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exhibit10-2.htm

    
      
        

      

    

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    Exhibit
      10.2

     

    
      Medicaid
        HMO Contract

      Wellcare
        of Florida, Inc. 

      d/b/a
        Staywell Health Plan of Florida

      

      AHCA
        CONTRACT NO. FA615

      AMENDMENT
        NO. 4

      

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

      

      
        	
                1.  

              	
                Standard
                  Contract, Section II, Item A, Contract Amount, the first sentence
                  is
                  hereby revised to now read as
                  follows:

              

      

      

      
        	
                 

              	
                To
                  pay for contracted services according to the conditions of Attachment
                  I in
                  an amount not to exceed $1,215,610,993.00 (a decrease of $30,474,628.00),
                  subject to availability of funds. 

              

      

      

      
        	
                2.  

              	
                Attachment
                  I, Section B, Method of Payment, Item 1, General, the first paragraph
                  is
                  hereby revised to now read as
                  follows:

              

      

      

      
        	
                 

              	
                Notwithstanding
                  the payment amounts which may be computed with the rate tables
                  specified
                  in Exhibit III-C, the sum of total capitation payments under this
                  Contract
                  shall not exceed the total Contract amount of $1,215,610,993.00
                  (a
                  decrease of $30,474,628.00). 

              

      

      

      
        	
                3.  

              	
                Attachment
                  I, Scope of Services, is hereby amended to include Exhibit III-C,
                  January
                  1, 2008 – August 31, 2008 Medicaid Non-Reform HMO Capitation Rates,
                  attached hereto and made a part of the Contract.  All references
                  in the Contract to Exhibit III-B, September 1, 2007 – August 31, 2008
                  Medicaid Non-Reform HMO Capitation Rates, shall hereinafter instead
                  refer
                  to Exhibit III-C, January 1, 2008 - August 31, 2008 Medicaid Non-Reform
                  HMO Capitation Rates.

              

      

      

      
        	
                4.  

              	
                This
                  Amendment shall have an effective date of January 1, 2008, or the
                  date on
                  which both parties execute the Amendment, whichever is
                  later.

              

      

      

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

      

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

      

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

      

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

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

       

      
        
          
            AHCA
              Contract No. FA615, Amendment No. 4, Page 1 of
              2

          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Medicaid
          HMO Contract

        Wellcare
          of Florida, Inc. 

        d/b/a
          Staywell Health Plan of Florida

      IN
        WITNESS WHEREOF, the parties hereto
        have caused this seven (7) page Amendment (which includes all attachments
        hereto) to be executed by their officials thereunto duly
        authorized.

      

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

                
                

              	
                STATE
                  OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

              
	
                SIGNED BY:  /s/  Todd
                  S.
                  Farha 

              	
                SIGNED
                  BY:   /s/  Illegible    
                  

              
	
                NAME:  
                  Todd S. Farha

              	
                   
                  (for)

                NAME: 
                  Andrew C. Agwunobi,
                  M.D.

              
	
                TITLE:   President
                  and CEO

              	
                TITLE:   
                  Secretary                                           
                  

              
	
                DATE: 1/2/08

              	
                DATE:   1/3/08

              
	 	 

      

      

      List
        of
        attachments included as part of this Amendment:

      

      
        	
                Specify
                  Type

              	
                Letter/
                  Number

              	
                Description

              
	
                Exhibit

              	
                III-C

              	
                January
                  1, 2008 - August 31, 2008 Medicaid Non-Reform HMO Capitation Rates
                  (5
                  Pages)

              

      

      

      

      
        
          
            AHCA
              Contract No. FA615, Amendment No. 4, Page 2 of 2

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

     

    

    
      	
              EXHIBIT
                III-C

            
	
              January
                1, 2008 - August 31, 2008

            
	
              MEDICAID
                Non-Reform HMO CAPITATION RATES

            
	
              By
                Area , Age and Eligibility Category

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                1

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

               (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,113.27

            	
              198.95

            	
              103.84

            	
              65.12

            	
              132.96

            	
              71.10

            	
              261.06

            	
              165.11

            	
              341.74

            	
              9,915.13

            	
              1,434.75

            	
              428.74

            	
              197.94

            	
              218.40

            	
              704.25

            	
              692.24

            	
              266.36

            	
              96.67

            	
              79.38

            
	
              02

            	
              1,113.27

            	
              198.95

            	
              103.84

            	
              65.12

            	
              132.96

            	
              71.10

            	
              261.06

            	
              165.11

            	
              341.74

            	
              9,915.13

            	
              1,434.75

            	
              428.74

            	
              197.94

            	
              218.40

            	
              704.25

            	
              692.24

            	
              266.36

            	
              96.67

            	
              79.38

            
	
              03

            	
              1,274.97

            	
              229.73

            	
              120.11

            	
              76.19

            	
              153.87

            	
              83.11

            	
              303.58

            	
              192.99

            	
              401.92

            	
              11,138.97

            	
              1,629.39

            	
              486.94

            	
              229.48

            	
              252.31

            	
              812.92

            	
              803.12

            	
              268.11

            	
              89.89

            	
              74.16

            
	
              04

            	
              1,110.20

            	
              200.37

            	
              105.01

            	
              66.79

            	
              134.42

            	
              72.81

            	
              265.41

            	
              168.95

            	
              352.65

            	
              10,499.42

            	
              1,537.71

            	
              460.11

            	
              217.21

            	
              238.35

            	
              768.93

            	
              759.32

            	
              324.10

            	
              92.63

            	
              76.37

            
	
              05

            	
              1,239.65

            	
              223.90

            	
              117.11

            	
              74.70

            	
              150.07

            	
              81.25

            	
              296.43

            	
              188.63

            	
              393.68

            	
              11,579.76

            	
              1,692.54

            	
              506.42

            	
              237.96

            	
              262.13

            	
              843.24

            	
              832.21

            	
              224.84

            	
              86.91

            	
              72.45

            
	
              06

            	
              1,093.25

            	
              198.54

            	
              104.28

            	
              66.96

            	
              133.36

            	
              72.80

            	
              264.61

            	
              168.97

            	
              354.37

            	
              10,652.91

            	
              1,564.02

            	
              468.08

            	
              222.16

            	
              243.74

            	
              785.88

            	
              776.94

            	
              278.82

            	
              84.03

            	
              69.54

            
	
              07

            	
              1,111.11

            	
              201.05

            	
              105.33

            	
              67.26

            	
              134.84

            	
              73.19

            	
              266.60

            	
              169.92

            	
              355.07

            	
              10,979.12

            	
              1,613.56

            	
              482.68

            	
              229.82

            	
              251.86

            	
              810.88

            	
              802.37

            	
              320.94

            	
              87.44

            	
              72.54

            
	
              08

            	
              1,042.42

            	
              189.18

            	
              99.15

            	
              63.67

            	
              127.01

            	
              69.25

            	
              251.65

            	
              160.56

            	
              336.69

            	
              9,334.29

            	
              1,365.81

            	
              408.73

            	
              192.99

            	
              211.83

            	
              682.67

            	
              674.08

            	
              187.79

            	
              83.02

            	
              68.67

            
	
              09

            	
              1,080.64

            	
              194.68

            	
              101.92

            	
              64.82

            	
              130.37

            	
              70.43

            	
              257.53

            	
              163.82

            	
              341.26

            	
              10,421.98

            	
              1,530.82

            	
              457.89

            	
              217.75

            	
              238.53

            	
              769.06

            	
              760.32

            	
              201.31

            	
              90.28

            	
              74.77

            
	
              10

            	
              1,100.94

            	
              199.64

            	
              104.76

            	
              67.19

            	
              133.94

            	
              73.01

            	
              265.61

            	
              169.34

            	
              354.88

            	
              13,515.72

            	
              1,994.98

            	
              596.62

            	
              285.93

            	
              313.86

            	
              1,009.79

            	
              999.91

            	
              251.29

            	
              103.32

            	
              85.55

            
	
              11

            	
              1,424.99

            	
              256.12

            	
              134.00

            	
              84.75

            	
              171.50

            	
              92.47

            	
              338.04

            	
              214.66

            	
              446.26

            	
              14,158.43

            	
              2,076.63

            	
              621.17

            	
              294.21

            	
              323.57

            	
              1,040.93

            	
              1,029.21

            	
              329.75

            	
              157.24

            	
              128.37

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                2

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                + Mental Health
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,113.29

            	
              198.97

            	
              105.45

            	
              76.61

            	
              143.70

            	
              81.84

            	
              265.43

            	
              169.48

            	
              345.42

            	
              9,915.21

            	
              1,434.83

            	
              436.06

            	
              245.19

            	
              261.65

            	
              784.29

            	
              722.71

            	
              266.57

            	
              108.13

            	
              90.84

            
	
              02

            	
              1,113.30

            	
              198.98

            	
              106.70

            	
              85.04

            	
              146.15

            	
              84.29

            	
              264.41

            	
              168.46

            	
              344.65

            	
              9,915.29

            	
              1,434.91

            	
              442.30

            	
              275.44

            	
              262.86

            	
              756.05

            	
              716.70

            	
              286.23

            	
              111.42

            	
              94.13

            
	
              03

            	
              1,274.98

            	
              229.74

            	
              121.41

            	
              85.22

            	
              159.85

            	
              89.09

            	
              305.10

            	
              194.51

            	
              403.24

            	
              11,139.04

            	
              1,629.46

            	
              493.10

            	
              264.64

            	
              272.48

            	
              836.42

            	
              814.21

            	
              274.85

            	
              98.72

            	
              82.99

            
	
              04

            	
              1,110.21

            	
              200.38

            	
              106.36

            	
              76.19

            	
              140.65

            	
              79.04

            	
              266.99

            	
              170.53

            	
              354.02

            	
              10,499.53

            	
              1,537.82

            	
              469.70

            	
              272.02

            	
              269.79

            	
              805.57

            	
              776.62

            	
              348.24

            	
              109.12

            	
              92.86

            
	
              05

            	
              1,239.66

            	
              223.91

            	
              118.30

            	
              83.23

            	
              158.04

            	
              89.22

            	
              299.67

            	
              191.87

            	
              396.42

            	
              11,579.81

            	
              1,692.59

            	
              511.36

            	
              269.84

            	
              291.31

            	
              897.24

            	
              852.76

            	
              227.52

            	
              99.51

            	
              85.05

            
	
              06

            	
              1,093.27

            	
              198.56

            	
              106.10

            	
              79.99

            	
              145.53

            	
              84.97

            	
              269.56

            	
              173.92

            	
              358.55

            	
              10,652.98

            	
              1,564.09

            	
              474.49

            	
              263.57

            	
              281.64

            	
              856.02

            	
              803.63

            	
              280.11

            	
              87.85

            	
              73.36

            
	
              07

            	
              1,111.13

            	
              201.07

            	
              107.08

            	
              79.74

            	
              146.50

            	
              84.85

            	
              271.34

            	
              174.66

            	
              359.07

            	
              10,979.18

            	
              1,613.62

            	
              488.70

            	
              268.67

            	
              287.42

            	
              876.69

            	
              827.42

            	
              323.49

            	
              97.78

            	
              82.88

            
	
              08

            	
              1,042.43

            	
              189.19

            	
              100.39

            	
              72.32

            	
              132.74

            	
              74.98

            	
              253.11

            	
              162.02

            	
              337.95

            	
              9,334.36

            	
              1,365.88

            	
              414.63

            	
              226.70

            	
              231.18

            	
              705.20

            	
              684.72

            	
              194.53

            	
              96.02

            	
              81.67

            
	
              09

            	
              1,080.66

            	
              194.70

            	
              103.44

            	
              75.45

            	
              137.41

            	
              77.47

            	
              259.32

            	
              165.61

            	
              342.81

            	
              10,422.05

            	
              1,530.89

            	
              464.12

            	
              253.29

            	
              258.93

            	
              792.81

            	
              771.54

            	
              208.05

            	
              99.71

            	
              84.20

            
	
              10

            	
              1,100.96

            	
              199.66

            	
              106.65

            	
              80.33

            	
              142.64

            	
              81.71

            	
              267.82

            	
              171.55

            	
              356.80

            	
              13,515.81

            	
              1,995.07

            	
              604.83

            	
              332.84

            	
              340.78

            	
              1,041.14

            	
              1,014.71

            	
              258.03

            	
              111.24

            	
              93.47

            
	
              11

            	
              1,425.01

            	
              256.14

            	
              135.59

            	
              95.85

            	
              178.86

            	
              99.83

            	
              339.91

            	
              216.53

            	
              447.88

            	
              14,158.51

            	
              2,076.71

            	
              628.03

            	
              333.34

            	
              346.02

            	
              1,067.09

            	
              1,041.56

            	
              336.86

            	
              165.16

            	
              136.29

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    AHCA
      Contract No. FA615,
      Exhibit III-C, Page 1 of 5

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              EXHIBIT
                III-C

            
	
              January
                1, 2008 - August 31, 2008

            
	
              MEDICAID
                Non-Reform HMO CAPITATION RATES

            
	
              By
                Area , Age and Eligibility Category

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                3

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                + MH + Dental
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

               (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,113.30

            	
              198.98

            	
              107.51

            	
              80.86

            	
              148.10

            	
              85.55

            	
              267.24

            	
              171.09

            	
              348.77

            	
              9,915.21

            	
              1,434.84

            	
              438.23

            	
              248.95

            	
              264.93

            	
              787.11

            	
              726.07

            	
              267.06

            	
              110.40

            	
              92.29

            
	
              02

            	
              1,113.31

            	
              198.99

            	
              108.76

            	
              89.29

            	
              150.55

            	
              88.00

            	
              266.22

            	
              170.07

            	
              348.00

            	
              9,915.29

            	
              1,434.92

            	
              444.47

            	
              279.20

            	
              266.14

            	
              758.87

            	
              720.06

            	
              286.72

            	
              113.69

            	
              95.58

            
	
              03

            	
              1,274.99

            	
              229.75

            	
              124.44

            	
              91.46

            	
              166.32

            	
              94.55

            	
              308.06

            	
              197.14

            	
              408.70

            	
              11,139.05

            	
              1,629.48

            	
              496.42

            	
              270.39

            	
              277.50

            	
              839.92

            	
              818.38

            	
              275.38

            	
              101.75

            	
              84.93

            
	
              04

            	
              1,110.22

            	
              200.39

            	
              108.37

            	
              80.34

            	
              144.96

            	
              82.68

            	
              269.75

            	
              172.98

            	
              359.12

            	
              10,499.53

            	
              1,537.83

            	
              471.87

            	
              275.78

            	
              273.08

            	
              808.82

            	
              780.50

            	
              350.21

            	
              112.15

            	
              94.80

            
	
              05

            	
              1,239.67

            	
              223.93

            	
              121.70

            	
              90.26

            	
              165.34

            	
              95.37

            	
              306.75

            	
              198.16

            	
              409.49

            	
              11,579.82

            	
              1,692.61

            	
              516.20

            	
              278.22

            	
              298.64

            	
              904.66

            	
              861.60

            	
              231.88

            	
              107.72

            	
              90.31

            
	
              06

            	
              1,093.28

            	
              198.57

            	
              108.70

            	
              85.35

            	
              151.09

            	
              89.66

            	
              273.12

            	
              177.08

            	
              365.12

            	
              10,652.98

            	
              1,564.10

            	
              477.61

            	
              268.98

            	
              286.37

            	
              860.37

            	
              808.82

            	
              281.92

            	
              92.55

            	
              76.38

            
	
              07

            	
              1,111.14

            	
              201.08

            	
              109.20

            	
              84.12

            	
              151.04

            	
              88.68

            	
              273.83

            	
              176.87

            	
              363.67

            	
              10,979.18

            	
              1,613.63

            	
              491.76

            	
              273.97

            	
              292.05

            	
              879.75

            	
              831.07

            	
              325.09

            	
              100.89

            	
              84.88

            
	
              08

            	
              1,042.44

            	
              189.20

            	
              103.37

            	
              78.47

            	
              139.11

            	
              80.35

            	
              256.08

            	
              164.65

            	
              343.42

            	
              9,334.36

            	
              1,365.89

            	
              417.70

            	
              232.02

            	
              235.83

            	
              708.74

            	
              688.94

            	
              195.98

            	
              99.12

            	
              83.66

            
	
              09

            	
              1,080.67

            	
              194.71

            	
              106.32

            	
              81.39

            	
              143.57

            	
              82.66

            	
              261.04

            	
              167.14

            	
              345.98

            	
              10,422.05

            	
              1,530.90

            	
              466.81

            	
              257.94

            	
              263.00

            	
              794.47

            	
              773.52

            	
              208.76

            	
              101.52

            	
              85.36

            
	
              10

            	
              1,100.97

            	
              199.67

            	
              109.45

            	
              86.12

            	
              148.64

            	
              86.77

            	
              269.62

            	
              173.15

            	
              360.11

            	
              13,515.82

            	
              1,995.09

            	
              608.51

            	
              339.22

            	
              346.35

            	
              1,043.21

            	
              1,017.18

            	
              260.05

            	
              113.76

            	
              95.09

            
	
              11

            	
              1,425.02

            	
              256.15

            	
              139.31

            	
              103.51

            	
              186.81

            	
              106.53

            	
              341.50

            	
              217.94

            	
              450.82

            	
              14,158.52

            	
              2,076.73

            	
              632.27

            	
              340.68

            	
              352.44

            	
              1,070.67

            	
              1,045.82

            	
              341.18

            	
              169.15

            	
              138.85

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                4

            	 	 	 	 	 	 	 	 	 	 
	
              General
                + MH + Transportation
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
(14-20)

            	
              AGE
(21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,118.75

            	
              200.33

            	
              106.30

            	
              77.12

            	
              145.59

            	
              83.08

            	
              268.47

            	
              171.82

            	
              348.55

            	
              9,957.91

            	
              1,462.40

            	
              441.61

            	
              247.63

            	
              267.67

            	
              803.95

            	
              738.94

            	
              273.23

            	
              121.63

            	
              99.45

            
	
              02

            	
              1,118.76

            	
              200.34

            	
              107.55

            	
              85.55

            	
              148.04

            	
              85.53

            	
              267.45

            	
              170.80

            	
              347.78

            	
              9,957.99

            	
              1,462.48

            	
              447.85

            	
              277.88

            	
              268.88

            	
              775.71

            	
              732.93

            	
              292.89

            	
              124.92

            	
              102.74

            
	
              03

            	
              1,281.58

            	
              231.39

            	
              122.43

            	
              85.84

            	
              162.13

            	
              90.58

            	
              308.77

            	
              197.34

            	
              407.02

            	
              11,192.94

            	
              1,664.26

            	
              500.10

            	
              267.71

            	
              280.08

            	
              861.25

            	
              834.72

            	
              283.33

            	
              118.23

            	
              95.44

            
	
              04

            	
              1,115.15

            	
              201.61

            	
              107.13

            	
              76.65

            	
              142.36

            	
              80.16

            	
              269.73

            	
              172.65

            	
              356.86

            	
              10,543.16

            	
              1,565.99

            	
              475.37

            	
              274.51

            	
              275.95

            	
              825.67

            	
              793.21

            	
              355.09

            	
              124.64

            	
              102.76

            
	
              05

            	
              1,243.79

            	
              224.94

            	
              118.94

            	
              83.62

            	
              159.46

            	
              90.15

            	
              301.97

            	
              193.65

            	
              398.78

            	
              11,614.53

            	
              1,714.99

            	
              515.87

            	
              271.82

            	
              296.21

            	
              913.23

            	
              865.96

            	
              233.30

            	
              113.31

            	
              93.85

            
	
              06

            	
              1,097.25

            	
              199.55

            	
              106.72

            	
              80.36

            	
              146.91

            	
              85.87

            	
              271.77

            	
              175.63

            	
              360.83

            	
              10,687.23

            	
              1,586.20

            	
              478.95

            	
              265.53

            	
              286.48

            	
              871.79

            	
              816.65

            	
              285.34

            	
              99.27

            	
              80.64

            
	
              07

            	
              1,115.00

            	
              202.04

            	
              107.68

            	
              80.11

            	
              147.83

            	
              85.72

            	
              273.49

            	
              176.32

            	
              361.29

            	
              11,015.88

            	
              1,637.32

            	
              493.47

            	
              270.76

            	
              292.60

            	
              893.60

            	
              841.37

            	
              329.04

            	
              109.71

            	
              90.50

            
	
              08

            	
              1,047.92

            	
              190.56

            	
              101.24

            	
              72.83

            	
              134.64

            	
              76.22

            	
              256.16

            	
              164.37

            	
              341.09

            	
              9,375.02

            	
              1,392.12

            	
              419.92

            	
              229.03

            	
              236.92

            	
              723.92

            	
              700.18

            	
              200.51

            	
              110.58

            	
              90.96

            
	
              09

            	
              1,085.95

            	
              196.02

            	
              104.26

            	
              75.95

            	
              139.24

            	
              78.67

            	
              262.26

            	
              167.88

            	
              345.85

            	
              10,464.52

            	
              1,558.31

            	
              469.65

            	
              255.72

            	
              264.93

            	
              812.36

            	
              787.69

            	
              214.85

            	
              115.26

            	
              94.12

            
	
              10

            	
              1,104.68

            	
              200.59

            	
              107.22

            	
              80.68

            	
              143.93

            	
              82.55

            	
              269.89

            	
              173.15

            	
              358.93

            	
              13,554.29

            	
              2,019.92

            	
              609.83

            	
              335.04

            	
              346.22

            	
              1,058.87

            	
              1,029.34

            	
              265.22

            	
              128.61

            	
              104.55

            
	
              11

            	
              1,428.21

            	
              256.94

            	
              136.08

            	
              96.15

            	
              179.96

            	
              100.55

            	
              341.69

            	
              217.91

            	
              449.71

            	
              14,187.41

            	
              2,095.37

            	
              631.78

            	
              334.99

            	
              350.10

            	
              1,080.40

            	
              1,052.54

            	
              341.70

            	
              177.46

            	
              144.14

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    AHCA Contract No. FA615, Exhibit
      III-C, Page 2 of 5

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              EXHIBIT
                III-C

            
	
              January
                1, 2008 - August 31, 2008

            
	
              MEDICAID
                Non-Reform HMO CAPITATION RATES

            
	
              By
                Area , Age and Eligibility Category

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                5

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                + Transportation
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,118.73

            	
              200.31

            	
              104.69

            	
              65.63

            	
              134.85

            	
              72.34

            	
              264.10

            	
              167.45

            	
              344.87

            	
              9,957.83

            	
              1,462.32

            	
              434.29

            	
              200.38

            	
              224.42

            	
              723.91

            	
              708.47

            	
              273.02

            	
              110.17

            	
              87.99

            
	
              02

            	
              1,118.73

            	
              200.31

            	
              104.69

            	
              65.63

            	
              134.85

            	
              72.34

            	
              264.10

            	
              167.45

            	
              344.87

            	
              9,957.83

            	
              1,462.32

            	
              434.29

            	
              200.38

            	
              224.42

            	
              723.91

            	
              708.47

            	
              273.02

            	
              110.17

            	
              87.99

            
	
              03

            	
              1,281.57

            	
              231.38

            	
              121.13

            	
              76.81

            	
              156.15

            	
              84.60

            	
              307.25

            	
              195.82

            	
              405.70

            	
              11,192.87

            	
              1,664.19

            	
              493.94

            	
              232.55

            	
              259.91

            	
              837.75

            	
              823.63

            	
              276.59

            	
              109.40

            	
              86.61

            
	
              04

            	
              1,115.14

            	
              201.60

            	
              105.78

            	
              67.25

            	
              136.13

            	
              73.93

            	
              268.15

            	
              171.07

            	
              355.49

            	
              10,543.05

            	
              1,565.88

            	
              465.78

            	
              219.70

            	
              244.51

            	
              789.03

            	
              775.91

            	
              330.95

            	
              108.15

            	
              86.27

            
	
              05

            	
              1,243.78

            	
              224.93

            	
              117.75

            	
              75.09

            	
              151.49

            	
              82.18

            	
              298.73

            	
              190.41

            	
              396.04

            	
              11,614.48

            	
              1,714.94

            	
              510.93

            	
              239.94

            	
              267.03

            	
              859.23

            	
              845.41

            	
              230.62

            	
              100.71

            	
              81.25

            
	
              06

            	
              1,097.23

            	
              199.53

            	
              104.90

            	
              67.33

            	
              134.74

            	
              73.70

            	
              266.82

            	
              170.68

            	
              356.65

            	
              10,687.16

            	
              1,586.13

            	
              472.54

            	
              224.12

            	
              248.58

            	
              801.65

            	
              789.96

            	
              284.05

            	
              95.45

            	
              76.82

            
	
              07

            	
              1,114.98

            	
              202.02

            	
              105.93

            	
              67.63

            	
              136.17

            	
              74.06

            	
              268.75

            	
              171.58

            	
              357.29

            	
              11,015.82

            	
              1,637.26

            	
              487.45

            	
              231.91

            	
              257.04

            	
              827.79

            	
              816.32

            	
              326.49

            	
              99.37

            	
              80.16

            
	
              08

            	
              1,047.91

            	
              190.55

            	
              100.00

            	
              64.18

            	
              128.91

            	
              70.49

            	
              254.70

            	
              162.91

            	
              339.83

            	
              9,374.95

            	
              1,392.05

            	
              414.02

            	
              195.32

            	
              217.57

            	
              701.39

            	
              689.54

            	
              193.77

            	
              97.58

            	
              77.96

            
	
              09

            	
              1,085.93

            	
              196.00

            	
              102.74

            	
              65.32

            	
              132.20

            	
              71.63

            	
              260.47

            	
              166.09

            	
              344.30

            	
              10,464.45

            	
              1,558.24

            	
              463.42

            	
              220.18

            	
              244.53

            	
              788.61

            	
              776.47

            	
              208.11

            	
              105.83

            	
              84.69

            
	
              10

            	
              1,104.66

            	
              200.57

            	
              105.33

            	
              67.54

            	
              135.23

            	
              73.85

            	
              267.68

            	
              170.94

            	
              357.01

            	
              13,554.20

            	
              2,019.83

            	
              601.62

            	
              288.13

            	
              319.30

            	
              1,027.52

            	
              1,014.54

            	
              258.48

            	
              120.69

            	
              96.63

            
	
              11

            	
              1,428.19

            	
              256.92

            	
              134.49

            	
              85.05

            	
              172.60

            	
              93.19

            	
              339.82

            	
              216.04

            	
              448.09

            	
              14,187.33

            	
              2,095.29

            	
              624.92

            	
              295.86

            	
              327.65

            	
              1,054.24

            	
              1,040.19

            	
              334.59

            	
              169.54

            	
              136.22

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                6

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                + Dental
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE
                (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,113.28

            	
              198.96

            	
              105.90

            	
              69.37

            	
              137.36

            	
              74.81

            	
              262.87

            	
              166.72

            	
              345.09

            	
              9,915.13

            	
              1,434.76

            	
              430.91

            	
              201.70

            	
              221.68

            	
              707.07

            	
              695.60

            	
              266.85

            	
              98.94

            	
              80.83

            
	
              02

            	
              1,113.28

            	
              198.96

            	
              105.90

            	
              69.37

            	
              137.36

            	
              74.81

            	
              262.87

            	
              166.72

            	
              345.09

            	
              9,915.13

            	
              1,434.76

            	
              430.91

            	
              201.70

            	
              221.68

            	
              707.07

            	
              695.60

            	
              266.85

            	
              98.94

            	
              80.83

            
	
              03

            	
              1,274.98

            	
              229.74

            	
              123.14

            	
              82.43

            	
              160.34

            	
              88.57

            	
              306.54

            	
              195.62

            	
              407.38

            	
              11,138.98

            	
              1,629.41

            	
              490.26

            	
              235.23

            	
              257.33

            	
              816.42

            	
              807.29

            	
              268.64

            	
              92.92

            	
              76.10

            
	
              04

            	
              1,110.21

            	
              200.38

            	
              107.02

            	
              70.94

            	
              138.73

            	
              76.45

            	
              268.17

            	
              171.40

            	
              357.75

            	
              10,499.42

            	
              1,537.72

            	
              462.28

            	
              220.97

            	
              241.64

            	
              772.18

            	
              763.20

            	
              326.07

            	
              95.66

            	
              78.31

            
	
              05

            	
              1,239.66

            	
              223.92

            	
              120.51

            	
              81.73

            	
              157.37

            	
              87.40

            	
              303.51

            	
              194.92

            	
              406.75

            	
              11,579.77

            	
              1,692.56

            	
              511.26

            	
              246.34

            	
              269.46

            	
              850.66

            	
              841.05

            	
              229.20

            	
              95.12

            	
              77.71

            
	
              06

            	
              1,093.26

            	
              198.55

            	
              106.88

            	
              72.32

            	
              138.92

            	
              77.49

            	
              268.17

            	
              172.13

            	
              360.94

            	
              10,652.91

            	
              1,564.03

            	
              471.20

            	
              227.57

            	
              248.47

            	
              790.23

            	
              782.13

            	
              280.63

            	
              88.73

            	
              72.56

            
	
              07

            	
              1,111.12

            	
              201.06

            	
              107.45

            	
              71.64

            	
              139.38

            	
              77.02

            	
              269.09

            	
              172.13

            	
              359.67

            	
              10,979.12

            	
              1,613.57

            	
              485.74

            	
              235.12

            	
              256.49

            	
              813.94

            	
              806.02

            	
              322.54

            	
              90.55

            	
              74.54

            
	
              08

            	
              1,042.43

            	
              189.19

            	
              102.13

            	
              69.82

            	
              133.38

            	
              74.62

            	
              254.62

            	
              163.19

            	
              342.16

            	
              9,334.29

            	
              1,365.82

            	
              411.80

            	
              198.31

            	
              216.48

            	
              686.21

            	
              678.30

            	
              189.24

            	
              86.12

            	
              70.66

            
	
              09

            	
              1,080.65

            	
              194.69

            	
              104.80

            	
              70.76

            	
              136.53

            	
              75.62

            	
              259.25

            	
              165.35

            	
              344.43

            	
              10,421.98

            	
              1,530.83

            	
              460.58

            	
              222.40

            	
              242.60

            	
              770.72

            	
              762.30

            	
              202.02

            	
              92.09

            	
              75.93

            
	
              10

            	
              1,100.95

            	
              199.65

            	
              107.56

            	
              72.98

            	
              139.94

            	
              78.07

            	
              267.41

            	
              170.94

            	
              358.19

            	
              13,515.73

            	
              1,995.00

            	
              600.30

            	
              292.31

            	
              319.43

            	
              1,011.86

            	
              1,002.38

            	
              253.31

            	
              105.84

            	
              87.17

            
	
              11

            	
              1,425.00

            	
              256.13

            	
              137.72

            	
              92.41

            	
              179.45

            	
              99.17

            	
              339.63

            	
              216.07

            	
              449.20

            	
              14,158.44

            	
              2,076.65

            	
              625.41

            	
              301.55

            	
              329.99

            	
              1,044.51

            	
              1,033.47

            	
              334.07

            	
              161.23

            	
              130.93

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    AHCA Contract No. FA615, Exhibit
      III-C, Page 3 of 5

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              EXHIBIT
                III-C

            
	
              January
                1, 2008 - August 31, 2008

            
	
              MEDICAID
                Non-Reform HMO CAPITATION RATES

            
	
              By
                Area , Age and Eligibility Category

            
	
              TABLE
                7

            	 	 	 	 	 	 	 	 	 	 
	
              General
                + Dental + Transportation
                Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,118.74

            	
              200.32

            	
              106.75

            	
              69.88

            	
              139.25

            	
              76.05

            	
              265.91

            	
              169.06

            	
              348.22

            	
              9,957.83

            	
              1,462.33

            	
              436.46

            	
              204.14

            	
              227.70

            	
              726.73

            	
              711.83

            	
              273.51

            	
              112.44

            	
              89.44

            
	
              02

            	
              1,118.74

            	
              200.32

            	
              106.75

            	
              69.88

            	
              139.25

            	
              76.05

            	
              265.91

            	
              169.06

            	
              348.22

            	
              9,957.83

            	
              1,462.33

            	
              436.46

            	
              204.14

            	
              227.70

            	
              726.73

            	
              711.83

            	
              273.51

            	
              112.44

            	
              89.44

            
	
              03

            	
              1,281.58

            	
              231.39

            	
              124.16

            	
              83.05

            	
              162.62

            	
              90.06

            	
              310.21

            	
              198.45

            	
              411.16

            	
              11,192.88

            	
              1,664.21

            	
              497.26

            	
              238.30

            	
              264.93

            	
              841.25

            	
              827.80

            	
              277.12

            	
              112.43

            	
              88.55

            
	
              04

            	
              1,115.15

            	
              201.61

            	
              107.79

            	
              71.40

            	
              140.44

            	
              77.57

            	
              270.91

            	
              173.52

            	
              360.59

            	
              10,543.05

            	
              1,565.89

            	
              467.95

            	
              223.46

            	
              247.80

            	
              792.28

            	
              779.79

            	
              332.92

            	
              111.18

            	
              88.21

            
	
              05

            	
              1,243.79

            	
              224.95

            	
              121.15

            	
              82.12

            	
              158.79

            	
              88.33

            	
              305.81

            	
              196.70

            	
              409.11

            	
              11,614.49

            	
              1,714.96

            	
              515.77

            	
              248.32

            	
              274.36

            	
              866.65

            	
              854.25

            	
              234.98

            	
              108.92

            	
              86.51

            
	
              06

            	
              1,097.24

            	
              199.54

            	
              107.50

            	
              72.69

            	
              140.30

            	
              78.39

            	
              270.38

            	
              173.84

            	
              363.22

            	
              10,687.16

            	
              1,586.14

            	
              475.66

            	
              229.53

            	
              253.31

            	
              806.00

            	
              795.15

            	
              285.86

            	
              100.15

            	
              79.84

            
	
              07

            	
              1,114.99

            	
              202.03

            	
              108.05

            	
              72.01

            	
              140.71

            	
              77.89

            	
              271.24

            	
              173.79

            	
              361.89

            	
              11,015.82

            	
              1,637.27

            	
              490.51

            	
              237.21

            	
              261.67

            	
              830.85

            	
              819.97

            	
              328.09

            	
              102.48

            	
              82.16

            
	
              08

            	
              1,047.92

            	
              190.56

            	
              102.98

            	
              70.33

            	
              135.28

            	
              75.86

            	
              257.67

            	
              165.54

            	
              345.30

            	
              9,374.95

            	
              1,392.06

            	
              417.09

            	
              200.64

            	
              222.22

            	
              704.93

            	
              693.76

            	
              195.22

            	
              100.68

            	
              79.95

            
	
              09

            	
              1,085.94

            	
              196.01

            	
              105.62

            	
              71.26

            	
              138.36

            	
              76.82

            	
              262.19

            	
              167.62

            	
              347.47

            	
              10,464.45

            	
              1,558.25

            	
              466.11

            	
              224.83

            	
              248.60

            	
              790.27

            	
              778.45

            	
              208.82

            	
              107.64

            	
              85.85

            
	
              10

            	
              1,104.67

            	
              200.58

            	
              108.13

            	
              73.33

            	
              141.23

            	
              78.91

            	
              269.48

            	
              172.54

            	
              360.32

            	
              13,554.21

            	
              2,019.85

            	
              605.30

            	
              294.51

            	
              324.87

            	
              1,029.59

            	
              1,017.01

            	
              260.50

            	
              123.21

            	
              98.25

            
	
              11

            	
              1,428.20

            	
              256.93

            	
              138.21

            	
              92.71

            	
              180.55

            	
              99.89

            	
              341.41

            	
              217.45

            	
              451.03

            	
              14,187.34

            	
              2,095.31

            	
              629.16

            	
              303.20

            	
              334.07

            	
              1,057.82

            	
              1,044.45

            	
              338.91

            	
              173.53

            	
              138.78

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              TABLE
                8

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              General
                + Mental Health + Dental +
                Transportation Rates:

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              TANF

            	
              SSI-N

            	
              SSI-B

            	
              SSI-AB

            
	
              Area

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE
                (14-20)

            	
              AGE
                (21-54)

            	
              AGE

              (55+)

            	
              BTHMO

              +2MO

            	
              3MO-11MO

            	
              AGE

              (1-5)

            	
              AGE

              (6-13)

            	
              AGE

              (14-20)

            	
              AGE

              (21-54)

            	
              AGE

              (55+)

            	 	
              AGE

              (65-)

            	
              AGE

              (65+)

            
	 	 	 	 	 	
              Female

            	
              Male

            	
              Female

            	
              Male

            	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              01

            	
              1,118.76

            	
              200.34

            	
              108.36

            	
              81.37

            	
              149.99

            	
              86.79

            	
              270.28

            	
              173.43

            	
              351.90

            	
              9,957.91

            	
              1,462.41

            	
              443.78

            	
              251.39

            	
              270.95

            	
              806.77

            	
              742.30

            	
              273.72

            	
              123.90

            	
              100.90

            
	
              02

            	
              1,118.77

            	
              200.35

            	
              109.61

            	
              89.80

            	
              152.44

            	
              89.24

            	
              269.26

            	
              172.41

            	
              351.13

            	
              9,957.99

            	
              1,462.49

            	
              450.02

            	
              281.64

            	
              272.16

            	
              778.53

            	
              736.29

            	
              293.38

            	
              127.19

            	
              104.19

            
	
              03

            	
              1,281.59

            	
              231.40

            	
              125.46

            	
              92.08

            	
              168.60

            	
              96.04

            	
              311.73

            	
              199.97

            	
              412.48

            	
              11,192.95

            	
              1,664.28

            	
              503.42

            	
              273.46

            	
              285.10

            	
              864.75

            	
              838.89

            	
              283.86

            	
              121.26

            	
              97.38

            
	
              04

            	
              1,115.16

            	
              201.62

            	
              109.14

            	
              80.80

            	
              146.67

            	
              83.80

            	
              272.49

            	
              175.10

            	
              361.96

            	
              10,543.16

            	
              1,566.00

            	
              477.54

            	
              278.27

            	
              279.24

            	
              828.92

            	
              797.09

            	
              357.06

            	
              127.67

            	
              104.70

            
	
              05

            	
              1,243.80

            	
              224.96

            	
              122.34

            	
              90.65

            	
              166.76

            	
              96.30

            	
              309.05

            	
              199.94

            	
              411.85

            	
              11,614.54

            	
              1,715.01

            	
              520.71

            	
              280.20

            	
              303.54

            	
              920.65

            	
              874.80

            	
              237.66

            	
              121.52

            	
              99.11

            
	
              06

            	
              1,097.26

            	
              199.56

            	
              109.32

            	
              85.72

            	
              152.47

            	
              90.56

            	
              275.33

            	
              178.79

            	
              367.40

            	
              10,687.23

            	
              1,586.21

            	
              482.07

            	
              270.94

            	
              291.21

            	
              876.14

            	
              821.84

            	
              287.15

            	
              103.97

            	
              83.66

            
	
              07

            	
              1,115.01

            	
              202.05

            	
              109.80

            	
              84.49

            	
              152.37

            	
              89.55

            	
              275.98

            	
              178.53

            	
              365.89

            	
              11,015.88

            	
              1,637.33

            	
              496.53

            	
              276.06

            	
              297.23

            	
              896.66

            	
              845.02

            	
              330.64

            	
              112.82

            	
              92.50

            
	
              08

            	
              1,047.93

            	
              190.57

            	
              104.22

            	
              78.98

            	
              141.01

            	
              81.59

            	
              259.13

            	
              167.00

            	
              346.56

            	
              9,375.02

            	
              1,392.13

            	
              422.99

            	
              234.35

            	
              241.57

            	
              727.46

            	
              704.40

            	
              201.96

            	
              113.68

            	
              92.95

            
	
              09

            	
              1,085.96

            	
              196.03

            	
              107.14

            	
              81.89

            	
              145.40

            	
              83.86

            	
              263.98

            	
              169.41

            	
              349.02

            	
              10,464.52

            	
              1,558.32

            	
              472.34

            	
              260.37

            	
              269.00

            	
              814.02

            	
              789.67

            	
              215.56

            	
              117.07

            	
              95.28

            
	
              10

            	
              1,104.69

            	
              200.60

            	
              110.02

            	
              86.47

            	
              149.93

            	
              87.61

            	
              271.69

            	
              174.75

            	
              362.24

            	
              13,554.30

            	
              2,019.94

            	
              613.51

            	
              341.42

            	
              351.79

            	
              1,060.94

            	
              1,031.81

            	
              267.24

            	
              131.13

            	
              106.17

            
	
              11

            	
              1,428.22

            	
              256.95

            	
              139.80

            	
              103.81

            	
              187.91

            	
              107.25

            	
              343.28

            	
              219.32

            	
              452.65

            	
              14,187.42

            	
              2,095.39

            	
              636.02

            	
              342.33

            	
              356.52

            	
              1,083.98

            	
              1,056.80

            	
              346.02

            	
              181.45

            	
              146.70

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    AHCA Contract No. FA615, Exhibit
      III-C, Page 4 of 5

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              EXHIBIT
                III-C

            
	
              January
                1, 2008 - August 31, 2008

            
	
              MEDICAID
                Non-Reform HMO CAPITATION RATES

            
	
              By
                Area , Age and Eligibility Category

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Area

            	 	
              Corresponding
                Counties

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Area
                1

            	 	
              Escambia,
                Okaloosa, Santa Rosa,
                Walton

            
	
              Area
                2

            	 	
              Bay,
                Calhoun, Franklin, Gadsden,
                Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor,
                Washington, Wakulla

            
	
              Area
                3

            	 	
              Alachua,
                Bradford, Citrus,
                Columbia, Dixie, Gilchrist, Hamiliton, Hernando, Lafayette, Lake,
                Levy,
                Marion, Putnam, Sumter, Suwannee, Union

            
	
              Area
                4

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

            
	
              Area
                5

            	 	
              Pasco,
                Pinellas

            
	
              Area
                6

            	 	
              Hardee,
                Highlands, Hillsborough,
                Manatee, Polk

            
	
              Area
                7

            	 	
              Brevard,
                Orange, Osceola,
                Seminole

            
	
              Area
                8

            	 	
              Charlotte,
                Collier, De Soto,
                Glades, Hendry, Lee, Sarasota

            
	
              Area
                9

            	 	
              Indian
                River, Okeechobee, St.
                Lucie, Martin, Palm Beach

            
	
              Area
                10

            	 	
              Broward

            
	
              Area
                11

            	 	
              Dade,
                Monroe

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              created
                on August 19,
                2006

            	 	 
	
              modified
                on September 11, 2006 -
                incresing dental rates.

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    AHCA Contract No. FA615, Exhibit
      III-C, Page 5 of 5exhibit10-3.htm

    
      
        

      

    

    Back
      to Form 8-K

    Exhibit
      10.3

    
Healthease of Florida,
      Inc. 

    Medicaid
      HMO Reform Contract

    AHCA
      CONTRACT NO. FAR001

    AMENDMENT
      NO. 7

    

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

    

    
      	
               

            	
              1.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section I.A., Definitions,
                is hereby amended as follows: 

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for Baker Act is hereby amended to read as follows:
                

            

    

    

    
      	
               

            	
              Baker
                Act- The Florida Mental Health Act, pursuant to Sections
                394.451 through 394.4789, F.S.. 

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for Children/Adolescents is hereby amended to read as
                follows:
                

            

    

    

    
      	
               

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

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for Contract Year is hereby amended to read as follows:
                

            

    

    

    
      	
               

            	
              Contract
                Year- Each September
                1
                through August 31 within the Contract Period.

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for HEDIS is hereby included as follows:
                

            

    

    

    
      	
               

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

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for Kick Payment is hereby amended to read as follows:
                

            

    

    

    
      	
               

            	
              Kick
                Payment– The method of
                reimbursing Prepaid Health
                Plans in the form of a separate one-time fixed payment for specific
                services. 

            

    

    

    
      	
               

            	
              --

            	
              The
                definition for Quality Improvement Plan is hereby included as follows:
                

            

    

    

    
      	
               

            	
              Quality
                Improvement Plan (QI Plan) -A written document that
                describes the Health Plan’s Quality Improvement Program (QIP), processes,
                and current strategy for improving the health care outcomes of its
                Enrollees.  It shall include, at a minimum, all components
                required in Section VIII, A. 2. b. (1) through (10).
                

            

    

    

    
      	
               

            	
              2.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section II., General
                Overview, Item D., General Responsibilities of the Health Plan, sub-item
                14, first paragraph, the second sentence is hereby deleted and replaced
                as
                follows: 

            

    

    

    A
      Medicaid Encounter Data System Companion Guide is located on the Medicaid web
      site: http://ahca.myflorida.com/Medicaid/meds/index.shtml.

     

    AHCA
      Contract No. FAR001, Amendment No. 7, Page 1 of 66

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

      Healthease
        of
        Florida, Inc. 
        Medicaid
          HMO Reform Contract

      

    

    
      	
              3.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section III., Eligibility
                and Enrollment, Item A., Eligibility, sub-item 2.a, is hereby deleted
                and
                replaced as follows:

            

    

    

    
      	
               

            	
              a.

            	
              Foster
                care Children/Adolescents, including Children/Adolescents receiving
                Medical Foster Care Services; 

            

    

    

    
      	
               

            	
              4.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section III., Eligibility
                and Enrollment, Item C., Disenrollment, sub-item 3.h.6., is hereby
                amended
                to read as follows: 

            

    

    

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

    

    
      	
               

            	
              5.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item A., Enrollee Services, sub-item 1.e.
                is
                hereby is deleted and replaced as follows:

            

    

    

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

    

    
      	
               

            	
              6.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item A., Enrollee Services, sub-item 4.a.(20),
                is
                hereby amended to read as follows: 

            

    

    

    
      	
               

            	
              (20)

            	
              Information
                regarding health care Advance Directives pursuant to Section 765.302
                through 765.309, F.S., and 42 CFR 422.128.

            

    

    

    
      	
               

            	
              7.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item A., Enrollee Services is hereby amended
                to
                include sub-items 10 and 11 as follows:

            

    

    

    
      	
               

            	
              10.

            	
              Prescribed
                Drug List (PDL) 

            

    

    

    
      	
               

            	
              The
                Health Plan’s website must include the Health Plan’s PDL.  The
                Health Plan may update the online PDL by providing thirty (30) days
                written notice of any change to the Bureaus of Managed Health Care
                and
                Pharmacy Services. 

            

    

    

    11.         
      Medicaid Redetermination Notices

    

    Upon
      implementation of a systems change relative to this section, the Agency will
      provide Medicaid recipient redetermination date information to the Health
      Plan.

    

    
      	
               

            	
              a.

            	
              This
                information may be used by the Health Plan only as indicated in this
                subsection. 

            

    

    

    
      	
               

            	
              b.

            	
              The
                Agency will notify the Health Plan sixty (60) Calendar Days prior
                to
                transmitting this information to the Health Plan and, at that time,
                will
                provide the Health Plan with the file format for this information.
                The
                Agency will decide whether or not to continue to provide this information
                to Health Plan annually and will notify the Health Plans of its decision
                by May 1 for the coming Contract Year. In addition, the Agency reserves
                the right to provide thirty (30) Calendar Days notice prior to
                discontinuing this subsection at any time.

            

    

    
      
        
          AHCA
            Contract No. FAR001, Amendment No. 7, Page 2 of
            66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    
      	
               

            	
              c.

            	
              Within
                thirty (30) Calendar Days after the date of the Agency’s notice of
                transmitting this redetermination date information, and annually
                by June 1
                thereafter, the Health Plan must notify the Agency’s Bureau of Managed
                Care (BMHC), in writing, if it will participate in the use of this
                information for the Contract Year.  The Health Plan’s
                participation in using this information is optional/voluntary.
                

            

    

    

    
      	
               

            	
              (1)

            	
              If
                the Health Plan does not respond in writing to the Agency within
                thirty
                (30) Calendar Days after the date of the Agency’s notice, the Health Plan
                forfeits its ability to receive and use this information until the
                next
                Contract Year. 

            

    

    

    
      	
               

            	
              (2)

            	
              If
                the Health Plan chooses to participate in the use of this information,
                it
                must provide with its response indicating it will participate, to
                the
                Agency for its approval, its policies and procedures regarding this
                subsection. 

            

    

    

    
      	
               

            	
              (i)

            	
              A
                Health Plan that chooses to participate in the use of this information
                may
                decide to discontinue using this information at any time. In this
                circumstance, the Health Plan must notify the Agency’s BMHC of such in
                writing.  The Agency will then delete the Health Plan from the
                list of Health Plans receiving this information for the remainder
                of the
                Contract Year. 

            

    

    

    
      	
               

            	
              (ii)

            	
              A
                Health Plan that chooses to participate in the use of this information
                must train all affected staff, prior to implementation, on its policies
                and procedures and the Agency’s requirements regarding this
                subsection.  The Health Plan must document such training has
                been provided including a record of those trained for the Agency
                review
                within five (5) Business days after the Agency’s request.
                

            

    

    

    
      	
               

            	
              (3)

            	
              If
                the Health Plan has opted-out of participating in the use of this
                information, it may not opt back in until the next Contract Year.
                

            

    

    

    
      	
               

            	
              (4)

            	
              Regardless
                of whether or not the Health Plan has declined to participate in
                the use
                of this information, it is subject to the sanctioning indicated in
                this
                subsection if this information has been or is misused by the Health
                Plan.
                

            

    

    

    
      	
               

            	
              d.

            	
              If
                the Health Plan chooses to participate in using this information,
                it may
                use the redetermination date information only in the methods listed
                below,
                and may choose to use both methods to communicate this information
                or just
                one method. 

            

    

    

    
      	
               

            	
              (1)

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

            

    

    

    
      	
               

            	
              (a)

            	
              The
                Health Plan must mail the redetermination date notice to each Enrollee
                for
                whom the Health Plan received a redetermination date. The Health
                Plan may
                send one notice to the Enrollee’s household when there are multiple
                Enrollees within a family that have the same Medicaid redetermination
                date
                provided that these Enrollees share the same mailing address.
                

            

    

    
      
        
          AHCA
            Contract No. FAR001, Amendment No. 7, Page 3 of
            66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              (b)

            	
              The
                Health Plan must use the Agency’s redetermination date notice template
                provided to the Health Plan for its notices.  The Health Plan
                may put this template on its letterhead for mailing; however, the
                Health
                Plan may make no other changes, additions or deletions to the letter
                text.
                

            

    

    

    
      	
               

            	
              (c)

            	
              The
                Health Plan must mail the redetermination date notices to each Enrollee
                whose redetermination date occurs within the month for which the
                enrollment file is received. Such notices must be mailed within five
                (5)
                Business Days after the Health Plan’s receipt of the Agency’s enrollment
                file for the month in which the Enrollee’s redetermination date occurs.
                

            

    

    

    
      	
               

            	
              (2)

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

            

    

    

    
      	
               

            	
              (a)

            	
              The
                Health Plan must send the redetermination date messages to each Enrollee
                whose redetermination date occurs within the month for which the
                enrollment file is received and for whom the Health Plan has a telephone
                number. The Health Plan may send an automated message to the Enrollee’s
                household when there are multiple Enrollees within a family that
                have the
                same Medicaid redetermination date provided that these Enrollees
                share the
                same mailing address/phone number. 

            

    

    

    
      	
               

            	
              (b)

            	
              For
                the voice messages, the Health Plan must use only the language in
                the
                Agency’s redetermination date notice template provided to the Health
                Plan.  The Health Plan may add its name to the message but may
                make no other changes, additions or deletions to the message text.
                

            

    

    

    
      	
               

            	
              (c)

            	
              The
                Health Plan must make such automated calls within five (5) Business
                Days
                after the Health Plan’s receipt of the Agency’s enrollment file for the
                month in which the Enrollee’s redetermination date occurs.
                

            

    

    

    
      	
               

            	
              (3)

            	
              The
                Health Plan may not include the redetermination date information
                in any
                file viewable by customer service or marketing staff. This information
                may
                only be used in the letter templates and automated scripts provided
                by the
                Agency and cannot be verbally referenced or discussed by the Health
                Plan
                with the Enrollees, unless in response to an Enrollee inquiry regarding
                the letter received, nor may it be used a future time by the Health
                Plan.
                If the Health Plan receives Enrollee inquiries regarding the notices,
                such
                inquiries must be referred to the Department of Children and Families.
                

            

    

    

    
      	
               

            	
              e.

            	
              If
                the Health Plan chooses to participate in using this information,
                the
                Health Plan must keep the following information available regarding
                each
                mailing made for the Agency’s review within five (5) Business Days after
                the Agency’s request: 

            

    

    
      
        
          AHCA
            Contract No. FAR001, Amendment
            No. 7, Page 4 of 66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              (1)

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

            

    

    

    
      	
               

            	
              (a)

            	
              A
                list of each Enrollee for whom a monthly mailing was sent. This list
                shall
                include each Enrollee’s name and Medicaid identification number to whom
                the notice was mailed and the address to which the notice was mailed.
                

            

    

    

    
      	
               

            	
              (b)

            	
              A
                log of returned, undeliverable mail received for these notices, by
                month,
                for each Enrollee for whom a returned notice was received.
                

            

    

    

    
      	
               

            	
              (2)

            	
              For
                each month of automated calls made, a list including of each Enrollee
                for
                whom a call was made, the Enrollee’s Medicaid identification number,
                telephone number to which the call was made, and the date each call
                was
                made. 

            

    

    

    The
      Health Plan must retain this documentation in accordance with the Agency’s
      Standard Contract, I.D., Retention of Records.

    

    
      	
               

            	
              f.

            	
              If
                the Health Plan chooses to participate in using this information,
                the
                Health Plan must keep up-to-date and approved policies and procedures
                regarding the use, storage and securing of this information as well
                as
                addressing all requirements of this subsection.

            

    

    

    
      	
               

            	
              g.

            	
              If
                the Health Plan chooses to participate in using this information,
                the
                Health Plan must submit to the Agency’s BMHC a completed quarterly summary
                report in accordance with Section XII, X., of this Attachment.
                

            

    

    

    
      	
               

            	
              h.

            	
              Should
                any complaint or investigation by the Agency result in a finding
                that the
                Health Plan has violated this subsection, the Health Plan will be
                sanctioned in accordance with Section XIV, B. The first such violation
                will result in a 30-day suspension of use of Medicaid redetermination
                dates; any subsequent violations will result in 30-day incremental
                increases in the suspension of use of Medicaid redetermination dates.
                In
                the event of any subsequent violations, additional penalties may
                be
                imposed in accordance with Section XIV, B. Additional or subsequent
                violations may result in the Agency’s rescinding of the provision of
                redetermination date information to the Health Plan.
                

            

    

    

    
      	
               

            	
              8.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item B., Marketing, sub-item 3.b., the first
                sentence is hereby amended to read as follows:

            

    

    

    The
      Health Plan may leave Request for Benefit Information (RBI) cards (as described
      in Section IV, B.7) in Provider offices, at Public Events and Health Fairs.
      

    

    
      	
               

            	
              9.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item B., Marketing, sub-item 4.b., is hereby
                deleted and replaced with the following:

            

    

    

    
      	
               

            	
              b.

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

            

    

    
      	
               

            	
              (1)

            	
              The
                Agency will approve or deny the Health Plan's request to market no
                later
                than five (5) Business Days from receipt of the request.
                

            

    

    
      
        
          AHCA
            Contract No.
            FAR001, Amendment No. 7, Page 5 of 66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

     

    
      	 	 (2)  	
               The
                Health Plan shall use the standard Agency format. Such format will
                include
                minimum requirements for necessary information. The Agency will explain
                in
                writing what is sufficient information for each requirement.

               

            
	
               

            	
              (3)

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

            

    

    

    
      	
               

            	
              (4)

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

            

    

    

    
      	
              10.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IV., Enrollee
                Services and Marketing, Item B., Marketing, sub-item 7.c, is hereby
                deleted and replaced with the following:

            

    

    

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

    

    
      	
               

            	
              (1)

            	
              Name;
                

            

    

    
      	
               

            	
              (2)

            	
              Address
                (home and mailing); 

            

    

    
      	
               

            	
              (3)

            	
              County
                of residence; 

            

    

    
      	
               

            	
              (4)

            	
              Telephone
                number; 

            

    

    
      	
               

            	
              (5)

            	
              Date
                of Application; 

            

    

    
      	
               

            	
              (6)

            	
              Applicant’s
                signature or signature of parent or guardian;

            

    

    
      	
               

            	
              (7)

            	
              Marketing
                Representative’s signature and DFS license number.
                

            

    

    
      	
               

            	
              (8)

            	
              Names
                of additional family members; 

            

    

    
      	
               

            	
              (9)

            	
              Birth
                day and month only of each family member;

            

    

    
      	
               

            	
              (10)

            	
              Gender
                of each family member; 

            

    

    
      	
               

            	
              (11)

            	
              Language
                preference; 

            

    

    
      	
               

            	
              (12)

            	
              Request
                for home visit. 

            

    

    

    Marketing
      Representatives may not verify a beneficiary’s eligibility.  Any
      issues or questions relating to the member’s eligibility must be forwarded to
      the Health Plan’s home office for eligibility verification.  The
      24-hour or one business day waiting period must elapse prior to any home or
      phone contact by the Health Plan or the Health Plan’s Marketing
      Representatives.  Only after such verification and the required
      waiting period may a home visit be made.

    

    RBI
      information may be used only once and may not be maintained in any files, either
      paper or electronic, or by any other means, for use a future time by the
      Marketing Representatives.  RBI information may only be retained by
      the Health Plan and may not be used for any future contacts should the
      beneficiary not be able to enroll in the Health Plan at that time.

    

    Should
      any complaint or investigation by the Agency result in a finding that the Health
      Plan’s Marketing Representative has violated this part, the Health Plan will be
      sanctioned in accordance with Section XIV, B..  The first such
      violation will result in a 30-day suspension of marketing; any subsequent
      violations will result in 30-day incremental increases in the suspension of
      marketing.  For example the first sanction will result in a 30-day
      marketing suspension, the second violation in a 60-day suspension, and the
      third
      violation in a 90-day suspension.

    

    In
      the
      event of any subsequent violations, additional penalties will be
      imposed.  In addition to the marketing suspension, a suspension of
      mandatory assignments to the Health Plan will be imposed

    
      
        
          AHCA
            Contract No. FAR001, Amendment
            No. 7, Page 6 of 66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    for
      the
      same time period.  For example, the fourth suspension will result in a
      suspension of marketing for 120 days and suspension of mandatory assignments
      for
      120 days.

    

    Any
      additional or subsequent violations may result in Contract
      termination.  These sanctions shall be cumulative during the remainder
      of the Contract in effect at the time of the violation. Any violation that
      occurred in the final year of the previous contract period will also be
      considered for the current Contract Period in determining the cumulative nature
      of the sanction.

    

    

    
      	
              11.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V. Covered
                Services, Item E., Customized Benefit Package, sub-item 2. is hereby
                amended to include the following as the last sentence of the paragraph:
                

            

    

    

    The
      Health Plan shall not place limits on services and/or medications provided
      to
      Enrollees diagnosed with HIV or AIDS.

    

    
      	
              12.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 5.a., the last sentence,
                is hereby amended to read as follows:

            

    

    

    In
      addition, the Health Plan shall not deny claims for treatment obtained when
      a
      representative of the Health Plan instructs the Enrollee to seek Emergency
      Services and Care in accord ance with Section 743.064, Florida Statutues.

    

    
      	
              13.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 5.k, he first sentence,
                is hereby amended to read as follows:

            

    

    

    
      	
               

            	
              k.
                

            	
              In
                accordance with 42 CFR 438.114, the Health Plan shall approve claims
                for
                Post Stabilization Care Services without authorization, regardless
                of
                whether the Enrollee obtains a service within or outside the Health
                Plan's
                networ k for the following situations:

            

    

    

    
      	
              14.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 5.n., is hereby
                amended
                to now read as follows: 

            

    

    

    
      	
               

            	
              n.
                

            	
              Notwithstanding
                the requirements set forth in this Section, the Health Plan shall
                approve
                all claims for Emergency Services and Care by nonparticipating providers
                pursuant to the requirements set forth in section 641 .3155, F.S.
                and 42
                CFR 438.114. 

            

    

    

    
      	
              15.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 7.c., he last sentence,
                is hereby amended to read as follows:

            

    

    

    See
      Section 390.01114, F.S.

    

    
      	
              16.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 8., is hereby amended
                to
                include the following: 

            

    

    

    
      	
               

            	
              (i)

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

            

    

    

    
      	
              17.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 9.b.(3) is hereby
                deleted
                and replaced with the following:

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 7 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    (3)         
      If not usually considered Medically Necessary, is considered Medically necessary
      such that the outpatient Hospital services necessitate being provided in a
      Hospital due to the Enrollee’s disability, mental health condition or abnormal
      behavior due to emotional instability or a developmental
      disability.

    

    
      	
              18.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 13.a., the second
                sentence, is hereby amended to now read as follows:
                

            

    

    

    
      	
               

            	
              As
                required by section 381.004, F.S., 2004 and 64C-7.009, F.A.C.
                

            

    

    

    
      	
              19.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 17, the third sentence
                is
                hereby deleted and replaced with the following:

            

    

    

    Therapy
      services are limited to Children/Adolescents under the age of twenty-one
      (21).

    

    
      	
              20.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 18.c.(2)., is hereby
                amended to now read as follows 

            

    

    

    
      	
               

            	
              (2)

            	
              Must
                provide Transportation Services for all Enrollees seeking Medically
                Necessary Medicaid services, regardless of whether or not those services
                being sought are covered under this Contract. This includes such
                services
                as Prescribed Pediatric Extended Care (PPEC);

            

    

    

    
      	
              21.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section V., Covered
                Services, Item F., Coverage Provisions, sub-item 18.g., is hereby
                deleted
                and replaced with the following: 

            

    

    

    
      	
               

            	
              g.
                

            	
              The
                Health Plan shall report immediately, in writing to the Agency’s Bureau of
                Managed Health Care, any aspect of Transportation Service delivery,
                by any
                Transportation services provider, any adverse or untoward incident
                (see
                Section 641.55, F.S.).  The Health Plan shall also report,
                immediately upon identification, in writing to the MPI, all instances
                of
                suspected Enrollee or Transportation Services Provider fraud or
                abuse.  (As defined in section 409.913, F.S.)
                

            

    

    

    The
      Health Plan shall file a written report with the MPI, immediately upon the
      detection of a potentially or suspected fraudulent or abusive action by a
      Transportation services provider.  At a minimum, the report must
      contain the name, tax identification number and contract information of the
      Transportation services provider and a description of the suspected fraudulent
      or abusive act.  The report shall be in the form of a
      narrative.

    

    
      	
              22.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item B., Service Requirements, sub-item 1.f., is hereby
                amended to now read as follows: 

            

    

    

    Crisis
      Stabilization Units may be used as a downward substitution for inpatient
      psychiatric hospital care when determined medically appropriate. These bed
      days
      are calculated on a two (2) for one (1) basis.  Two CSU days count
      toward one inpatient day. Beds funded by the Department of Children and
      Families, Substance Abuse and Mental Health (SAMH) cannot be used for Enrollees
      if there are non-funded clients in need of the beds. If CSU beds are at
      capacity, and some of the beds are occupied by Enrollees, and a non-funded
      client presents in need of services, the Enrollees must be transferred to an
      appropriate facility to allow the admission of the non-funded client. Therefore,
      the Health Plan must demonstrate adequate capacity for inpatient hospital care
      in anticipation of such transfers.

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 8 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    23.           
      Attachment II, Medicaid Reform Health Plan Model Contract, Section VI.,
      Behavioral Health Care, Item B., Service Requirements, sub-item 4.c.(2), the
      first sentence, is hereby amended to read as follows:

    

    Evaluation
      services, when determined Medically Necessary must include assessment of mental
      status, functional capacity, strengths and service needs by trained mental
      health staff.

    

    
      	
              24.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item B., Service Requirements, sub-item 4.j., the last
                sentence, is hereby amended to read as follows:

            

    

    

    The
      protocol for integrating mental health services with substance abuse services
      shall be monitored through the Quality of Care monitoring activities completed
      by the Agency’s EQRO contractor and the Quality Improvement requirements in
      Section VIII, A.3.b.

    

    
      	
              25.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item B., Service Requirements, sub-item 5.b.(2), the
                last
                bullet, is hereby amended to read as follows:

            

    

    

    
      	
               

            	
              ·

            	
              Do
                not possess the strengths, skills, or support system to allow them
                to
                access or coordinate services. The Health Plan will not be required
                to
                seek approval from the Department of Children and Families, District
                Substance Abuse and Mental Health (SAMH) Office for individual eligibility
                or mental health targeted case management agency or individual provider
                certification. The staffing requirements for case management services
                are
                listed below. Refer to Section VI, B.5.d., Additional Requirement
                For
                Targeted Case Management. 

            

    

    

    
      	
              26.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item B., Service Requirements, sub-item 9.a.(1), is
                hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              (1)

            	
              Mental
                health disorders due to or involving a general medical condition,
                specifically ICD -9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89,
                and
                310.1; and 

            

    

    

    
      	
              27.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item D., Assessment and Treatment of Mental Health Residents
                Who Reside in Assisted Living Facilities (ALF) that hold a Limited
                Mental
                Health License, the second sentence, is hereby amended to read as
                follows:
                

            

    

    

    A
      cooperative agreement, as defined in Section 429.02, F.S., must be developed
      with the ALF if an enrollee is a resident of the ALF.

    

    
      	
              28.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item G., Provision of Behavioral Health Services When
                Not
                Covered by the Health Plan, sub-item 3., the last sentence, is hereby
                amended to now read as follows: 

            

    

    

    
      	
               

            	
              The
                Health Plan shall request Disenrollment of all Enrollees receiving
                the
                services described in this Section VI., G., Provision of Behavioral
                Health
                Care Services When Not Covered by the Health Plan.
                

            

    

    

    
      	
              29.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VI., Behavioral
                Health Care, Item H., Behavioral Health Services Care Coordination
                and
                Management, sub-item 11., the parenthetical reference after the end
                of the
                first sentence, is hereby amended to read as follows:
                

            

    

    

    (See
      Section 409.912, F.S.)

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 9 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    30.           
      Attachment II, Medicaid Reform Health Plan Model Contract, Section VI.,
      Behavioral Health Care, Item H., Behavioral Health Services Care Coordination
      and Management, sub-item 11., the second paragraph, the last sentence, is hereby
      amended as follows:

    

    The
      Health Plan shall participate in the SAMH planning process in each DCF
      district.  (See Section 409.912, F.S.)

    

    
      	
              31.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item A., General Provisions, sub-item 1., is hereby amended
                to
                now read as follows: 

            

    

    

    
      	
               

            	
              1.

            	
              The
                Health Plan shall have sufficient facilities, service locations,
                service
                sites, and personnel to provide the Covered Services, described in
                Section
                V, and Behavioral Health Services, described in Section VI.
                

            

    

    

    
      	
              32.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item A., General Provisions, sub-item 8., is hereby amended
                to
                include the following: 

            

    

    

    
      	
               

            	
              The
                Health Plan shall require each Provider to have a unique Florida
                Medicaid
                Provider number, in accordance with the requirement of Section X,
                C. jj.,
                of this Contract. By May 2008, the Health Plan shall require each
                Provider
                to have a National Provider Identifier (NPI) in accordance with section
                1173(b) of the Social Security Act, as enacted by section 4707(a) of the Balanced
                Budget Act
                of 1997. 

            

    

    

    a.
             The Health Plan need not obtain an NPI from
      the following Providers: 

    

    Individuals
      or organizations that furnish atypical or nontraditional services that are
      only
      indirectly related to the provision of health care (examples include taxis,
      home
      and vehicle modifications, insect control, habilitation and respite services);
      and 

    

    
      	
               

            	
              b.
                

            	
              Individuals
                or businesses that only bill or receive payment for, but do not furnish,
                health care services or supplies (examples include billing services,
                repricers and value-added networks).

            

    

    

    
      	
              33.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 4., the first
                paragraph, is hereby amended to read as follows:
                

            

    

    

    The
      Health Plan’s array of Direct Service Behavioral Health Providers for adults and
      children under the age of eighteen (18) shall include Providers that are
      licensed or eligible for licensure, and demonstrate two (2) years of clinical
      experience in the following specialty areas or with the following
      populations:

    

    
      	
              34.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 4.g., is hereby
                amended to read as follows: 

            

    

    

    Behavior
      management and alternative therapies for children under the age of eighteen
      (18);

    

    
      	
              35.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 4.i., is hereby
                amended to read as follows: 

            

    

    

    Victims
      and perpetrators of sexual abuse (children under the age of eighteen (18) and
      adults);

    

    
      	
              36.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 4.j., is hereby
                amended to read as follows: 

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 10 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    Victims
      and perpetrators of violence and violent crimes (children under the age of
      eighteen (18) and adults);

    

    
      	
              37.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 5., is hereby
                amended to read as follows: 

            

    

    

    All
      Direct Service Behavioral Health Providers and mental health targeted case
      managers serving children under the age of eighteen (18) shall be certified
      by
      DCF to administer CFARS (or other rating scale required by DCF or the
      Agency).

    

    
      	
              38.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 7.a., the
                first
                sentence, is hereby amended to read as follows:

            

    

    

    Have
      a
      baccalaureate degree from an accredited university, with major course work
      in
      the areas of psychology, social work, health education or a related human
      service field and, if working with children under the age of eighteen (18),
      have
      a minimum of one (1) year full-time experience, or equivalent experience,
      working with the target population.

    

    
      	
              39.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E E., Behavioral Health Services, sub-item 7.b., the
                first sentence, is hereby amended to read as follows:
                

            

    

    

    Have
      a
      baccalaureate degree from an accredited university and if working with children
      under the age of eighteen (18), have at least three (3) years full-time or
      equivalent experience, working with the target population.

    

    
      	
              40.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 9, the first
                sentence, is hereby amended to read as follows:

            

    

    

    The
      Health Plan shall have access to no less than one (1) fully accredited
      psychiatric community Hospital bed per 2,000 Enrollees, as appropriate, for
      both
      children under the age of eighteen (18) and adults.

    

    
      	
              41.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 11, the first
                sentence, is hereby amended to read as follows:

            

    

    

    The
      Health Plan shall ensure that it has Providers that are qualified to serve
      Enrollees and experienced in serving severely emotionally disturbed children
      under the age of eighteen (18) and severely and persistent mentally ill
      adults.

    

    
      	
              42.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item E., Behavioral Health Services, sub-item 12, the first
                sentence, is hereby amended to read as follows:

            

    

    

    The
      Health Plan shall adhere to the staffing ratio of at least one (1) FTE
      Behavioral Health Care Case Manager for twenty (20) children under the age
      of
      eighteen (18) and at least one (1) FTE Behavioral Health Care Case Manager
      per
      forty (40) adults.

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 11 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    43.           
      Attachment II, Medicaid Reform Health Plan Model Contract, Section VII.,
      Provider Network, Item F., Specialists and Other Providers, is hereby
      amended to include the following as sub-item 7:

    

    
      	
               

            	
              7.

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

            

    

    

    
      	
              44.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VII., Provider
                Network, Item I., sub-item 3., the first paragraph, is hereby amended
                to read as follows: 

            

    

    

    The
      Health Plan shall make a good faith effort to give written notice of termination
      within fifteen (15) Calendar Days after receipt of a Provider’s termination
      notice to each Enrollee who received his or her primary care from, or was seen
      on a regular basis by, the terminated Provider.

    

    
      	
              45.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-items 1.b. through
                1.g., are
                hereby deleted and replaced with the following:

            

    

    

    
      	
               

            	
              b.

            	
              The
                Health Plan shall develop and submit to the Agency a written Quality
                Improvement Plan within thirty (30) Calendar Days from execution
                of the
                initial Contract, and resubmit it annually by June 1 to the Agency’s
                Bureau of Managed Health Care (BMHC) for written approval.  The
                QIP shall include sections defining how the QI Committee utilized
                any of
                the following programs to develop their performance improvement projects
                (PIP): credentialing processes, case management, utilization review,
                peer
                review, review of grievances, and review and response to adverse
                events.
                Any problems/issues that are identified, but are not included in
                a PIP,
                must be addressed and resolved by the QI Committee.
                

            

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan’s written policies and procedures shall address components of
                effective health care management including, but not limited to
                anticipation, identification, monitoring, measurement, evaluation
                of
                Enrollee’s health care needs, and effective action to promote Quality of
                care. 

            

    

    

    
      	
               

            	
              d.

            	
              The
                Health Plan shall define and implement improvements in processes
                that
                enhance clinical efficiency, provide effective utilization, and focus
                on
                improved outcome management achieving the highest level of success.
                

            

    

    

    
      	
               

            	
              e.

            	
              The
                Health Plan and its QI Plan shall demonstrate in its care management,
                specific interventions to better manage the care and promote healthier
                Enrollee outcomes. 

            

    

    

    
      	
               

            	
              f.

            	
              The
                Health Plan shall cooperate with the Agency and the External Quality
                Review Organization (EQRO). The Agency will set methodology and standards
                for Quality Improvement (QI) with advice from the EQRO.
                

            

    

    

    
      	
               

            	
              g.

            	
              Prior
                to implementation and annually thereafter, the Agency shall review
                the
                Health Plan QI Plan. 

            

    

    

    
      	
              46.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-items 2.a through 2.d.
                are
                hereby deleted and replaced with the following:

            

    

    

    
      	
               

            	
              a.

            	
              The
                Health Plan’s governing body shall oversee and evaluate the QIP. The role
                of the Health Plan’s governing body shall include providing strategic
                direction to the QIP, as well as ensuring the QIP is incorporated
                into the
                operations throughout the Health Plan.  The written
                

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 12 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              QI
                Plan shall clearly describe the mechanism within the Health Plan
                for
                strategic direction from the governing body to be provided to the
                QIP and
                for the QIP to communicate with the governing body.
                

            

    

    

    
      	
               

            	
              b.

            	
              The
                Health Plan shall have a QIP Committee. The Health Plan 's Medical
                Director shall serve as either the Chairman or Co-Chairman of the
                QIP
                Committee. Other committee representatives shall be selected to meet
                the
                needs of the Health Plan but must include: 1) the Quality Director;
                2) the
                Grievance Coordinator; 3) the Utilization Review Manager; 4) the
                Credentialing Manager; 5) the Risk Manager/Infection Control Professional
                (if applicable); 6) the Advocate Representative (if applicable) and
                7)
                Provider Representation, either through providers serving on the
                committee
                or through a provider liaison position, such as a representative
                from the
                network management department. Individual staff members may serve
                in
                multiple roles on the Committee if they also serve in multiple positions
                within the Health Plan. The Health Plan is encouraged to include
                an
                advocate representative on the QIP Committee. The Committee shall
                meet on
                a regular periodic basis, no less than quarterly. Its responsibilities
                shall include the development and implementation of a written QI
                Plan,
                which incorporates the strategic direction provided by the governing
                body.
                The QI Plan shall contain the following components:
                

            

    

    

    
      	
               

            	
              (1)

            	
              The
                Health Plan’s guiding philosophy for Quality Management and it should
                identify any nationally recognized, standardized approach that is
                used
                (for example, PDSA, Rapid Cycle Improvement, FOCUS-PDCA, Six Sigma,
                etc.).  Selection of performance indicators and sources for
                benchmarking shall also be described.

            

    

    

    
      	
               

            	
              (2)

            	
              A
                description of the Health Plan positions assigned to the QIP, including
                a
                description of why each representative was chosen to serve on the
                Committee and the roles each position is expected to fulfill. The
                resume
                of the QIP Committee shall be made available upon the Agency’s request.
                

            

    

    

    
      	 	
              (3)

            	
              Specific
                training regarding Quality that will be provided by the Health Plan
                to
                staff serving in the QIP. At a minimum, the training shall include
                protocols developed by the Centers for Medicare and Medicaid Services
                regarding Quality. 

            

    

    

    
      	
               

            	
              (4)

            	
              The
                role of its Providers in giving input to the QIP, whether that is
                by
                membership on the Committee, its Sub-Committees, or other means.
                

            

    

    

    
      	
               

            	
              (5)

            	
              A
                standard for how the Health Plan will assure that QIP activities
                take
                place throughout the Health Plan and document result Health Plan
                s of QIP
                activities for reviewers. Protocols for assigning tasks to individual
                staff persons and selection of time standards for completion shall
                be
                included. CMS protocols may be obtained from either http://www.cms.hhs.gov/MedicaidManagCare/or
                www.myfloridaeqro.com. 

            

    

    

    
      	
               

            	
              (6)

            	
              Standard
                describing the process the QIP will use to review and suggest new
                and/or
                improved QI activities; 

            

    

    

    
      	
               

            	
              (7)

            	
              The
                process for selected and directing task forces, committees, or other
                Health Plan activities to review areas of concern in the provision
                of
                health care services to Enrollees; 

            

    

    

    
      	
               

            	
              (8)

            	
              The
                process for selecting evaluation and study design procedures;
                

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 13 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              (9)

            	
              The
                process to report findings to appropriate executive authority, staff,
                and
                departments within the Health Plan as well as relevant stakeholders,
                such
                as network providers. The QI Plan shall also indicate how this
                communication will be documented for Agency review; and
                

            

    

    

    
      	
               

            	
              (10)

            	
              The
                process to direct and analyze periodic reviews of Enrollees' service
                utilization patterns. 

            

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan shall maintain minutes of all QI Committee and Sub-Committee
                meetings and make the minutes available for Agency review. The minutes
                shall demonstrate resolution of items or be brought forward to the
                next
                meeting. 

            

    

    

    
      	
              47.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3., the first
                sentence,
                is hereby amended to read as follows:

            

    

    

    The
      Health Plan shall monitor, evaluate, and improve the quality and appropriateness
      of care and service delivery (or the failure to provide care or deliver
      services) to Enrollees through performance improvement projects (PIPs), medical
      record audits, performance measures, surveys, and related
      activities.

    

    
      	
              48.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.a., is hereby
                amended
                to read as follows: 

            

    

    

    
      	
               

            	
              a.

            	
              PIPs
                

            

    

    

    Annually,
      by January 1, the Agency shall determine and notify the Health Plan if there
      are
      changes in the number and types of PIPs the Health Plan shall perform for the
      coming Contract Year.  Beginning with the September 1, 2007 Contract
      Year, the Health Plan shall perform four (4) Agency approved performance
      improvement projects.  There must be one clinical PIP and one
      non-clinical PIP.

    

    
      	
               

            	
              (1)

            	
              One
                (1) of the PIPs must focus on Language and Culture, Clinical Health
                Care
                Disparities, or Culturally and Linguistically Appropriate Services.
                

            

    

    

    
      	
               

            	
              (2)

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

            

    

    

    
      	
               

            	
              (3)

            	
              One
                (1) of the clinical PIPs must relate to Behavioral Health Services.
                

            

    

    

    
      	
               

            	
              (4)

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

            

    

    

    
      	
               

            	
              (5)

            	
              Each
                PIP must include a statistically significant sample of Enrollees.
                

            

    

    

    
      	
               

            	
              (6)

            	
              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
                

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 14 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              sustained
                for a period of two additional remeasurements. Measurement periods
                and
                methodologies shall be submitted to the Agency for approval prior
                to
                initiation of the PIP. PIPs that have successfully achieved sustained
                improvement as approved by the Agency shall be considered complete
                and
                shall not meet the requirement for one of the four PIPs, although
                the
                Health Plan may wish to continue to monitor the performance indicator
                as
                part of the overall QI program. In this event, the Health Plan shall
                select a new PIP and submit it to the Agency for approval.
                

            

    

    

    
      	 	
              (7)

            	
              Within
                90 Calendar Days after initial Contract execution and then on June
                1 of
                each subsequent Contract Year, the Health Plan shall submit to the
                Agency’s Bureau of Managed Health Care, 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.   Annual submissions for
                on-going PIPs shall update the form to reflect the Health Plan’s
                progress.  In the event that the Health Plan elects to modify a
                portion of the PIP proposal subsequent to initial Agency approval,
                a
                written request must be submitted to the Agency.  The External
                Quality Review PIP Validation Report Form may be obtained from the
                following website: 

            

    

    

    
      	
               

            	
              www.myfloridaeqro.com
                . 

            

    

    

    Instructions
      for using the form for submittal of PIP proposals and updates may be obtained
      from the Agency. 

    

    
      	
               

            	
              (8)

            	
              The
                Health Plan’s PIP methodology must comply with the most recent protocol
                set forth by the Centers for Medicare and Medicaid Services, Conducting Performance
                Improvement Projects.  This protocol may be obtained from
                either of the following websites: 

            

    

    

    
      	
               

            	
              http://www.cms.hhs.gov/MedicaidManagCare/
                or www.myfloridaeqro.com

            

    

    

    
      	
               

            	
              (9)

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

            

    

    

    
      	
               

            	
              (10)

            	
              The
                Health Plan’s PIPs shall be subject to review and validation by the
                External Quality Review Organization.  The Health Plan shall
                comply with any recommendations for improvement requested by the
                External
                Quality Review Organization, subject to approval by the Agency.
                

            

    

    

    
      	
              49.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.b.(3)(i), is
                hereby
                amended to read as follows: 

            

    

    

    Perform
      a
      quarterly review of a random selection of ten percent (10%) or fifty (50)
      medical records, whichever is less, of Enrollees who received Behavioral Health
      Services during the previous quarter; and,

    

    
      	
              50.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.b.(6), is hereby
                amended to read as follows: 

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 15 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    (6)            
      Composition of local advisory groups shall follow Section VI, Behavioral Health
      Care, P., Behavioral Health Managed Care Local Advisory Group.

    

    
      	
              51.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.c., is hereby
                deleted
                and replaced with the following: 

            

    

    

    c.         
      Performance Measures (PMs)

    

    The
      Health Plan shall collect data on patient outcome Performance Measures (PMs),
      as
      defined by the Healthcare Effectiveness Data and Information Set (HEDIS) or
      otherwise defined by the Agency.  The Agency may add or remove
      reporting requirements with sixty (60) Calendar Days advance
      notice.

    

    Health
      Plan reporting on Performance Measures shall be submitted to the Agency on
      an
      annual basis in a three-year phase-in schedule as specified in Attachment II,
      Section XII, A.1.d., and in the Performance Measures Reporting Requirements
      chart in Section XII, I.  The submission of measures shall be
      cumulative so that all measures must be collected and reported for Measurement
      Year Three.”

    

    
      	
              52.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.h.(2)(c), is
                hereby
                deleted in its entirety. 

            

    

    

    
      	
              53.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-items 3.h.(2)(d) through
                (2)(h) are hereby renumbered as (2)(c) through (2)(g), respectively.
                

            

    

    

    
      	
              54.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3.h(5)(d), the
                last
                sentence, is hereby amended to read as follows:

            

    

    

    For
      each
      PCP and each OB/GYN Provider serving as a PCP, documentation in the Health
      Plan’s credentialing files regarding the site survey shall include the
      following:

    

    
      	
              55.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII, Quality
                Management, Item A., Quality Improvement, sub-item 3., is hereby
                revised
                to include the following: 

            

    

    

    i.         
      Cultural Competency Plan

    

    
      	
               

            	
              (1)
                

            	
              In
                accordance with 42 CFR 438.206, the Health Plan shall have a comprehensive
                written Cultural Competency Plan (CCP) describing the program the
                Health
                Plan has in place to ensure that services are provided in a culturally
                competent manner to all Enrollees, including those with limited English
                proficiency. The CCP must describe how Providers, Health Plan employees,
                and systems will effectively provide services to people of all cultures,
                races, ethnic backgrounds, and religions in a manner that recognizes
                values, affirms, and respects the worth of the individual Enrollees
                and
                protects and preserves the dignity of each. The CCP shall be updated
                annually and submitted to the Bureau of Managed Health Care by October
                1
                for approval for implementation by January 1 of each Contract Year.
                

            

    

    

    
      	
               

            	
              (2)
                

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

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 16 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    
      	
               

            	
              (3)
                

            	
              The
                Health Plan shall complete an annual evaluation of the effectiveness
                of
                its CCP. This evaluation may include results from the CAHPS or other
                comparative member satisfaction surveys, outcomes for certain cultural
                groups, member grievances, member appeals, provider feedback and
                Health
                Plan employee surveys. The Health Plan shall track and trend any
                issues
                identified in the evaluation and shall implement interventions to
                improve
                the provision of services. A description of the evaluation, its results,
                the analysis of the results and interventions to be implemented shall
                be
                described in the annual CCP submitted to the Agency.
                

            

    

    

    
      	
              56.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII., Quality
                Management, Item B., Utilization Management (UM), sub-item 1.b.,
                is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              b.

            	
              The
                Health Plan shall report Fraud and Abuse information identified through
                the Utilization Management program to the Agency’s MPI as described in
                Section X, and referenced in 42 CFR. 455.1(a)(1).
                

            

    

    

    
      	
              57.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII., Quality
                Management, Item B., Utilization Management (UM), sub-item 5.h, the
                last
                sentence, is hereby amended to now read as follows:
                

            

    

    

    The
      Health Plan shall honor any written documentation of Prior Authorization of
      ongoing Covered Services for a period of thirty (30) Calendar Days after the
      effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's
      treatment plan for the following types of Enrollees:

    

    
      	
              58.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII., Quality
                Management, Item B., Utilization Management (UM), sub-items 6.b.
                and 6.c.,
                and the first paragraph of sub-item 6.d., are hereby amended to now
                read
                as follows: 

            

    

    

    
      	
               

            	
              b.

            	
              Each
                Disease Management program shall have policies and procedures that
                follow
                the National Committee for Quality Assurance’s (NCQA’s) most recent
                Disease Management Standards and Guidelines, which may be accessed
                online
                at http://web.ncqa.org/tabid/381/Default.aspx.  In addition to
                policies and procedures, the Health Plan shall have a Disease Management
                program description for each disease state that describes how the
                program
                fulfills the principles and functions of each of the NCQA Disease
                Management Standards and Guidelines categories.  Each program
                description should also describe how Enrollees are identified for
                eligibility and stratified by severity and risk level.  The
                Health Plan shall submit a copy of its policies and procedures and
                program
                description for each of its Disease Management programs to the Agency
                by
                April 1st
                of each year. 

            

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan shall have a policy and procedure regarding the transition
                of
                Enrollees from disease management services outside the Health Plan
                to the
                Plan’s Disease Management program.  This policy and procedure
                shall include coordination with the Disease Management Organization
                (DMO)
                that provided services to the Enrollee prior to his/her enrollment
                in the
                Health Plan.  Additionally, the Health Plan shall request that
                the Enrollee sign a limited Release of Information to aid the Plan
                in
                accessing the DMO’s information for the Enrollee.
                

            

    

    

    
      	
               

            	
              d.

            	
              The
                Health Plan must develop and use a plan of treatment for chronic
                disease
                follow-up care that is tailored to the individual Enrollee. The purpose
                of
                the plan of treatment is to assure appropriate ongoing treatment
                reflecting the highest standards of medical care designed to minimize
                further deterioration and complications. The plan of treatment shall
                be on
                file for each Enrollee with a chronic disease and shall contain sufficient
                information to explain the 

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 17 of 66

          

        

        
        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

          

        

      

      
        
        

        
           

        

      

    

    
      	
               

            	
              progress
                of treatment. Medication management, the review of medications that
                an
                Enrollee is currently taking, should be an ongoing part of the plan
                of
                treatment to ensure that the Enrollee does not suffer adverse effects
                or
                interactions from contraindicated medications. The Enrollee’s ability to
                adhere to a treatment regimen should be monitored in the plan of
                treatment
                as well. 

            

    

    

    
      	
              59.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section VIII., Quality
                Management, Item B., Utilization Management (UM), sub-item 6.e.(4).,
                is
                hereby amended to now read as follows:

            

    

    

    
      	
               

            	
              (4)

            	
              If
                the Agency determines that the Health Plan will conduct the Disease
                Management Provider satisfaction surveys, the Agency will provide
                the
                Health Plan with the required sampling methodology and survey
                specifications by July 1, 2007. 

            

    

    

    
      	
              60.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX, Grievance
                System, Item A., General Requirements, sub-item 2., the second sentence,
                is hereby amended to read as follows:

            

    

    

    Before
      implementation, the Health Plan must request and receive written approval from
      the Agency regarding the Health Plan’s Grievance System policies and
      procedures.

    

    
      	
              61.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX, Grievance
                System, Item A., General Requirements, sub-item 3, is hereby amended
                to
                read as follows: 

            

    

    

    
      	
               

            	
              3.

            	
              The
                Health Plan shall refer all Enrollees and/or providers, on behalf
                of the
                Enrollee, (whether the provider is a participating Provider or a
                nonparticipating provider) who are dissatisfied with the Health Plan
                or
                its Actions to the Health Plan’s Grievance/Appeal Coordinator for
                processing and documentation in accordance with this Contract and
                the
                Health Plan's Agency-approved policies and procedures.
                

            

    

    

    
      	
              62.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX., Grievance
                System, Item B., Grievance Process, sub-item 3, is hereby amended
                to read
                as follows: 

            

    

    

    
      	
               

            	
              3.

            	
              The
                Health Plan must complete the Grievance process in time to permit
                the
                Enrollee's disenrollment to be effective in accordance with the time
                frames specified in 42 CFR 438.56(e)(1) and Section 409.91211, F.S.
                

            

    

    

    
      	
              63.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX., Grievance
                System, Item C., The Appeal Process, sub-item 4.d., is hereby amended
                to
                read as follows: 

            

    

    

    
      	
               

            	
              d.

            	
              If
                services were not furnished while the Appeal was pending and the
                Appeal
                panel reverses the Health Plan's decision to deny, limit or delay
                services, the Health Plan must authorize or provide the disputed
                services
                promptly and as quickly as the Enrollee's health condition requires.
                

            

    

    

    
      	
              64.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX., Grievance
                System, Item C., The Appeal Process, sub-item 4.e., is hereby amended
                to
                read as follows: 

            

    

    

    
      	
               

            	
              e.

            	
              If
                the services were furnished while the Appeal was pending and the
                Appeal
                panel reverses the Health Plan's decision to deny, limit or delay
                services, the Health Plan must approve payment for disputed services
                in
                accordance with State policy and regulations.

            

    

    

    
      	
              65.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section IX., Grievance
                System, Item C., The Appeal Process, sub-item 5.c., is hereby amended
                to
                read as follows: 

            

    

    
      
        
          
            
              AHCA
                Contract No. FAR001, Amendment
                No. 7, Page 18 of 66

            

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan shall resolve each Appeal within State-established time
                frames
                not to exceed forty-five (45) Calendar Days from the day the Health
                Plan
                received the initial Appeal request, whether oral or in writing.
                

            

    

    

    
      	
              66.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item C., Provider Contracts Requirements, sub-item
                2.gg.
                is hereby amended to read as follows:

            

    

    

    
      	
               

            	
              gg.

            	
              Contain
                no provision requiring the Provider to contract for more than one
                Health
                Plan product line or otherwise be excluded (pursuant to Section 641.315,
                F.S.); 

            

    

    

    
      	
              67.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management , Item D., Provider Termination, sub-item 3., is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              3.
                

            	
              The
                Health Plan shall notify Enrollees in accordance with the provisions
                of
                this Contract regarding Provider termination; and,
                

            

    

    

    
      	
              68.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item E., Provider Services, sub-item 6.a., is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              a.

            	
              The
                Health Plan shall establish a provider complaint system that permits
                a
                provider to dispute the Health Plan’s policies, procedures, or any aspect
                of a Health Plan’s administrative functions, including proposed Actions.
                

            

    

    

    
      	
              69.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item E., Provider Services, sub-item 6.e.(2), is
                hereby
                amended to read as follows: 

            

    

    

    (2)         
      Have dedicated staff for providers to contact via telephone, electronic mail,
      or
      in person,to ask questions, file a provider complaint and resolve
      problems;

    

    
      	
              70.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item F., Medical Records Requirements, sub-item 2.b,
                is
                hereby amended to read as follows: 

            

    

    

    
      	
               

            	
              b.

            	
              Must
                be legible and maintained in detail consistent with the clinical
                and
                professional practice which facilitates effective internal and external
                peer review, medical audit and adequate follow-up treatment; and,
                

            

    

    

    
      	
              71.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item H., Encounter Data, sub-item 3., is hereby amended
                to
                read as follows 

            

    

    

    
      	
               

            	
              3.

            	
              Health
                Plans shall have the capability to convert all information that enters
                their claims systems via hard copy paper claims to encounter data
                to be
                submitted in the appropriate HIPAA compliant formats. Health Plans
                shall
                ensure that network providers receiving subcapitation or a flat rate
                also
                generate encounters, and the Health Plan is responsible for submitting
                these encounters in the appropriate HIPAA compliant formats.
                

            

    

    

    
      	
              72.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item H., Encounter Data, sub-item 5., is hereby amended
                to
                read as follows: 

            

    

    

    
      	
               

            	
              5.

            	
              Health
                Plans shall require each Provider to have a unique Florida Medicaid
                Provider number, in accordance with the requirement of Section X,
                C. ii.
                of this Contract. 

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 19 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    
      	
              73.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., Fraud Prevention, sub-item 4.d., is hereby
                amended to read as follows: 

            

    

    

    d.         
      Contain provisions for the confidential reporting of Health Plan violations
      to
      theAgency’s MPI;

    

    
      	
              74.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., Fraud Prevention, sub-item 4.g., is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              g.

            	
              Require
                all instances of provider or Enrollee Fraud and Abuse under State
                and/or
                federal law be reported to the MPI. Additionally, any final resolution
                must include a written statement that provides notice to the provider
                or
                enrollee that the resolution in no way binds the State of Florida
                nor
                precludes the State of Florida from taking further action for the
                circumstances that brought rise to the matter;

            

    

    

    
      	
              75.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., Fraud Prevention, sub-item 4.h., first paragraph,
                is hereby amended to read as follows:

            

    

    

    h.         
      Ensure that the Health Plan and all providers, upon request, and as required
      by
      State and/orfederal law, shall:

    

    
      	
              76.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., Fraud Prevention, sub-item 4.i., is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              i.

            	
              Ensure
                that the Health Plan shall cooperate fully in any investigation by
                the
                Agency, MPI, MFCU or any subsequent legal action that may result
                from such
                an investigation. 

            

    

    

    
      	
              77.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., Fraud Prevention, sub-item 4., is hereby
                amended
                to include the following: 

            

    

    

    
      	
               

            	
              l.

            	
              Provide
                details about the following, as required by Section 6032 of the federal
                Deficit Reduction Act of 2005: 

            

    

    (1)         
      the False Claim Act;

    (2)         
      the penalties for submitting false claims and statements;

    (3)         
      whistleblower protections;

    (4)         
      the law’s role in preventing and detecting fraud, waste and abuse;
      and

    (5)         
      each person’s responsibility relating to detection and prevention.

    

    
      	
              78.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item J., sub-items 5 and 6 are hereby amended to
                now read
                as follows: 

            

    

    

    
      	
               

            	
              5.

            	
              In
                accordance with Section 6032 of the federal Deficit Reduction Act
                of 2005
                the Health Plan shall distribute written Fraud and Abuse policies
                to all
                employees. If the Health Plan has an employee handbook, the Health
                Plan
                shall include specific information about Section 6032 of the federal
                Deficit Reduction Act of 2005, the Health Plan‘s policies, and the rights
                of employees to be protected as whistleblowers.

            

    

    

    
      	
               

            	
              6.

            	
              The
                Health Plan shall comply with all reporting requirements set forth
                in
                Section XII., Reporting Requirements.

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 20 of 66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    7.      
      The Health Plan shall meet with the Agency periodically, at the Agency’s
      request, to discuss fraud, abuse, neglect and overpayment issues. For purpose
      of
      this section, the Health Plan Compliance Officer shall be the point of contact
      for the Health Plan and the Agency’s Medicaid Fraud and Abuse Liaison shall be
      the point of contact for the Agency.

    

    
      	
              79.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section X., Administration
                and Management, Item I., Enhanced Benefit Program, The Healthy Behaviors
                Definition and Reporting Requirements Table, is hereby deleted in
                its
                entirety and replaced as follows: 

            

    

    

    Healthy
      Behaviors Definitions and Reporting Requirements

    

    
      	
              Children

            	 	 
	
              Behavior
                #

            	
              Behavior
                Name

            	
              Reporting
                Process

            
	
              1

            	
              Childhood
                dental exam

            	
              Reported
                by the plan using CPT code

            
	
              2

            	
              Childhood
                vision exam

            	
              Reported
                by the plan using CPT code

            
	
              3

            	
              Childhood
                preventive care ( age-appropriate screenings and
                immunizations)

            	
              Reported
                by the plan using CPT code

            
	
              4

            	
              Childhood
                wellness visit

            	
              Reported
                by the plan using CPT code

            
	
              5

            	
              Keeps
                all primary care appointments

            	
              Reported
                by the plan using CPT code

            
	
              Adults

            	 	 
	
              Behavior
                #

            	
              Behavior
                Name

            	
              Reporting
                Process

            
	
              1

            	
              Keeps
                all primary care appointments

            	
              Reported
                by the plan using CPT code

            
	
              2

            	
              Mammogram

            	
              Reported
                by the plan using CPT code

            
	
              3

            	
              PAP
                Smear

            	
              Reported
                by the plan using CPT code

            
	
              4

            	
              Colorectal
                Screening

            	
              Reported
                by the plan using CPT code

            
	
              5

            	
              Adult
                Vision Exam

            	
              Reported
                by the plan using CPT code

            
	
              6

            	
              Adult
                Dental Exam

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              Additional
                Behaviors

            	 
	
              Behavior
                #

            	
              Behavior
                Name

            	
              Reporting
                Process

            
	
              1

            	
              Disease
                management participation

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              2a

            	
              Alcohol
                and/or drug treatment program participation

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              2b

            	
              Alcohol
                and/or drug treatment program 6 month success

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              3a

            	
              Smoking
                cessation program participation

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              3b

            	
              Smoking
                cessation program 6 month success

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              4a

            	
              Weight
                loss program participation

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              4b

            	
              Weight
                loss program 6 month success

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              5a

            	
              Exercise
                program participation

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              5b

            	
              Exercise
                program 6 month success

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              6

            	
              Flu
                Shot when recommended by physician

            	
              Reported
                by the plan using CPT code or Enhanced Benefit Universal Form
                (EBUF)

            
	
              7

            	
              Compliance
                with prescribed maintenance medications

            	
              Provided
                and reported by the plan using NDC/GCN
                #

            

    

    

    
      
        
          AHCA
            Contract No. FAR001, Amendment
            No. 7, Page 21 of 66

        

      

      
        
        

        
          

        

      

      
        Healthease
          of Florida, Inc. 

        Medicaid
          HMO Reform Contract

      

       

      
        
        

      

    

    
      	
              80.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XI., Information
                Management and Systems, Item D., sub-item 7., is hereby deleted and
                replaced as follows: 

            

    

    

    
      	
               

            	
              7.

            	
              The
                Health Plan shall provide to the Agency full written documentation
                that
                includes a corrective action plan. The corrective action plan shall
                include a description of how problems with critical Systems functions
                will
                be prevented from occurring again, and shall be delivered to the
                Agency
                within five (5) Business Days of the problem’s occurrence.
                

            

    

    

    
      	
              81.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XI., Information
                Management and Systems, Item H., Other Requirements, sub-item c.,
                is
                hereby amended to read as follows: 

            

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan shall also cooperate with the Agency in the continuing
                development of the State’s health care data site
                (www.floridahealthstat.com). 

            

    

    

    
      	
              82.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item A., Health Plan Reporting Requirements, sub-item
                1.c.,
                is hereby amended to read as follows:

            

    

    

    
      	
               

            	
              c.

            	
              The
                Health Plan must submit its certification concurrently with the certified
                data as outlined in Table 1 of Section XII (see 42 CFR 438.606(c)).
                The
                certification page should be scanned and submitted electronically
                with the
                certified data. 

            

    

    

    
      	
              83.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item A., Health Plan Reporting Requirements, sub-item
                1.d.,
                is hereby deleted and replaced as follows:

            

    

    

    
      	
               

            	
              d.

            	
              By
                July 1 of each year, the Health Plan shall deliver to the Florida
                Center
                for Health Information and Policy Analysis a certification by an
                Agency-approved independent auditor that the Performance Measure
                data
                reported for the previous calendar year are fairly and accurately
                presented.” 

            

    

    

    
      	
              84.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item A., Health Plan Reporting Requirements, sub-item
                6, is
                hereby amended to read as follows: 

            

    

    

    
      	
               

            	
              6.

            	
              If
                the Health Plan fails to submit the required reports accurately and
                within
                the timeframes specified, the Agency shall fine or otherwise sanction
                the
                Health Plan in accordance with Section XIV, Sanctions. To be considered
                accurate, the error ratio cannot exceed three percent (3%) for the
                total
                records submitted. 

            

    

    

    

    
      	
               

            	
              REMAINDER
                OF PAGE INTENTIONALLY LEFT BLANK

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 22 of 66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    

    
      	
              85.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item A., Health Plan Reporting Requirements, sub-item
                7.,
                Digit 1 Report Identifiers table, is hereby amended to read as follows:
                

            

    

    

    
      	
              Digit
                1 Report Identifiers

            
	
              R

            	
              Marketing
                Representative

            
	
              I

            	
              Information
                Systems Availability

            
	
              G

            	
              Grievance
                System Reporting

            
	
              H

            	
              Inpatient
                Discharge Reporting

            
	
              F

            	
              Financial
                Reporting

            
	
              M

            	
              Minority
                Reporting

            
	
              C

            	
              Claims
                Inventory

            
	
              T

            	
              Transportation

            
	
              S

            	
              Critical
                Incident Summary

            
	
              E

            	
              Behavioral
                Health Encounter Data

            
	
              B

            	
              Behavioral
                Health Pharmacy Encounter Data

            
	
              P

            	
              Behavioral
                Health Required Staff/Providers

            
	
              O

            	
              FARS/CFARS

            

    

    

    

    
      	
              86.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Table 1, is hereby deleted in its entirety and replaced
                by
                the following table: 

            

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    

    
      AHCA
        Contract No. FAR001, Amendment
        No. 7, Page 23 of 66

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc.

          Medicaid
            HMO Reform Contrac

        

      

    

    

    

    
      	
              Table
                1

            
	
              SUMMARY
                OF REPORTING REQUIREMENTS

            
	 	 	 	 	 
	
              Health
                Plan Reports Required by AHCA 

            

    

     

    
      
        	
                Report
                  

              	 	
                Specific
                  Data Elements 

              	 	
                Format
                  

              	 	
                Frequency
                  Requirements 

              	 	
                Data
                  and Certifications to be Submit Concurrently to: 

              	 
	
                Suspected
                  Fraud Reporting

              	 	
                See
                  Section X, K.

              	 	
                Narrative

              	 	
                Immediately
                  upon occurrence

              	 	
                Via
                  electronic mail to MPI 

              	 
	
                Critical
                  Incident Report

              	 	
                See
                  Section XII.F.

              	 	
                Code
                  15 Report

              	 	
                Immediately
                  upon occurrence

              	 	
                electronic
                  mail and Surface Mail to the Health Plan’s analyst at the Bureau of
                  Managed Health Care

              	 
	
                Choice
                  Counseling  Disenrollment  Reason Report

                
                

                
                

                
                

              	 	
                See
                  Section XII B, 2

              	 	
                Choice
                  Counseling Vendor proprietary format

                
                

              	 	
                Monthly–
                  Provided by the Choice Counseling Vendor to the plan on
                  the first
                  Tuesday after Monthly Magic

              	 	
                Uploaded
                  to the Choice Counseling vendor’s secure ftp directory

              	 
	
                Choice
                  Counseling Involuntary Disenrollment Report

              	 	
                See
                  Section XII B 3

              	 	
                Choice
                  Counseling Vendor proprietary format

              	 	
                Monthly–
                  Provided by the plan to the Choice Counseling Vendor on
                  the first
                  Thursday of every month.

                
                

              	 	
                Uploaded
                  to the Choice Counseling Vendor’s secure ftp directory

              	 
	
                Catastrophic
                  Component

                Threshold
                  and Benefit Maximum

                Report

                
                

              	 	
                See
                  Section XII. AA,

                Table
                  18

                
                

              	 	
                electronic
                  template to

                be
                  provided by the

                Agency

                
                

              	 	
                Monthly –
Due
                  fifteen (15) days
                  after

                the
                  end of the month being reported

                
                

              	 	
                Data
                  and Certification via Secure File Transfer Protocol (SFTP)

              	 
	
                Provider
                  Network Report

              	 	
                See
                  Section XII, D., Table 3

              	 	
                Fixed
                  record length ASCII flat file (.dat)

              	 	
                Monthly–
Due
                  on the first (1st) Thursday of
                  the month (optional weekly submissions on each Thursday for the
                  remainder
                  of the month) 

              	 	
                FTP
                  to Choice Counseling vendor 

              	 
	
                (???REFPROVYYYYMMDD.dat)

              	 	 	 	 	 

      

       

      
        
          
            AHCA
              Contract No. FAR001, Amendment
              No. 7, Page 24 of 66

          

        

        
          
          

          
            Healthease
              of Florida, Inc.

            Medicaid
              HMO Reform Contrac

            

          

        

         

        
          	
                  Report
                    

                	 	
                  Specific
                    Data Elements 

                	 	
                  Format
                    

                	 	
                  Frequency
                    Requirements 

                	 	
                  Data
                    and Certifications to be Submit Concurrently to: 

                	 

        

        
        

      

      
        	
                Marketing
                  Representative Report

              	 	
                See
                  Section XII, E., Table 4

              	 	
                electronic
                  template provided by the Agency

              	 	
                Monthly–
If
                  the Health Plan is engaged in
                  marketing activities, due within fifteen (15) days after the end
                  of the
                  reporting month- Contains previous calendar month’s data 

              	 	
                Data
                  and certification to Bureau of Managed Health Care (BMHC) by electronic
                  mail to mmcdata@ahca.myflorida.com 

              	 
	
                (R***YYMM.xls)

              	 	 	 	 	 
	
                Information
                  Systems Availability and Performance Report

              	 	
                See
                  Section XII, L., Table 6

              	 	
                electronic
                  template provided by the Agency

              	 	
                Monthly–
Due
                  within fifteen (15) days after
                  the end of the reporting month- Contains previous calendar month’s data
                  

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  

              	 
	
                (I***YYMM.xls)

              	 	 	 	 	 
	
                Minority
                  Reporting 

                (M***YYMM.xls)

              	 	
                See
                  Section XII, Z.

              	 	
                Narrative

              	 	
                Monthly–
Due
                  fifteen (15) days after the
                  end of the month being reported 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  

              	 
	
                Enhanced
                  Benefits Report

              	 	
                See
                  Section XII, F., Table 5

              	 	
                electronic
                  template provided by the Agency

              	 	
                Monthly–
Due
                  ten (10) days after the end of
                  the month being reported 

              	 	
                Submit
                  via the Secure File Transmission Protocol (SFTP) SITE or mail CD
                  ROM/DVD
                  to the Choice Counseling Section MS # 8 

              	 
	
                Customized
                  Benefit Package Exhaustion of Benefits Report

              	 	
                See
                  Section XII. BB, Table 19

              	 	
                Electronic
                  template to be provided by the Agency

              	 	
                Monthly –
Due
                  fifteen (15) days after the end
                  of the month being reported

              	 	
                Data
                  and Certification via Secure File Transfer Protocol (SFTP)

                
                

              	 
	
                Inpatient
                  Discharge Report(H***yyQ*.txt)

              	 	
                See
                  Section XII CC, Table 20

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly
                  – Due 30 Calendar days following the end of the quarter being reported
–
                  Contains data for the entire quarter.

              	 	
                Data
                  and certification via SFTP to the Agency

              	 
	
                Grievance
                  System Reporting

              	 	
                See
                  Section XII, C., Table 2

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly–
Due
                  forty-five (45) days after
                  the end of the quarter being reported – Contains data for the entire
                  quarter.  Combines both medical and behavioral health care
                  requirements to cover all grievances and appeals related to services
                  across the plan. 

              	 	
                Data
                  and certification to BMHC by Secure FTP (SFTP) or CD/DVD submission
                  

              	 
	
                (G***
                  yyQ*).txt)

              	 	 	 	 	 
	
                Financial
                  Reporting

                (F***
                  yyQ*).xls)

              	 	
                See
                  Section XII, J.

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Quarterly–
Due
                  forty-five (45) days after
                  the end of the quarter being reported – Contains data for the entire
                  quarter. 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcfin@ahca.myflorida.com
                  

              	 

      

       

      
        AHCA
          Contract No. FAR001, Amendment
          No. 7, Page 25 of 66

      

      
        
          
          

        

        
          
          

          
            Healthease
              of Florida, Inc.

            Medicaid
              HMO Reform Contrac

            

          

        

         

        
          	
                  Report
                    

                	 	
                  Specific
                    Data Elements 

                	 	
                  Format
                    

                	 	
                  Frequency
                    Requirements 

                	 	
                  Data
                    and Certifications to be Submit Concurrently to: 

                	 

        

      

      
        	
                Claims
                  Inventory Summary Reports

                (C***YYQQ.xls)

              	 	
                See
                  Section XII.M.,Tables 7-A,  7-B,  7-C and
                  7-D

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Quarterly 
–.  Due
                  forty-five (45) days after the end of the quarter being reported
–
                  Contains data for the entire quarter. 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcclms@ahca.myflorida.com
                  

              	 
	
                Transportation
                  Services and Performance Measures

              	 	
                See
                  Section XII, Q., Tables 9 – 9i

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Quarterly–due
                  forty-five (45) days after
                  the end of the quarter being reported – Contains data for the entire
                  quarter. 

                Annually–
due
                  on August 15  
                  - contains cumulative data for the entire year 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  

              	 
	
                (T***
                  yyQ*).xls)

              	 	 	 	 	 
	
                Pharmacy
                  Encounter Data

                *see
                  section XII.N.3 for naming convention

              	 	
                See
                  Section XII.O.

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly–
Due
                  30 days after the end of the
                  quarter being reported – Contains data for the entire quarter. Requires
                  certification letter.

              	 	
                Data
                  and certification by CD/DVD to HSD Contract Manager, or his/her
                  designee,
                  at HSD

              	 
	
                Medicaid
                  Redetermination Notice Summary Report

              	 	
                See
                  Section XII, DD.

              	 	
                Template
                  to be provided by the Agency

              	 	
                Quarterly
                  – Due forty-five (45) days after the end of the quarter being reported
–
                  Contains data for the entire quarter, by month.

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com or CD/DVD
                  submission to BMHC

              	 
	
                Hernandez
                  Settlement Agreement (HSA) Ombudsman Log

              	 	
                See
                  Section XII, H.

              	 	
                Narrative

              	 	
                Quarterly–
Due
                  forty-five (45) days after
                  the end of the quarter being reported – Contains a copy of Hernandez
                  Ombudsman Log for the quarter. 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  or CD/DVD submission to BMHC 

              	 

      

       

      
        AHCA
          Contract No. FAR001, Amendment
          No. 7, Page 26 of 66

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
            Healthease
              of Florida, Inc.

            Medicaid
              HMO Reform Contrac

          

        

         

        
          	
                  Report
                    

                	 	
                  Specific
                    Data Elements 

                	 	
                  Format
                    

                	 	
                  Frequency
                    Requirements 

                	 	
                  Data
                    and Certifications to be Submit Concurrently to: 

                	 

        

      

      
        	
                Hernandez
                  Settlement Agreement (HSA) Report

              	 	
                See
                  Section XII, H.

              	 	
                Narrative

              	 	
                Annually
                  - Due on August 1. Requires
                  submission of the HSA Survey 

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  or CD/DVD submission to BMHC 

              	 
	
                Performance
                  Measures

              	 	
                See
                  Section XII, I

                Table
                  21

              	 	
                Healthcare
                  Effectiveness Data and Information Set (HEDIS) and Agency Defined
                  measures

              	 	
                Annually
                  - Due no later than July 1 after
                  the measurement year. Reporting is done for each calendar year.
                  

              	 	
                Electronic
                  mail or CD/DVD submission to the Florida   Center for Health
                  Information and Policy Analysis. 

              	 
	
                
                

                Cultural
                  Competency Plan

              	 	
                
                

                See
                  Section VIII A, 3. i

              	 	
                
                

                Narrative

              	 	
                
                

                Annually-
Due
                  on October 1 st
                  for implementation by January 1 of each Contract year. 

                
                

              	 	
                
                

                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  or CD/DVD submission to BMHC 

              	 
	
                Audited
                  Financial Report

              	 	
                See
                  Section XII,J.

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Annually
                  - Within ninety (90) Calendar Days
                  after the end of the Health Plan Fiscal Year. Reporting is done
                  for each
                  calendar year. 

              	 	
                electronic
                  mail to mmcfin@ahca.myflorida.com. In addition to the financial
                  template,
                  the plan must provide a copy of the audited financial report by
                  a
                  certified auditing firm, CPA and include a copy of the CPA's letter
                  of
                  opinion. This can be submitted via a pdf file or hard copy to MS#26,
                  Attn:
                  Program Compliance Unit. 

              	 
	
                Child
                  Health Check Up Reports

              	 	
                See
                  Section XII, N., Tables 8 and 8a

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Annually
                  - For previous federal fiscal year
                  (Oct-Sep) due by January 15. Audited report due by October 1.
                  

              	 	
                Data
                  and certification to BMHC by electronic mail to mmcdata@ahca.myflorida.com
                  

              	 

      

    

    

    
      AHCA
        Contract No. FAR001, Amendment
        No. 7, Page 27 of 66

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    Table
      1 Continued

    

      
        	
                Behavioral
                  Health Specific Reporting 

              

      

    

    
      
        	
                Report
                  

              	 	
                Specific
                  Data Elements 

              	 	
                Format
                  

              	 	
                Frequency
                  Requirements 

              	 	
                Submit
                  to: 

              
	
                Critical
                  Incidents Individual

              	 	
                See
                  Section XII, U., Table 12a

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Immediately
                  upon occurrence

              	 	
                BMHC
                  via Secure FTP (SFTP) and hardcopy to BMHC analyst 

              
	
                Critical
                  Incident Summary

              	 	
                See
                  Section XII. U., Table 12

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Monthly –
Due
                  on the fifteenth (15th) of the
                  month- Contains previous calendar month’s data 

              	 	
                BMHC
                  via Secure FTP (SFTP) 

              
	
                (S***YYMM.xls)

              	 	 	 	 	 	 
	
                Behavioral
                  Health Services Grievance and Appeals

              	 	
                See
                  Section XII.T. (see Section XII.C. and Table 2 for reporting
                  instructions)

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly 
–
Due
                  45 days after the end
                  of the quarter being reported – Contains data for the entire quarter.
                  Requires certification letter. 

              	 	
                Data
                  and certification via SFTP site

                
                

              
	
                Behavioral
                  Health Encounter
                  Data  (E***YYQ*.txt)

              	 	
                See
                  section XII.X. Table 15

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly–
Due
                  45 days after the end of the
                  quarter being reported – Contains data for the entire
                  quarter.

              	 	
                Data
                  and certification via SFTP site

                
                

              
	
                Behavioral
                  Health Pharmacy Encounter Data

                (B***YYQ*.txt)

              	 	
                See
                  section XII.W. Tables 16

              	 	
                Fixed
                  record length text file

              	 	
                Quarterly–
Due
                  45 days after the end of the
                  quarter being reported – Contains data for the entire
                  quarter.

              	 	
                Data
                  and certification via SFTP site

                
                

              
	
                Required
                  Staff/Providers

              	 	
                See
                  Section XII, V., Table 13

              	 	
                Electronic
                  template provided by the Agency

              	 	
                Quarterly–
Due
                  forty-five (45) days after
                  the end of the quarter being reported – Contains data for the entire
                  quarter. 

              	 	
                Electronic
                  mail to mmcdata@ahca.myflorida.com 

              
	
                (P***
                  yyQ*).xls)

              	 	 	 	 	 	 
	
                FARS
                  / CFARS  (O***YY06.txt or
                  O***YY12.txt)

              	 	
                See
                  Section XII,W., Table 14

              	 	
                Fixed
                  record length text file

              	 	
                Semi-annually
-
                  The reporting periods cover
                  January through June and July through December. It is due forty-five
                  (45)
                  days after the end of the reporting period (August 15 and February
                  15).
                  

              	 	
                Data
                  and certification via SFTP 

              
	
                Enrollee
                  Satisfaction Survey Summary 

              	 	
                See
                  Section XII, R., Table 10

              	 	
                Hardcopy
                  

              	 	
                Annually 
                  - Due sixty (60) days after the end
                  of the calendar year being reported. Also requires submission of
                  copy of
                  survey tool, the methodology used, and the results. 

              	 	
                Electronic
                  mail to mmcdata@ahca.myflorida.com or
                  hardcopy to BMHC 

              

         

        
          AHCA
            Contract No. FAR001, Amendment
            No. 7, Page 28 of 66

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

          
            Healthease
              of Florida, Inc. 

            Medicaid
              HMO Reform Contract

             

             

          

        

        	
                Stakeholders
                  Satisfaction Survey Summary

              	 	
                See
                  Section XII, S., Table 11

              	 	
                Hardcopy

              	 	
                Annually 
                  - Due sixty (60) days after the end
                  of the calendar year being reported. Also requires submission of
                  copy of
                  survey tool, the methodology used, and the results. 

              	 	
                Electronic
                  mail to mmcdata@ahca.myflorida.com 

              

      

       

    

    
      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK 

       

       

      

        AHCA
          Contract No. FAR001, Amendment
          No. 7, Page 29 of 66

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Healthease
      of Florida, Inc. 

    Medicaid
      HMO Reform Contract

    

    
      	
              87.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item B., Enrollment/Disenrollment Reports, sub-item
                2, is
                hereby deleted and replaced with the following:

            

    

    

    
      	
              2.

            	
              Choice
                Counseling Disenrollment Reason Reports

            

    

    

    The
      Agency or its Agent will provide Reform Disenrollment reason information to
      the
      Health Plans after Contract execution.  The Agency or its Agent will
      report Disenrollment reason information to the Health Plans on a monthly
      basis.  The Agency or its Agent will provide the file format for
      Disenrollment reports.  The information on these reports includes only
      those Disenrollments (voluntary/involuntary) processed by the Agency’s Choice
      Counselor/Enrollment Broker.

    

    
      	
              88.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item B., Enrollment/Disenrollment Reports, is hereby
                amended
                to include the following as sub-item 3:

            

    

    

    
      	
               

            	
              3.

            	
              Involuntary
                Disenrollment Reports 

            

    

    

    Involuntary
      Disenrollments that meet the criteria established by the Agency shall be
      submitted by the Health Plan to the Agency or its Agent in a manner and format
      prescribed by the Agency.  The Health Plan shall submit involuntary
      Disenrollments monthly, by the first Thursday of the month, to the Agency’s
      Choice Counselor/Enrollment Broker.  Upon sixty (60) day notification
      from the Agency, the report format and submission requirements may
      change

    

    
      	
              89.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item D., Provider Reporting, sub-item 3., is hereby
                deleted
                and replaced as follows: 

            

    

    

    
      	
               

            	
              3.

            	
              The
                file is an ASCII flat file and is a complete refresh of the provider
                information. The file must be submitted on the first Thursday of
                each
                month. The file may be submitted each week by close of business on
                Thursday. The Agency or its Choice Counselor/Enrollment Broker will
                reload
                the provider information each Friday evening. The file name will
                be ???_PROVYYYYMMDD.dat (replacing ?’s with the
                Health Plan’s three character approved abbreviation and yyyymmdd with the
                date the file is submitted).  Both the Choice
                Counselor/Enrollment Broker and the Agency will use this required
                file.  The Health Plan may use this optional file submission
                opportunity to ensure that the information presented to beneficiaries
                is
                the most current data available.  Updated provider network
                information is available to the Agency or its Choice Counselor/Enrollment
                staff each Saturday morning. 

            

    

    

    
      	
              90.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item D., Provider Reporting, Table 3., is hereby deleted
                in
                its entirety and replaced with the following:

            

    

    

    
      	
               

            	
              REMAINDER
                OF PAGE INTENTIONALLY LEFT BLANK 

            

    

    

    
      AHCA
        Contract No. FAR001, Amendment
        No. 7, Page 30 of 66

    
      
        
          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc.

          Medicaid
            HMO Reform Contract

        

      

    

    

    Note:
      The following reporting material is proprietary information of ACS Inc. and
      may
      not be used, duplicated, or altered without the written permission of Corporate
      Management.

     

    TABLE
      3

        MEDICAID
      PROVIDER FILE
      LAYOUT   

    
    

    

    
      	
              Field
                #

            	
              Field
                Name

            	
              Field
                Length

            	
              Required
                Field

            	
              Field
                Format

            	
              Justification

            	
              Comments

            
	
              1

            	
              Plan
                Code

            	
              9

            	
              X

            	
              alpha

            	
              HMO
&
PSN
                :

              Left
                with leading zeros

              
              

              MediPass:
                right justified

            	
              This
                is the 9 digit  HMO Medicaid
                Provider ID, or PSN Supergroup, number specific to the county of
                operation.

              Effective
                9-19-07, the Non-reform PSN subnetwork
                (SFCCN-PHT) will use a Supergroup number.

              
              

              This
                is the MediPass plan County
                identifier = MP+county number (MP06 = MediPass Broward). Used for MediPass Providers, Non-Reform
                MediPass
                Supergroups

            
	
              2

            	
              Provider
                Type

            	
              1

            	
              X

            	
              alpha

            	
              Left

            	
              Identifies
                the provider’s general area of service with an alpha character, as
                follows:

              P
                =
                Primary Care Provider (PCP)

              I
                =
                Individual Practitioner other than a PCP

              B
                =
                Birthing Center

              T
                =
                Therapy

              G
                =
                Group Practice (includes FQHCs and RHCs)

              H
                =
                Hospital

              C
                =
                Crisis Stabilization Unit

              D
                =
                Dentist

              R
                =
                Pharmacy

              A
                =
                Ancillary Provider (DME providers, Home Health Care

              Agencies,
                or other non-hospital, non-physician providers not listed as a separate
                provider type, etc.)

            
	
              3

            	
              Plan
                Provider Number

            	
              15

            	
              X

            	
              alpha

            	
              Left
                with leading zeros

            	
              Unique
                number assigned to the provider by the plan.

            
	
              4

            	
              Group
                Affiliation

            	
              15

            	
              Required
                for all groups (type G) and providers (type P, I, D, or T) who are
                members
                of a group

              See
                Note For Individual
                Providers

            	
              alpha

            	
              Left
                with leading zeros

            	
              The
                unique provider number assigned by the plan to the group
                practice.  This field is required for all providers who are
                members of a group, such as PCPs and specialists.  The group
                affiliation number must be the same for all providers who are members
                of
                that group.  A record is also
                required for each group practice (provider G) being
                reported.

              
              

              For
                groups (provider Type G), this identification number must be the
                same as
                the plan provider number.

              
              

              NOTE:
                HMO and/or Reform PSNs: For HMO or Reform PSN individual providers
                that
                do NOT practice as members of a group use the plan code (Plan Medicaid ID for the county) with
                leading zeros.

            

      
        
        

      

      	
              5

            	
              SSN
                or FEIN

            	
              9

            	
              X

            	
              alpha

            	
              Left
                with leading zeros

            	
              Social
                Security number or Federal Identification Number for the individual
                provider or the group practice.

            
	
              6

            	
              Provider
                last name

            	
              30

            	
              X

            	
              alpha

            	
              Left

            	
              The
                last name of the provider, or the first 30 characters of the name
                of the
                group.  (Please do not include courtesy titles such as Dr., Mr.,
                Ms., since these titles can interfere with electronic searches of
                the
                data.)  This field should also be used to note hospital
                name.  UPPER CASE ONLY PLEASE.

            
	
              7

            	
              Provider
                first name

            	
              30

            	
              X

            	
              alpha

            	
              Left

            	
              The
                first name of the provider, or the continuation of the name of the
                group.  UPPER CASE ONLY PLEASE.

            
	
              8

            	
              Address
                line 1

            	
              30

            	
              X

            	
              alpha

            	
              Left

            	
              Physical
                location of the provider or practice.  Do not use P.O. Box or
                mailing address is different from practice location.  UPPER CASE
                ONLY PLEASE.

            
	
              9

            	
              Address
                line 2

            	
              30

            	 	
              alpha

            	
              Left

            	
              Second
                line of the location address for the provider. UPPER CASE ONLY PLEASE
                

            
	
              10

            	
              City

            	
              30

            	
              X

            	
              alpha

            	
              Left

            	
              Physical
                city location of the provider or practice.  UPPER CASE ONLY
                PLEASE

            
	
              11

            	
              Zip
                Code

            	
              9

            	
              X

            	
              numeric

            	
              Left
                with trailing zeros

            	
              Physical
                zip code location of the provider or practice.  Please note that
                the format does not allow for use of a hyphen. Accuracy is important,
                since address information is one of the standard items used to search
                for
                providers that are located in close proximity to the
                member.

            
	
              12

            	
              Phone
                area code

            	
              3

            	 	
              numeric

            	
              Left

            	
              Area
                code for the phone number of the office. Please note that the format
                does
                not allow for use of a hyphen.

            
	
              13

            	
              Phone
                number

            	
              7

            	 	
              numeric

            	
              Left

            	
              Phone
                number of the office. Please note that the format does not allow
                for use
                of a hyphen.

            
	
              14

            	
              Phone
                extension

            	
              4

            	 	
              numeric

            	
              Left

            	
              Phone
                number extension of the office, if applicable. Please note that the
                format
                does not allow for use of a hyphen.

            
	
              15

            	
              Gender

            	
              1

            	 	
              alpha

            	
              Left

            	
              The
                gender of the provider.

              Valid
                values:  M = Male; F = Female; U = Unknown

            
	
              16

            	
              PCP
                Indicator

            	
              1

            	
              X

              Required
                for Provider Type P, or G if the
                group will be selected as the PCP.

            	
              alpha

            	
              Left

            	
              Used
                to indicate if an individual provider is a primary care
                physician.

              Valid
                values:  P = Yes, the provider is a
                PCP;

                                      N
                = No, the provider is not a PCP.

              
              

              This
                field should not be used to note group providers as PCPs for HMOs,
                since
                members must be assigned to specific providers, not group
                practices.  MediPass, MPN, ER Div and Non-reform PSNs may allow
                enrollment to the group if appropriate.

            
	
              17

            	
              Provider
                Limitation

            	
              1

            	
              Required
                if PCP Indicator = P

            	
              alpha

            	
              Left

            	
              X
                =
                Accepting new patients

              N
                =
                Not accepting new patients but remaining a contracted network
                provider

              L
                =
                Not accepting new patients; leaving the network  (Please note
                the “L” designation at the earliest opportunity)

              P
                =
                Only accepting current patients

              C
                =
                Accepting children only

              A
                =
                Accepting adults only

              R
                =
                Refer member to HMO member services/Restricted Provider for
                MediPass

              F
                =
                Only accepting female patients

              S
                =
                Only serving children through CMS (MediPass/PSN only)

              NOTE:
This
                limitation code is critical to
                providing edits for Med. Options/Choice Counseling staff to enroll
                within
                the provider’s patient parameters.

            
	
              18

            	
              HMO/

              MediPass
                Indicator

            	
              1

            	
              X

            	
              alpha

            	
              Left

            	
              Valid
                Values: H = HMO, P= PSN,
                M=MediPass

              This
                field must be completed with this designation for each record submitted
                by
                the Plan.

            
	
              19

            	
              Evening
                hours

            	
              1

            	 	
              alpha

            	
              Left

            	
              Y
                =
                Yes; N = No

            
	
              20

            	
              Saturday
                hours

            	
              1

            	 	
              alpha

            	
              Left

            	
              Y
                =
                Yes; N = No

            
	
              21

            	
              Age
                restrictions

            	
              20

            	 	
              alpha

            	
              Left

            	
              Populate
                this field with free-form text, to identify any age restriction the
                provider may have on their practice.

            
	
              22

            	
              Primary
                Specialty

            	
              3

            	
              Required
                if Provider Type = P, I, D or T; also required for provider type
                G (group)
                for MediPass and PSN where recipients are enrolled to the
                group.

            	
              numeric

            	
              Left
                with leading zeros

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

              
              

            	
              Insert
                the 3 digit code that most closely describes

              
              

              001
                Adolescent Medicine

              002
                Allergy

              003
                Anesthesiology

              004
                Cardiovascular Medicine

              005
                Dermatology

              006
                Diabetes

              007
                Emergency Medicine

              008
                Endocrinology

              009
                Family Practice

              010
                Gastroenterology

              011
                General Practice

              012
                Preventative Medicine

              013
                Geriatrics

              014
                Gynecology

              015
                Hematology

              016
                Immunology

              017
                Infectious Diseases

              018
                Internal Medicine

              019
                Neonatal/Perinatal

              020
                Neoplastic Diseases

              021
                Nephrology

              022
                Neurology

              023
                Neurology/Children

              024
                Neuropathology

              025
                Nutrition

              026
                Obstetrics

              027
                OB-GYN

              028
                Occupational Medicine

              029
                Oncology

              030
                Ophthalmology

              031
                Otolaryngology

              032
                Pathology

              033
                Pathology, Clinical

              034
                Pathology, Forensic

              035
                Pediatrics

              036
                Pediatric Allergy

              037
                Pediatric Cardiology

              038
                Pediatric Oncology &Hematology

              039
                Pediatric Nephrology

              040
                Pharmacology

              041
                Physical Medicine and Rehab

              042
                Psychiatry, Adult

              043
                Psychiatry, Child

              044
                Psychoanalysis

              045
                Public Health

              046
                Pulmonary Diseases

              047
                Radiology

              048
                Radiology, Diagnostic

              049
                Radiology, Pediatric

              050
                Radiology, Therapeutic

              051
                Rheumatology

              052
                Surgery, Abdominal

              053
                Surgery, Cardiovascular

              054
                Surgery, Colon / Rectal

              055
                Surgery, General

              056
                Surgery, Hand

              057
                Surgery, Neurological

              058
                Surgery, Orthopedic

              059
                Surgery, Pediatric

              060
                Surgery, Plastic

              061
                Surgery, Thoracic

              062
                Surgery, Traumatic

              063
                Surgery, Urological

              064  Other
                Physician Specialty

              065
                Maternal/Fetal

              066
                Assessment Practitioner

              067
                Therapeutic Practitioner

              068
                Consumer Directed Care

              069
                Medical Oxygen Retailer

              070
                Adult Dentures Only

              071
                General Dentistry

              072
                Oral Surgeon (Dentist)

              073
                Pedodontist

              074
                Other Dentist

              075
                Adult Primary Care Nurse Practitioner

              076
                Clinical Nurse Spec

              077
                College Health Nurse Practitioner

              078
                Diabetic Nurse Practitioner

              079
                Brain & Spinal Injury Medicine

              080
                Family/Emergency Nurse Practitioner

              081
                Family Planning Nurse Practitioner

              082
                Geriatric Nurse Practitioner

              083
                Maternal/Child Family Planning Nurse Practitioner

              084  Reg.
                Nurse Anesthetist

              085
                Certified Registered Nurse Midwife

              086
                OB/GYN Nurse Practitioner

              087
                Pediatric Neonatal

              088
                Orthodontist

              089
                Assisted Living for the Elderly

              090
                Occupational Therapist

              091
                Physical Therapist

              092
                Speech Therapist

              093
                Respiratory Therapist

              100
                Chiropractor

              101
                Optometrist

              102
                Podiatrist

              103
                Urologist

              104
                Hospitalist

              BH1
                Psychology, Adult

              BH2
                Psychology, Child

              BH3
                Mental Health Counselor

              BH4
                Community Mental Health Center

              BH5
                Case Manager

              
              

            
	
              23

            	
              Specialty
                2

            	
              3

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              Use
                codes listed above.

            
	
              24

            	
              Specialty
                3

            	
              3

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              Use
                codes listed above.

            
	
              25

            	
              Language
                1

            	
              2

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              01
                = English

              02
                = Spanish

              03
                = Haitian Creole

              04
                = Vietnamese

              05
                = Cambodian

              06
                = Russian

              07
                = Laotian

              08
                = Polish

              09
                = French

              10
                = Other

            
	
              26

            	
              Language
                2

            	
              2

            	 	
              numeric

            	 	
              Use
                codes listed above.

            
	
              27

            	
              Language
                3

            	
              2

            	 	
              numeric

            	 	
              Use
                codes listed above.

            
	
              28

            	
              Hospital
                Affiliation 1

            	
              9

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              Hospital
                with which the provider is affiliated.  Use the AHCA ID1
                for accurate
                identification.

            
	
              29

            	
              Hospital
                Affiliation 2

            	
              9

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              as
                above

            
	
              30

            	
              Hospital
                Affiliation 3

            	
              9

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              as
                above

            
	
              31

            	
              Hospital
                Affiliation 4

            	
              9

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              as
                above

            
	
              32

            	
              Hospital
                Affiliation 5

            	
              9

            	 	
              numeric

            	
              Left
                with leading zeros

            	
              as
                above

            
	
              33

            	
              Wheel
                Chair Access

            	
              1

            	 	
              alpha

            	 	
              Indicates
                if the provider’s office is wheelchair accessible.  Use Y = Yes
                or

              N
                =
                No.

            
	
              34

            	
              #
                of member patients

            	
              4

            	
              X

              (MediPass
                and PSN for Groups only)

            	
              numeric

            	
              Left
                with leading zeros

            	
              Information
                must be provided for PCPs only.  Indicates the total number of
                patients who are enrolled in submitting plan.  For providers who
                practice at multiple locations, the number of members specific to
                each
                physical location must be specified.

            
	
              35

            	
              Active
                Patient Load

            	
              4

            	
              X
                (not required for MediPass)

            	
              numeric

            	
              Left
                with leading zeros

            	
              Total
                Active Patient Load, as defined in HMO or PSN contract

            
	
              36

            	
              Professional
                License Number

            	
              15

            	
              X

            	
              alpha/
                numeric

            	
              Left
                with trailing spaces

              (padded)

            	
              Must
                be included for all health care professionals and facilities.

              NOTE:
                When AHCA has provided facility ID
                list with license information, the professional license number will
                be
                required for providers other than health care
                professional.  Ancillary (provider type A) providers that are
                not health care professionals, Birthing Centers (B), Crisis Stabilization
                Unit (C), Group (G), Hospital (H), and Pharmacy ® provider records do not
                require a license number).

            
	
              37

            	
              AHCA
                Hospital ID /Facility ID2

            	
              8

            	
              Required
                if Provider Type = “H”, for HMO or PSN

            	
              numeric

            	
              Left
                with leading zeros

            	
              The
                number assigned by the Agency to uniquely identify each specific
                hospital
                by physical location.

              Currently,
                this field /ID number is required only
                for provider type H=Hospital.  Any out of state hospital
                for which an AHCA ID is not included should be designated with the
                pseudo-number 99999999.

              
              

            
	
              38

            	
              County
                Health Department (CHD) Indicator

            	
              1

            	
              X
                (not required for MediPass)

            	
              alpha

            	 	
              Used
                to designate whether the individual or group provider is associated
                only
                with a county health department.  Y = Yes; N =
                No.  This field must be completed for all PCP and specialty
                providers.

            
	
              39
                

            	
              NPI
                Type I 

            	
              10
                

            	
              X
                as noted in comments

            	 	
              Left
                with Leading zeros

            	
              For
                health care providers who are individual
                human beings providing direct services. 

            
	
              40
                

            	
              NPI
                Type II 

            	
              10
                

            	 	 	
              Left
                with Leading zeros

            	
              For
                organization health care providers
                .

            
	
              41
                

            	
              Medicaid
                Provider ID# 

            	
              12
                

            	
              X

            	 	
              Left
                with Leading zeros

            	
              Provider
                Medicaid ID is required here even if it is in field #3. Note the
                difference in field length. Report Medicaid IDs for provider Types
                A, B,
                C, D, G, I, P, or T.

            
	
              42
                

            	
              Filler
                

            	
              10
                

            	
              X

            	 	 	 

    

    

      

    

     

       

      1
        AHCA provided the list of AHCA IDS for hospitals to plans on
        3-16-07.

    

     

      2
        AHCA
        provided the revised list of AHCA IDS for hospitals to plans on
        3-16-07.  The AHCA Facility ID will be provided to Plans at a later
        date.  At that time, Facility IDs will be required for Provider Types
        H, B and C after the Plans have been given time to implement these numbers
        for
        their facilities.

       

       

    

    REMAINDER
      OF PAGE
      INTENTIONALLY LEFT BLANK

     

     

    
      AHCA
        Contract No. FAR001, Amendment No. 7, Page 38 of
        66

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      Healthease
        of Florida, Inc. 

      Medicaid
        HMO Reform Contract

a.           
      Trailer Record

    

    The
      trailer record is used to balance the number of records received with the number
      loaded on BESST.  The data from the Trailer Record is not loaded on
      BESST.

    

    RECORD
      LENGTH:  76

    

    
      	
              
              

              Filed
                Name

            	
              Field 
                Length

            	
              Field 
                Format

            	
              Values

            
	
              Trailer
                Record Text

            	
              36

            	
              Alpha

            	
              ‘TRAILER
                RECORD DATA’

            
	
              Record
                Count

            	
              7

            	
              Numeric

            	
              Total
                number of records on file

              excluding
                the trailer record (right

              justified,
                zero filled)

            
	
              System
                Process date

            	
              8

            	
              Alpha

            	
              Mmddyyyy

            
	
              Filler

            	
              25

            	 	 
	 	 	 	 

    

    

    b.           
      Provider File Load

    

    Each
      weekend ACS compiles the provider files and loads it to the Provider
      table.  During this process an error file is created for each plan
      identifying the records that do not load to the table.

    

    IF
      the
      plan does not send a new file, then the previous file is used for this
      load.  The tables are RELOADED not refreshed.  Therefore, a
      file is needed for each plan.  If the file attempts to load and all
      records error off, there will not be providers for that plan in the
      database.  Weekly files are due by end of business on
      Thursday.

    

    ACS
      does
      not correct records provided by the plan.  All records are loaded as
      they are received.  The plans are responsible for ensuring the data
      provided is correct and complete.

    

    All
      data
      in the file is loaded in upper case for use by BESST.  All zip codes
      are abbreviated to the first 5 digits of the zip code to facilitate
      searches.

    

    c.           
      Rules (Most provider network file rules are imbedded in the file layout
      above.)

    

    
      	
               

            	
              a)

            	
              If
                a provider practices at multiple ‘location
                addresses’, one record is submitted for each
                location.  The address is required and should be complete with
                city and zip code. 

            

    

    
      	
               

            	
              b)

            	
              First
                occurrence of specialty code should be the ‘Primary’.  This field should be
                populated only with valid, state approved, specialty
                codes.  This field is not required but if not populated with a
                valid code, will omit the provider from a by specialty search.
                

            

    

    
      	
               

            	
              c)

            	
              HMO
                and Reform PSN beneficiaries do not have to select their PCP provider
                at
                the time of enrollment. If they elect to do so, a provider, assigned
                to
                the plan selected, will be identified with a PCP Indicator of P.
                If the
                PCP Indicator is N or not populated, the provider cannot be selected
                as
                the beneficiary’s doctor, groups cannot be selected as the primary care
                provider for an HMO or PSN plan. 

            

    

    
      	
               

            	
              d)

            	
              MediPass,
                Minority Physician Networks and ER Diversion Project beneficiaries
                DO have
                to select a PCP at the time of enrollment.

            

    

    

    d.           
      Definitions (Field numbers correspond with layout grid above.)

    
      
        
          
            9HCA
              Contract No. FAR001, Amendment No. 7, Page 39 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    1.            
      Plan
      Code:  Required – For HMOs and Reform PSNs, this is the 9
      digit HMO
      Medicaid Provider ID, or PSN
      Supergroupnumber specific to the county of
      operations.  Effective 9-19-07,  the Non-reform
      PSN subnetwork
(SFCCN-PHT) will use a Supergroup number.  This is the
MediPassplan
      County
      identifier = MP + county number (MP06 = MediPass Broward).  Used for MediPass Provider
      and
      Non-Reform Medipass Supergroups.

    

    
      	
               

            	
              2.

            	
              Provider
                Type: Required
                - Identifies the physician’s general area of service with an alpha
                character.  See the provider description reference table for all
                accepted values.  Treating providers that are members of a group
                will have their own record, provider type P, PCP indicator P, so
                the group
                or the individual may be selected for enrollment. For PSN and Medipass-MPN
                and ER Diversion, each Beneficiary will be enrolled to the Supergroup,
                the
                individual Provider selected by the beneficiary will be provided
                to the
                PSN/MPN/PERD in the monthly Recipient Data file.
                

            

    

    

    
      	
               

            	
              3.

            	
              Plan
                Provider
                Number: Required - The unique number assigned to the
                provider by the plan.  Plans will be required to fill leading
                spaces with zeros.  For MediPass, MPNs, PERD, and Nonreform PSN,
                this is the assigned 9 digit Medicaid ID for the provider.
                

            

    

    

    
      	
               

            	
              4.

            	
              Group
                Affiliation:Required
                for Groups and members
                of groups (provider types, P, I, D or T and G) (This field may be
                NULL for
                other records not associated with a group)– This is the Plan
                Provider Number assigned by the HMO, PSN or MediPass to the group
                practice
                that the provider is affiliated with.  The group affiliation
                number is the same for all providers within that group.  While
                the Group Affiliation is not required to be used for PCPs that are
                not
                members of a group or for individual providers (i.e. non-PCPs), the
                provider file analysis is not able to determine which I, T or D providers
                (or P) are solo practitioners.  Therefore, HMO
                or Reform
                PSNindividual providers that do NOT practice as members
                of a
                group plan should populate this field and may use the plan code (Plan
                Medicaid ID for the
                county) with leading zeroes or another number, such as a
                number assigned to the provider by the plan, provider’s Medicaid ID or
                other number. 

            

    

    

    
      	
               

            	
              5.

            	
              SSN/FEIN
                Number: Required - Social Security Number or Federal
                Identification Number for the individual provider or group practice.
                

            

    

    

    
      	
               

            	
              6.

            	
              Provider
                Last Name:
                Required - The last name of the provider (or beginning of group name).
                

            

    

    

    
      	
               

            	
              7.

            	
              Provider
                First
                Name:Optional - The first name of the provider (or
                continuation of group name). 

            

    

    

    
      	
               

            	
              8.

            	
              Address
                Line 1: Required
                - First line of the practice/location address for the provider.
                

            

    

    

    
      	
               

            	
              9.

            	
              Address
                Line 2: Optional
                - Second line of the practice/location address for the provider.
                

            

    

    

    
      	
               

            	
              10.

            	
              City:
                Required – The city where
                the provider is located. 

            

    

    

    
      	
               

            	
              11.

            	
              Zip
                Code: Required – The zip code for the address of the
                provider. 

            

    

    

    
      	
               

            	
              12.

            	
              Phone
                Area
                Code:Optional – The area code for the phone number of the
                provider. 

            

    

    

    
      	
               

            	
              13.

            	
              Phone
                Number: Optional – The phone number for the provider.
                

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 40 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              14.

            	
              Extension:
                Optional – The
                extension for the phone number of the provider.

            

    

    

    
      	
               

            	
              15.

            	
              Gender:
                Optional – The gender of
                the provider.  The allowed values are M=Male, F=Female,
                U=Unknown or null. 

            

    

    

    
      	
               

            	
              16.

            	
              PCP
                Indicator: Required
                if Provider Type is P for all plans– Indicates if the provider or group
                can be selected as a PCP.  Valid Values are P=Yes the provider can be selected
                as the
                primary, and N-No the provider cannot
                be selected as the primary care provider.  For Medipass or PSN
                enrollments, if the group record is to be selected for enrollment,
                the PSP
                indicator must be P for the G, group record.  These are the only
                valid values for this field.  See examples in this document.
                

            

    

    

    
      	
               

            	
              17.

            	
              Provider
                Limitation: Required if the PCP indicator is P – Limitation
                code the provider has specified. 

            

    

    

    
      	
               

            	
              18.

            	
              HMO/MediPass
                Indicator: Required – Identifies if the provider is with an
                HMO=H, MediPass=M or PSN=P.  These are the only valid values for
                this field. 

            

    

    

    
      	
               

            	
              19.

            	
              Evening
                Hours: Optional
                – Indicates that the doctor or clinic is open in the
                evenings.  Values can be Y=Yes, N=No or null.
                

            

    

    

    
      	
               

            	
              20.

            	
              Saturday
                Hours: Optional – Indicates that the doctor or clinic is
                open on Saturdays.  Values can be Y=Yes, N=No or null.
                

            

    

    

    
      	
               

            	
              21.

            	
              Age
                Restrictions:
                Optional – Identifies the age restrictions that the provider may have on
                their practice.  This field is free form text, populate if
                available. 

            

    

    

    
      	
               

            	
              22.

            	
              Primary
                Specialty: Three
                character field.  Required if
                Provider Type = P, I, D or T.  Also required for provider
                type G (group) for MediPass and PSN where recipients are enrolled
                to the
                group number.  Primary specialty of the doctor.
                

            

    

    

    
      	
               

            	
              23.

            	
              Specialty
                2: Optional –
                Second specialty held by the doctor.

            

    

    

    
      	
               

            	
              24.

            	
              Specialty
                3: Optional –
                Third specialty held by the doctor.

            

    

    

    
      	
               

            	
              25.

            	
              Language
                1: Optional –
                Primary language spoken at the office.  English should be
                reported and not assumed spoken as the primary or other language
                spoken by
                the provider. 

            

    

    

    
      	
               

            	
              26.

            	
              Language
                2:Optional – Second language spoken at the office.
                

            

    

    

    
      	
               

            	
              27.

            	
              Language
                3: Optional –
                Third language spoken at the office.

            

    

    

    
      	
               

            	
              28.

            	
              Hospital
                1: Optional –
                First hospital the provider is affiliated with.  See hospital
                codes. 

            

    

    

    
      	
               

            	
              29.

            	
              Hospital
                2: Optional – Second hospital the provider is affiliated
                with. 

            

    

    

    
      	
               

            	
              30.

            	
              Hospital
                3:Optional – Third hospital the provider is affiliated with.
                

            

    

    

    
      	
               

            	
              31.

            	
              Hospital
                4:Optional – Fourth hospital the provider is affiliated
                with. 

            

    

    

    
      	
               

            	
              32.

            	
              Hospital
                5: Optional –
                Fifth hospital the provider is affiliated with.

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 41 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

          

        

      

    

    
      	
               

            	
              33.

            	
              Wheel
                Chair Access:
                Optional – Indicates if the provider or clinic facility is wheelchair
                accessible.  Values are Y=Yes, N=No or null.
                

            

    

    

    
      	
               

            	
              34.

            	
              #
                Beneficiaries:  This field is required for Primary
                Care Providers, Provider Type P.  (HMOs and PSN) if assigning to
                an individual provider or G if assigning to a group (MediPass/PSN).
                The
                total number of beneficiaries that have been assigned to the
                provider/group at the location in the record.

            

    

    

    
      	
               

            	
              35.

            	
              Active
                Patient
                Load: Required for HMOs and PSNs.  Total Active
                Patient Load, as defined in contract

            

    

    

    
      	
               

            	
              36.

            	
              Professional
                License
                Number: Required.  The professional license number issued
                by the state for individual practitioners.  Must be included for
                all health care professionals (Provider
                Types P, I, T, or D).  This
                field should be left justified and padded with trailing
                spaces  to maintain field length.  NOTE: When
                AHCA has provided facility ID list with license information, the
                professional license number will be required for providers other
                than
                health care professionals.  Ancillary (provider type A)
                providers that are not health care professionals, Birthing Centers
                (B),
                Crisis Stabilization Unit (C), Group (G), Hospital (H), and Pharmacy
                (R)
                provider records do not require a license number.
                

            

    

    

    
      	
               

            	
              37.

            	
              AHCA
                Hospital ID3/Facility
                ID:  Required for HMOs and PSNs.  The
                number assigned by the Agency to uniquely identify each specific
                hospital
                or facility by physical location.  Any out of state hospital or
                facility for which an AHCA ID is not included should be designated
                with
                the pseudo-number 99999999.  The ID is required for all provider
                types reported. 

            

    

    

    
      	
               

            	
              38.

            	
              County
                Health
                Department (CHD) Indicator:  Required for HMOs and
                PSNs.  Used to designate whether the individual or group
                provider is associated only with a
                county health department.  Y = Yes; N = No.  This
                field must be completed for all PCP and specialty providers.
                

            

    

    

    
      	
               

            	
              39.

            	
              NPI
                Type I:
                Required (all plans) for health care providers who are individual human beings providing
                direct
                services.

            

    

    

    
      	
               

            	
              40.

            	
              NPI
                Type II: Optional
                (all plans) for organization
                health care providers 

            

    

    

    
      	
               

            	
              41.

            	
              Medicaid
                Provider
                ID #: Required for all plans.  An individual Provider’s Medicaid ID
                is required
                here even if it is in field #3 (expanded from 9 to 12 characters
                in the
                event of future expansion). 

            

    

    

    These
      provider types are:

    P=Primary
      Care Provider (PCP)

    I=Individual
      Practitioners other than a PCP

    B=Birthing
      Center

    T=Therapy

    G=Group
      Practice (includes FQHCs and RHCs)

    C=Crisis
      Stabilization Unit

    D=Dentist

    A=Ancillary
      Provider

    

      

    

      
      3 AHCA
        provided the
        revised list of AHCA IDS for hospitals to plans on 3-16-07.  The AHCA
        Facility ID will be provided to Plans at a later date.  At that time,
        Facility IDs will be required for Provider Types H, B and C after the Plans
        have
        been given time to implement these numbers for their
        facilities.

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 42 of
              66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              42.

            	
              Filler
                – required to maintain full record length.

            

    

    

    e.           
      Valid Codes

    

    HMO
      Table

    Provider
      Description Information Table

    Specialty
      Code Table

    Hospital/Facility
      Code Table (Updated table to be provided by AHCA)

    

    f.           
      Provider Record Examples

    

    PCP
      who practices outside of a group

     

    
      	
              Last
                Name

            	
              Plan
                Provider Number

            	
              Group
                Affiliation

            	
              PCP
                Indicator

            
	
              Smith

            	
              15
                digit Medicaid id

            	
              Not
                used (or can be equal to Plan Provider Number)

            	
              P

            

    

    

    Treating
      provider – non PCP (i.e., specialist – private practice)

     

    
      	
              Last
                Name

            	
              Plan
                Provider Number

            	
              Group
                Affiliation

            	
              PCP
                Indicator

            
	
              Smith

            	
              15
                digit Medicaid id

            	
              Not
                used (or can be equal to Plan Provider Number)

            	
              N

            

    

    

    PCP
      who practices as part of a group

     

    
      	
              Last
                Name

            	
              Plan
                Provider Number

            	
              Group
                Affiliation

            	
              PCP
                Indicator

            
	
              Smith

            	
              15
                digit Medicaid id assigned to the individual

            	
              Equal
                to Group’s Plan Provider Number

            	
              N

            
	
              Clinic
                or Group Name

            	
              15
                digit Medicaid id assigned to group

            	
              Equal
                to Group’s Plan Provider Number

            	
              P

            

    

    

    Specialist
      (group practice) – informational only, beneficiaries cannot enroll with these
      providers unless the group is identified as a PCP.

     

    
      	
              Last
                Name

            	
              Plan
                Provider Number

            	
              Group
                Affiliation

            	
              Primary
                Spec

            	
              PCP
                Ind

            
	
              Smith

            	
              15
                digit Medicaid id

            	
              Equal
                to Group’s Plan Provider Number

            	
              
              

              001

              
              

            	
              N

            
	
              Clinic
                or Group Name

            	
              15
                digit Medicaid id

            	
              Equal
                to Plan Provider Number

            	
              071

            	
              N

            

    

     

    
      MPN/ER
        Diversion PCP Group or Individual PCP

    
    

    
      	
              Last
                Name

            	
              Plan
                Provider Number

            	
              Group
                Affiliation

            	
              PCP
                Indicator

            
	
              Smith

            	
              15
                digit Medicaid id assigned to the individual

            	
              Equal
                to MPN/ER Diversion Supergroup Provider Number

            	
              P

            
	
              Clinic
                or Group Name

            	
              15
                digit Medicaid id assigned to group

            	
              Equal
                to MPN/ER Diversion Supergroup Provider Number

            	
              P

            

    

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 43 of
              66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

          

        

      

    

    g.           
      Provider Error File

    

    This
      file
      is produced by ACS for HMOs, PSNs and MediPass (including special
      networks/projects) and contains information on the number of provider records
      that were loaded into BESST and records that had errors and were not
      loaded.  The file is sent to each HMO, PSN and MediPass for each
      provider file that is sent to ACS.  The file is available the same day
      the new provider information is available in BESST.

    

    File
      Name
      =

    

    
      	
              Provider
                Error File 

            	
              ???_PROV_ERRyyyymmdd.dat

            	
              The
                date is the day the file is made available.

            

    

    1..1.             
      ??? = 3 character plan identifier

    

    File
      Layout

     

    
      	
              Row
                #

            	
              Type

            	
              Description

            
	
              1

            	
              Text

            	
              Message
                identifying purpose of file

            
	
              2

            	
              Date

            	
              Date
                file was processed

            
	
              3

            	
              Title
                and count

            	
              Count
                of records skipped by load process

            
	
              4

            	
              Title
                and count

            	
              Count
                of records read by load process

            
	
              5

            	
              Title
                and count

            	
              Count
                of records rejected by load process

            
	
              6

            	
              Title
                and count

            	
              Count
                of records discarded by load process

            
	
              7

            	
              Count

            	
              Number
                of rows loaded – should match the number of rows in the trailer record
                minus any skipped, rejected or discarded

            
	
              8

            	
              Blank

            	 
	
              9

            	
              Title

            	
              BAD:

            
	
              10

            	
              Blank

            	
              List
                of records skipped

            
	
              11

            	
              Title

            	
              DISCARDED

            
	
              12

            	
              Blank

            	
              List
                of records read and discarded

            
	
              13

            	
              Title

            	
              Trailer
                record

            
	
              14

            	
              Trailer
                record

            	
              Trailer
                record from provider file

            

    

    

    Notes:

    
      	
               

            	
              ·

            	
              If
                the trailer record of the submitted provider file is not 76 characters
                it
                will be counted as Discarded and under Trailer Record section of
                the error
                file. 

            

    

    
      	
               

            	
              ·

            	
              If
                the trailer record starts with ‘TRAILER RECORD DATA’ but does not
                otherwise match the trailer record format for the provider file,
                it will
                be listed as Discarded and under Trailer Record section of the error
                file.
                

            

    

    
      	
               

            	
              ·

            	
              Blank
                rows in the provider file will show in the error file under BAD.
                This
                section of the file generally only has one blank row between it and
                the
                DISCARDED section. If more rows exist then the program is reporting
                blank
                rows in the provider file. 

            

    

    
      	
               

            	
              ·

            	
              If
                there is no trailer record listed in the Trailer Record of the file
                then
                there was no trailer record in the provider file. A trailer record
                must
                match the file layout to be considered by the program as a trailer
                record.
                

            

    

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 44 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    File
      Example

    

    THE
      FOLLOWING ERRORS WERE FOUND IN YOUR PROVIDER FILE

    15-Feb-2006

    Total
      logical records
      skipped:          0

    Total
      logical records
      read:          5983

    Total
      logical records
      rejected:         0

    Total
      logical records
      discarded:       0

      5983
      Rows successfully loaded.

    

    BAD:

    

    DISCARDED:

    

    Trailer
      Record:

    TRAILER
      RECORD
      DATA                 000598302132006

    

    
      	
              91.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item F., Enhanced Benefits Report, including Table
                5, is
                hereby deleted in its entirety and replaced with the following:
                

            

    

    

    
      	
               

            	
              F.

            	
              Enhanced
                Benefits
                Report

            

    

    

    
      	
               

            	
              The
                Health Plan shall submit a monthly report (flat text file) of all
                claims
                paid for the following procedure codes in the prescribed format below.
                The
                report shall be submitted to the Agency’s Bureau of Health Systems
                Development via AHCA’s Secure FTP site, by the tenth (10th)
                Calendar Day of the month for all claims paid for the previous month.
                

            

    

    

    
      	
               

            	
              Table
                5 

            

    

    

    
      	
               

            	
              Enhanced
                Benefits Naming Convention 

            

    

    

    The
      record is 90 bytes.  File to include header record, detail records and
      trailer record. Record fields are TAB delimited.

    

    Health
      Plan Monthly Report

    

    
      	
              Digit
                Number

            	
            	
            	
            
	
              1

            	
              Report
                Identifier

            	
              Indicates
                the Report Type

            	
              "C"

            
	
              2,3,4

            	
              Plan
                Identifier

            	
              3
                letter unique Plan Identifier from Choice Counseling

            	
              "XXX"

            
	
              5,6

            	
              Year

            	
              The
                Date is the date the data was sampled

            	
              "06"

            
	
              7,8

            	
              Month

            	
            	
              "12"

            
	
              9,10

            	
              Day

            	
            	
              "31"

            
	
              
              

              Example:

            	 	 	 
	
              CXXX061009.txt

            	 	 	 
	
              CXXXYYMMDD.txt

              
              

            	 	 	 

    

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 45 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    Health
      Plan Enhanced Benefits Credit Transaction

    

    
      	
               

            	
              Format
                of the header
                record:

            

    

    
      	
               

            	
              Bytes

            	
              01
                – 01 Character ‘H’ indicating header

            

    

    
      	
               

            	
              02
                – 02 Character TAB delimiter 

            

    

    
      	
               

            	
              03
                – 12 First of the month date to be processed, CCYY-MM-DD
                

            

    

    
      	
               

            	
              13
                – 13 Character TAB delimiter 

            

    

    
      	
               

            	
              14
                – 15 Numeric 2 whole digits 

            

    

    
      	
               

            	
              File
                Type 01 = Health Plan Enhanced Benefit Credit Import
                

            

    

    
      	
               

            	
              16
                – 16 Character TAB delimiter 

            

    

    
      	
               

            	
              17
                - 87 Character, spaces 

            

    

    
      	
               

            	
              88
                - 88 Character TAB delimiter 

            

    

    
      	
               

            	
              89-89
                Line Feed character 

            

    

    
      	
               

            	
              90-90
                Carriage Return character 

            

    

    

    Format
      of each detail
      record:

    Bytes          01
      – 01 Character ‘D’ indicating detail

                       02
      – 02 Character TAB delimiter

                       03
      – 11 Character, 9  Plan ID

               
            12 – 12 Character TAB
      delimiter 

                       13
      – 21 Character, 9 Recipient ID 

                       22
      – 22 Character TAB
      delimiter                                                                                     

                       23
      – 32 CCYY-MM-DD  Date of Birth

                       33
      – 33 Character TAB delimiter

                       34
      – 38 Character, 5 Procedure Code

                       39
      – 39 Character
      TAB  delimiter                

                       40
      – 49 CCYY-MM-DD Date of Paid Claim / Date HP received
      EB
      Universal Form 

                       50
      – 50 Character TAB  delimiter

                       51
      – 61 Character, 11 NDC

                       62
      – 62 Character TAB  delimiter

                       63
      – 67 Character, 5 GCN

                       68
      – 68 Character TAB  delimiter

                       69
      – 72 Numeric, 4 Quantity

                       73
      – 73 Character TAB  delimiter

                       74
      – 76 Numeric, 3 Day Supply

                       77
      – 77 Character TAB  delimiter

                       78
      – 87 CCYY-MM-DD  Date of Service  / End Date on the
      EB
      Universal Form

                       88
      – 88 Character TAB  delimiter

                       89
      – 89 Line Feed Character

                       90
      – 90  Carriage Return Character

    

    Format
      of the trailer
      record:

    Bytes    01
      – 01 Character ‘T’ indicating trailer

                 02
      – 02 Character TAB  delimiter

                 03
      – 09 Total number of detail records,  Sign Leading Separate 7 whole
      digits

                 10
      – 10 Character TAB  delimiter

                  11
      – 88 Character, spaces

                  89
      – 89 Line Feed Character

                  90
      – 90 Carriage Return Character

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 46 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

     

    Table
      5A

    CPT
      Procedure Codes and Enhanced Benefit Codes for  Reporting
      Healthy Behaviors

     

    
      	
              CPT
                & EB CODES

               

            
	
              No.

            	
              Procedure
                Code Number

            	
              Procedure

            	
              Occurrence
                Limit

            	
              Credit
                Amount Adult

            	
              Credit
                Amount Child

            
	
              1

            	
              45330

            	
              CR

            	
              1
                

            	
              $25.00
                

            	
              $25.00
                

            
	
              2

            	
              45378 
                

            	
              CR
                

            
	
              3

            	
              76090
                

            	
              MAMMO
                

            	
              1
                

            	
              $25.00
                

            	
              $25.00
                

            
	
              4

            	
              76091
                

            	
              MAMMO
                

            
	
              5

            	
              76092
                

            	
              MAMMO
                

            
	
              6

            	
              88141
                

            	
              PAP
                

            	
              1
                

            	
              $25.00
                

            	
              $25.00
                

            
	
              7

            	
              88142
                

            	
              PAP
                

            
	
              8

            	
              88143
                

            	
              PAP
                

            
	
              9

            	
              88150
                

            	
              PAP
                

            
	
              10

            	
              88155
                

            	
              PAP
                

            
	
              11

            	
              88164
                

            	
              PAP
                

            
	
              12

            	
              88174
                

            	
              PAP
                

            
	
              13

            	
              88175
                

            	
              PAP
                

            
	
              14

            	
              92002
                

            	
              EYE
                Adult/Child 

            	
              1
                

            	
              $25.00
                

            	
              $25.00
                

            
	
              15

            	
              920
                04 

            	
              EYE
                Adult/Child 

            
	
              16

            	
              92012
                

            	
              EYE
                Adult/Child 

            
	
              17

            	
              92014
                

            	
              EYE
                Adult/Child 

            
	
              18

            	
              92015
                

            	
              EYE
                Adult/Child 

            
	
              19

            	
              92018
                

            	
              EYE
                Adult/Child 

            
	
              20

            	
              92020
                

            	
              EYE
                Adult/Child

            
	
              21

            	
              99201
                

            	
              OV
                Initial-Adult/Child 

            	
              2

            	
              $15.00
                

            	
              $25.00
                

            
	
              22

            	
              99202
                

            	
              OV
                Initial-Adult/Child 

            
	
              23

            	
              99203
                

            	
              OV
                Initial-Adult/Child 

            
	
              24

            	
              99204
                

            	
              OV
                Initial-Adult/Child 

            
	
              25

            	
              99205
                

            	
              OV
                Initial-Adult/Child 

            
	
              26

            	
              99211
                

            	
              OV
                Initial-Adult/Child 

            
	
              27

            	
              99212
                

            	
              OV
                Initial-Adult/Child 

            
	
              28

            	
              99213
                

            	
              OV
                Initial-Adult/Child 

            
	
              29

            	
              99214
                

            	
              OV
                Initial-Adult/Child 

            
	
              30

            	
              99215
                

            	
              OV
                Initial-Adult/Child 

            
	
              31

            	
              99381
                

            	
              PREV
                Child 

            	
              5

            	
              $0.00
                

            	
              $25.00
                

            
	
              32

            	
              99382
                

            	
              PREV
                Child 

            
	
              33

            	
              99383
                

            	
              PREV
                Child 

            
	
              34

            	
              99384
                

            	
              PREV
                Child 

            
	
              35

            	
              99385
                

            	
              PREV
                Child 

            
	
              36

            	
              99386
                

            	
              PREV
                Child 

            
	
              37

            	
              99387
                

            	
              PREV
                Child 

            
	
              38

            	
              99391
                

            	
              PREV
                Child 

            

    

     

    
      AHCA
        Contract No. FAR001, Amendment No. 7, Page 47 of
        66

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

       

      
        	
                CPT
                  & EB CODES

                 

              
	
                No.

              	
                Procedure
                  Code Number

              	
                Procedure

              	
                Occurrence
                  Limit

              	
                Credit
                  Amount Adult

              	
                Credit
                  Amount Child

              

      

    

    
      	
              39

            	
              99392
                

            	
              PREV
                Child 

            	 	 	 
	
              40

            	
              99393
                

            	
              PREV
                Child 

            
	
              41

            	
              99394
                

            	
              PREV
                Child 

            
	
              42

            	
              99395
                

            	
              PREV
                Child 

            
	
              43

            	
              99396
                

            	
              PREV
                Child 

            
	
              44

            	
              99397
                

            	
              PREV
                Child 

            
	
              45

            	
              99403
                

            	
              PREV
                Child 

            
	
              46

            	
              99431
                

            	
              PREV
                Child 

            
	
              47

            	
              99432
                

            	
              PREV
                Child 

            
	
              48

            	
              99435
                

            	
              PREV
                Child 

            
	
              49

            	
              D1110
                

            	
              Dental
                

            	
              2

            	
              $15.00
                

            	
              $25.00
                

            
	
              50

            	
              D1120
                

            	
              Dental
                

            
	
              51

            	
              D1203
                

            	
              Dental
                

            
	
              52

            	
              D1330
                

            	
              Dental
                

            
	
              53

            	
              D1351
                

            	
              Dental
                

            
	
              54

            	
              EB001
                

            	
              Congestive
                Heart Failure Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              55

            	
              EB002
                

            	
              Diabetes
                Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              56

            	
              EB003
                

            	
              Asthma
                Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              57

            	
              EB004
                

            	
              HIV/AIDS
                Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              58

            	
              EB005
                

            	
              Hypertension
                Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              59

            	
              EB006
                

            	
              Other
                Disease Management Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              60

            	
              EB007
                

            	
              Flu
                Shot 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              61

            	
              EB008
                

            	
              Adult
                Dental Cleaning (preventative services) 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              62

            	
              EB009
                

            	
              Alcoholics
                Anonymous Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              63

            	
              EB109
                

            	
              Alcoholic
                Treatment 6 months success 

            	
              2

            	
              $15.00
                

            	
              $15.00
                

            
	
              64

            	
              EB010
                

            	
              Narcotics
                Anonymous Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              65

            	
              EB110
                

            	
              Narcotics
                Treatment 6 months success 

            	
              2

            	
              $15.00
                

            	
              $15.00
                

            

    

    
      
         

        AHCA
          Contract No. FAR001, Amendment No. 7, Page 48 of
          66

      

      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        Healthease
          of Florida, Inc. 

        Medicaid
          HMO Reform Contract

         

      

    

    
      	
              66

            	
              EB011
                

            	
              Smoking
                Cessation Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              67

            	
              EB111
                

            	
              Smoking
                Cessation. 6 months Success 

            	
              2

            	
              $15.00
                

            	
              $15.00
                

            
	
              68

            	
              EB012
                

            	
              Exercise
                Program 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              69

            	
              EB112
                

            	
              Exercise
                Program 6 months success 

            	
              2

            	
              $15.00
                

            	
              $15.00
                

            
	
              70

            	
              EB013
                

            	
              Weight
                Management 

            	
              1

            	
              $25.00
                

            	
              $25.00
                

            
	
              71

            	
              EB113
                

            	
              Weight
                Management 6 months success 

            	
              2

            	
              $15.00
                

            	
              $15.00
                

            

    

     

    
       

    

    

    
      	
              92.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item I., Performance Measures Report, is hereby deleted
                and
                replaced with the following: 

            

    

    

    Agency-Defined
      Performance Measure– These performance measures, not included in
      the HEDIS data set, have been determined by the Agency to be critical to the
      needs of the Medicaid population.

    

    Hybrid
      Measure– A measure that requires the identification of a numerator
      using both administrative and medical record data.  The denominator
      consists of a systematic sample of Enrollees drawn from the measure’s eligible
      population.

    

    Measurement
      Year– January 1 - December 31

    

    Report
      Year– The calendar year immediately following the Measurement
      Year

    

    
      	
               

            	
              1.

            	
              The
                following Performance Measures Reporting Requirements chart provides
                the
                listing of measures to be reported by the Health Plan and the phase-in
                schedule encompassing the addition of the new measures. Measures
                1 through
                20 shall be collected and reported for all Enrollees. Measures 21
                through
                33 shall be collected and reported for Enrollees in the Health Plan’s
                respective Disease Management programs. The Performance Measure (PM)
                report is due by July 1 after the Measurement Year being reported.
                

            

    

    

    
      	
               

            	
              a.

            	
              Measurement
                Year One captures January 1, 2007-December 31, 2007. The report submission
                date for Year One is July 1, 2008. 

            

    

    

    
      	
               

            	
              b.

            	
              Measurement
                Year Two captures January 1, 2008-December 31, 2008. The report submission
                date for Year Two is July 1, 2009. 

            

    

    

    
      	
               

            	
              c.

            	
              Measurement
                Year Three captures January 1, 2009-December 31, 2009. The report
                submission date for Year Three is July 1, 2010.

            

    

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 49 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    Table
      21

    Performance
      Measures Report

     

    
      
        	
                
                

                Medicaid
                  Reform Performance Measures

              	
                
                

                Yr
                  1

              	
                
                

                Yr2

              	
                
                

                Yr3

              	
                
                

                 Comments

              
	
                Plan
                  Population Measures

                
                

              	
                Existing
                  Contract  Measures

              
	
                1.

              	
                Breast
                  Cancer Screening – (BCS)

              	 	
                ü

              	 	 
	
                2.

              	
                Cervical
                  Cancer Screening – (CCS)

              	
                ü

              	 	 	 
	
                3.

              	
                Childhood
                  Immunization Status – (CIS)

              	 	
                ü

              	 	 
	
                4.

              	
                Adolescent
                  Immunization Status – (AIS)

              	 	
                ü

              	 	 
	
                5.

              	
                Well-Child
                  Visits in the First 15 Months of Life – (W15)

              	
                ü

              	 	 	 
	
                6.

              	
                Well-Child
                  Visits in the Third, Fourth, Fifth and Sixth Years of Life–
                  (W34)

              	
                ü

              	 	 	 
	
                7.

              	
                Adolescent
                  Well Care Visits – (AWC)

              	
                ü

              	 	 	 
	
                8.

              	
                Number
                  of Enrollees Admitted to the State Mental Hospital

              	
                ü

              	 	 	
                Agency-Defined
                  Measure

              
	
                New
                  Performance Measures & Contract Replacement
                  Measures

              
	
                9.

              	
                Follow-Up
                  after Hospitalization for Mental Illness – (FUH)

              	
                ü

              	 	 	
                Contract
                  Replacement Measure

              
	
                10.

              	
                Antidepressant
                  Medication Management – (AMM)

              	 	
                ü

              	 	 
	
                11.

              	
                Use
                  of Appropriate Medications for People with Asthma – (ASM)

              	 	
                ü

              	 	
                Allows
                  trending for effectiveness of Disease Management
                  Program

              
	
                12.

              	
                Controlling
                  High Blood Pressure – (CBP)

              	
                ü

              	 	 	
                Same
                  As Above

              
	
                13.

              	
                Comprehensive
                  Diabetes Care – (CDC) – Without Blood
                  Pressure
                  Measure

              	
                ü

              	 	 	
                Same
                  As Above

              
	
                14.

              	
                Adults
                  Access to Preventive /Ambulatory Health Services – (AAP)

              	 	
                ü

              	 	 
	
                15.

              	
                Annual
                  Dental Visits – (ADV)

              	
                ü

              	 	 	
                Contract
                  Replacement Measure

              
	
                16.

              	
                Prenatal
                  and Postpartum Care – (PPC)

              	
                ü

              	 	 	
                Partial
                  Prior Year Data Needed

              
	
                17.

              	
                Frequency
                  of Ongoing Prenatal Care – (FPC)

              	 	
                ü

              	 	
                Partial
                  Prior Year Data Needed

              
	
                18.

              	
                Ambulatory
                  Care – (AMB)

              	
                ü

              	 	 	 
	
                19.

              	
                Mental
                  Health Utilization – Inpatient Discharges & Average Length Of Stay
                  –  (MIP)

              	 	
                ü

              	 	 
	
                20.

              	
                Mental
                  Health Utilization – Inpatient, Intermediate, & Ambulatory Services –
                  (MPT)

              	 	 	
                ü

              	 
	
                
                

                Disease
                  Management (DM) Measures

              	
                All
                  Disease Management Programs

              
	
                21.

              	
                Smoking
                  Cessation

              	
                ü

              	 	 	
                Agency-Defined
                  Measure

              
	
                22.

              	
                Body
                  Weight Monitoring and / Loss (includes BMI)

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                23.

              	
                Medication
                  Regimen Adherence

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                Diabetes
                  Disease Management Program

              
	
                24.

              	
                Foot
                  Exam Annually

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                25.

              	
                Blood
                  Glucose Self-Monitoring

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                Congestive
                  Heart Failure Disease Management Program

              
	
                26.

              	
                Use
                  Angiotensin-Converting Enzyme (ACE) Inhibitors/Angiotensin Receptor
                  Blockers (ARB) Therapy

              	 	
                ü

              	 	
                Agency-Defined
                  Measure

              
	
                Hypertension
                  Disease Management Program

              
	
                27.

              	
                Lipid
                  Profile Annually

                
                

              	 	
                ü

              	 	
                Agency-Defined
                  Measure

              
	
                Asthma
                  Disease Management Program

              
	
                28.

              	
                Use
                  of Beta Agonist

              	
                ü

              	 	 	
                Agency-Defined
                  Measure

              
	
                29.

              	
                Use
                  of Rescue Medication

              	 	
                ü

              	 	
                Agency-Defined
                  Measure

              
	
                30.

              	
                Use
                  of Controller Medication

              	 	
                ü

              	 	
                Agency-Defined
                  Measure

              
	
                31.

              	
                Asthma
                  Action Plan

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                HIV/AIDS
                  Disease Management Program

              
	
                32.

              	
                CD4
                  Test Performed and Results

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                33.

              	
                Viral
                  Load Test Performed and Results

              	 	 	
                ü

              	
                Agency-Defined
                  Measure

              
	
                
                

                Cumulative
                  Total Measures

                
                

              	
                
                

                13

                
                

              	
                
                

                25

                
                

              	
                
                

                33

                
                

              	 

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      
        
          
            
              AHCA
                Contract No. FAR001, Amendment No. 7, Page 51 of
                66

            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            Healthease
              of Florida, Inc. 

            Medicaid
              HMO Reform Contract

          

        

      

    

    
      	
               

            	
              2.

            	
              Reporting
                Instructions 

            

    

    

    
      	
               

            	
              a.

            	
              Beginning
                with Measurement Year One data, each Health Plan shall submit PM
                data no
                later than July 1 of the following year (Report Year).
                

            

    

    

    
      	
               

            	
              b.

            	
              Data
                must be aggregated by Health Plan. 

            

    

    

    
      	
               

            	
              c.

            	
              For
                HEDIS and Agency-Defined PM there is no rotation schedule. Every
                PM is due
                to the agency by July 1 of the report year.

            

    

    

    
      	
               

            	
              d.

            	
              Data
                must be reported for every required data field for each PM. However,
                when
                the denominator is less than 30, report "*" (asterisk) in the "rate"
                field. For these PMs, other than "rate" report all data elements,
                including the numerator and denominator.

            

    

    

    
      	
               

            	
              e.

            	
              Extensions
                to the due date will be granted by the Agency for a maximum of 30
                days
                from the due date in response to a written request signed by the
                chief
                executive officer of the Health Plan or designee. The request must
                be
                received prior to the due date and the delay must be due to unforeseen
                and
                unforeseeable factors beyond the control of the reporting Health
                Plan.
                Extensions shall not be granted to verbal requests.
                

            

    

    

    
      	
               

            	
              f.

            	
              Each
                Health Plan shall submit indicator data in a text (ASCII) or Microsoft
                Excel file. The file name shall be in the format: PlanIDyyyy.txt
                or
                PlanIDyyyy.xls, where "PlanID" is the three-letter Health Plan
                identification code as assigned by the Agency and "yyyy" is the
                Measurement Year of the PM data 

            

    

    

    
      	
               

            	
              g.

            	
              Each
                Health Plan shall send indicator data by electronic mail to RPM@ahca.myflorida.com,
                or to the Agency’s mailing address using a 3.5'' diskette or CD as
                follows: 

            

    

    

    Agency
      for Health Care Administration

    Attention:
      Medicaid Reform Performance Measures

    2727
      Mahan Drive, MS16

    Tallahassee,
      Florida 32308

    

    
      	
               

            	
              h.

            	
              Health
                Plans submitting indicator data using a diskette or CD must have
                an
                external label affixed with the following information:
                

            

    

    

    
      	
               

            	
              (a)

            	
              Text:
                "Medicaid Reform Performance Measure Data";

            

    

    
      	
               

            	
              (b)

            	
              The
                three-letter Health Plan identification code;

            

    

    
      	
               

            	
              (c)

            	
              Medicaid
                Reform Health Plan name; 

            

    

    
      	
               

            	
              (d)

            	
              File
                name in the format PlanIDyyyy.txt or PlanIDyyyy.xls.
                

            

    

    

    
      	
               

            	
              i.

            	
              Health
                Plans submitting indicator data using electronic mail shall include
                in the
                electronic mailing the following information:

            

    

    

    (a)
      Text:
      "Medicaid Reform Performance Measure Data";

    (b)
      The
      three-letter Health Plan identification code;

    (c)
      Medicaid Reform Health Plan name;

    (d)
      File
      name in the format PlanIDyyyy.txt or PlanIDyyyy.xls.

    

    AHCA
      Contract No. FAR001, Amendment No. 7, Page 52 of 66

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              3.

            	
              Data
                Specifications 

            

    

    

    Each
      Health Plan shall report the data elements described below for each of the
      required PMs.  Report PM data in the following format with a space or
      tab between each data element (text files), or a single column for each data
      element (Excel files).  Start a new line with each different
      PM:

    

    
      	
               

            	
              a.

            	
              Health
                Plan Identification Number – The nine-digit Medicaid ID number that
                identifies the plan and county of operation, as assigned by the Agency
                for
                reporting purposes.  Format: Nine digits.

            

    

    

    
      	
               

            	
              b.

            	
              Measurement
                Year – The calendar year of the data.  Format: Four digits.
                

            

    

    

    
      	
               

            	
              c.

            	
              Performance
                Measure Identifier – The three character code of the PM as specified in
                the Performance Measures Reporting Requirements chart in parentheses
                after
                the PM name in Section XII, I. Format:  Three characters.
                

            

    

    

    
      	
               

            	
              d.

            	
              Data
                Collection Method – The source of data and approach used in gathering the
                data for all PMs as specified by HEDIS or Agency
                definitions:  Format: One digit, as below:
                

            

    

    

    
      	
               

            	
              1.
                Administrative method – Enter "1". 

            

    

    
      	
               

            	
              2.
                Hybrid method – Enter "2". 

            

    

    

    
      	
               

            	
              e.

            	
              Eligible
                Enrollee Population – The number meeting the criteria as specified by
                HEDIS or Agency definitions.  Format: Number of digits required.
                

            

    

    

    
      	
               

            	
              f.

            	
              Sample
                Size – Minimum required sample size as specified by HEDIS for HEDIS
                measures only.  This data element is not required if the
                administrative method is used. Leave blank (zero-fill) if e. above
                is
                1.  Format: Number of digits required.
                

            

    

    

    
      	
               

            	
              g.

            	
              Denominator
                – If the administrative method is used, eligible member population
                minus
                exclusions, if any, as specified by HEDIS or Agency
                definitions.  If the hybrid method is used, the sample size is
                the denominator or as specified by HEDIS or Agency
                definitions.  Format: Number of digits required.
                

            

    

    

    
      	
               

            	
              h.

            	
              Numerator
                – Number of numerator events from all data sources as specified by
                HEDIS
                or Agency definitions.  Format: Number of digits required.
                

            

    

    

    
      	
               

            	
              i.

            	
              Rate
                – Numerator divided by denominator times 100.00.
                

            

    

    

    
      	
               

            	
              j.

            	
              Lower
                CI – Lower 95% confidence interval as specified by HEDIS.  If
                the lower CI is less than zero, report 000.00.  This statistic
                is to be calculated for all PMs. 

            

    

    

    
      	
               

            	
              k.

            	
              Upper
                CI – Upper 95% confidence interval as specified by HEDIS.  If
                the upper CI exceeds 100, report 100.00.  This statistic is to
                be calculated for all PMs. 

            

    

     

    
      	
               

            	
              l.

            	
              Format
                for Rate, Lower CI and Upper CI: Five digits with two decimal places
                required, right-justified. Zero-fill leading digits. Include decimal.
                Use
                the format: xxx.xx where x represents any digit and xxx is a value
                between
                0 and 100.00. 

            

    

    

    
      	
               

            	
              4.

            	
              The
                Number of Enrollees Admitted to State Mental Health Treatment Facilities,
                Smoking Cessation, and Asthma – Use of Beta Agonist are Agency-Defined
                Measures required for Measurement Year One and shall be collected
                and
                submitted following the specifications

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 53 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              listed
                below. All other Measurement Year One measures shall be collected
                and
                submitted according to HEDIS specifications.

            

    

    

    
      	
               

            	
              a.

            	
              Number
                of Enrollees Admitted to State Mental Health Treatment Facilities
                (MHF)
                

            

    

    

    The
      percentage of all Enrollees 18 years of age and older who receive a commitment
      order to a state mental health treatment facility within the measurement
      year.

    

    Ages:  Eighteen
      years of age and older
      as of December 31 of the measurement year.

    

    Data
      Collection Method:  Administrative
      data, based on provider reporting.  No sampling allowed.

    

    Enrollment:  No
      minimum or continuous
      period of enrollment is required.  Include all eligible Enrollees
      during the measurement year, regardless of period of enrollment.

    

    Calculation:  Results
      will be expressed
      as a percentage rate:

    

    Denominator:
      Number of enrollees with a mental
      health diagnosis during the measurement year or the year prior to the
      measurement year.

    

    "Mental
      health diagnosis" is defined from the following list of ICD-9-CM
      codes.  Codes can be a principal diagnosis or any secondary
      diagnosis:

     

    290
      -
      290.43; 293 - 298.9; 300 - 301.9; 302.7, 306.51 - 312.4; 312.81 through 314.9;
      315.3, 315.31, 315.5, 315.8, and 315.9.

    

    Numerator:
Number
      of Enrollees for whom a
      commitment order was signed during the measurement year.

    

    
      	
               

            	
              Exclusions:
                

            

    

    

    
      	
               

            	
              ·

            	
              Enrollees
                for whom the commitment process has been initiated but who have not
                yet
                received an order for placement; 

            

    

    
      	
               

            	
              ·

            	
              Enrollees
                who are awaiting transport and whose order was reported in an earlier
                reporting period; 

            

    

    
      	
               

            	
              ·

            	
              New
                enrollees whose commitment process was in progress prior to enrollment
                in
                the Health Plan. 

            

    

    

    
      	
               

            	
              b.

            	
              Smoking
                Cessation (SMO). 

            

    

    

    The
      percentage of all health plan Enrollees who are participants in a Disease
      Management program and who reported being daily smokers at the baseline
      assessment and subsequently became (a) occasional smokers or (b) former
      smokers.  These two categories are reported separately.

    

    Ages:
      Ages 18 years and older as of December 31
      of the measurement year.

     

    Results
      should be stratified into two age groups and an overall total rate:

     

    
      	
               

            	
              ·

            	
              18
                to 24 years old 

            

    

    
      AHCA
        Contract No. FAR001, Amendment No. 7, Page 54 of
        66

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    
      	
               

            	
              ·

            	
              25
                years old and older 

            

    

     

    
      	
               

            	
              ·

            	
              Total
                (Calculate "total" as the sum of the numerators for each age group
                divided
                by sum of the denominators for each age group.)

            

    

    

    Data
      Collection Method: Administrative data or
      Disease Management program record review, including survey data, if
      available.

    

    Enrollment:
      Enrollees in any of the Health Plan’s
      Disease Management programs for a minimum of six continuous months during the
      measurement year.  No more than one gap of up to 30 Calendar Days in
      the Disease Management program is allowed during the six-month
      period.

    

    Calculation:  Results
      will be expressed
      as a percentage rate:

    

    Denominator:  The
      number of Disease
      Management Enrollees 18 years and older who reported being daily smokers at
      the
      baseline assessment for the Disease Management program.

    

    
      	
               

            	
              Numerator:
                

            

    

     

    
      	
               

            	
              ·

            	
              Occasional:
                The
                number of Disease Management Enrollees who report having changed
                their
                smoking habits from daily to occasionally at a follow-up or annual
                assessment or other contact under the Disease Management program.
                

            

    

     

    
      	
               

            	
              ·

            	
              Former:  The
                number of Disease Management Enrollees who report having quit smoking,
                regardless of the length of this quit effort, at a follow-up or annual
                assessment or other contact under the Disease Management program.
                

            

    

    

    c.           
      Asthma - Use of Beta Agonist (UBE).

    

    The
      percentage of Asthma Disease Management Enrollees during the measurement year
      who had prescriptions for beta agonist medications filled during the measurement
      year.

    

    Ages:  Ages
      5 to 56 years as of
      December 31 of the measurement year.

    

    Results
      should be stratified into three age groups and an overall total
      rate:

     

    ·      
      5 to 9 years old

     

    ·      
      10 to 17 years old

     

    ·      
      18 to 56 years old

     

    
      	
               

            	
              ·

            	
              Total
                (Calculate "total" as the sum of the numerators for each age group
                divided
                by sum of the denominators for each age group.)

            

    

    

    Data
      Collection Method:  Administrative
      data.  No sampling allowed.

    

    Enrollment:
      Enrollees in the Health Plan’s Asthma
      Disease Management program for a minimum of six continuous months during the
      measurement year.  No more than one gap of up to 30 Calendar Days in
      the Asthma Disease Management program is allowed during the six-month
      period.

    

    Calculation:  Results
      will be expressed
      as a percentage rate:

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 55 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc.

           Medicaid
            HMO Reform Contract

        

      

    

    

    Denominator:  The
      number of Disease
      Management Enrollees ages 5 to 56 years old who are in the Health Plan’s Asthma
      Disease Management program.

    

    Numerator:  The
      number of Disease
      Management Enrollees who had at least one prescription for beta agonist
      medication filled during the measurement year.  Beta agonist
      medications are defined with the following therapeutic class
      codes:  J5D and J5G.

    

    
      	
               

            	
              5.

            	
              The
                Agency shall supply specifications for Agency-Defined Measures scheduled
                for Measurement Year Two and Measurement Year Three at least 30 Calendar
                Days prior to the date collection is scheduled to begin.
                

            

    

    

    
      	
               

            	
              6.

            	
              Data
                Certification 

            

    

    

    
      	
               

            	
              a.

            	
              By
                July 1 of each year, the Health Plan shall deliver to the Agency
                a
                certification by an independent auditor that the PM data reported
                for the
                previous year (Measurement Year) have been fairly and accurately
                presented. This certification should accompany the PM data.
                

            

    

    

    
      	
               

            	
              b.

            	
              The
                Health Plan shall submit and attest to the accuracy and completeness
                of
                data from all subcontracted entities, including, but not limited
                to,
                behavioral health managed care organizations, disease management
                organizations and laboratories as described in Section XII, A.,of
                the
                Health Plan Model Contract. In no instance will separate, direct
                submission of data to the Agency from such entities be permitted.
                

            

    

    

    
      	
               

            	
              7.

            	
              Data
                Validation 

            

    

    

    
      	
               

            	
              a.

            	
              As
                specified in Section VIII, A.1.e., the Health Plan shall cooperate
                with
                the Agency and the External Quality Review Organization (EQRO). The
                Agency
                will set methodology and standards for Quality Improvement with advice
                from the EQRO. 

            

    

    

    
      	
               

            	
              b.

            	
              Each
                Health Plan shall participate in the EQRO's performance measures
                validation process according to CMS protocol.

            

    

    

    
      	
               

            	
              c.

            	
              Any
                Health Plan failing to participate with the external EQRO PM validation
                process will be deemed non-compliant.

            

    

    

    
      	
               

            	
              8.

            	
              Report
                Deficiencies 

            

    

    

    
      	
               

            	
              a.

            	
              A
                report, certification, or other information required for PM reporting
                is
                incomplete when it does not contain all data required by the Agency
                or
                when it contains inaccurate data. A report or certification is “false” if
                done or made with the knowledge of the preparer or a superior of
                the
                preparer that it contains information or data that is not true or
                not
                accurate. 

            

    

    

    
      	
               

            	
              b.

            	
              A
                Health Plan that refuses to file, fails to timely file, or files
                a false
                or incomplete report or a report that cannot be certified, validated,
                or
                excludes other information required to be filed may be subject to
                administrative penalties pursuant to Section XIV., Sanctions, of
                the
                Health Plan Model Contract. 

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 56 of
              66

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

     

    
      	
              93.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item K., Suspended Fraud Reporting, sub-item 1.a.,
                is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              a.

            	
              Upon
                detection of a potential or suspected fraudulent claim submitted
                by a
                provider, the Health Plan shall file a report with the Agency’s MPI.”
                

            

    

    

    
      	
              94.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item K., Suspended Fraud Reporting, sub-item 2.a.,
                is hereby
                amended to read as follows: 

            

    

    

    
      	
               

            	
              a.

            	
              Upon
                detection of all instances of fraudulent claims or acts by an Enrollee,
                the Health Plan shall file a report with the Agency’s MPI.
                

            

    

    

    
      	
              95.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item N., Child Health Check-Up Reports, sub-item 1.,
                the
                second sentence, is hereby amended to read as follows:
                

            

    

    

    The
      Health Plan shall submit the report annually in the format set forth in Table
      8,
      below.

    

    
      	
              96.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item N., Child Health Check-Up Reports, sub-item 7.1,
                the
                first sentence, is hereby amended to read as follows:
                

            

    

    

    The
      Health Plan shall submit the Child Health Check Up, FL 60% Ratio Report annually
      and in the formats as presented in Table 8.

    

    
      	
              97.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item Q., Transportation Services, the section title
                is
                hereby amended to now read as follows:

            

    

    

    Q.   Transportation
      Reports and Performance Measures

    

    
      	
              98.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item U., Critical Incident Reporting, sub-items f and
                g are
                hereby amended to read as follows: 

            

    

    

    
      	
               

            	
              f.

            	
              The
                Health Plan shall report monthly to the Agency, in accordance with
                the
                format in Table 13 Critical Incidents Summary, below, a summary of
                all
                critical incidents. 

            

    

    

    
      	
               

            	
              g.
                

            	
              In
                addition to supplying a monthly Critical Incidents Summary, the Health
                Plan shall also report Critical Incidents in the manner prescribed
                by the
                appropriate district’s DCF Alcohol, Drug Abuse Mental Health office, using
                the appropriate DCF reporting forms and procedures.
                

            

    

    

    
      	
              99.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item V., Required Staff/Providers, the first sentence,
                is
                hereby amended to read as follows:

            

    

    
      
        
          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 57 of
              66

          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          Healthease
            of Florida, Inc. 

          Medicaid
            HMO Reform Contract

        

      

    

    The
      Health Plan shall submit contracted and subcontracted staffing information
      by
      position, name and FTE for all direct service positions on a quarterly basis
      in
      accordance with Table 13, Required Staff/Providers, below.

    

    
      	
              100.

            	
              Attachment
                II, Medicaid Reform Health Plan Model Contract, Section XII., Reporting
                Requirements, Item W., FARS/CFARS, Table 14 is hereby deleted in
                its
                entirety and replaced by the following table:

            

    

     

    
      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

       

      AHCA
        Contract No. FAR001, Amendment No. 7, Page 58 of 66

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      Healthease
        of Florida, Inc. 

      Medicaid
        HMO Reform Contract

       

    

    
      	
              Table
                14

              FUNCTIONAL
                ASSESSMENT RATING SCALE/CHILDREN’S FUNCTIONAL ASSESSMENT RATING SCALE
                Reporting

              
              

              O***YY06.txt
                (January through June, due August 15) OR

              O***YY12.txt
                (July through December, due February 15)

               

            
	
              Data
                Element Name

            	
              Length

            	
              Start
                Column

            	
              End
                Column

            	
              Description

            
	
              Recipient
                Identification Number

            	
              9

            	
              1

            	
              9

            	
              9-Digit
                Medicaid Identification Number of Enrollee.

            
	
              Recipient
                Date of Birth

            	
              10

            	
              10

            	
              19

            	
              Enrollee’s
                date of birth in CCYYMMDD format, e.g., 20010101.

            
	
              Recipient
                First Name

            	
              15

            	
              20

            	
              35

            	
              Enrollee’s
                first name.

            
	
              Recipient
                Last Name

            	
              15

            	
              36

            	
              50

            	
              Enrollee’s
                last name.

            
	
              Provider
                Identification Number

            	
              9

            	
              51

            	
              59

            	
              9-Digit
                Medicaid Plan Identification Number.

            
	
              Contractor
                Identification Number

            	
              10

            	
              60

            	
              70

            	
              10-digit
                Federal Tax Identification Number or National Provider Identifier
                (NPI) of
                the provider conducting the assessment.

            
	
              Contract
                Number

            	
              5

            	
              71

            	
              76

            	
              Up
                to 5-digit alphanumeric number of the Department of Children and
                Families
                contract responsible for serving the enrollee being evaluated through
                FUNCTIONAL ASSESSMENT RATING SCALE or CHILDREN’S FUNCTIONAL ASSESSMENT
                RATING SCALE.  If the provider does not have a contract, enter
                “00000”.

            
	
              Assessment
                Type

            	
              1

            	
              77

            	
              77

            	
              1-digit
                code to designate the type of functional assessment that was done,
                i.e.,

              “F”
                = FUNCTIONAL ASSESSMENT RATING SCALE
                or

              “C”
=
                CHILDREN’S FUNCTIONAL ASSESSMENT
                RATING SCALE

            
	
              Assessment
                Purpose

            	
              1

            	
              78

            	
              78

            	
              1-digit
                code to designate the purpose for doing the assessment, i.e.,

              “1”
=
                Initial assessment at time of
                admission into provider agency;

              “2”
=
                every 6-month after admission,
                or

              “3”
=
                assessment at time of discharge from
                provider agency

            
	
              Assessment
                Date

            	
              8

            	
              79

            	
              86

            	
              Date
                of assessment in CCYYMMDD format, e.g.,
                20060812.

            

    

     

     

    
      AHCA
        Contract No. FAR001, Amendment No. 7, Page 59 of
        66

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      Healthease
        of Florida, Inc. 

      Medicaid
        HMO Reform Contract

      
        	
                Data
                  Element Name

              	
                Length

              	
                Start
                  Column

              	
                End
                  Column

              	
                Description

              
	
                Disability
                  Score

              	
                2

              	
                87

              	
                88

              	
                Sum
                  of the assessment scores for all the scales in the Disability
                  domain.

              
	
                Emotionality
                  Score

              	
                2

              	
                89

              	
                90

              	
                Sum
                  of the assessment score for all the scales in the Emotionality
                  domain.

              
	
                Relationship
                  Score

              	
                2

              	
                91

              	
                92

              	
                Sum
                  of the assessment score for all the scales in the Relationships
                  domain.

              
	
                Safety
                  Score

              	
                2

              	
                93

              	
                94

              	
                Sum
                  of the assessment score for all the scales in the Personal Safety
                  domain.

              
	
                Overall
                  Assessment Score

              	
                3

              	
                95

              	
                97

              	
                Sum
                  of all domain scores.

              

      

    

     

    The
      definitions of FUNCTIONAL ASSESSMENT RATING SCALE and CHILDREN’S FUNCTIONAL
      ASSESSMENT RATING SCALE domains and related functional scales and subscales
      for
      each domain are available on the following Florida Mental Health Institute
      web
      site:  http://outcomes.fmhi.usf.edu.
For example,
      the following are domains
      and functional scales for FUNCTIONAL ASSESSMENT RATING SCALE and CHILDREN’S
      FUNCTIONAL ASSESSMENT RATING SCALE:

    
      
        

        
          	
                  Domains

                	
                  Functional
                    Scales

                	
                  FARS

                	
                  CFARS

                
	
                  Disability

                	
                  Hyper
                    Affect

                	
                  ü

                	 
	
                  Thought
                    Process

                	
                  ü

                	
                  ü

                
	
                  Cognitive
                    Performance

                	
                  ü

                	 
	
                  Medical/Physical

                	
                  ü

                	
                  ü

                
	
                  Activity
                    of Daily Living

                	
                  ü

                	
                  ü

                
	
                  Ability
                    to Care for Self

                	
                  ü

                	 
	 	 	 	 
	
                  Emotionality

                	
                  Depression

                	
                  ü

                	
                  ü

                
	 	
                  Anxiety

                	
                  ü

                	
                  ü

                
	 	
                  Traumatic
                    Stress

                	
                  ü

                	
                  ü

                
	 	 	 	 
	
                  Relationships

                	
                  Interpersonal
                    Relations

                	
                  ü

                	
                  ü

                
	 	
                  Family
                    Relations

                	
                  ü

                	 
	 	
                  Family
                    Environment

                	
                  ü

                	 
	 	
                  Socio-Legal

                	
                  ü

                	 
	 	
                  Work
                    or School

                	
                  ü

                	
                  ü

                
	 	
                  Danger
                    to Others

                	
                  ü

                	
                  ü

                
	 	
                  Hyper
                    Activity

                	 	
                  ü

                
	 	
                  Cognitive
                    Performance

                	 	
                  ü

                
	 	
                  Behavior
                    in Home Setting

                	 	
                  ü

                
	 	 	 	 
	
                  Personal
                    Safety

                	
                  Substance
                    Use

                	
                  ü

                	
                  ü

                
	 	
                  Danger
                    to Self

                	
                  ü

                	
                  ü

                
	 	
                  Security
                    Management Needs

                	
                  ü

                	
                  ü

                
	 	
                  Socio-Legal

                	 	
                  ü

                

        

        

        AHCA
          Contract No. FAR001, Amendment No. 7, Page 60 of 66

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
         

        Healthease
          of Florida, Inc. 

        Medicaid
          HMO Reform Contract

      

      
        

          
            	
                    101.

                  	
                    Attachment
                      II, Medicaid Reform Health Plan Model Contract, Section XII.,
                      Reporting
                      Requirements, Item X., Behavioral Health Encounter Report,
                      sub-item 3., is
                      hereby amended to include the following:

                  

          

          

          
            	
                     

                  	
                    c.

                  	
                    Additional
                      procedure codes for Community Mental Health Services 90801;
                      90802; 90804 -
                      90819; 90821 - 90824; 90826 - 90829; 90846; 90847; 90849; 90853;
                      90857;
                      90862; 90870; 90880; 90901; 96101; 96103; 96150 - 96155; 99058;
                      99212;
                      99221 - 99223; 99231 - 99236; 99238 - 99239; 99241 - 99245;
                      99251 - 99255;
                      and 99281 – 99285. 

                  

          

          

          
            	
                    102.

                  	
                    Attachment
                      II, Medicaid Reform Health Plan Model Contract, Section XII.,
                      Reporting
                      Requirements, Item X., Behavioral Health Encounter Report,
                      sub-items 4 and
                      5 are hereby deleted and replaced as follows

                  

          

          
            	
                     

                  	
                    4.

                  	
                    Physician
                      Services 

                  

          

          

          
            	
                     

                  	
                    Provider
                      Type 25 (MD) or 26 (DO) with a specialty code of "042" Psychiatrist,
                      "043”
                      Child Psychiatrist, or "044" Psychoanalysis –All Claim Input Indicators
                      submitted by these specialists apply.

                  

          

          

          
            	
                     

                  	
                    5.

                  	
                    Advanced
                      Nurse Practitioner Provider Type 30 (ARNP) with a specialty
                      code of “076”
                      – Clinical Nurse Specialist – All Claim Input Indicators submitted by
                      these specialists apply. 

                  

          

          

          
            	
                    103.

                  	
                    Attachment
                      II, Medicaid Reform Health Plan Model Contract, Section XII.,
                      Reporting
                      Requirements, Item X., Behavioral Health Encounter Report,
                      Table 15 is
                      hereby deleted in its entirety and replaced with the following:
                      

                  

          

          

          Table
            15

          Behavioral
            Health Encounter Data

          
            	
                    Field
                      Name

                  	
                    Field
                      Length

                  	
                    Comments

                  
	
                    Medicaid
                      ID

                  	
                    9

                  	
                    First
                      9 digits of the Enrollee ID number

                  
	
                    Plan
                      ID

                  	
                    9

                  	
                    9
                      digit Medicaid ID of the  Health Plan in which Enrollee was
                      Enrolled on the first date of service

                  
	
                    Service
                      Type

                  	
                    1

                  	
                    I         
                      Hospital Inpatient

                    C         
                      CSU

                    O         
                      Hospital Outpatient

                    P         
                      Physician (MD or DO)

                    A         
                      Advanced Nurse Practitioner, ARNP

                    H         
                      Comm. Mental Health, Mental Health Practitioner

                    T         
                      Targeted Case Management

                    L         
                      Locally Defined or Optional Service

                    
                    

                  
	
                    First
                      Date of Service

                  	
                    8

                  	
                    For
                      Inpatient and CSU encounters, this equals the admit date.  Use
                      YYYYMMDD format.

                  
	
                    Revenue
                      Code

                  	
                    4

                  	
                    Use
                      only for Hospital Inpatient and Hospital Outpatient
                      Encounters

                  
	
                    Procedure
                      Code

                  	
                    5

                  	
                    5
                      digit CPT or HCPCS Procedure Code (For Inpatient Claims only,
                      use the
                      ICD9-CM Procedure Code.)

                  
	
                    Procedure
                      Modifier 1

                  	
                    2

                  	 
	
                    Procedure
                      Modifier 2

                  	
                    2

                  	 

             

            
              AHCA
                Contract No. FAR001, Amendment No. 7, Page 61 of 66

               

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

               

              
                Healthease
                  of Florida, Inc. 

                Medicaid
                  HMO Reform Contract

                 

              

            

            
              	
                      Field
                        Name

                    	
                      Field
                        Length

                    	
                      Comments

                    

            

            	
                    Units
                      of Service

                  	
                    3

                  	
                    For
                      Inpatient and CSU encounters, report the number of covered
                      days.  For all other encounters, use the units of service
                      referenced in the appropriate Medicaid Coverage and Limitations
                      Handbook.

                  
	
                    Diagnosis

                  	
                    6

                  	
                    Primary
                      Diagnosis Code

                  
	
                    Provider
                      Type

                  	
                    2

                  	
                    01          
                      General Hospital

                    02          
                      Special Hospital/Outpatient Rehab

                    05          
                      Community Alcohol Drug Mental Health

                    07          
                      Mental Health Practitioner

                    08          
                      District Schools

                    25          
                      Physician (MD)

                    26          
                      Physician (DO)

                    30          
                      Advanced Registered Nurse Practitioner

                    31          
                      Registered Nurse

                    32          
                      Social Worker/Case Worker

                    66          
                      Rural Health Clinic

                    68          
                      Federally Qualified Health Center

                    91          
                      Case Management Agency

                    
                    

                  
	
                    Provider
                      ID Type

                  	
                    1

                  	
                    Type
                      of unique identifier for the direct service provider:

                                 A
                      = AHCA ID

                                M
                      = Medicaid Provider ID

                                 L
                      = Professional License Number

                  
	
                    Provider
                      ID

                  	
                    9

                  	
                    Unique
                      identifier for the direct service provider

                  
	
                    Amount
                      Paid

                  	
                    10

                  	
                    Costs
                      associated with the claim.  Format with an explicit decimal
                      point and 2 decimal places but no explicit
                      commas.  Optional.

                  
	
                    Run
                      Date

                  	
                    8

                  	
                    The
                      date the file was prepared.  Use YYYYMMDD
                      format

                  
	
                    Claim
                      Reference Number

                  	
                    25

                  	
                    The  Health
                      Plan’s internal unique claim record
                      identifier

                  

          

          
            	
                    104.

                  	
                    Attachment
                      II, Medicaid Reform Health Plan Model Contract, Section XII.,
                      Reporting
                      Requirements, Item AA., Catastrophic Component Threshold and
                      Benefit
                      Maximum Report, is hereby amended to read as follows:
                      

                  

          

          

          Health
            Plans that choose to cover the comprehensive component shall submit this
            report
            for each Enrollee, whose costs for Covered Services reach $25,000 in
            a Contract
            Year.  The report shall be in the format shown in Table 18 below
            unless modified by the Agency within the notice requirements indicated
            in A.3.
            of this Section.  The report shall be submitted monthly from the time
            the Enrollee’s costs reach $25,000 through the end of the Contract
            Year.

          

          

          REMAINDER
            OF PAGE INTENTIONALLY LEFT BLANK

           

           

          
            AHCA
              Contract No. FAR001, Amendment No. 7, Page 62 of 66

             

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            Healthease
              of Florida, Inc. 

            
              Medicaid
                HMO Reform Contract

              

              

              
                	
                        105.

                      	
                        Attachment
                          II, Medicaid Reform Health Plan Model Contract, Section
                          XII., Reporting
                          Requirements, Item AA., Catastrophic Component Threshold
                          and Benefit
                          Maximum Report, Table 18 is hereby deleted in it’s entirety and replaced
                          with the following: 

                      

              

              

              Table
                18 

               

              Catastrophic
                Component Threshold and Benefit Maximum Report

              

              
                	 	 	
                        Reporting
                          Period

                      	 
	
                        Enrollee
                          Medicaid ID

                      	
                        Date
                          of Birth

                      	
                        First
                          Date of Service

                      	
                        Last
                          Date of Service

                      	
                        Amount

                      
	
                      	
                        MMDDYYYY

                      	
                        MMDDYYYY

                      	
                        MMDDYYYY

                      	
                      
	 	 	 	 	 
	
                        Note:
                          The Enrollee Benefit Maximum will be confirmed using Encounter
                          data priced
                          according to the Medicaid Fee Schedule.

                      	 

              

              

              

              
                	
                        106.

                      	
                        Attachment
                          II, Medicaid Reform Health Plan Model Contract, Section
                          XII., Reporting
                          Requirements, is hereby amended to include the following
                          as sub-items CC.
                          and DD.: 

                      

              

              

              
                	
                         

                      	
                        CC.

                      	
                        Inpatient
                          Discharge
                          Data

                      

              

              

              
                	
                         

                      	
                        1.

                      	
                        The
                          Health Plan shall submit its Inpatient Discharge Report
                          to the Agency on a
                          quarterly basis via the AHCA Secure File Transfer Protocol
                          (SFTP) site.
                          The required file will be due within thirty (30) Calendar
                          Days following
                          the end of the quarter being reported.

                      

              

              

              
                	
                         

                      	
                        2.

                      	
                        The
                          Health Plan shall ensure that the Inpatient Discharge Report,
                          as described
                          in Table 20 of this Section, is an electronic representation
                          of the Health
                          Plan’s complete listing of all Medicaid Enrollees discharged
                          from
                          inpatient hospitalization during the quarter being reported.
                          

                      

              

              

              
                	
                         

                      	
                        3.

                      	
                        The
                          Inpatient Discharge Report shall be in an ASCII flat file
                          in the format
                          described in Table 20 of this Section. The file name will
                          be H***yyQ*.txt (replacing
                          *** with the Health Plan’s
                          three character approved abbreviation and replacing yyQ*
                          with the year and
                          number of the quarter being reported).  This file name
                          may change upon notice from the Agency.

                      

              

              

              
                	
                         

                      	
                        4.

                      	
                        Inpatient
                          Psychiatric care will be identified as an Admit Type of
“2”, restricted to
                          claims for Enrollees with a primary ICD-9CM diagnosis code
                          of 290 through
                          290.43; 293 through 298.9; 300 through 301.9; 302.7, 306.51
                          through 312.4;
                          312.81 through 314.9; 315.3, 315.31, 315.5, 315.8, and
                          315.9.
                          

                      

              

              

              REMAINDER
                OF PAGE INTENTIONALLY LEFT BLANK

               

              
                AHCA
                  Contract No. FAR001, Amendment No. 7, Page 63 of
                  66

              

              

              
                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                Healthease
                  of Florida, Inc. 

                
                  Medicaid
                    HMO Reform Contract

                

              

              Table
                20

               

              Structure
                for Inpatient Discharge Reporting File

               

              
                	
                        Field
                          Name 

                      	
                        Type
                          

                      	
                        Width
                          

                      	
                        Description
                          

                      
	
                        PLAN_ID
                          

                      	
                        Character
                          

                      	
                        9
                          

                      	
                        9
                          Digit Medicaid provider number of Health Plan 

                      
	
                        RECIP_ID
                          

                      	
                        Character
                          

                      	
                        9
                          

                      	
                        9
                          Digit Medicaid ID number of Enrollee 

                      
	
                        RECIP_LAST
                          

                      	
                        Character
                          

                      	
                        20
                          

                      	
                        Last
                          name of Enrollee 

                      
	
                        RECIP_FIRS
                          

                      	
                        Character
                          

                      	
                        10
                          

                      	
                        First
                          name of Enrollee 

                      
	
                        RECIP_DOB
                          

                      	
                        Date
                          

                      	
                        10
                          

                      	
                        Enrollee’s
                          date of birth 

                      
	
                        AHCA_ID
                          

                      	
                        Character
                          

                      	
                        8
                          

                      	
                        AHCA
                          ID Number of admitting hospital 

                      
	
                        HOSP_NAME
                          

                      	
                        Character
                          

                      	
                        60
                          

                      	
                        Please
                          use upper case only 

                      
	
                        ADMIT
                          

                      	
                        Date
                          

                      	
                        10
                          

                      	
                        Date
                          of Admission 

                      
	
                        DISCH
                          

                      	
                        Date
                          

                      	
                        10
                          

                      	
                        Date
                          of Discharge 

                      
	
                        ADMIT_TYPE
                          

                      	
                        Character
                          

                      	
                        1
                          

                      	
                        Indicates
                          the Type of Admission 

                        1=General
                          Acute Care  2=Inpatient Psych 

                      
	
                        TPL
                          

                      	
                        Numeric
                          

                      	
                        7
                          

                      	
                        Amount
                          paid by third party (whole dollars) 

                      
	
                        DIAGI
                          

                      	
                        Character
                          

                      	
                        7
                          

                      	
                        Primary
                          ICD-9 Diagnosis 

                      
	
                        DIAG2
                          

                      	
                        Character
                          

                      	
                        7
                          

                      	
                        Secondary
                          ICD-9 Diagnosis (if applicable) 

                      
	
                        DIAG3
                          

                      	
                        Character
                          

                      	
                        7
                          

                      	
                        Tertiary
                          ICD-9 Diagnosis (if applicable) 

                      
	
                        PROC1
                          

                      	
                        Character
                          

                      	
                        5
                          

                      	
                        For
                          an surgical or obstetrical admission, the principal ICD-9
                          Procedure Code
                          

                      
	
                        PROC2
                          

                      	
                        Character
                          

                      	
                        5
                          

                      	
                        For
                          an surgical or obstetrical admission, the secondary ICD-9
                          Procedure Code
                          

                      
	
                        PROC3
                          

                      	
                        Character
                          

                      	
                        5
                          

                      	
                        For
                          an surgical or obstetrical admission, the tertiary ICD-9
                          Procedure Code
                          

                      

              

              

              DD.  Medicaid
                Redetermination Notice Summary Report

              

              This
                report must be submitted to the Agency if the Health Plan participates
                in the
                receipt of Medicaid redetermination date information for its
                Enrollees.  If the Health Plan does not receive Medicaid
                redetermination date information during a quarter, then the Health
                Plan does not
                submit this report.  For Health Plans that must submit this report,
                the following information and requirements apply:

              

              
                	
                         

                      	
                        1.

                      	
                        The
                          Agency will send the Health Plan the format and template
                          for this report
                          when it notifies the Health Plan that it will transmit
                          the redetermination
                          date information to the Health Plan (see Attachment II,
                          Section IV.,
                          Enrollee Services, A.11.). 

                      

              

               

               

              
                AHCA
                  Contract No. FAR001, Amendment No. 7, Page 64 of
                  66

              
                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                
                  Healthease
                    of Florida, Inc. 

                  
                    Medicaid
                      HMO Reform Contract

                  

                

              
                	
                         

                      	
                        2.

                      	
                        The
                          Health Plan must submit to the Agency’s BMHC a completed quarterly summary
                          report due forty-five (45) Calendar Days after the end
                          of the calendar
                          quarter being reported.  The summary report must include the
                          following: 

                      

              

              

              

              a.      
                For mailed notices:

              

              (1)           
                Number of notices mailed each month, by month

              (2)           
                Date(s) the notices were mailed, by month

              (3)           
                Copy of the letter sent each month

              
                	
                         

                      	
                        (4)

                      	
                        Number
                          of returned notices received at the Health Plan each calendar
                          quarter.
                          

                      

              

              

              b.      
                For automated voice messages:

              

              (1)           
                Number of automated calls made each month, by month

              (2)           
                Dates the messages were made each month

              

              

              
                	
                        107.

                      	
                        Attachment
                          II, Medicaid Reform Health Plan Model Contract, Section
                          XIII., Method of
                          Payment, Item C., Kick Payments, sub-item 4.a., is hereby
                          amended to read
                          as follows: 

                      

              

              

              
                	
                         

                      	
                        a.

                      	
                        The
                          Health Plan must submit an accurate and complete claim
                          form in sufficient
                          time to be received by the Fiscal Agent within nine (9)
                          months following
                          the date of service delivery. The Health Plan must submit
                          the claim
                          electronically in a HIPAA compliant X12 837P format.
                          

                      

              

              

              
                	
                        108.

                      	
                        Attachment
                          II, Medicaid Reform Health Plan Model Contract, Section
                          XVI., Terms and
                          Conditions, Item M., Misuse of Symbols, Emblems, or Names
                          in Reference to
                          Medicaid, the first sentence, is hereby amended to read
                          as follows:
                          

                      

              

              

              No
                person
                or Health Plan may use, in connection with any item constituting
                an
                advertisement, solicitation, circular, book, pamphlet or other communication,
                or
                a broadcast, telecast, or other production, alone or with other words,
                letters,
                symbols or emblems the words “Medicaid,” or “Agency for Health Care
                Administration,” except as required in the Agency’s core contract, page six (6),
                unless prior written approval is obtained from the Agency.

              

              
                	
                        109.

                      	
                        Attachment
                          II, Medicaid Reform Health Plan Model Contract, Section
                          XVI., Terms and
                          Conditions, Item 0., Subcontracts, is hereby amended to
                          include sub-item
                          10. as follows: 

                      

              

              

              
                	
                         

                      	
                        10.

                      	
                        Provide
                          details about the following, as required by Section 6032
                          of the federal
                          Deficit Reduction Act of 2005: 

                      

              

              
                	
                         

                      	
                        (6)

                      	
                        the
                          False Claim Act; 

                      

              

              
                	
                         

                      	
                        (7)

                      	
                        the
                          penalties for submitting false claims and statements;
                          

                      

              

              
                	
                         

                      	
                        (8)

                      	
                        whistleblower
                          protections; 

                      

              

              
                	
                         

                      	
                        (9)

                      	
                        the
                          law’s role in preventing and detecting fraud, waste and abuse;
                          and
                          

                      

              

              
                	
                         

                      	
                        (10)

                      	
                        each
                          person’s responsibility relating to detection and prevention.
                          

                      

              

              

              
                	
                        110.

                      	
                        This
                          Amendment shall have an effective date of January 1, 2008,
                          or the date on
                          which both parties execute the Amendment, whichever is
                          later.
                          

                      

              

               

               

              
                AHCA
                  Contract No. FAR001, Amendment No. 7, Page 65 of
                  66

              

              
                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                
                  Healthease
                    of Florida, Inc. 

                  
                    Medicaid
                      HMO Reform Contract

                  

                

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

              

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

              

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

              

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

              

              IN
                WITNESS WHEREOF, the parties hereto have caused this sixty six (66)
                page
                Amendment (including all attachments) to be executed by their officials
                thereunto duly authorized.

              

              
                	
                        HEALTHEASE
                          OF FLORIDA, INC.

                      	
                        STATE
                          OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

                      
	
                        SIGNED
                          BY: /s/  Todd
                          S.
                          Farha 

                      	
                        SIGNED
                          BY:   /s/  Illegible  
                           

                      
	
                        NAME:  
                          Todd S. Farha

                      	
                            
                          (for)

                        NAME:  Andrew
                          C. Agwunobi,
                          M.D.

                      
	
                        TITLE:   President
&
CEO

                      	
                        TITLE:  Secretary

                      
	
                        DATE:  1/2/08

                      	
                        DATE:  1/3/08

                      

              

              

              

              REMAINDER
                OF PAGE INTENTIONALLY LEFT BLANK

               

               

              
                AHCA
                  Contract No. FAR001, Amendment No. 7, Page 66 of
                  66

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