    

    
      
        	
                2.

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

              

      

    

    
      
        	
                3.

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

              

      

    

    
      
        	
                4.

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

              

      

    

    
      
        	
                5.

              	
                Be
      furnished in a manner not primarily intended for the convenience of the
      recipient, the recipient's caretaker, or the
  contractor.

              

      

    

    
      
        	
                B.

              	
                "Medically
      necessary" or "medical necessity" for inpatient hospital services requires
      that those  services furnished in a hospital on an inpatient
      basis could not, consistent with the provisions of  appropriate
      medical care, be effectively furnished more economically on an outpatient
      basis or in  an inpatient facility of a different
      type.

              

      

    

    
      
        	
                C.

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

              

      

    

    
      

      Medicare
- the medical assistance program authorized by Title XVIII of the federal Social
Security Act, 42 U.S.C. s. 1395 et seq., and regulations there
under.

    

    
      

      Nursing
Facility - an institutional care facility licensed under Chapter 395,
F.S., or Chapter 400, F.S., that furnishes medical or allied inpatient care and
services to individuals needing such services.

    

    
      

      Other
Qualified Provider - a contracted provider who meets the qualifications
of Chapter 430.703(7), F.S..

    

    
      

      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 24-hour period regardless of the hour of admission, whether or not a bed is
used, or whether or not the patient remains in the facility past
midnight.

    

    
      

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

    

    
      

      Plan of
Care - A plan which describes the service needs of each recipient,
showing the projected duration, desired frequency, type of provider furnishing
each service, and scope of the services to be provided.

    

    
      

      Potential
Enrollee - according to 42 CFR 438.10(a) means a Medicaid recipient who
is subject to mandatory enrollment or may voluntarily elect to enroll in a given
managed care program, but is not yet an enrollee of a specific managed care
program.

    

    
      

      Prepaid
Health Plan or Plan - the prepaid health care plan developed by the
contractor in performance of its duties and responsibilities under this
contract; or a contractual arrangement between the Agency and a comprehensive
health care contractor for the provision of Medicaid care, goods, or services on
a prepaid basis to Medicaid recipients.

    

    
      

      Primary
Care Physician - a
Medicaid-participating or prepaid health plan-affiliated physician practicing as
a general or family practitioner, internist, pediatrician, obstetrician,
gynecologist, 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.

    

    
       

      Project
- Long Term Care Community Diversion Program.

    

    
       

      Protocols
- written guidelines or documentation outlining steps to be followed for
handling a

    

    
      

      Attachment
I - Page 81

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      particular
situation, resolving a problem, or implementing a plan of medical, social,
nursing, psycho social, developmental and educational
services.

    

    
      

      Provider
- a
person or entity who is responsible for or directly provides any medical or
social services authorized by this contract.

    

    
      

      Provider
Handbook - a
document that provides information to a Medicaid provider regarding enrollee
eligibility, claims submission and processing, provider participation, covered
care, goods, or services and limitations, procedure codes and fees, and other
matters related to Medicaid program participation.

    

    
      

      Quality
Assurance -
the process of assuring that the delivery of health care is appropriate, timely,
accessible, available, and medically necessary.

    

    
      

      Recipient - any individual whom
the Department of Children and Families 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 is enrolled in
the Medicaid program.

    

    
      

      Risk - the potential for loss
that is assumed by an entity and that may arise because the cost of providing
care, goods, or services may exceed the capitation or other payment made by the
Agency to the plan under terms of the contract.

    

    
      

      Service
Area - the
designated geographical area within which the contractor is authorized by
contract to furnish covered services to enrollees and within which the enrollees
reside.

    

    
      

      State - State of
Florida.

    

    
      

      Subcontract - an agreement entered
into by a contractor for the provision of benefits to enrollees or to perform
any administrative function or service for the contractor specifically related
to securing or fulfilling the contractor's obligations under this contract.
Subcontracts include, but are not limited to the following: agreements with all
providers of medical or ancillary services, unless directly employed by the
contractor; management or administrative agreements; third party billing or
other indirect administrative/fiscal services, including provision of mailing
lists or direct mail services; and any contract which benefits any person with a
control interest in the contractor's organization.

    

    
      

      Subcontractor - any person to which
the contractor has contracted or delegated some of its functions, services or
its obligations under this contract.

    

    
      

      Surplus - Net worth, i.e., total
assets minus total liabilities. Surplus has the same meaning as in Chapter
641.19(19), F.S..

    

    
      

      Attachment
I - Page 82

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      Third
Party Resources - an individual, entity, or program, excluding Medicaid,
that is, may be, could be, should be, or has been liable for all or part of the
cost of medical services related to any medical assistance covered by Medicaid.
An example is an individual's auto insurance company, which typically provides
payment of some medical expenses related to automobile accidents and
injuries.

    

    
      

      Transportation
- an appropriate means of conveyance furnished to an enrollee to obtain services
authorized under this contract.

    

    
      

      Transition
Care Services - services necessary in order to safely maintain a person
in the community both prior to and after the effective date of their enrollment
in the project until the initial Plan of Care is implemented.

    

    
      

      Transition
Period - the
period of time from the effective date of enrollment until the initial Plan of
Care is effective,

    

    
      

      Urgent
Grievance - an adverse determination when the standard timeframe of the
grievance procedure would seriously jeopardize the life or health of an
enrollee, or the enrollee's ability to regain maximum
function.

    

    
      

      Violation
- each determination by the department and/or Agency that a contractor failed to
act as specified in the contract or in applicable statutes or rules governing
Medicaid prepaid health plans. Each day that an ongoing violation continues may
be considered for the purposes of this contract to be a separate violation. In
addition, each instance of failing to furnish necessary and/or required services
Or items to enrollees is considered for purposes of this contract to be a
separate violation.

    

    
      

      Attachment
I - Page 83

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001                                    Agreement
Number XQ744

       

    

    
      EXHIBIT
A

    

    
      MULTIPLE
SIGNATURE VERIFICATION AGREEMENT  

       

      Account
Number: _______________________

    

    
      

      In
consideration of the mutual promises and undertakings expressed herein, this
Agreement is entered into between
______________________________Bank ("Bank") and_______________Long-Term
Care Diversion Provider ("Provider"), effective
as_____________________________of the ________day of ________,
20___.

    

    
      

    

    
      1.               Provider
is opening the Bank business investment account referenced by number above ("the
Account"), pursuant to the conditions contained in the agreement entered between
Provider and the Office of the Secretary of the Department of Elder Affairs,
State of Florida Department of Elder Affairs ("DOEA") dated September
1,   20.

    

    
      

    

    
      2.               Pursuant
to its agreement with DOEA, Provider desires', and Bank agrees to provide, a
"hold" on the account so that withdrawals may be made only by properly
authorized written request, and upon manual examination of the requests, which
service shall be subject to the terms and restrictions set forth
below.

    

    
      

      3.          Bank
will only honor written requests for withdrawals that bear the signatures of two
authorized representatives of DOEA and two signatures of authorized
representatives of Provider. DOEA and Provider will provide to Bank examples of
the signatures of the authorized representatives.

    

    
      

      4.          Provider
will present the written, properly executed requests for withdrawal to
_______________________, at _______________________ Bank,
located at  ____________, Florida, _____________ , between
the hours of
8:00 am and 4:00 pm, EST, during banking business days. The request will contain
the Account number, the amount of the funds to be withdrawn, a description of
the payee who shall receive the funds, and the signatures of two authorized
representatives of DOEA and two signatures of authorized representatives of
Provider.

    

    
      

      5.          Bank
agrees to review the requests; draft the Account for the amount of the requested
withdrawal, and prepare a Bank Official Check in the withdrawn amount, in
accordance with the terms of the request. Bank agrees to undertake the above and
make the Check available to Provider no later than the close of the banking day
following the banking day in which the request was presented to Bank in
accordance with Paragraph 4, above. [Optional language: Provider agrees to pay
to Bank a fee of $5.00 for each Official Bank Check issued.]

    

    
      

      6.          Bank
shall return to Provider any request that does not meet the above-described
requirements. Bank shall have the sole discretion to determine whether the
requirements have been met.

    

    
      

      7.          Pursuant
to its agreement with DOEA, Provider agrees that in the event that DOEA
determines Provider to be insolvent and notifies Bank of its determination, DOEA
may make withdrawals on the account by two authorized representatives of DOEA,
without authorized signatures from Provider. Bank shall not be responsible or
liable for determining insolvency. Bank shall not be required to permit
withdrawals upon the sole order of DOEA until written notification is received
from DOEA at the address described in Paragraph 4, and Bank has had a reasonable
time to act thereon but in no event later than two (2) business
days.

    

    
      

      8.          Except
to the extent that Bank is negligent in performing its duties under this
Agreement, Provider shall indemnify and hold Bank harmless against any claim,
loss, liability, damage, cost or expense (including reasonable attorneys' fees
incurred by Bank) arising out of or in any way relating to Bank's compliance
with the terms of this Agreement.

    

    
      

      9.          This
Agreement shall supplement the Bank Deposit Agreement, any corporate or other
resolution of Provider relating to the Account, and any other agreements or
terms affecting the Account. All legal rights and obligations of Provider and
Bank under such other documents and pursuant to any applicable laws and banking
regulations shall remain in effect, except as expressly modified by this
Agreement.

    

    
      

      10.          This
Agreement shall be executed by all currently authorized signers on the Account,
and it shall continue in effect notwithstanding any subsequent change of
authorized signers, and without any requirement that it be re-executed or
amended.

    

    
      

      Attachment
I - Page 84

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    
      Amendment
001        Agreement
Number XQ744

    

    

    
      

      11.           This
Agreement may be terminated at any time by Bank or Provider, provided Provider
provides Bank written approval from DOEA, and provided that the indemnification
provision of paragraph 7 above shall continue in effect after any such
termination with respect to any withdrawals or requests handled by Bank prior to
such termination. This Agreement shall be binding upon and shall inure to the
benefit of any successors and assigns of Provider, DOEA, and
Bank.

    

    
      

      The
undersigned parties have executed this Agreement through their duly authorized
representatives as of the date shown above.

    

    
      

      BANK

    

    
      

      By:                                                

    

    
      Title:                                      :           

    

    
       

      PROVIDER

    

    
      

      By:                                                

    

    
      Title:                                       

    

    
      

      PROVIDER'S
CERTIFICATION OF AUTHORITY

    

    
      

      The
undersigned hereby certifies that: (1) (s)he is the Secretary of
__________________________________ Provider; and (2) the foregoing
Agreement is consistent with any corporate or other resolution(s) of Provider
previously or contemporaneously provided to Bank.

    

    
      

      By:                                                

    

    
      Title:                                                

    

    
      

      Date of
Certification:                                                

    

    
      

      [Affix
corporate seal]

    

    
      

      AUHORIZED
SIGNATURES

    

    

    
      	
              
                PROVIDER:
      _________________________________

              

            	
              
                DEPARTMENT
      OF ELDER AFFAIRS

              

            
	
              
                Title
      Print Name:______________________________

              

            	
              
                Deputy
      Secretary Print Name:
  ______________________________

              

            
	 
      	 
      
	
              
                Title
      Print Name: ______________________________

              

            	
              
                Chief
      Financial Officer Print Name:
      ______________________________

              

            
	 
      	 
      
	
              
                Title
      Print Name: ______________________________

              

            	
              
                Print
      Name: ______________________________

              

            
	 
      

    

    
      

      Attachment
I - Page 85

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      Amendment
001         Agreement
Number XQ744

    

    
      

      EXHIBIT
B

    

    
      

      Long-Term
Care Community Diversion Pilot Project

    

    
      

      Disenrollment
Summary Report

    

    
      

      (Plan
Name)

    

    
      

      (Reporting
Month)

    

    
      

      Were any
disenrollments filed during this reporting month?  YES □NO
□

    

    
      

      DISENROLLMENT

    

    

    
      	 
      	
              
                Last
      Name

              

            	
              
                First
      Name

              

            	
              
                Medicaid
      ID#

              

            	
              
                County
      Name

              

            	
              
                Provider
      Number

              

            	
              
                Disenrollment
      Reason Code*

              

            	
              
                Disenrollment

              

              
                Reason

              

              
                Occurrence
      Date

              

            
	
              
                1

              

            	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
              
                2

              

            	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
              
                3

              

            	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
              
                4

              

            	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
              
                5

              

            	 
      	 
      	 
      	 
      	 
      	 
      	 
      

    

    
      

    

    
      
        	
                ·  

              	
                Disenrollment
      Reason Codes:

              

      

    

    
      

    

    
      	
              
                 

                EXP
      = Death

              

               

            	
              FRD
      = Fraudulent use of Medicaid or plan ID card

            	
              NET
      = Moved to an out-of-network nursing home

            
	
              ELG
      = Lost Medicaid eligibility

            	
              INC
      = Incarceration

            	
              ALF
      = Moved to an out-of-network ALF

            
	
              PRJ
      = Lost project eligibility

            	
              SDA
      = Subject to DOEA approval

            	
              OUT
      = No longer wish to participate in diversion program

            
	
              CTY
      = Moved outside of contractor's service area

            	
              S
      VR = Dissatisfaction with quality and/or quantity of
    services

            	
              JFR
      = Transfer to another provider

            

    

    
      

      SUMMARY

    

    
      

      Total
Disenrollments:__________________

    

    
      

      Attachment!
- Page 86

    

    

    
      
        
           

        

        
           

          
            

          

        

        
           

        

      

    

    

    

    
      

      Amendment
001        Agreement
Number XQ744

    

    

    
      

      EXHIBIT
C

    

    
      

      Encounter
Data Reporting Format

    

    
      

      Service
Utilization Reporting

    

    
      

      The plan
shall provide recipient-specific service utilization data in the electronic
format as specified below. The service utilization data reported represents the
comprehensive array of services that might be necessary to maintain a member at
home while avoiding nursing home placement, including acute and long-term care
services.

    

    
      

      These
data must be provided as reported quarterly in two ASCII fixed-length text
files. One file will contain long-term care services and a separate file will
contain acute care services. Each file will contain one row/record for each
enrollee for each month they receive services. For example, if an enrollee was
enrolled for an entire quarter, you would include three separate rows/records in
each of the two files submitted for the quarter, where each row represents
services received during the one-month period. The acute care services would be
recorded in one file and long-term care services would be reported in the other.
These two files, the Long-Term Care Services file and the Acute Care Services
file, must be submitted once every quarter to your DOEA contract manager. You
have up to three months after the last month in a specific quarter to submit the
quarterly files. Contractors must also resubmit the Acute Care Services and the
Long-Term Care Services files for the previous quarter with the most-up-to-date
claim data along with the current quarter files.

    

    
      

      If no
units of service are provided in a particular category or if the category is not
applicable to you, fill that field with the specified number of spaces (using
the spacebar) that match that particular field length. Right justify all fields
unless noted otherwise. For amount paid, include the sum of Medicaid and
Medicare crossover claims (deductibles and co-payments for Medicare claims).* If
you have questions about the definitions of these services please reference the
appropriate Medicaid coverage and limitations handbook for Medicaid State Plan
Services. Note: Please do not use commas between fields and round currency to
the nearest dollar amount.

    

    
      

      For
individuals designated "Medicaid Pending" who do not yet have a Medicaid ID, the
Medicaid ID field must be set to "PENDING".

    

    
      

      The
contractors shall use the data validation software provided by the department to
generate data validation reports for long-term care and acute care services. All
"red flag" items on the data validation reports must be corrected or certified
by the contractor. The contractor shall submit one password protected zipped
file that includes the long-term and acute care services data files, validation
report files, and if applicable, certification files. The contractor shall
adhere to the file-naming format located below.

    

    
      

      

    

    
      

       FILE
1:   Long-Term Care Services

       

    

    
      	
              
                Field
      Name

              

            	
              
                Description

              

            	
              
                Unit
      of Measurement

              

            	
              
                Field
      Length

              

            	
              
                Start
      Col.

              

            	
              
                End
      Col.

              

            	
              
                Text/Numeric

              

            
	
              
                SSN

              

            	
              
                Social Security Number Cleft
      justify)

              

            	
              
                000000000

              

            	
              
                9

              

            	
              
                1

              

            	
              
                9

              

            	
              
                Numeric

              

            
	
              
                MEDICAID

              

            	
              
                Medicaid ID Number

              

            	
              
                0000000000

              

            	
              
                10

              

            	
              
                10

              

            	
              
                19

              

            	
              
                Numeric

              

            
	
              
                ENROLL

              

            	
              
                Initial Date of Program
      Enrollment

              

            	
              
                MMYYYY

              

            	
              
                6

              

            	
              
                20

              

            	
              
                25

              

            	
              
                Numeric

              

            
	
              
                DISENROL

              

            	
              
                Date of Disenrollment,  if
      Applicable

              

            	
              
                MMYYYY

              

            	
              
                6

              

            	
              
                26

              

            	
              
                31

              

            	
              
                Numeric

              

            
	
              
                REINST

              

            	
              
                Reinstate date

              

            	
              
                MMYYYY

              

            	
              
                6

              

            	
              
                32

              

            	
              
                37

              

            	
              
                Numeric

              

            
	
              
                ALF

              

            	
              
                ALF Resident
Indicator

              

            	
              
                l=Yes: 2=No

              

            	
              
                1

              

            	
              
                38

              

            	
              
                38

              

            	
              
                Numeric

              

            
	
              
                MONTH

              

            	
              
                Report Month

              

            	
              
                MMYYYY

              

            	
              
                6

              

            	
              
                31

              

            	
              
                44

              

            	
              
                Numeric

              

            
	
              
                ADMINS

              

            	
              
                Administrative Costs

              

            	
              
                Amount Paid

              

            	
              
                6

              

            	
              
                «

              

            	
              
                50

              

            	
              
                Numeric

              

            

    

    
      

      *
Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
enrollees who are also eligible for Medicare.

    

    
      

      Attachment
1 - Page 87

       

      

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001

        

        
          

          Agreement
Number XQ744

        

        

        
          	
                  
                    Field
      Name

                  

                	
                  
                    Description

                  

                	
                  
                    Unit
      of Measurement

                  

                	
                  
                    Field
      Length

                  

                	
                  
                    Start
      Col.

                  

                	
                  
                    End
      Col.

                  

                	
                  
                    Text/Numeric

                  

                
	
                  
                    Lone-term
      care SERVICES

                  

                	
                  
                    DESCRIPTION

                  

                	
                  
                    UNIT
      OF SERVICE/ COST

                  

                	 
      	 
      	 
      	 
      
	
                  
                    ADCOMP

                  

                	
                  
                    Adult
      Companion Services

                  

                	
                  
                    IS
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    51

                  

                	
                  
                    H

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ADCOMPS

                  

                	
                  
                    Adult
      Companion Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    55

                  

                	
                  
                    60

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ADAYHLTH

                  

                	
                  
                    Adult
      Day Health Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    16

                  

                	
                  
                    64

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ADAYHLS

                  

                	
                  
                    Adult
      Day Health Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    65

                  

                	
                  
                    70

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ALFSVS

                  

                	
                  
                    Assisted
      Living Services

                  

                	
                  
                    Days

                  

                	
                  
                    2

                  

                	
                  
                    71

                  

                	
                  
                    72

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ALFSVSSS

                  

                	
                  
                    Assisted
      Living Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    73

                  

                	
                  
                    78

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ATTCARE

                  

                	
                  
                    Attendant
      Care Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    79

                  

                	
                  
                    82

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ATTCARES

                  

                	
                  
                    Attendant
      Care Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    83

                  

                	
                  
                    88

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CASEAID

                  

                	
                  
                    Case
      Aide

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    89

                  

                	
                  
                    92

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CASEAIDS

                  

                	
                  
                    Case
      Aide

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    93

                  

                	
                  
                    98

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CASEMGMT

                  

                	
                  
                    Case
      Management (Internal)

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    99

                  

                	
                  
                    102

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CASEMGTS

                  

                	
                  
                    Case
      Management (Internal)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    103

                  

                	
                  
                    108

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CHORE

                  

                	
                  
                    Chore
      Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    2

                  

                	
                  
                    109

                  

                	
                  
                    110

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CHORES

                  

                	
                  
                    Chore
      Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    111

                  

                	
                  
                    116

                  

                	
                  
                    Numeric

                  

                
	
                  
                    COM
      MH

                  

                	
                  
                    Community
      Mental Health

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    117

                  

                	
                  
                    118

                  

                	
                  
                    Numeric

                  

                
	
                  
                    COM
      MH8

                  

                	
                  
                    Community
      Mental Health

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    119

                  

                	
                  
                    124

                  

                	
                  
                    Numeric

                  

                
	
                  
                    CNMS
      SS

                  

                	
                  
                    Consumable
      Medical Supplies

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    125

                  

                	
                  
                    130

                  

                	
                  
                    Numeric

                  

                
	
                  
                    COUNSEL

                  

                	
                  
                    Counseling

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    131

                  

                	
                  
                    134

                  

                	
                  
                    Numeric

                  

                
	
                  
                    COUNSELS

                  

                	 
      	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    135

                  

                	
                  
                    140

                  

                	
                  
                    Numeric

                  

                
	
                  
                    DME
      SS

                  

                	
                  
                    Durable
      Medical Equipment

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    141

                  

                	
                  
                    146

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ENVHUA

                  

                	
                  
                    Environmental
      Accessibility Adaptations

                  

                	
                  
                    Job

                  

                	
                  
                    2

                  

                	
                  
                    147

                  

                	
                  
                    148

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ENVIRRAAS

                  

                	
                  
                    Environmental
      Accessibility Adaptations

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    149

                  

                	
                  
                    154

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ESCORT

                  

                	
                  
                    Escort
      Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    155

                  

                	
                  
                    158

                  

                	
                  
                    Numeric

                  

                
	
                  
                    ESCORTS

                  

                	
                  
                    Escort
      Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    159

                  

                	
                  
                    164

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FAMT
      I

                  

                	
                  
                    Family
      Training Services (Individual)

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    2

                  

                	
                  
                    165

                  

                	
                  
                    166

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FAMT
      IS

                  

                	
                  
                    Family
      Training Services (Individual)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    167

                  

                	
                  
                    172

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FAMT
      G

                  

                	
                  
                    Family
      Training Services (Group)

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    2

                  

                	
                  
                    173

                  

                	
                  
                    174

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FAMT
      GS

                  

                	
                  
                    Family
      Training Services (Group)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    175

                  

                	
                  
                    180

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FINARRS

                  

                	
                  
                    Financial
      Assessment/Risk Reduction Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    181

                  

                	
                  
                    184

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FINARRS

                  

                	
                  
                    Financial
      Assessment/Risk Reduction Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    185

                  

                	
                  
                    190

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FINM
      RRS

                  

                	
                  
                    Financial
      Maintenance/Risk Reduction Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    191

                  

                	
                  
                    194

                  

                	
                  
                    Numeric

                  

                
	
                  
                    FMM
      RRS

                  

                	
                  
                    Financial
      Maintenance/Risk Reduction Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    195

                  

                	
                  
                    200

                  

                	
                  
                    Numeric

                  

                
	
                  
                    HDMEAL

                  

                	
                  
                    Home
      Delivered Meals

                  

                	
                  
                    Meal

                  

                	
                  
                    2

                  

                	
                  
                    201

                  

                	
                  
                    202

                  

                	
                  
                    Numeric

                  

                
	
                  
                    HDMEALS

                  

                	
                  
                    Home
      Delivered Meals

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    203

                  

                	
                  
                    208

                  

                	
                  
                    Numeric

                  

                
	
                  
                    HOMESRVS

                  

                	
                  
                    Homemaker
      Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    209

                  

                	
                  
                    212

                  

                	
                  
                    Numeric

                  

                
	
                  
                    HOMESRVCS

                  

                	
                  
                    Homemaker
      Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    213

                  

                	
                  
                    218

                  

                	
                  
                    Numeric

                  

                
	
                  
                    MH
      CM

                  

                	
                  
                    Mental
      Health Case Management

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    219

                  

                	
                  
                    222

                  

                	
                  
                    Numeric

                  

                
	
                  
                    MH
      CMS

                  

                	
                  
                    Mental
      Health Case Management

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    223

                  

                	
                  
                    228

                  

                	
                  
                    Numeric

                  

                
	
                  
                    SNF

                  

                	
                  
                    Nursing
      Facility Services- Long-term

                  

                	
                  
                    Days

                  

                	
                  
                    2

                  

                	
                  
                    229

                  

                	
                  
                    230

                  

                	
                  
                    Numeric

                  

                
	
                  
                    SNFSS

                  

                	
                  
                    Nursing
      Facility Services-Long-term

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    231

                  

                	
                  
                    236

                  

                	
                  
                    Numeric

                  

                
	
                  
                    NUTR
      RRS

                  

                	
                  
                    Nutritional
      Assessment/Risk Reduction Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    14

                  

                	
                  
                    237

                  

                	
                  
                    240

                  

                	
                  
                    Numeric

                  

                
	
                  
                    NUTR
      RRS

                  

                	
                  
                    Nutritional
      Assessment/Risk Reduction Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    241

                  

                	
                  
                    246

                  

                	
                  
                    Numeric

                  

                
	
                  
                    OT

                  

                	
                  
                    Occupational
      Therapy

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    247

                  

                	
                  
                    250

                  

                	
                  
                    Numeric

                  

                
	
                  
                    OTS

                  

                	
                  
                    Occupational
      Therapy

                  

                	 
      	
                  
                    6

                  

                	
                  
                    251

                  

                	
                  
                    256

                  

                	 
      
	
                  
                    PCS

                  

                	
                  
                    Personal
      Care Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    257

                  

                	
                  
                    260

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PCS

                  

                	
                  
                    Personal
      Care Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    261

                  

                	
                  
                    266

                  

                	 
      
	
                  
                    PERS
      I

                  

                	
                  
                    Personal
      Emergency Response System Installation

                  

                	
                  
                    Job

                  

                	
                  
                    2

                  

                	
                  
                    267

                  

                	
                  
                    268

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PERS
      IS

                  

                	
                  
                    Personal
      Emergency Response System

                  

                	
                  
                    Amount

                  

                	
                  
                    6

                  

                	
                  
                    269

                  

                	
                  
                    274

                  

                	
                  
                    Numeric

                  

                

        

        
          

          Attachment
I - Page 88

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        

        
          

          Amendment
001

        

        
          

          Agreement
Number XQ744

        

        

        
          	
                  
                    Field Name

                  

                	
                  
                    Description

                  

                	
                  
                    Unit of Measurement

                  

                	
                  
                    Field Length

                  

                	
                  
                    Start Col.

                  

                	
                  
                    End Col.

                  

                	
                  
                    Text/Numeric

                  

                
	 
      	
                  
                    Installation

                  

                	
                  
                    Paid

                  

                	 
      	 
      	 
      	 
      
	
                  
                    PERS
      M

                  

                	
                  
                    Personal
      Emergency Response System -Maintenance

                  

                	
                  
                    Day

                  

                	
                  
                    2

                  

                	
                  
                    275

                  

                	
                  
                    276

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PERS
      MS

                  

                	
                  
                    Personal
      Emergency Response System-Maintenance

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    277

                  

                	
                  
                    282

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PEST
      I

                  

                	
                  
                    Pest
      Control - Initial Visit

                  

                	
                  
                    Job

                  

                	
                  
                    2

                  

                	
                  
                    283

                  

                	
                  
                    284

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PEST
      IS

                  

                	
                  
                    Pest
      Control-Initial Visit

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    285

                  

                	
                  
                    290

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PEST
      M

                  

                	
                  
                    Pest
      Control — Maintenance

                  

                	
                  
                    Month

                  

                	
                  
                    1

                  

                	
                  
                    291

                  

                	
                  
                    291

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PEST
      MS

                  

                	
                  
                    Pest
      Control- Maintenance

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    292

                  

                	
                  
                    297

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PT

                  

                	
                  
                    Physical
      Therapy

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    298

                  

                	
                  
                    301

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PTS

                  

                	
                  
                    Physical
      Therapy

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    302

                  

                	
                  
                    307

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RISKREDU

                  

                	
                  
                    Physical
      Risk Assessment and Reduction

                  

                	
                  
                    IS
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    308

                  

                	
                  
                    311

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RISKREDS

                  

                	
                  
                    Physical
      Risk Assessment and Reduction

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    312

                  

                	
                  
                    317

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PRIVNURS

                  

                	
                  
                    Private
      Duty Nursing Services

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    318

                  

                	
                  
                    321

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PRIVNURS

                  

                	
                  
                    Private
      Duty Nursing Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    322

                  

                	
                  
                    327

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PT
      R

                  

                	
                  
                    Registered
      Physical Therapist

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    328

                  

                	
                  
                    329

                  

                	
                  
                    Numeric

                  

                
	
                  
                    PT
      RS

                  

                	
                  
                    Registered
      Physical Therapist

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    330

                  

                	
                  
                    335

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RSPTH

                  

                	
                  
                    Respiratory
      Therapy

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    336

                  

                	
                  
                    339

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RSPTHS

                  

                	
                  
                    Respiratory
      Therapy

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    340

                  

                	
                  
                    345

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RESP
      HM

                  

                	
                  
                    Respite
      Care - In Home

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    346

                  

                	
                  
                    349

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RESP
      HMS

                  

                	
                  
                    Respite
      Care- In Home

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    350

                  

                	
                  
                    355

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RESP
      FA€

                  

                	
                  
                    Respite
      Care - Facility-Based

                  

                	
                  
                    Days

                  

                	
                  
                    2

                  

                	
                  
                    356

                  

                	
                  
                    357

                  

                	
                  
                    Numeric

                  

                
	
                  
                    RESP
      FAS

                  

                	
                  
                    Respite
      Care- Facility-Based

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    358

                  

                	
                  
                    363

                  

                	
                  
                    Numeric

                  

                
	
                  
                    NURSE

                  

                	
                  
                    Skilled
      Nursing

                  

                	
                  
                    Visit

                  

                	
                  
                    4

                  

                	
                  
                    364

                  

                	
                  
                    367

                  

                	
                  
                    Numeric

                  

                
	
                  
                    NURSES

                  

                	
                  
                    Skilled
      Nursing

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    368

                  

                	
                  
                    373

                  

                	
                  
                    Numeric

                  

                
	
                  
                    SPTH

                  

                	
                  
                    Speech
      Therapy

                  

                	
                  
                    15
      Minute Unit

                  

                	
                  
                    4

                  

                	
                  
                    374

                  

                	
                  
                    377

                  

                	
                  
                    Numeric

                  

                
	
                  
                    SPTHS

                  

                	
                  
                    Speech
      Therapy

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    378

                  

                	
                  
                    383

                  

                	
                  
                    Numeric

                  

                
	
                  
                    TRANSPOR

                  

                	
                  
                    Transportation
      Services (not included in Escort or Adult Day Health
      services)

                  

                	
                  
                    Trips

                  

                	
                  
                    3

                  

                	
                  
                    384

                  

                	
                  
                    386

                  

                	
                  
                    Numeric

                  

                
	
                  
                    TRANSPORS

                  

                	
                  
                    Transportation
      Services (not included in Escort or Adult Day Health
      services)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    387

                  

                	
                  
                    392

                  

                	
                  
                    Numeric

                  

                
	
                  
                    OTH
      UNIT

                  

                	
                  
                    Other
      LTC Service not listed (unit)

                  

                	
                  
                    Unit/Visit

                  

                	
                  
                    6

                  

                	
                  
                    393

                  

                	
                  
                    398

                  

                	
                  
                    Numeric

                  

                
	
                  
                    DESCR
      1

                  

                	
                  
                    Description
      of other LTC service

                  

                	 
      	
                  
                    35

                  

                	
                  
                    399

                  

                	
                  
                    433

                  

                	
                  
                    Text

                  

                
	
                  
                    OTH
      SS

                  

                	
                  
                    Other
      LTC service not listed (amount)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    434

                  

                	
                  
                    439

                  

                	
                  
                    Numeric

                  

                
	
                  
                    DESCR
      2

                  

                	
                  
                    Description
      of other LTC service

                  

                	 
      	
                  
                    35

                  

                	
                  
                    440

                  

                	
                  
                    474

                  

                	
                  
                    Text

                  

                

        

        
          

          File
2: Acute Care Services

        

        

        
          	
                  
                    Code

                  

                	
                  
                    Field
      Name

                  

                	
                  
                    Description

                  

                	
                  
                    Unit
      of Measurement

                  

                	
                  
                    Field
      Length

                  

                	
                  
                    Start
      Col.

                  

                	
                  
                    End
      Col.

                  

                	
                  
                    Text/Numeric

                  

                
	 
      	
                  
                    ACUTE SERVICES

                  

                	
                  
                    DESCRIPTION

                  

                	
                  
                    UNITS OF

                  

                  
                    SERVICE/

                  

                  
                    COST

                  

                	 
      	 
      	 
      	 
      
	 
      	
                  
                    SSN

                  

                	
                  
                    Social
      Security Number (left justify)

                  

                	
                  
                    000000000

                  

                	
                  
                    9

                  

                	
                  
                    1

                  

                	
                  
                    9

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    MEDICAID

                  

                	
                  
                    Medicaid
      ID Number

                  

                	
                  
                    0000000000

                  

                	
                  
                    10

                  

                	
                  
                    10

                  

                	
                  
                    19

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    MONTH

                  

                	
                  
                    Report
      Month

                  

                	
                  
                    MMYYYY

                  

                	
                  
                    6

                  

                	
                  
                    20

                  

                	
                  
                    25

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    CLINIC

                  

                	
                  
                    Clinic
      Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    26

                  

                	
                  
                    27

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    CLINICSS

                  

                	
                  
                    Clinic
      Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    28

                  

                	
                  
                    33

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    DENTAL

                  

                	
                  
                    Dental
      Services

                  

                	
                  
                    Visit

                  

                	
                  
                    6

                  

                	
                  
                    34

                  

                	
                  
                    39

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    DENTALSS

                  

                	
                  
                    Dental
      Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    40

                  

                	
                  
                    45

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    DIALYSIS

                  

                	
                  
                    Dialysis
      Center

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    46

                  

                	
                  
                    47

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    DIALYSSS

                  

                	
                  
                    Dialysis
      Center Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    48

                  

                	
                  
                    53

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    ER

                  

                	
                  
                    Emergency
      Room Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    54

                  

                	
                  
                    55

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    ER
      SS

                  

                	
                  
                    Emergency
      Room Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    56

                  

                	
                  
                    61

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    FQHC

                  

                	
                  
                    FQHC
      Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    62

                  

                	
                  
                    63

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    FQHC
      SS

                  

                	
                  
                    FQHC
      Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    64

                  

                	
                  
                    69

                  

                	
                  
                    Numeric

                  

                

        

        
          

          Attachment
I - Page 89

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                    Agreement
Number XQ744

           

        

        

        
          	
                  
                    Code

                  

                	
                  
                    Field Name

                  

                	
                  
                    Description

                  

                	
                  
                    Unit of .
      Measurement

                  

                	
                  
                    Field Length

                  

                	
                  
                    Start Col.

                  

                	
                  
                    End Col.

                  

                	
                  
                    Text/Numeric

                  

                
	 
      	
                  
                    HEAR

                  

                	
                  
                    Hearing
      Services including hearing aids

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    70

                  

                	
                  
                    75

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    MPTSVS

                  

                	
                  
                    Inpatient
      Hospital Services

                  

                	
                  
                    Day

                  

                	
                  
                    3

                  

                	
                  
                    76

                  

                	
                  
                    78

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    INPTSVSS

                  

                	
                  
                    Inpatient
      Hospital Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    79

                  

                	
                  
                    84

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    LAB

                  

                	
                  
                    Independent
      Laboratory or Portable X-ray Services

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    85

                  

                	
                  
                    90

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    ARNP

                  

                	
                  
                    Nurse
      Practitioner Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    91

                  

                	
                  
                    92

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    ARNP
      SS

                  

                	
                  
                    Nurse
      Practitioner Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    93

                  

                	
                  
                    98

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    RX
      SS

                  

                	
                  
                    Pharmaceuticals

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    99

                  

                	
                  
                    104

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    PA

                  

                	
                  
                    Physical
      Assistant

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    105

                  

                	
                  
                    106

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    PA
      S$

                  

                	
                  
                    Physical
      Assistant Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    107

                  

                	
                  
                    112

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    MD

                  

                	
                  
                    Physician
      Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    113

                  

                	
                  
                    114

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    MD
      SS

                  

                	
                  
                    Physician
      Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    115

                  

                	
                  
                    120

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    OUTPT

                  

                	
                  
                    Outpatient
      Hospital Services

                  

                	
                  
                    Encounter

                  

                	
                  
                    3

                  

                	
                  
                    121

                  

                	
                  
                    123

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    OUTPT
      SS

                  

                	
                  
                    Outpatient
      Hospital Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    124

                  

                	
                  
                    129

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    PODIATRY

                  

                	
                  
                    Podiatry

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    130

                  

                	
                  
                    131

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    PODIATSS

                  

                	
                  
                    Podiatry
      Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    132

                  

                	
                  
                    137

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    RURAL

                  

                	
                  
                    Rural
      Health Services

                  

                	
                  
                    Visit

                  

                	
                  
                    2

                  

                	
                  
                    138

                  

                	
                  
                    139

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    RURALSS

                  

                	
                  
                    Rural
      Health Services Costs

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    140

                  

                	
                  
                    145

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    SNFREHA

                  

                	
                  
                    Skilled
      nursing facility services-rehabilitation

                  

                	
                  
                    Days

                  

                	
                  
                    2

                  

                	
                  
                    146

                  

                	
                  
                    147

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    SNFREHAS

                  

                	
                  
                    Skilled
      nursing facility services-rehabilitation**

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    148

                  

                	
                  
                    153

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    EYE
      SS

                  

                	
                  
                    Visual
      Services including eyeglasses

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    154

                  

                	
                  
                    159

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    OTH
      UNIT

                  

                	
                  
                    Other
      Acute Service not listed (unit)

                  

                	
                  
                    Unit/
      Visit

                  

                	
                  
                    6

                  

                	
                  
                    160

                  

                	
                  
                    165

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    OTH
      SS

                  

                	
                  
                    Other
      Acute service not listed (amount)

                  

                	
                  
                    Amount
      Paid

                  

                	
                  
                    6

                  

                	
                  
                    166

                  

                	
                  
                    171

                  

                	
                  
                    Numeric

                  

                
	 
      	
                  
                    DESCR
      1

                  

                	
                  
                    Description
      of other Acute service

                  

                	 
      	
                  
                    35

                  

                	
                  
                    172

                  

                	
                  
                    206

                  

                	
                  
                    Text

                  

                
	 
      	
                  
                    DESCR
      2

                  

                	
                  
                    Description
      of other Acute service

                  

                	 
      	
                  
                    35

                  

                	
                  
                    207

                  

                	
                  
                    241

                  

                	
                  
                    Text

                  

                

        

        
          

          *'Medicare
Crossovers

        

        
          

          Encounter
Data Pile Naming Format

        

        
          Replace
*** with the contractor's prearranged 3-character file code, MON with the
beginning month of the reporting quarter and YY with the reporting
year.

        

        

        
          	 
      	
                  
                    Long-Term
      Care Services

                  

                	
                  
                    Acute
      Care Services

                  

                
	
                  
                    Data
      File

                  

                	
                  
                    ***
      MON YYLTC.txt

                  

                	
                  
                    ***
      MON YYACS.txt

                  

                
	
                  
                    Validation
      Report

                  

                	
                  
                    ***
      MON YY LTC DV.pd'f

                  

                	
                  
                    ***
      MON YY ACS DV.pdf

                  

                
	
                  
                    Certification
      File (if applicable)

                  

                	
                  
                    ***
      MON YY LTC CERT.doc

                  

                	
                  
                    ***
      MON YY ACS CERT.doc

                  

                
	ZIP
      file	***
      MON YY.zip	***
      MON YY.zip
	
                  
                     

                  

                	
                  
                     

                  

                

        

        
          

           

          Attachment
I - Page 90

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        

        
          

          Amendment
001        Agreement
Number XQ744

        

        EXHIBIT D

        
          

          Report
of Grievances/Appeals 

           

          (Plan Name) 

           

          (Reporting Quarter)

           

          Were any
new grievances filed during this reporting quarter? 
 YES       NO

        

        

        
          	 
      	
                  
                    Enrollee's

                    Last
      Name

                  

                	
                  
                    Enrollee's
      

                    First
      Name

                  

                	
                  
                    Enrollee's
      Medicaid D>#

                  

                	
                  
                    Enrollee's
      Social Security #

                  

                	
                  
                    Grievance
      Type*

                  

                	
                  
                    Grievance
      Date

                  

                	
                  
                    Expedited
      Request? (VorN)

                  

                	
                  
                    Disposition
      Type**

                  

                	
                  
                    Disposition
      Date

                  

                	
                  
                    Resolved?
      

                    (YorN)

                  

                
	
                  
                    1

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    2

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    3

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    4

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    5

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      

        

        
           

          Were any
new appeals filed during this reporting
quarter?     YES   NO

        

        

        
          	 
      	
                  
                    Enrollee's
      

                    Last
      Name

                  

                	
                  
                    Enrollee's
      

                    First
      Name

                  

                	
                  
                    Enrollee's
      Medicaid

                  

                	
                  
                    Enrollee's
      

                    Social
      Security #

                  

                	
                  
                    Appeals
      Type *

                  

                	
                  
                    Appeals
      Date

                  

                	
                  
                    Expedited
      Request? (YorN)

                  

                	
                  
                    Disposition

                  

                  
                    Type
      **

                  

                	
                  
                    Disposition
      Date

                  

                	
                  
                    Resolved?
      (YorN)

                  

                
	
                  
                    1

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    2

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    3

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    4

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    5

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      

        

         

        
        

        
          	
                  
                     

                  

                	 
	 * Grievance/Appeals
      Type	**
      Disposition
      type
	
                  
                    1 =
      Quality of Care

                  

                	7 =
      Enrollment/Disenrollment	
                  
                    

                      1 =
      Reassigned Case Manager

                    

                  

                	7 =
      Disenrolled Self
	
                  
                    2    =
      Access to Care

                  

                	8=
      Termination of Contract	
                  
                    2 =
      Service Added to Plan of Care

                  

                	8 =
      Disenrolled by plan
	
                  
                    3    =
      Not Medically Necessary svcs

                  

                	

                  9=
      Unauthorized out of plan

                	
                  
                    3 =
      Service Increased

                  

                	9 =
      In QA Review
	
                  
                    

                      4 =
      Excluded Benefit

                    

                  

                	

                  10
      = Unauthorized in-plan sacs

                	
                  
                    

                      4    =
      Changed to Another Provider

                    

                  

                	10
      = In Grievance/Appeal Process
	
                  
                    
                      5 =
      Billing Dispute

                    

                  

                	

                  11
      = Benefits available in plan

                	
                  
                    

                      5 =
      Reinstated in Plan

                    

                  

                	11
      = Lost Contact with Enrollee
	6 =
      Contract Interpretation	12
      = Other	6 =
      Billing Issue Resolved	12
      = Other

        

        

        
          

          Attachment
I - Page 91

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001         Agreement
Number XQ744

        

        

        
           

          EXHIBIT
E

        

        
          

          Minority
Business Enterprise Contract Reporting

        

        
          

          Vendor
Name

        

        
           

          Quarterly
Vendor 

           

          Expenditure
Activity

        

        

        
          	
                  
                    Reporting
      Timeframe

                  

                	
                  
                    Due
      Date

                  

                
	
                  
                    Quarter
      1 (January thru March)

                  

                	
                  
                    April
      15

                  

                
	
                  
                    Quarter
      2 (April thru June)

                  

                	
                  
                    July
      05

                  

                
	
                  
                    Quarter
      3 (July thru September)

                  

                	
                  
                    October
      15

                  

                
	
                  
                    Quarter
      4 (October thru December)

                  

                	
                  
                    January
      15

                  

                

        

        

        
          	
                  
                    Subcontractor
      Name

                  

                	
                  
                    Subcontractor
      Address

                  

                	
                  
                    Subcontractor
      Telephone #

                  

                	
                  
                    Subcontractor
      Federal Identification #
      or Social Security #

                  

                	
                  
                    Total
      Amount Expended With Subcontractor (Current Reporting Quarters
      Only)

                  

                	
                  
                    Total
      Amount Expended With Subcontractor (Prior Reporting
      Quarters)

                  

                
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Completed
      By:

                  

                  
                    Telephone 
      #:

                  

                  
                    Completion
      Date:

                  

                

        

        
          

          Attachment
I - Page 92

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001

        

        
          

          Agreement
Number XQ744

        

        

        

        

        
          

          Long-Term
Care Community Diversion Pilot Project

        

        
          Reconciliation
Report

        

        
          For
(Contractor name) (Month/Year)

        

        
          

          EXHIBIT
F

        

        

        
          	 
      	
                  
                    Last
      Name

                  

                	
                  
                    First
      Name

                  

                	
                  
                    Medicaid
      ID Number

                  

                	
                  
                    Provider
      Number

                  

                	
                  
                    Error
      Code

                  

                	
                  
                    Comments

                  

                
	
                  
                    1

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    2

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    3

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    4

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    5

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    6

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    7

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    8

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    9

                  

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    10

                  

                	 
      	 
      	 
      	 
      	 
      	 
      

        

        

        
          	
                  
                    Error
      Codes

                  

                	
                  
                    Error
      Summary Description

                  

                	
                  
                    Error
      Codes

                  

                	
                  
                    Error
      Summary Description

                  

                
	
                  
                    01

                  

                	
                  
                    Action
      Code Invalid

                  

                	
                  
                    14

                  

                	
                  
                    Recipient
      Ineligible

                  

                
	
                  
                    02

                  

                	
                  
                    HMO
      Number Invalid

                  

                	
                  
                    15

                  

                	
                  
                    Recipient
      Already enrolled

                  

                
	
                  
                    03

                  

                	
                  
                    HMO
      Number Not Found

                  

                	
                  
                    16

                  

                	
                  
                    Invalid
      Recipient AID Cat

                  

                
	
                  
                    04

                  

                	
                  
                    Recipient
      ID Not Found

                  

                	
                  
                    17

                  

                	
                  
                    Capitation
      Group Not Covered

                  

                
	
                  
                    05

                  

                	
                  
                    Recipient
      ID Not on File

                  

                	
                  
                    18

                  

                	
                  
                    Transaction
      Date Invalid

                  

                
	
                  
                    06

                  

                	
                  
                    Recipient
      Date of Birth Invalid

                  

                	
                  
                    19

                  

                	
                  
                    Transaction
      Date Incorrect

                  

                
	
                  
                    07

                  

                	
                  
                    Recipient
      Date of Birth Unmatched

                  

                	
                  
                    20

                  

                	
                  
                    Outpatient
      Dollars Invalid

                  

                
	
                  
                    08

                  

                	
                  
                    Recipient
      Has Major Medical

                  

                	
                  
                    21

                  

                	
                  
                    Inpatient
      Units Invalid

                  

                
	
                  
                    09

                  

                	
                  
                    HMO
      Not A Medicaid Provider

                  

                	
                  
                    22

                  

                	
                  
                    Invalid
      Fiscal Year

                  

                
	
                  
                    10

                  

                	
                  
                    Recipient
      Amount Not Met

                  

                	
                  
                    23

                  

                	
                  
                    Bad
      Capitation Update

                  

                
	
                  
                    11

                  

                	
                  
                    Recipient
      Not Enrolled

                  

                	
                  
                    24

                  

                	
                  
                    Cancelled
      by Choice Counselor   .

                  

                
	
                  
                    12

                  

                	
                  
                    Recipient
      Enrolled In Other HMO

                  

                	
                  
                    25

                  

                	
                  
                    Recipient
      In a Nursing Home

                  

                
	
                  
                    13

                  

                	
                  
                    Enrollment
      Error

                  

                	 
      	 
      

        

        
          

          Attachment
I - Page 93

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001        Agreement
Number XQ744

        

        
          

          EXHIBIT
G

        

        DEPARTMENT
OF ELDER AFFAIRS

        LONG-TERM
CARE DIVERSION PILOT PROJECT

        REQUEST
FOR DISENROLLMENT

        

        
          

          CURRENT PROVIDER
NAME:  COUNTY:

          

          PROVIDER
ADDRESS:

          

          TELEPHONE
NUMBER:(           )  FAX:(           )

          

        

        

        PARTICIPANT
NAME:

        

        MEDICAID
#:  DOB:TELEPHONE NUMBER: (           )

        

        PARTICIPANT
ADDRESS:

        

          COUNTY:

        

        

        

        

        

        □Does enrollee wish to file a
grievance?[  ]
Yes[  ]
No

        
          	
                  VOLUNTARY
      (Check All That Apply):

                
	
                   

                  □Dissatisfied
      with services (SVR)

                  □Moving
      to out-of-network nursing home (NET)

                  □Moving
      to out-of-network ALF

                   

                	
                  □No
      longer wish to participate in diversion program (OUT)

                  □Transfer
      to new provider (TFR)

                   

                

        

        COMMENTS:

        

        
          	 
      	 
      	 
      
	
                  Signature
      of Participant or Authorized Representative

                	 
      	
                  Date

                
	 
      	 
      	 
      
	
                  If
      representative, please print
    name

                	 
      	
                  Please
      state relationship to
      participant

                   

                

        

        FOR
DIVERSION PROVIDER USE ONLY

        
          	
                  INVOLUNTARY
      (Check All That Apply):

                
	
                  □Death
      (Date: ____________________) (EXP)

                  □Not
      eligible for Medicaid (ELG)

                  □Not
      eligible for project (PRJ)

                  □Moving
      out of the service area (CTY)

                   

                	
                  □Fraudulent
      use of Medicaid ID card (FRD)

                  □Incarceration

                  □Subject
      to Department of Elder Affairs approval
(SDA)

                

        

        

        
          	
                  EFFECTIVE
      DATE OF DISENROLLMENT:

                   

                	 
      	 
      
	
                  Case
      Manager Signature

                	 
      	
                  Date
      CARES Office Notified

                
	 
      	 
      	 
      
	
                  Program
      Administrator Signature

                	 
      	
                  CARES
      Fax Number

                
	
                   

                  REQUEST FOR TRANSFER TO NEW
      PROVIDER

                   

                  NAME OF NEW
      PROVIDER:  COUNTY: 

                   

                

        

        
          

          

        

        
          

          

        

        
          

          Attachment
I - Page 94

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001        Agreement
Number XQ744

        

        

        
          

          DEPARTMENT
OF ELDER AFFAIRS

        

        
          

          LONG-TERM
CARE DIVERSION PILOT PROJECT

        

        
          SOLICITUD
PARA DARSE DE BAJA

        

        
          

          Nombre actual del
proveedor: 

           

          Condado:  

          

          Dirección
del proveedor: 

          

          Numero de
Teléfono: (           )  FAX:(           )

          

        

        

        Nombre
del Participante:

        

        Numero de
Medicaid: Fecha de
Nacimiento:   Numero de
teléfono: __________

        

        Dirección
del Participante:Condado:  

        

        DESEA
INFORMAR ACERCA DE ALGUNA QUEJA?[  ] Si[  ] No

        

        
          	
                  VOLUNTARIO
      (MARQUE LAS QUE SE APLICAN):

                
	
                   

                  □No
      esta satisfecho con el servicio (SVR)

                  □Se
      muda a una clínica de reposo fuera del área (NET) 

                  □Se
      muda a una residencia de vivienda asistida fuera del área
      (ALF)

                   

                	
                  □No
      desea participar en el programa de diversión (OUT)

                  □Solicita
      un nuevo proveedor (TFR)

                   

                

        

        

        COMMENTS:

        

        
          	 
      	 
      	 
      
	
                  Firma
      del participante o representante autorizado

                	 
      	
                  Fecha

                
	 
      	 
      	 
      
	
                  Si
      es represéntate, por favor escribir
      letras

                	 
      	
                  Por
      favor indicar el relación con el participante

                   

                

        

        PARA
USO DEL PROVEEDOR DE DIVERSION

        
          	
                  INVOLUNTARIO
      (Marque las que apliquen)

                
	
                  □Fallecimiento
      (Fecha: _________) (EXP)

                  □No
      es elegible para Medicaid (ELG)

                  □No
      es elegible para el programa (PRJ)

                  □Se
      mudo fuera del área de servicio

                   

                	
                  □Uso
      fraudulento de la tarjeta Medicaid (FRD)

                  □     Encarcelamiento
      (INC)

                  □Sujeto
      a aprobación del departamento de Elder Affairs
  (SDA)

                

        

        

        
          	
                   

                  Fecha
      de desenlistamiento:

                	 
      	 
      
	
                   

                  Firma
      del manejador de caso

                	 
      	
                   

                  Fecha
      de notificación a las oficinas de CARES

                   

                
	
                  Firma
      del administrador del programa

                	 
      	
                  Numero
      de fax de la oficina de CARES

                
	
                   

                  □SOLICITUD PARA TRANSFERIR A UN
      NUEVO PROVEEDOR

                   

                  NOMBRE DEL NUEVO
      PROVEEDOR:
        CONDADO: 

                   

                

        

        
          

          

        

        
          

          Attachment
I - Page 95

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001        Agreement
Number XQ744

        

        
          

          EXHIBIT
H

        

        

        
          

          Provider
Name

           Street
Address 

          City, FL
ZIP

        

        
          

          Phone:                         Plan
Contact:

        

        
          FAX:                            Email:

        

        
          

          List Date
x/xx/xx

           

        

        
          	
                  
                    Covered
      Services

                  

                	
                  
                    Provider
      Name

                  

                	
                  
                    Name
      of Provider Contact

                  

                	
                  
                    Phone
      Number

                  

                	
                  
                    Street
      Address

                  

                	
                  
                    City

                  

                	
                  
                    State

                  

                	
                  
                    Zip
      Code

                  

                	
                  
                    County
      Served

                  

                	
                  
                    Comments

                  

                
	
                  
                    Adult
      Companion Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Adult
      Companion Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Adult
      Day Health Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Adult
      Day Health Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Assisted
      Living Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Assisted
      Living Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Case
      Management Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Chore
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Chore
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Consumable
      Medical Supply Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Consumable
      Medical Supply Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Dental

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Dental

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Environmental
      Accessibility Adaptation Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Environmental
      Accessibility Adaptation Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Escort
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Escort
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Family
      Training Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Family
      Training Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Financial
      Assessment/Risk Reduction Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Financial
      Assessment/Risk Reduction Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Hearing

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Hearing

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Home
      Delivered Meals

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Home
      Delivered Meals

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Homemaker
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Homemaker
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Nursing
      Facility Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Nursing
      Facility Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      

        

        
          

          Attachment
I - Page 96

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        Amendment
001        Agreement Number
XQ744

        
          	
                  
                     

                  

                	 
      	
                  
                     

                  

                  
                     

                  

                	 
      	 
      	 
      	 
      	 
      
	
                  
                    Nutritional
      Assessment/Risk Reduction Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Nutritional
      Assessment/Risk Reduction Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Occupational
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Occupational
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Personal
      Care Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Personal
      Care Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Personal
      Emergency Response Systems (PERS):

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Personal
      Emergency Response Systems (PERS):

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Physical
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Physical
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Respite
      Care Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Respite
      Care Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Speech
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Speech
      Therapy

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Vision

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Vision

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Optional Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Transportation
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  
                    Expanded
      Services

                  

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      

        

        

        
          	
                  
                    Staff
      Positions

                  

                	
                  
                    Staff
      Name

                  

                	
                  
                    Phone
      Number

                  

                	
                  
                    Email

                  

                	
                  
                    Fax
      Number

                  

                
	
                  
                    Contract
      Manager / Plan Administrator

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Case
      Management Supervisor

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Case
      Manager

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Data
      Processing

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Grievance
      Coordinator

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Medical
      Director

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Medical
      Records Coordinator

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Member
      Services

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Quality
      Assurance Coordinator

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Training
      Coordinator

                  

                	 
      	 
      	 
      	 
      
	
                  
                    Utilization
      Review

                  

                	 
      	 
      	 
      	 
      

        

        
          

          Attachment
I - Page 97

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                    Agreement
Number XQ744

        

        
          EXHIBIT
I

        

        
          

          Capitation
Rates

        

        

        
          	
                  
                    Provider
      ID

                  

                	
                  
                    Provider
      Name

                  

                	
                  
                    County
      Name

                  

                	
                  
                    1/1/2008
      - 8/31/2008
      Diversion
      Capitation
      Rate

                  

                
	
                  
                    0150771
      00

                  

                	
                  
                    WellCare

                  

                	
                  
                    Orange

                  

                	
                  
                    1,351.22

                  

                
	
                  
                    0150771
      01

                  

                	
                  
                    WellCare

                  

                	
                  
                    Osceola

                  

                	
                  
                    1,351.22

                  

                
	
                  
                    0150771
      02

                  

                	
                  
                    WellCare

                  

                	
                  
                    Seminole

                  

                	
                  
                    1,351.22

                  

                
	
                  
                    0150771
      03

                  

                	
                  
                    WellCare

                  

                	
                  
                    Duval

                  

                	
                  
                    1,410.43

                  

                

        

        
          

          The
following table lists the initial rates for prospective
expansions.

        

        

        
          	
                  
                    PSA

                  

                	
                  
                    Counties

                  

                	
                  
                    1/1/08-8/31/2008 
      Diversion
      Capitation Rate

                  

                
	
                  
                    1

                  

                	
                  
                    Escambia,
      Okaloosa Santa Rosa, and Walton

                  

                	
                  
                    1,514.64

                  

                
	
                  
                    2

                  

                	
                  
                    Bay,
      Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
      Liberty, Taylor, Wakulla, and Washington

                  

                	
                  
                    1,514.64

                  

                
	
                  
                    3

                  

                	
                  
                    Alachua,
      Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lake,
      Levy, Marion, Putman, Sumter, Suwannee, and Union

                  

                	
                  
                    1,544.36

                  

                
	
                  
                    4

                  

                	
                  
                    Baker,
      Clay, Duval, Flagler, Nassau, St. Johns, and Volusia

                  

                	
                  
                    1,410.43

                  

                
	
                  
                    5

                  

                	
                  
                    Pasco
      and Pinellas

                  

                	
                  
                    1,568.98

                  

                
	
                  
                    6

                  

                	
                  
                    Hardee,
      Highlands, Hillsborough, Manatee, and Polk

                  

                	
                  
                    1,542.84

                  

                
	
                  
                    7

                  

                	
                  
                    Brevard,
      Orange, Osceoia, and Seminole

                  

                	
                  
                    1,351.22

                  

                
	
                  
                    8

                  

                	
                  
                    Charlotte,
      Collier, DeSoto, Glades, Hendry, Lee, and Sarasota

                  

                	
                  
                    1,529.72

                  

                
	
                  
                    9

                  

                	
                  
                    Indian
      River, Martin, Okeechobee, Palm Beach, and St. Lucie

                  

                	
                  
                    1,512.27

                  

                
	
                  
                    10

                  

                	
                  
                    Broward

                  

                	
                  
                    1,558.68

                  

                
	
                  
                    11

                  

                	
                  
                    Miami-Dade
      and Monroe

                  

                	
                  
                    1,570.30

                  

                

        

        
          

          Attachment
I - Page 98

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                    Agreement
Number XQ744

        

        
          Contract
#2007-2008-01 

          EXHIBIT
J

        

        
          

          SWORN
STATEMENT PURSUANT TO CHAPTER 287.133(3)(a), 

          FLORIDA STATUTES. ON
PUBLIC ENTITY CRIMES

        

        
          

          THIS FORM
MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS.

        

        
          

          1.          This
sworn statement is submitted to_____________________(print
name of the public entity)  

          by  _________________________(print
individual's name and title)                                                                                                              

        

        
          for
_________________________(print name of entity submitting sworn
statement)

        

        
          

          whose
business address
is   _________________________________________

          
 

        

        
          and, if
applicable, its Federal Employer Identification Number (FEIN)
is

        

        
          

          If the
entity has no FEIN, include the Social Security Number of the individual signing
this sworn statement:

          __________________________________________________________________________________

        

        
          

          
            	
                    2.

                  	
                    I
      understand that a "public entity crime" as defined in Paragraph
      287.133(l)(g), Florida
      Statutes, means a violation of any state or federal law by a person
      with respect to and directly related to the transaction of business with
      any public entity or with an agency or political subdivision of any other
      state or of the United States, including, but not limited to, any bid or
      contract for goods or services to be provided to any public entity or an
      agency or political subdivision of any other state or of the United States
      and involving antitrust, fraud, theft, bribery, collusion, racketeering,
      conspiracy, or material
representation.'

                  

          

        

        
          

          
            	
                    3.

                  	
                    I
      understand that "convicted" or "conviction" as defined in Paragraph
      287.133(1 )(b), Florida
      Statutes, means a finding of guilt or a conviction of a public
      entity crime, with or without an adjudication of guilt, in any federal or
      state trial court of record relating to charges brought by indictment or
      information after July 1, 1989, as a result of a jury verdict, non-jury
      trial, or entry of a plea of guilty or nolo contendere.

                     

                  
	4. 	I
      understand that an "affiliate" as defined in Paragraph 287.133(l)(a),
      Florida
      Statutes, means:

          

        

        
                

        

        
          
            	a. 	A
      predecessor or successor of a person convicted of a public entity crime;
      or
	
                    b.

                  	
                    An
      entity under the control of any natural person who is active in the
      management of the entity and who has been convicted of a  public
      entity crime. The term "affiliate" includes those officers, directors,
      executives, partners, shareholders, employees, members,  and
      agents who are active in the management of the affiliate. The ownership by
      one person of shares constituting a controlling  interest in
      another person, or a pooling of equipment or income among persons when not
      for fair market value under an arm's length  agreement, shall be
      a prima facie case that one person controls another person. A. person who
      knowingly enters into a joint venture  with a person who has
      been convicted of a public entity crime in Florida during the preceding 36
      months shall be considered
  an  affiliate.

                  

          

        

        
          

          
            	
                    5.

                  	
                    I
      understand that a "person" as defined in Paragraph 287.133(l)(e), Florida
      Statutes, means any natural person or entity organized under the
      laws of any state or of the United States with the legal power to enter
      into a binding contract and which bids or applies to bid on contracts for
      the provision of goods or services let by a public entity, or which
      otherwise transacts or applies to transact business with a public entity.
      The term "person" includes those officers, directors, executives,
      partners, shareholders, employees, members, and agents who are active in
      management of an entity.

                  

          

        

        
          

          
            	
                    6.

                  	
                    Based
      on information and belief, the statement which I have marked below is true
      in relation to the entity submitting this sworn statement. (Indicate which
      statement applies.)

                  

          

        

        
          

          Neither the entity submitting this
sworn statement, nor any of its officers, directors, executives, partners,
shareholders, employees, members,
or agents who are active in the management of the entity, nor any affiliate of
the entity has been charged with and convicted of a public entity crime
subsequent to July 1,1989.

        

        
          

          Attachment
I - Page 99

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                    Agreement
Number XQ744

        

        
          Contract
#2007-2008-01 EXHIBIT J

        

        
          

          SWORN
STATEMENT PURSUANT TO CHAPTER 287.133(3)(a), FLORIDA STATUTES. ON
PUBLIC ENTITY CRIMES

        

        
          

          THIS FORM
MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS.

        

        
          

          

        

        
          

          1.          This
sworn statement is submitted to the Florida Department of
Elder Affairs   

           

          by   Todd Farha,
President and CEO  (print individual's name and
title)  

           

          for WellCare of Florida,
Inc. (print name of entity submitting
sworn  statement)                                              

        

        
                                                                                                                            

        

        whose business address is: 
8735 Henderson Road Tampa,
FL 33634

        
          

          and, if
applicable, its Federal Employer Identification Number (FEIN)
is

        

        
          

          If the
entity has no FEIN, include the Social Security Number of the individual signing
this sworn statement:
______________________________________________

        

        
          

          
            	
                    2.

                  	
                    I
      understand that a "public entity crime" as defined in Paragraph
      287,133(l)(g). Florida
      Statutes, means a violation of any state or federal law by a person
      with respect to and directly related to the transaction of business with
      any public entity or with an agency or political subdivision of any other
      state or of the United States, including, but not limited to, any bid or
      contract for goods or services to be provided to any public entity or an
      agency or political subdivision of any other state or of the United States
      and involving antitrust, fraud, theft, bribery, collusion, racketeering,
      conspiracy, or material
representation.

                  

          

        

        
          

          
            	
                    3.

                  	
                    I
      understand that "convicted" or "conviction" as defined in Paragraph
      287.133(l)(b), Florida
      Statutes, means a finding of guilt or a conviction of a public
      entity crime, with or without an-adjudication of guilt, in any federal or
      state trial court of record relating to charges brought by indictment or
      information after July 1, 1989, as a result of a jury verdict, non-jury
      trial, or entry of a plea of guilty or nolo contendere.

                     

                  
	4. 	I
      understand that an "affiliate" as defined in Paragraph 287.133(l)(a),
      Florida
      Statutes, means:

          

        

        
           

        

        
              

        

        
          
            	a.   	
                    A
      predecessor or successor of a person convicted of a public entity crime;
      or

                     

                  
	
                    b.

                  	
                    An
      entity under the control of any natural person who is active in the
      management of the entity and who has been convicted of a  public
      entity crime. The term "affiliate" includes those officers, directors,
      executives, partners, shareholders, employees, members,  and
      agents who are active in the management of the affiliate. The ownership by
      one person of shares constituting a controlling  interest in
      another person, or a pooling of equipment or income among persons when not
      for fair market value under an arm's length  agreement, shall be
      a prima facie case that one person controls another person. A person who
      knowingly enters into a joint venture  with a person who has
      been convicted of a public entity crime in Florida during the preceding 36
      months shall be considered
  an  affiliate.

                  

          

        

        
          

          
            	
                    5.

                  	
                    I
      understand that a "person" as defined in Paragraph 287.133(l)(e), Florida
      Statutes, means any natural person or entity organized under the
      laws of any state or of the United States with the legal power to enter
      into a binding contract and which bids or applies to bid on contracts for
      the provision of goods or services let by a public entity, or which
      otherwise transacts or applies to transact business with a public entity.
      The term "person" includes those officers, directors, executives,
      partners, shareholders, employees, members, and agents who are active in
      management of an entity.

                  

          

        

        
          

          
            	
                    6.

                  	
                    Based
      on information and belief, the statement which I have marked below is true
      in relation to the entity submitting this sworn statement. (Indicate which
      statement applies.)

                  

          

        

        
          

             X   Neither
the entity submitting this sworn statement, nor any of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active
in the management of the entity, nor any affiliate of the entity has been
charged with and convicted of a public entity crime subsequent to July 1,
1989.

        

        
          

          Attachment
I - Page 99

        

        
          

          

        

        
          

          

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                Agreement
Number XQ744

        

        
          

        

        
          

        

        
          

        

        
          

        

        
           The entity submitting this
sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members,
or agents who are active in the management of the entity, or an affiliate of the
entity has been charged with and convicted of a public entity subsequent to July
1,1989.

        

        
          

          _______
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees,

        

        
          

           members,
or agents who are active in the management of the entity, or an affiliate of the
entity has been charged with and convicted of a public entity subsequent to July
1, 1989. However, there has been a subsequent proceeding before a Hearing
Officer of the State of Florida, Division of Administrative Hearings and the
Final Order entered by the Hearing Officer determined that it was not in the
public interest to place the entry submitting this sworn statement on the
convicted vendor list. (Attach a copy of the final order.)

        

        
          

          

        

        
          I UNDERSTAND THAT THE SUBMISSION OF
THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED
IN PARAGRAPH 1 (ONE) ABOVE
IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31
OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT 1 AM REQUIRED
TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE
THRESHOLD PROVIDED IN CHAPTER 287.017, FLORIDA
STATUTES FOR CATEGORY TWO
OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS
FORM.

        

        
          

        

        
          

        

        
          

        

        
          	 
      	
                  /s/  Todd S.
      Farha

                  (Signature)

                
	 
      	
                  12/27/07

                

        

        
           

        

        

        

        
          STATE OF
FLORIDA

        

        
          

        

        
          COUNTY OF
HILLSBOROUGH

        

        
          

        

        
          PERSONALLY APPEARD BEFORE ME, the
undersigned authority,  Todd S. Farha, who, after first being sworn by
me, affixed his/her signature in the space provided above on this 27th Day of
December, 2007.

        

        
          

        

        
          /s/  Sara
Gallo

        

        
          Notary
Public

        

        
          

        

        
          My
commission expires: 1/29/2010

        

        
          Jan
2001

        

        
          Form 102
Sworn State Public Entity Crimes (Jan 2001)                   

        

        

        

        
          

        

        
          Attachment
I-Page 100

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                    Agreement
Number XQ744 

          CONTRACT#2007-2008-0

          EXHIBIT
K

        

        
          

          INSTRUCTIONS                                                                                                         

        

        
          CERTIFICATION
REGARDING                                                                                                                          

        

        
          DEBARMENT,
SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS

        

        
          

          
            	
                    1.

                  	
                    Each
      recipient or vendor whose contract equals or exceeds $100,000 in federal
      monies must sign this debarment certification prior to contract execution.
      Independent auditors who audit federal programs regardless of the dollar
      amount are required to sign a debarment certification form. Neither the
      Department of Elder Affairs nor its contract recipients or vendors can
      contract with subrecipients 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 is entered into. If it is later determined that
      the signed knowingly rendered an erroneous certification, the Federal
      Government may pursue available remedies, including suspension and/or
      debarment.

                  

          

        

        
          

          
            	
                    3.

                  	
                    The
      recipient or vendor shall provide immediate written notice to the contract
      manager at any time the recipient or 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 and 45 CFR (Code of Federal Regulations), Part 76.
      You may contact the contract manager for assistance in obtaining a copy of
      those regulations.

                  

          

        

        
          

          
            	
                    5.

                  	
                    The
      recipient or vendor further 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 unless authorized by the Federal
      Government.

                  

          

        

        
          

          
            	
                    6.

                  	
                    The
      recipient or vendor further agrees by submitting this certification that
      it will require each subrecipient of this contract whose payment will
      equal or exceed $100,000 in federal monies, to submit a signed copy of
      this certification with each
contract.

                  

          

        

        
          

          
            	
                    7.

                  	
                    The
      Department of Elder Affairs and its contract recipients or vendor may rely
      upon a certification of a recipient/subrecipients that is not debarred,
      suspended, ineligible, or voluntarily exclude from
      contracting/subcontracting unless it knows that the certification is
      erroneous.

                  

          

        

        
          

          
            	
                    8.

                  	
                    If
      the recipient or vendor is an Area Agency on Aging (AAA), the AAA may rely
      upon a certification of a recipient/subrecipient or vendor entity that is
      not debarred, suspended, ineligible, or voluntarily excluded from
      contracting/subcontracting unless the AAA knows that the certification is
      erroneous.

                     

                  
	9.	The
      signed certifications of all subrecipients or vendors shall be kept on
      file with recipient.

          

        

        
          

                     

        

        
          

          DOEAFORM112A
(Revised May 2002)

        

        
          

          Attachment
I - Page 101

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001        Agreement
Number XQ744

        

        
          Contract
2007-2008-01

        

        

        
          

          INSTRUCTIONS

        

        
          CERTIFICATION
REGARDING

        

        
          DEBARMENT,
SUSPENSION, INELIGIBILITY

        

        
          AND
VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS

        

        
          

          This
certification is required by the regulation 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).

        

        
          

          
            	
                    (1)

                  	
                    The
      prospective recipient or 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 contacting with the Department of Elder Affairs by any
      federal department or agency.

                  

          

        

        
          

          
            	
                    (2)

                  	
                    Where
      the prospective recipient or vendor is unable to certify to any of the
      statements in this certification, such prospective recipient or vendor
      shall attach an explanation to this
  certification.

                  

          

        

        
          

          

        

        
          

          
            	
                     
      

                  	
                    Signature:
      /s/ Todd S.
      Farha

                  

          

        

        
          

          
            	
                     
      

                  	
                    Date:
      12/27/07

                  

          

        

        
          

        

        
          
            	
                     
      

                  	
                    Todd S. Farha,
      President & CEO

                  

          

        

        
          Name and
Title of Authorized Individual(Print or Type)

        

        
          

        

        
          

        

        
          
            	
                     
      

                  	
                    WellCare of Florida ,
      Inc.

                  

          

        

        
          
            	
                     
      

                  	
                    Name
      of Organization

                  

          

        

        
          
            	
                     
      

                  	
                    DOEA
      Form 112B

                  

          

        

        
          
            	
                     
      

                  	
                    (revised
      May 2002)

                  

          

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                    Agreement
Number XQ744

        

        
          

          EXHIBIT
L

        

        
          

          
          

        

        
          
            Long-Term
Care Diversion Pilot Project Hospice Enrollment Report

          Number
of Enrollees Electing Hospice Monthly

        

        
          

          Month
of: __________________________

        

        
          Contractor:
________________________

        

        

        
          	 
      	
                  
                    County

                  

                	
                  
                    Number
      of enrollees

                  

                	
                  
                    For
      Profit

                  

                	
                  
                    Not
      for Profit

                  

                
	
                  
                    1

                  

                	 
      	 
      	 
      	 
      
	
                  
                    2

                  

                	 
      	 
      	 
      	 
      
	
                  
                    3

                  

                	 
      	 
      	 
      	 
      
	
                  
                    4

                  

                	 
      	 
      	 
      	 
      
	
                  
                    5

                  

                	 
      	 
      	 
      	 
      
	
                  
                    6

                  

                	 
      	 
      	 
      	 
      
	
                  
                    7

                  

                	 
      	 
      	 
      	 
      
	
                  
                    8

                  

                	 
      	 
      	 
      	 
      
	
                  
                    9

                  

                	 
      	 
      	 
      	 
      
	
                  
                    10

                  

                	 
      	 
      	 
      	 
      
	
                  
                    11

                  

                	 
      	 
      	 
      	 
      
	
                  
                    12

                  

                	 
      	 
      	 
      	 
      
	
                  
                    13

                  

                	 
      	 
      	 
      	 
      
	
                  
                    14

                  

                	 
      	 
      	 
      	 
      
	
                  
                    15

                  

                	 
      	 
      	 
      	 
      
	
                  
                    16

                  

                	 
      	 
      	 
      	 
      
	
                  
                    17

                  

                	 
      	 
      	 
      	 
      
	
                  
                    18

                  

                	 
      	 
      	 
      	 
      
	
                  
                    19

                  

                	 
      	 
      	 
      	 
      
	
                  
                    20

                  

                	 
      	 
      	 
      	 
      
	
                  
                    21

                  

                	 
      	 
      	 
      	 
      
	
                  
                    22

                  

                	 
      	 
      	 
      	 
      
	
                  
                    23

                  

                	 
      	 
      	 
      	 
      
	
                  
                    24

                  

                	 
      	 
      	 
      	 
      
	
                  
                    25

                  

                	 
      	 
      	 
      	 
      

        

        
          

          Submitted
by:                                                                                       

        

        
          

          Submit to
your contract manager by the 15lh day
after the reporting month.

        

        
          

          Attachment
I-Page 103

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                 Agreement
Number XQ744

        

        
          

          ATTACHMENT
II

        

        
          

          CERTIFICATION
REGARDING LOBBYING

        

        
          

          CERTIFICATION
FOR CONTRACTS, GRANTS, LOANS AND

        

        
          COOPERATIVE
AGREEMENT

        

        
          

          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 state or federal agency, a member
      of congress, an officer or employee of congress, an employee of a member
      of congress, or an officer or employee of the state legislator, in
      connection with the awarding of any federal grant, the making of any
      federal loan, the entering into of any cooperative agreement, and the
      extension, continuation, renewal, amendment, or modification of any
      federal contract, grant, loan, or cooperative
  agreement.

                  

          

        

        
          

          
            	
                    (2)

                  	
                    If
      any funds other than federal appropriated funds have been paid or will be
      paid to any person for influencing or attempting to influence an officer
      or employee of any agency, a member of congress, an officer or employee of
      congress, or an employee of a member of congress in connection with this
      federal contract, grant, loan, or cooperative agreement, the undersigned
      shall complete and submit Standard Form-LLL, "Disclosure Form to Report
      Lobbying," in accordance with its
instructions.

                  

          

        

        
          

          
            	
                    (3)

                  	
                    The
      undersigned shall require that the language of this certification be
      included in the award documents for all sub-awards at all tiers (including
      subcontracts, sub-grants, and contracts under grants, loans and
      cooperative agreements) and that all sub-recipients shall certify and
      disclose accordingly.

                  

          

        

        
          

          This
certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.

        

        
          

                                                                                    

        

        
          

                                                                                                           

        

        
                                                                                    

        

        
          

        

        
          

        

        
          

        

        
          	
                  /s/  Todd S.
      Farha

                  Signature

                   

                	
                  12/27/07

                
	
                  Todd S.
      Farha

                  Name
      of Authorized Individual

                   

                	
                  XQ744

                  Application
      or contract number

                
	
                  WellCare of Florida,
      Inc.  P.O Box 26011, Tampa, FL 33623

                  Name
      and Address of Organization

                   

                

        

        
          

        

        
          

        

        
          DOEA Form
103 (Revised Nov 2002)

        

        
          ATTACHMENT
II - Page 1

        

        
           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          

        

        
          

        

        
          

        

        
          Amendment
001        Agreement
Number XQ744

        

        
          ATTACHMENT
III

        

        
          

        

        
          CERTIFICATION
REGARDING DATA INTEGRITY COMPLIANCE FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE
AGREEMENTS

        

        
          

          The
undersigned, an authorized representative of the recipient named in the contract
or agreement to which this form is an attachment, hereby certifies
that:

        

        
          

          
            	
                    (1)

                  	
                    The
      recipient and any sub-recipients of services under this contract have
      financial management systems capable of providing certain information,
      including: (1) accurate, current, and complete disclosure of the financial
      results of each grant-funded project or program in accordance with the.
      prescribed reporting requirements; (2) the source and application of funds
      for all contract supported activities; and (3) the comparison of outlays
      with budgeted amounts for each award. The inability to process information
      in accordance with these requirements could result in a return of grant
      funds that have not been accounted for
properly.

                  

          

        

        
          

          
            	
                    (2)

                  	
                    Management
      Information Systems used by the recipient, sub-recipient(s), or any
      outside entity on which the recipient is dependent for data that is to be
      reported, transmitted or calculated, have been assessed and verified to be
      capable of processing data accurately, including year-date dependent data.
      For those systems identified to be non-compliant, recipient(s) will take
      immediate action to assure data
integrity.

                  

          

        

        
          

          
            	
                    (3)

                  	
                    If
      this contract includes the provision of hardware, software, firmware,
      microcode or imbedded chip technology, the undersigned warrants that these
      products are capable of processing year-to-date dependent data accurately.
      All versions of these products offered by the recipient (represented by
      the undersigned) and purchased by the State will be verified for accuracy
      and integrity of data prior to
transfer.

                  

          

        

        
          

          In the
event of any decrease in functionality related to time and date related codes
and internal subroutines that impede the hardware or software programs from
operating properly, the recipient agrees to immediately make required
corrections to restore hardware and software programs to the same level of
functionality as warranted herein, at no charge to the State, and without
interruption to the ongoing business of the state, time being of the
essence.

        

        
          

          
            	
                    (4)

                  	
                    The
      recipient and any sub-recipient(s) of services under this contact warrant
      their policies and procedures include a  disaster plan to
      provide for service delivery to continue in case of an emergency including
      emergencies arising from  data integrity compliance
      issues.

                  

          

        

        
          

          The
recipient shall require that the language of this certification be included in
all subcontracts, subgrants, and other agreements and that all sub-contractors
shall certify compliance 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 OMB Circulars A-102 and A-l 10.

        

        

        
          	
                  WellCare of Florida,
      Inc.  8735 Henderson Road, Tampa, FL 33634

                  Name
      and Address of Organization

                   

                
	
                  /s/  Todd S.
      Farha

                  Signature

                   

                	
                  President &
      CEO

                  Title

                	
                  12/27/07

                  Date

                
	
                  Todd S.
      Farha

                  Name
      of Authorized Individual

                   

                	 
      	 
      
	 
      	 
      

        

        
          

          

        

        
          

          ATTACHMENT
III - Page 1

        

        
          
             

          

          
             

            
              

            

          

          
             

          

        

        
          Amendment
001                                                                                Agreement
Number XQ744

        

        
          

          ATTACHMENT
IV

        

        
          

          AGREEMENT
TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID
PENDING

        

        
          

        

        
          ....................
No, contractor does not elect to provide services to individuals designated as
Medicaid Pending.

        

        
          ....................Yes,
contractor elects to provide services to individuals designated as Medicaid
Pending.

        

        
          

          By
checking YES above, contractor agrees to provide services to individuals
referred to them by CARES who have been designated as Medicaid Pending in
accordance with Section 430.705(5), Florida Statutes. The contractor will meet
all conditions of this contract and the following:

        

        
          

          
            	
                     
      

                  	
                    a.

                  	
                    The
      contractor is responsible for compliance with all pertinent insurance laws
      and regulations prior to providing services to Medicaid Pending
      individuals.

                  

          

        

        
          
 

          
            	
                     
      

                  	
                    b.

                  	
                    CARES
      staff will refer individuals, identified as Medicaid pending and who
      choose to receive Medicaid Pending services, to the chosen contractor.
      Included with the referral will be the Freedom of Choice form, 701 B
      Assessment, 3008, Informed Consent, and the Level of
  Care.

                  

          

        

        
          

          
            	
                     
      

                  	
                    c.

                  	
                    The
      contractor may assist Medicaid pending individuals through the Medicaid
      financial eligibility process by submitting the ACCESS Florida Application
      (online or hardcopy) to the Department of Children and Families and when
      contacted by DCF, forward at a minimum the following documentation:
      Financial Release (CF ES 2613), CARES' level of care decision (Form 603)
      and the Certification of Enrollment Status (HCBS) (CF-AA 2515).
      Applications may be completed and submitted online at the following
      website: www.myflorida.com/accesssflorida

                     

                  

          

        

        
          
            	
                     
      

                  	
                    d.

                  	
                    Once
      the individual is determined financially eligible, the contractor must
      notify CARES and provide a copy of the Notice of Case Action within two
      business days of receipt.

                     

                  

          

        

        
          
            	
                     
      

                  	
                    e.

                  	
                    The
      contractors will be responsible for submitting 834 enrollment transactions
      to the Medicaid fiscal agent one week prior to the regular submission date
      for only the Medicaid pending individuals. The enrollment date will be
      retroactive to the first of the month following the CARES eligibility
      determination, not to exceed four
      (4)
      months.

                     

                  

          

        

        
          
            	
                     
      

                  	
                    f.

                  	
                    Services
      must be in place on the first of the month following the CARES eligibility
      determination.

                     

                  

          

        

        
          
            	
                     
      

                  	
                    g.

                  	
                    The
      contractor will be paid the capitation rate for services rendered
      retroactive to the first of the month following the CARES eligibility
      determination.  The contractor shall make available, on request
      from the department, proof of services, which meet the timeframes listed
      above.

                     

                  

          

        

        
          
            	
                     
      

                  	
                    h.

                  	
                    Payment
      will be made once full financial eligibility has been
      determined

                     

                  

          

        

        
          
            	
                     
      

                  	
                    i.

                  	
                    In
      the event the individual is determined not to be financially eligible by
      the Department of Children & Families, the contractor must notify
      CARES and can seek reimbursement from the individual in accordance with
      the Medicaid Coverage and Limitations Handbooks and the associated fee
      schedules.

                  

          

        

        
          

        

        
          

        

        
          

          Signature.     /s/  Todd
S. Farha

        

        
          

          Date:   12/27/07

        

        
          

          Todd S.
Farha

        

        
          Name and
Title of Authorized Individual (Print or type)

        

        
          

          ATTACHMENT
IV - Page 1

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