Document:

ahcafa904amend3.htm

Back to Form 10-Q

EXHIBIT 10.11

 

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 	 

                                                                                 

AHCA CONTRACT NO. FA904 

AMENDMENT NO. 3

 

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 III., Item C, Contract Managers, sub-item 1., the Agency's Contract Manager's telephone number is hereby amended to now read as follows:

 

        (850) 412-4067

 

	
2.

	
Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms, Item A., Definitions, the following definitions are hereby amended to now read as follows:

 

Catastrophic Component Threshold - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The point at which the cost of covered services, based on Medicaid fee-for-service payment levels, reaches $50,000 for an enrollee in a Contract year. For a Health Plan that accepts the comprehensive capitation rate only, the Agency begins reimbursing the Health Plan for the cost of covered services received by the enrollee for the remainder of the Contract year. This reimbursement is based on a percentage of Medicaid fee-for-service payment levels.

 

Comprehensive Component - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The amount of financial risk assumed by a Health Plan to provide covered service up to $50,000 per enrollee based on Medicaid fee-for-service payment levels.

 

	
3.

	
Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 3.a.(6) is hereby amended to now read as follows:

 

	
        (6)

	
A request to update the enrollee's name, address (home and mailing), county of residence, and telephone number, and include information on how to update this information with the health plan and through DCF and/or the Social Security Administration;

 

	
4.

	
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item A., Quality Improvement, is hereby amended to include sub-item 3.c.(6) as follows:

 

	
        (6)

	
The Agency may offer incentives to high-performing Health Plans. The Agency will notify the Health Plan annually on or before December 31 of the incentives that will be offered for the following calendar year. Incentives may be awarded to all high-performing Health Plans or may be offered on a competitive basis. Incentives may include, but are not limited to, quality designations, quality awards, and enhanced auto-assignments. The Agency, at its discretion, may disqualify a Health Plan for any reason the Agency deems appropriate including, but not limited to, Health Plans that received a monetary sanction for performance measures or any other sanctionable offense.

 

	
5.

	
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item B., Utilization Management (UM), sub-item 2., Care Management, is hereby deleted in its entirety and replaced as follows:

 

The Health Plan shall be responsible for the management and continuity of medical care for all enrollees. The Health Plan shall maintain written case management and continuity of care protocols that include the following minimum functions:

 

	
        a.

	
Appropriate referral and scheduling assistance for enrollees needing specialty health care or transportation services, including those identified through CHCUP screenings;

 

AHCA Contract No. FA904, Amendment No. 3, Page 1 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	
        b.

	
Determination of the need for non-covered services and referral of the enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) with assistance, as needed, by the area Medicaid office;

 

	
        c.

	
Case management follow-up services for children/adolescents whom the Health Plan identifies through blood screenings as having abnormal levels of lead;

 

	
        d.

	
A mechanism for direct access to specialists for enrollees identified as having special health care needs, as appropriate for their conditions and identified needs;

 

	
        e.

	
An outreach program and other strategies for identifying every pregnant enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating providers to notify the plan of any Medicaid enrollee who is identified as being pregnant;

 

	
        f.

	
Documentation of referral services in enrollee medical records, including reports resulting from the referral;

 

	
        g.

	
Monitoring of enrollees with ongoing medical conditions and coordination of services for high utilizers to address the following, as appropriate: acting as a liaison between the enrollee and providers, ensuring the enrollee is receiving routine medical care, ensuring the enrollee has adequate support at home, assisting enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the enrollee in developing community resources to manage a medical condition;

 

	
        h.

	
Documentation of emergency care encounters in enrollee medical records with appropriate medically indicated follow-up;

 

	
        i.

	
Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate;

 

	
        j.

	
Sharing with other Health Plans serving the enrollee the results of its identification and assessment of any enrollee with special health care needs so that those activities need not be duplicated;

 

	
        k.

	
Ensuring that in the process of coordinating care, each enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

 

	
6.

	
Attachment II, Core Contract Provisions, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, Table 2-A, Summary of Submission Requirements, is hereby deleted in its entirety and replaced with the following Table 2-B, Revised Summary of Submission Requirements. All references in the Contract to Table 2-A shall hereinafter refer to Table 2-B.

 

TABLE 2-B

 

REVISED SUMMARY OF SUBMISSION REQUIREMENTS

 

 

2.     Other Health Plan submissions (not in Table 1-A) required by the Agency are as follows:

 

AHCA Contract No. FA904, Amendment No. 3, Page 2 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Attachment I, Section B., Item 3.a.

	

Increase in enrollment levels

	

Capitated Health Plans; FFS PSNs; CCC

	

Before increases occur

	

BMHC and HSD

	

Attachment I, Section D., Item 3.b.

	

Changes to optional or expanded services

	

FFS PSNs; CCC

	

Annually, by June 15th

	

HSD

	

Attachment I, Section D., Item 3.c.

	

Changes to optional or expanded services

	

Capitated Health Plans

	

    Annually, by June 15th

	

HSD

	

 

Subsequent references are to Attachment II and its Exhibits

	

Section II, Item D.4.

	

Policies, procedures, model provider agreements & amendments, subcontracts, All materials related to Contract for distribution to enrollees, providers,

public

	

All

	

Before beginning use; whenever changes occur

	

BMHC

	

Section II, Item D.4.a.

	

Written materials

	

All

	

Forty-five (45) calendar days before effective date

	

BMHC

	

Section II, Item D.4.b

	

Written notice of change to enrollees

	

All

	

Thirty (30) calendar days before effective date

	

Enrollees affected by change

	

Section II, Item D.6.

	

Enrollee materials, PDL, provider & enrollee handbooks

	

All

	

Available on Health Plan's web site without log-in

	

Plan web site

	

    Section III, Item B.3.c.(l)

	

Enrollee pregnancy

	

All

	

Upon confirmation

	

DCF & MPI

	

Section III, Item B.3.c.(3)

	

Unborn activation notice

	

All

	

Presentation for delivery

	

DCF & MPI

	

Section III, Item B.3.d.

	

Birth information if no unborn activation

	

All

	

Upon delivery

	

DCF

	

Section III, Item C.4.b.

	

Involuntary disenrollment request

	

All

	

Forty-five (45) calendar days before effective date

	

BMHC

	

Section III, Item C.4.e.

	

Notice that Health Plan is requesting disenrollment in next Contract month

	

All

	

Before effective date

	

Enrollee affected

 

AHCA Contract No. FA904, Amendment No. 3, Page 3 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section IV, Item A.1.e.

	

Notice of reinstatement of enrollee

	

All

	

By 1st calendar day of month after learning of reinstatement or within five (5) calendar days from receipt of enrollment file, whichever is later

	

Person being reinstated

	

Section IV, Item A.2.a. and Item A. 6.a.(17); Section VIII, Item A.4.

	

How to get Health Plan information in alternative formats

	

All

	

Include in cultural competency plan and enrollee handbook, and upon request

	

Enrollees &

potential enrollees

	

Section IV, Item A.2.c.

	

Right to get information about Health Plan

	

All

	

Annually

	

Enrollees

	

Section IV, Item A.7.c.

	

Provider directory online file

	

All

	

Update monthly & submit attestation

	

BMHC

	

Section IV, Item A.9.a.

	

Enrollee assessments

	

All

	

Within thirty (30) calendar days of enrollment notify about pregnancy screening

	

Enrollees

	

Section IV, Item A.9.c.

	

Enrollees more than 2 months behind in periodicity screening

	

All

	

Contact twice, if needed

	

Enrollees who

meet criteria

	

Section IV, Item A.11.f.

	

Toll-free help line performance standards

	

All

	

Get approval before beginning operation

	

BMHC

	

Section IV, Item A.12. and Item A.,6.a.(17); Section VIII, Item A.4.

	

How to access translation services

	

All

	

Include in cultural competence plan and enrollee handbook

	

Enrollees

	

Section IV, Item A.14.a.

	

Incentive program

	

All

	

Get approval before offering

	

BMHC

	

Section IV, Item A.14.g.

	

Pre-natal care programs

	

All

	

Before implementation

	

BMHC

	

Section IV, Item A.17.c

	

Notice of change in participation in redetermination notices

	

All

	

If change in participation, annually, by June 1st

	

BMHC

	

Section IV, Item A.17.c.(1)

	

Redetermination policies & procedures

	

All

	

When Health Plan agrees to  participate

	

BMHC

	

Section IV, Item A.17.c.(1)(a)

	

Notice in writing to discontinue Medicaid redetermination date data use

	

All

	

Thirty (30) calendar days before stopping

	

BMHC

 

AHCA Contract No. FA904, Amendment No. 3, Page 4 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section IV, Item B.3.c.

	

Member services phone script responding to community outreach calls and outreach materials

	

All

	

Before use

	

BMHC

	

Section IV, Item B.4.c.

	

In case of force majeure, notice of participation in health fair or other public event

	

All

	

By day of event

	

BMHC

	

Section IV, Item B.6.f.

	

Report of staff or community outreach rep. violations

	

All

	

Within fifteen (15) calendar days of knowledge

	

BMHC

	

Section V, Item C.1.

	

Written details of expanded services

	

All

	

Before implementation

	

HSD

	

Section V, Item F.

	

Decision to not offer a service on moral/religious grounds

	

All

	

One-hundred and twenty (120) calendar days before implementation

 

Thirty (30) calendar days before implementation

	

BMHC

 

Enrollees

 

 

 

	

Section V, Item H.10.b.2.

	

UNOS form & disenrollment request for specified transplants

	

All

	

When enrollee listed

	

BMHC

	

Section V, Item H.14.e.

	

Attestation that the Health Plan has

advised providers to enroll in VFC program

	

All

	

Annually, by October 1st

	

BMHC

	

Section V, Item H.16.a.(4)

	

PDL update

	

All

	

Annually, by October 1st.

 

Thirty (30) calendar days written notice of change.

	

BMHC and Bureau of Medicaid Pharmacy Services

	

Section VII, Item A.2.

	

Capacity to provide

covered services

	

All

	

Before taking enrollment

	

BMHC

	

Section VII, Item C.1.

	

Request for initial or expansion review

	

All

	

When requesting initial enrollment or expansion into a county.

	

BMHC and HSD

 

AHCA Contract No. FA904, Amendment No. 3, Page 5 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section VII, Item C.2.

	

Compliance with access requirements following significant changes in service area or new populations

	

All

	

Before expansion

	

BMHC and HSD

	

Section VII, Item C.3.

	

Significant network changes

	

All

	

Within seven (7) business days

	

BMHC

	

Section VII, Item C.5.

	

When PCP leaves network

	

All

	

Within fifteen (15) calendar days of knowledge.  A copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after receipt of the PCP termination notice.

	

BMHC & affected enrollees

	

Section VII, Item D.2.jj.

	

Waiver of provider agreement indemnifying clause

	

All

	

Approval before use

	

BMHC

	

Section VII, Item E.3.

	

Notice of terminated providers due to imminent danger/impairment

	

All

	

Immediate

	

BMHC and Provider

	

Section VII, Item E.4.

	

Termination or suspension of providers; for "for cause" terminations, include reasons for termination

	

All

	

Sixty (60) calendar days before termination effective date

	

BMHC, affected enrollees, & provider

	

Section VIII, Item A.1.b.

	

Written Quality Improvement Plan

	

All

	

Within thirty (30) calendar days of initial Contract execution; Thereafter, Annually by April 1st

	

BMHC

	

Section VIII, Item A.3.a.(6)

	

Measurement periods and methodologies

	

All

	

Any new PIPs before initiation

	

BMHC

	

Section VIII, Item A.3.a.(7)

	

Proposal for each planned PIP

	

All

	

Ninety (90) calendar days after Contract execution; Thereafter, Annually by June 1st

	

BMHC

	

Section VIII, Item A.3.c.(1)

	

Performance measure data and auditor certification

	

All

	

Annually by July 1st

	

BMQM

 

AHCA Contract No. FA904, Amendment No. 3, Page 6 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section VIII, Item A.3.c.(4)

	

Performance measure action plan

	

All

	

Within thirty (30) calendar days of determination of unacceptable performance

	

BMQM

	

Section VIII, Item A.3.e.(7)

	

Written strategies for medical record review

	

All

	

Before use

	

BMHC

	

Section VIII, Item  B.1.a.(4)(a)

	

Service authorization protocols & any changes

	

All

	

Before use

	

BMHC

	

Section VIII, Item B.4.

	

Changes to UM component

	

All

	

Thirty (30) calendar days before effective date

	

BMHC

	

Section IX, Item A.8.

	

Complaint log

	

All

	

Upon request

	

BMHC

	

Section X, Item B.2.

	

Changes in staffing

	

All

	

Five (5) business days of any change

	

BMHC & HSD

	

Section X Item B.2.b.

	

Full-Time Administrator

	

All

	

Before designating duties of any other position

	

BMHC

	

Section X, Item D. 3. a.

	

Reform and non-Reform historical encounter data for all typical and atypical services

	

All

	

According to Agency-approved schedules and no later than 10/31/09

	

MEDS team & Fiscal Agent

	

Section X, Item D.3.b.

	

Encounter data for all typical and atypical services

	

All

	

Within sixty (60) calendar days following end of month in which Health Plan paid claims for services, and as specified in MEDS Companion Guide

	

MEDS Team & Agency Fiscal Agent

	

Section X, Item E.4.

	

Fraud & abuse compliance plan & policies & procedures

	

All

	

Before implementation

	

MPI

	

Section XI, Item D.4.a.

	

Any problem that threatens system performance

	

All

	

Within one (1) hour

	

Applicable Agency staff

	

Section XI, Item D.8.a.

	

Business Continuity-Disaster Recovery Plan

	

All

	

Before beginning operation and certification if plan is unchanged by April 30 annually thereafter;

 

Changes within ten (10) calendar days of change

	

BMHC

 

AHCA Contract No. FA904, Amendment No. 3, Page 7 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section XI, Item E.1.

	

System changes

	

All

	

Ninety (90) calendar days before change 

	

HSD

	

Section XIV, Item A.1.(a)

	

Corrective action plan

 

	

All

	

Within ten (10) business days of notice of violation or non-compliance with Contract

	

Agency Bureau sending violation notice

	

Section XIV, Item A.1.(b)

	

Performance measure action plan

	

All

	

Within thirty (30) calendar days of notice of failure to meet a performance standard

	

Agency Bureau sending violation notice

	

Section XV, Item C.

	

Proof of working capital

	

All

	

Before enrollment

	

BMHC

	

Section XV, Item G.2.

	

Physician incentive plan

	

All

	

Written description before use

	

BMHC

	

Section XV, Item H.

	

Third party coverage identified

	

All

	

As soon as known

	

Medicaid Third Party Liability Vendor

	

Section XV, Item I.

	

Proof of fidelity bond coverage

	

All

	

Within sixty (60) calendar days of Contract execution & before delivering health care

	

HSD Contract manager

	

Section XVI, Item C.1.

	

Request for assignment or transfer of contract in approved merger/acquisition

	

All

	

Ninety (90) days before effective date

	

HSD

	

Section XVI, Item M.

	

Use of "Medicaid" or "AHCA"

	

All

	

Before use

	

BMHC

	

Section XVI, Item O.

	

All subcontracts for Agency approval

	

All

	

Before effective date

	

BMHC

	

Section XVI, Item O.1.f.

	

Subcontract monitoring schedule

	

All

	

Annually, by December 1

	

BMHC

	

Section XVI, Item V.1.

	

Ownership & management disclosure forms

	

All

	

With initial application; and then annually by September 1

	

HSD - for initial application; BMHC & HSD for annual

	

Section XVI, Item V.1.

	

Changes in ownership & control

	

All

	

Within five (5) calendar days of knowledge & sixty (60) days before effective date

	

BMHC & HSD

	

Section XVI, Item V.4.

	

Fingerprints for principals

	

All

	

Before Contract execution; Thereafter, Annually by September 1

	

HSD

 

AHCA Contract No. FA904, Amendment No. 3, Page 8 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section XVI, Item V.4.c.

	

Fingerprints of newly hired principals

	

All

	

Within thirty (30) calendar days of hire date

	

HSD

	

Section XVI, Item V.5.

	

Information about offenses listed in 435.03

	

All

	

Within five (5) business days of

knowledge

	

HSD

	

Section XVI, Item V.6.

	

Corrective action plan related to principals committing offenses under 435.03

	

All

	

As prescribed by the Agency

	

HSD

	

Section XVI, Item Y.

	

General insurance policy declaration pages

	

All except CCC

	

Annually upon renewal

	

BMHC

	

Section XVI, Item Z.

	

Workers' compensation insurance declaration page

	

All except CCC

	

Annually upon renewal

	

BMHC

	

Section XVI, Item BB.

	

Emergency Management Plan

	

All

	

Before beginning operation and by May 31 annually thereafter

	

BMHC

	

Exhibit 2, Section II, Item D.4.c.

	

Policies & procedures for screening for clinical eligibility & any changes to them

	

CCC

	

Before implementation

	

BMHC

	

Exhibit 3, Section III, Item C.5.

	

Disenrollment notice

	

CCC

	

Get template approved before use

 

At least two (2) months before anticipated effective date of involuntary disenrollment

	

BMHC

 

Enrollee

 

 

	

Exhibit 5, Section V, Item A.6.

	

Letters about exhaustion of benefits under customized benefit package

	

Reform capitated Health Plans

	

Before use

	

BMHC

	

Exhibit 5, Section V, Item H.20.g.

	

Transportation subcontract

	

NR HMO offering transportation; Reform Health Plans

	

Before execution

	

BMHC

	

Exhibit 5, Section V, Item H.20.h.

	

Transportation policies & procedures

	

NR HMO offering transportation; Reform Health Plans

	

Before use

	

BMHC

 

AHCA Contract No. FA904, Amendment No. 3, Page 9 of 14

  

  

  

	 WellCare of Florida, Inc. 	
 

 

	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Exhibit 5, Section V, Item H.20.i.

	

Transportation adverse incidents

	

NR HMO offering transporation; Reform Health Plans

	

Within two (2) business days of the occurrence

	

BMHC

	

Exhibit 5, Section V, Item H.20.i.

	

Transportation suspected fraud

	

NR HMO offering transportation; Reform Health Plans

	

Immediately upon identification

	

MPI

	

Exhibit 5, Section V, Item H.20.p.

	

Performance measures

	

NR HMO offering transportation; Reform Health Plans

	

Annually report by July 1

	

BMQM

	

Exhibit 5, Section V, Item H.20.q. & r.

	

Attestation that Health Plan complies with transportation policies & procedures & drivers pass background checks & meet qualifications

	

NR HMO offering transportation; Reform Health Plans

	

Annually by January 1

	

BMHC

	

Exhibit 6, Item A.3.

	

Review & approval of behavioral health services staff & subcontractors for licensure compliance

	

Reform Health Plans & NR HMOs

	

Before providing services

	

BMHC

	

Exhibit 6, Item B.9.

	

Model agreement with community mental health centers

	

Reform Health Plans & NR HMOs

	

Before agreement is executed

	

BMHC

	

Exhibit 6, Item C.3.e.

	

Denied appeals from providers for emergency services claims

	

Plans covering behavioral health

	

Within ten (10) days after Health Plan's final denial

	

BMHC

	

Exhibit 6, Item C.5.a.(3)

	

Medical necessity criteria for community mental health services

	

Plans covering behavioral health

	

Before use and before changes implemented

	

BMHC

	

Exhibit 6, Item L.2.

	

MBHO staff  psychiatrist and model contracts for each specialty type

	

Plans covering behavioral health

	

Before execution

	

BMHC

	

Exhibit 6, Item M.

	

Optional services

	

Plans covering behavioral health

	

Before offering

	

BMHC

	

Exhibit 6, Item R.3.a.

	

Schedule for administrative and program monitoring and clinical record review

	

Plans covering behavioral health

	

Annually by July 1

	

BMHC

	

Exhibit 8, Section VIII, Item B.5.

	

Substitute disease management initiatives

	

CCC

	

Within sixty (60) calendar days of Contract execution

	

BMHC

 

AHCA Contract No. FA904, Amendment No. 3, Page 10 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Exhibit 8, Section VIII, Item A.3.f.

	

Provider satisfaction survey

	

All Reform Health Plans

	

By end of 8th month of Contract

	

BMHC

	

Exhibit 8, Section VIII, Item B.5.b.

	

Policies and procedures and program descriptions for each disease management program

	

All Reform Health Plans

	

Annually, by April 1

	

BMHC

	

Exhibit 8, Section VIII, Item B. 1. e. (5)

	

Caseload maximums for case managers

	

HIV/AIDS specialty plan

	

Before providing services

	

BMHC

	

Exhibit 10, Section X, Item C. 5. a.

	

Discrepancies in ERV

	

FFS Health Plans; CCC

	

Within ten (10) business days of discovery

	

HSD analyst

	

Exhibit 15, Section XV, Item A. 1. a.

	

Plan for transition from FFS to prepaid capitated plan

	

FFS PSNs; CCC

	

Last calendar day of 24th month of

Health Plan's initial Reform operation

	

HSD

	

Exhibit 15, Section XV, Item A. 1. b.

	

Conversion application to capitated Health

Plan

	

FFS PSNs; CCC

 

	

By August 1 of 4th year of Reform operation

	

HSD

	

Exhibit 15, Section XV, Item I.

	

Proof of coverage for any non-government subcontractor

	

CCC

	

Within sixty (60) calendar days of execution and before delivery of care

	

BMHC

NR HMO = Non-Reform health maintenance organization, includes Health Plans covering

Frail/Elderly Program services as specified in Attachment I

Ref HMO = Reform health maintenance organization

Ref Cap PSN = Reform capitated provider service network

Ref FFS PSN = Reform Fee-for-Service Provider Service Network

NR Cap PSN = Non-Reform Capitated Provider Service Network

NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network

CCC = Specialty plan for children with chronic conditions

HIV/AIDS = Specialty plan for recipients living with HIV/AIDS

 

	
7.

	
Attachment II, Core Contract Provisions, Section XIII, Method of Payment, the third line of the title, is hereby amended to now read as follows:

 

See Attachment II, Exhibit 13

 

	
8.

	
Attachment II, Core Contract Provisions, Section XIV, Sanctions, Item G., is hereby included as follows:

 

	
  

	
G.   Performance Measure Sanctions

           

	
  

	
The Agency shall sanction the Health Plan for failure to achieve minimum scores on HEDIS performance measures after the first year of poor performance. The Agency may impose monetary sanctions as described below in the event that the PMAP fails to result in performance consistent with the Agency's expected minimum standards, as specified in sub-items 2.a. and 2.b. of this item.

 

AHCA Contract No. FA904, Amendment No. 3, Page 11 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

The Agency shall assign performance measures a point value that correlates to the National Committee for Quality Assurance HEDIS National Means and Percentiles. The scores will be assigned according to the table below. Individual performance measures will be grouped and the scores averaged within each group.

 

	

PM Ranking

	

Score

	

>90th percentile

	

6

	

75th-89th percentile

	

5

	

60th-74th percentile

	

4

	

50th-59th percentile

	

3

	

25th- 49th percentile

	

2

	

10th,-24th percentile

	

1

	

<10th percentile

	

0

 

 

1.     PMAP Sanctions

 

The Health Plan shall complete a PMAP after the first year of poor performance as described in Attachment II, Section VIII, A.3.c.(5). If the PMAP fails to result in scores above the minimum performance standard, the Health Plan may be assessed monetary sanctions under this section.

 

2.     Monetary sanctions

 

	 	
  

	
a.   The Health Plan may receive a monetary sanction of up to $10,000 for each performance measure group where the group score is two (2) or lower but above zero (0). Performance measure groups are as follows:

 

  (1)      Mental Health and Substance Abuse

 

                        (a)      Follow-Up Hospitalization After Mental Illness (7 day)

 

                        (b)      Antidepressant Medication Management

 

                        (c)      Follow-Up Care for Children Prescribed ADHD Medication

 

  (2)      Well-Child

 

(a)      Childhood Immunization Status

 

(b)      Well-Child Visits in the First 15 Months of Life (6 or more)

 

(c)      Well-Child Visits 3rd, 4th, 5th, and 6th Years of Life

 

(d)      Adolescent Well-Care Visits

(e)      Lead Screening in Children

 

(3)    Other Preventive Care

 

(a)      Breast Cancer Screening

 

(b)      Cervical Cancer Screening

 

(c)      Adults' Access to Preventive/Ambulatory Health Services

(d)      Annual Dental Visits

 

AHCA Contract No. FA904, Amendment No. 3, Page 12 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

(e) BMI Assessment

 

(4)      Prenatal/Postpartum

  (a)      Prenatal and Postpartum Care (includes two (2) measures)

  (b)      Frequency of Ongoing Prenatal Care

 

(5)      Chronic Care

 

   (a)      Use of Appropriate Medications for People with Asthma

 

   (b)      Controlling High Blood Pressure

   (c)      Persistence of Beta-Blocker Treatment After a Heart Attack

 

(6)      Diabetes - Comprehensive Diabetes Care (excluding the blood pressure submeasures)

 

	 	
  b.

	
If the Health Plan receives a score of zero (0) on any of the individual measures in the following performance measure groups: Mental Health and Substance Abuse, Chronic Care, or Diabetes; the Health Plan may be sanctioned for individual performance measures, which will result in a sanction of $500 for each member of the denominator not present in the numerator of the performance measure, as defined in the HEDIS manual. If the Health Plan fails to improve these performance measures in subsequent years, the Agency shall impose a sanction of $1,000 per member.

 

	 	
  c.

	
The Agency may amend the performance measure groups with sixty (60) days' advance notice.

 

	
3.

	
 Implementation - Performance measure sanctions will be implemented following the phase-in schedule below.

 

      a.      2010 Submission - PMAP assessed for all measures scored at two (2) or below.

  b.      2011 Submission - Individual measure sanctions as described in 2.b. above.

        

	
      c. 

	
2012 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 40th percentile

  

	
      d.  

	
2013 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 50th percentile

 

	
 9.

	
     Attachment II, Core  Contract  Provisions,  Section XV,   Financial  Requirements,  Item  D.,  Surplus Requirement, the first sentence, is hereby amended to now read as follows:

 

 In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at all times in the form of cash, investments that mature in less than 180 calendar days and allowable as admitted assets by the Department of Financial Services, and restricted funds of deposits controlled by the Agency (including the Health Plan's insolvency protection account) or the Department of Financial Services, a surplus amount equal to the greater of $1.5 million, ten percent (10%) of total liabilities, or two percent (2%) of the annualized amount of the Health Plan's prepaid revenues.

 

AHCA Contract No. FA904, Amendment No. 3, Page 13 of 14

  

  

  

	 WellCare of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	 10.	
 

	
 Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O., Subcontracts, sub-item I.e., is hereby deleted in its entirety and replaced with the following:

 

	 	
c. 

	
The Agency encourages use of minority business enterprise subcontractors. See Attachment II, Section VII, Provider Network, Item D., Provider Contract Requirements, for provisions and requirements specific to provider contracts. See Attachment II, Section XVI, Terms and Conditions, Item W., Minority Recruitment and Retention Plan, for other minority recruitment and retention plan requirements. The Health Plan shall provide a monthly Minority Participation Report (see Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the HSD designated minority participation report contact, summarizing the business it does with minority subcontractors or vendors.

 

	
 11.

	
Attachment II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item P., Community Behavioral Health Services Annual 80/20 Expenditure Report (HMOs serving non-Reform populations only), the third sentence is hereby amended to now read as follows:

 

In the event the Health Plan expends less than eighty percent (80%) of the capitation rate, the Health Plan shall return the difference to the Agency no later than April 1st of each Contract year.

 

	
 12.

	
Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral Health Reporting Requirements, sub-item 5., the second sentence is hereby amended to now read as follows:

 

For Health Plans operating less than one (1) year, the Health Plan shall submit this report to BMHC quarterly, forty-five (45) calendar days after the end of the quarter being reported.

 

Unless otherwise stated, this Amendment is effective upon execution by both parties or May 1, 2010 (whichever is later).

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 fourteen (14) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.

	
WELLCARE OF FLORIDA, INC.

D/B/A/ STAYWELL HEALTH PLAN OF

FLORIDA

	  	
STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

	
SIGNED

BY:

	  	
 

/s/ Thomas L. Tran

	  	
SIGNED

BY:

	  	
 

/s/ Thomas W. Arnold

	
NAME:

	  	
Thomas Tran

	  	
NAME:

	  	
Thomas W. Arnold

	
TITLE:

	  	
Chief Financial Officer

	  	
TITLE:

	  	
Secretary

	
DATE:

	  	
April 29, 2010

	  	
DATE:

	  	
5/3/10

 

AHCA Contract No. FA904, Amendment No. 3, Page 14 of 14ahcafa905amend3.htm

Back to Form 10-Q

EXHIBIT 10.12

 

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

                                                               

AHCA CONTRACT NO. FA905 

AMENDMENT NO. 3

 

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," or "Health Plan," is hereby amended as follows:

 

	
1.

	
Standard Contract, Section III., Item C, Contract Managers, sub-item 1., the Agency's Contract Manager's telephone number is hereby amended to now read as follows:

 

       (850) 412-4067

 

	
2.

	
Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms, Item A., Definitions, the following definitions are hereby amended to now read as follows:

 

Catastrophic Component Threshold - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The point at which the cost of covered services, based on Medicaid fee-for-service payment levels, reaches $50,000 for an enrollee in a Contract year. For a Health Plan that accepts the comprehensive capitation rate only, the Agency begins reimbursing the Health Plan for the cost of covered services received by the enrollee for the remainder of the Contract year. This reimbursement is based on a percentage of Medicaid fee-for-service payment levels.

 

Comprehensive Component - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The amount of financial risk assumed by a Health Plan to provide covered service up to $50,000 per enrollee based on Medicaid fee-for-service payment levels.

 

	
3.

	
Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 3.a.(6) is hereby amended to now read as follows:

 

	
        (6)

	
A request to update the enrollee's name, address (home and mailing), county of residence, and telephone number, and include information on how to update this information with the health plan and through DCF and/or the Social Security Administration;

 

	
4.

	
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item A., Quality Improvement, is hereby amended to include sub-item 3.c.(6) as follows:

 

	
        (6)

	
The Agency may offer incentives to high-performing Health Plans. The Agency will notify the Health Plan annually on or before December 31 of the incentives that will be offered for the following calendar year. Incentives may be awarded to all high-performing Health Plans or may be offered on a competitive basis. Incentives may include, but are not limited to, quality designations, quality awards, and enhanced auto-assignments. The Agency, at its discretion, may disqualify a Health Plan for any reason the Agency deems appropriate including, but not limited to, Health Plans that received a monetary sanction for performance measures or any other sanctionable offense.

 

	
5.

	
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item B., Utilization Management (UM), sub-item 2., Care Management, is hereby deleted in its entirety and replaced as follows:

 

The Health Plan shall be responsible for the management and continuity of medical care for all enrollees. The Health Plan shall maintain written case management and continuity of care protocols that include the following minimum functions:

 

	
        a.

	
Appropriate referral and scheduling assistance for enrollees needing specialty health care or transportation services, including those identified through CHCUP screenings;

 

AHCA Contract No. FA905, Amendment No. 3, Page 1 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	
        b.

	
Determination of the need for non-covered services and referral of the enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) with assistance, as needed, by the area Medicaid office;

 

	
        c.

	
Case management follow-up services for children/adolescents whom the Health Plan identifies through blood screenings as having abnormal levels of lead;

 

	
        d.

	
A mechanism for direct access to specialists for enrollees identified as having special health care needs, as appropriate for their conditions and identified needs;

 

	
        e.

	
An outreach program and other strategies for identifying every pregnant enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating providers to notify the plan of any Medicaid enrollee who is identified as being pregnant;

 

	
        f.

	
Documentation of referral services in enrollee medical records, including reports resulting from the referral;

 

	
        g.

	
Monitoring of enrollees with ongoing medical conditions and coordination of services for high utilizers to address the following, as appropriate: acting as a liaison between the enrollee and providers, ensuring the enrollee is receiving routine medical care, ensuring the enrollee has adequate support at home, assisting enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the enrollee in developing community resources to manage a medical condition;

 

	
        h.

	
Documentation of emergency care encounters in enrollee medical records with appropriate medically indicated follow-up;

 

	
        i.

	
Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate;

 

	
        j.

	
Sharing with other Health Plans serving the enrollee the results of its identification and assessment of any enrollee with special health care needs so that those activities need not be duplicated;

 

	
        k.

	
Ensuring that in the process of coordinating care, each enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

 

	
6.

	
Attachment II, Core Contract Provisions, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, Table 2-A, Summary of Submission Requirements, is hereby deleted in its entirety and replaced with the following Table 2-B, Revised Summary of Submission Requirements. All references in the Contract to Table 2-A shall hereinafter refer to Table 2-B.

 

TABLE 2-B

 

REVISED SUMMARY OF SUBMISSION REQUIREMENTS

 

 

2.     Other Health Plan submissions (not in Table 1-A) required by the Agency are as follows:

 

 

AHCA Contract No. FA905, Amendment No. 3, Page 2 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Attachment I, Section B., Item 3.a.

	

Increase in enrollment levels

	

Capitated Health Plans; FFS PSNs; CCC

	

Before increases occur

	

BMHC and HSD

	

Attachment I, Section D., Item 3.b.

	

Changes to optional or expanded services

	

FFS PSNs; CCC

	

Annually, by June 15th

	

HSD

	

Attachment I, Section D., Item 3.c.

	

Changes to optional or expanded services

	

Capitated Health Plans

	

    Annually, by June 15th

	

HSD

	

 

Subsequent references are to Attachment II and its Exhibits

	

Section II, Item D.4.

	

Policies, procedures, model provider

agreements & amendments,

subcontracts, All materials related to

Contract for distribution to enrollees, providers, public

	

All

	

Before beginning use; whenever changes occur

	

BMHC

	

Section II, Item D.4.a.

	

Written materials

	

All

	

Forty-five (45) calendar days before effective date

	

BMHC

	

Section II, Item D.4.b

	

Written notice of change to enrollees

	

All

	

Thirty (30) calendar days before effective date

	

Enrollees affected by change

	

Section II, Item D.6.

	

Enrollee materials, PDL, provider & enrollee handbooks

	

All

	

Available on Health Plan's web site without log-in

	

Plan web site

	

    Section III, Item B.3.c.(l)

	

Enrollee pregnancy

	

All

	

Upon confirmation

	

DCF & MPI

	

Section III, Item B.3.c.(3)

	

Unborn activation notice

	

All

	

Presentation for delivery

	

DCF & MPI

	

Section III, Item B.3.d.

	

Birth information if no unborn activation

	

All

	

Upon delivery

	

DCF

	

Section III, Item C.4.b.

	

Involuntary disenrollment request

	

All

	

Forty-five (45) calendar days before effective date

	

BMHC

	

Section III, Item C.4.e.

	

Notice that Health Plan is requesting disenrollment in next Contract month

	

All

	

Before effective date

	

Enrollee affected

 

AHCA Contract No. FA905, Amendment No. 3, Page 3 of 14

  

  

  

	Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section IV, Item A.1.e.

	

Notice of reinstatement of enrollee

	

All

	

By 1st calendar day of month after learning of reinstatement or within five (5) calendar days from receipt of enrollment file, whichever is later

	

Person being reinstated

	

Section IV, Item A.2.a. and Item A. 6.a.(17); Section VIII, Item A.4.

	

How to get Health Plan information in alternative formats

	

All

	

Include in cultural competency plan and enrollee handbook, and upon request

	

Enrollees &

potential enrollees

	

Section IV, Item A.2.c.

	

Right to get information about Health Plan

	

All

	

Annually

	

Enrollees

	

Section IV, Item A.7.c.

	

Provider directory online file

	

All

	

Update monthly & submit attestation

	

BMHC

	

Section IV, Item A.9.a.

	

Enrollee assessments

	

All

	

Within thirty (30) calendar days of enrollment notify about pregnancy screening

	

Enrollees

	

Section IV, Item A.9.c.

	

Enrollees more than 2 months behind in periodicity screening

	

All

	

Contact twice, if needed

	

Enrollees who

meet criteria

	

Section IV, Item A.11.f.

	

Toll-free help line performance standards

	

All

	

Get approval before beginning operation

	

BMHC

	

Section IV, Item A.12. and Item A.,6.a.(17); Section VIII, Item A.4.

	

How to access translation services

	

All

	

Include in cultural competence plan and enrollee handbook

	

Enrollees

	

Section IV, Item A.14.a.

	

Incentive program

	

All

	

Get approval before offering

	

BMHC

	

Section IV, Item A.14.g.

	

Pre-natal care programs

	

All

	

Before implementation

	

BMHC

	

Section IV, Item A.17.c

	

Notice of change in participation in redetermination notices

	

All

	

If change in participation, annually, by June 1st

	

BMHC

	

Section IV, Item A.17.c.(1)

	

Redetermination policies & procedures

	

All

	

When Health Plan agrees to participate

	

BMHC

	

Section IV, Item A.17.c.(1)(a)

	

Notice in writing to discontinue Medicaid redetermination date data use

	

All

	

Thirty (30) calendar days before stopping

	

BMHC

 

AHCA Contract No. FA905, Amendment No. 3, Page 4 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section IV, Item B.3.c.

	

Member services phone script responding to community outreach calls and outreach materials

	

All

	

Before use

	

BMHC

	

Section IV, Item B.4.c.

	

In case of force majeure, notice of participation in health fair or other public event

	

All

	

By day of event

	

BMHC

	

Section IV, Item B.6.f.

	

Report of staff or community outreach rep. violations

	

All

	

Within fifteen (15) calendar days of knowledge

	

BMHC

	

Section V, Item C.1.

	

Written details of expanded services

	

All

	

Before implementation

	

HSD

	

Section V, Item F.

	

Decision to not offer a service on moral/religious

grounds

	

All

	

One-hundred and twenty (120) calendar days before implementation

 

Thirty (30) calendar days before implementation

	

BMHC

 

Enrollees

 

 

 

	

Section V, Item H.10.b.2.

	

UNOS form & disenrollment request for specified transplants

	

All

	

When enrollee listed

	

BMHC

	

Section V, Item H.14.e.

	

Attestation that the Health Plan has

advised providers to enroll in VFC program

	

All

	

Annually, by October 1st

	

BMHC

	

Section V, Item H.16.a.(4)

	

PDL update

	

All

	

Annually, by October 1st.

 

Thirty (30) calendar days written notice of change.

	

BMHC and Bureau of Medicaid Pharmacy Services

	

Section VII, Item A.2.

	

Capacity to provide

covered services

	

All

	

Before taking enrollment

	

BMHC

	

Section VII, Item C.1.

	

Request for initial or expansion review

	

All

	

When requesting initial enrollment or expansion into a county.

	

BMHC and HSD

 

AHCA Contract No. FA905, Amendment No. 3, Page 5 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section VII, Item C.2.

	

Compliance with access requirements following significant changes in service area or new populations

	

All

	

Before expansion

	

BMHC and HSD

	

Section VII, Item C.3.

	

Significant network changes

	

All

	

Within seven (7) business days

	

BMHC

	

Section VII, Item C.5.

	

When PCP leaves network

	

All

	

Within fifteen (15) calendar days of knowledge.  A copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after receipt of the PCP termination notice.

	

BMHC & affected enrollees

	

Section VII, Item D.2.jj.

	

Waiver of provider agreement indemnifying clause

	

All

	

Approval beforeuse

	

BMHC

	

Section VII, Item E.3.

	

Notice of terminated providers due to imminent danger/impairment

	

All

	

Immediate

	

BMHC and Provider

	

Section VII, Item E.4.

	

Termination or suspension of providers; for "for cause" terminations, include reasons for termination

	

All

	

Sixty (60) calendar days before termination effective date

	

BMHC, affected enrollees, & provider

	

Section VIII, Item A.1.b.

	

Written Quality Improvement Plan

	

All

	

Within thirty (30) calendar days of initial Contract execution; Thereafter, Annually by April 1st

	

BMHC

	

Section VIII, Item A.3.a.(6)

	

Measurement periods and methodologies

	

All

	

Any new PIPs before initiation

	

BMHC

	

Section VIII, Item A.3.a.(7)

	

Proposal for each planned PIP

	

All

	

Ninety (90) calendar days after Contract execution; Thereafter, Annually by June 1st

	

BMHC

	

Section VIII, Item A.3.c.(1)

	

Performance measure data and auditor certification

	

All

	

Annually by July 1st

	

BMQM

 

AHCA Contract No. FA905, Amendment No. 3, Page 6 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section VIII, Item A.3.c.(4)

	

Performance measure action plan

	

All

	

Within thirty (30) calendar days of determination of unacceptable performance

	

BMQM

	

Section VIII, Item A.3.e.(7)

	

Written strategies for medical record review

	

All

	

Before use

	

BMHC

	

Section VIII, Item  B.1.a.(4)(a)

	

Service authorization protocols & any changes

	

All

	

Before use

	

BMHC

	

Section VIII, Item B.4.

	

Changes to UM component

	

All

	

Thirty (30) calendar days before effective date

	

BMHC

	

Section IX, Item A.8.

	

Complaint log

	

All

	

Upon request

	

BMHC

	

Section X, Item B.2.

	

Changes in staffing

	

All

	

Five (5) business days of any change

	

BMHC & HSD

	

Section X Item B.2.b.

	

Full-Time Administrator

	

All

	

Before designating duties of any other position

	

BMHC

	

Section X, Item D. 3. a.

	

Reform and non-Reform historical encounter data for all typical and atypical services

	

All

	

According to Agency-approved schedules and no later than 10/31/09

	

MEDS team & Fiscal Agent

	

Section X, Item D.3.b.

	

Encounter data for all typical and atypical services

	

All

	

Within sixty (60) calendar days following end of month in which Health Plan paid claims for services, and as specified in MEDS Companion Guide

	

MEDS Team & Agency Fiscal Agent

	

Section X, Item E.4.

	

Fraud & abuse compliance plan & policies & procedures

	

All

	

Before implementation

	

MPI

	

Section XI, Item D.4.a.

	

Any problem that threatens system performance

	

All

	

Within one (1) hour

	

Applicable Agency staff

	

Section XI, Item D.8.a.

	

Business Continuity-Disaster Recovery Plan

	

All

	

Before beginning operation and certification if plan is unchanged by April 30 annually thereafter;

 

Changes within ten (10) calendar days of change

	

BMHC

 

AHCA Contract No. FA905, Amendment No. 3, Page 7 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section XI, Item E.1.

	

System changes

	

All

	

Ninety (90) calendar days before change 

	

HSD

	

Section XIV, Item A.1.(a)

	

Corrective action plan

 

	

All

	

Within ten (10) business days of notice of violation or non-compliance with Contract

	

Agency Bureau sending violation notice

	

Section XIV, Item A.1.(b)

	

Performance measure action plan

	

All

	

Within thirty (30) calendar days of notice of failure to meet a performance standard

	

Agency Bureau sending violation notice

	

Section XV, Item C.

	

Proof of working capital

	

All

	

Before enrollment

	

BMHC

	

Section XV, Item G.2.

	

Physician incentive plan

	

All

	

Written description before use

	

BMHC

	

Section XV, Item H.

	

Third party coverage identified

	

All

	

As soon as known

	

Medicaid Third Party Liability Vendor

	

Section XV, Item I.

	

Proof of fidelity bond coverage

	

All

	

Within sixty (60) calendar days of Contract execution & before delivering health care

	

HSD Contract manager

	

Section XVI, Item C.1.

	

Request for assignment or transfer of contract in approved merger/acquisition

	

All

	

Ninety (90) days before effective date

	

HSD

	

Section XVI, Item M.

	

Use of "Medicaid" or "AHCA"

	

All

	

Before use

	

BMHC

	

Section XVI, Item O.

	

All subcontracts for Agency approval

	

All

	

Before effective date

	

BMHC

	

Section XVI, Item O.1.f.

	

Subcontract monitoring schedule

	

All

	

Annually, by December 1

	

BMHC

	

Section XVI, Item V.1.

	

Ownership & management disclosure forms

	

All

	

With initial application; and then annually by September 1

	

HSD - for initial application; BMHC & HSD for annual

	

Section XVI, Item V.1.

	

Changes in ownership & control

	

All

	

Within five (5) calendar days of knowledge & sixty (60) days before effective date

	

BMHC & HSD

	

Section XVI, Item V.4.

	

Fingerprints for principals

	

All

	

Before Contract execution; Thereafter, Annually by September 1

	

HSD

AHCA Contract No. FA905, Amendment No. 3, Page 8 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Section XVI, Item V.4.c.

	

Fingerprints of newly hired principals

	

All

	

Within thirty (30) calendar days of hire date

	

HSD

	

Section XVI, Item V.5.

	

Information about offenses listed in 435.03

	

All

	

Within five (5) business days of

knowledge

	

HSD

	

Section XVI, Item V.6.

	

Corrective action plan related to principals committing offenses under 435.03

	

All

	

As prescribed by the Agency

	

HSD

	

Section XVI, Item Y.

	

General insurance policy declaration pages

	

All except CCC

	

Annually upon renewal

	

BMHC

	

Section XVI, Item Z.

	

Workers' compensation insurance declaration page

	

All except CCC

	

Annually upon renewal

	

BMHC

	

Section XVI, Item BB.

	

Emergency Management Plan

	

All

	

Before beginning operation and by May 31 annually thereafter

	

BMHC

	

Exhibit 2, Section II, Item D.4.c.

	

Policies & procedures for screening for clinical eligibility & any changes to them

	

CCC

	

Before implementation

	

BMHC

	

Exhibit 3, Section III, Item C.5.

	

Disenrollment notice

	

CCC

	

Get template approved before use

 

At least two (2) months before anticipated effective date of involuntary disenrollment

	

BMHC

 

Enrollee

 

 

	

Exhibit 5, Section V, Item A.6.

	

Letters about exhaustion of benefits under customized benefit package

	

Reform capitated Health Plans

	

Before use

	

BMHC

	

Exhibit 5, Section V, Item H.20.g.

	

Transportation subcontract

	

NR HMO offering transportation; Reform Health Plans

	

Before execution

	

BMHC

	

Exhibit 5, Section V, Item H.20.h.

	

Transportation policies & procedures

	

NR HMO offering transportation; Reform Health Plans

	

Before use

	

BMHC

 

AHCA Contract No. FA905, Amendment No. 3, Page 9 of 14

  

  

  

	 Healthease of Florida, Inc. 	
 

	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Exhibit 5, Section V, Item H.20.i.

	

Transportation adverse incidents

	

NR HMO offering transporation; Reform Health Plans

	

Within two (2) business days of the occurrence

	

BMHC

	

Exhibit 5, Section V, Item H.20.i.

	

Transportation suspected fraud

	

NR HMO offering transportation; Reform Health Plans

	

Immediately upon identification

	

MPI

	

Exhibit 5, Section V, Item H.20.p.

	

Performance measures

	

NR HMO offering transportation; Reform Health Plans

	

Annually report by July 1

	

BMQM

	

Exhibit 5, Section V, Item H.20.q. & r.

	

Attestation that Health Plan complies with transportation policies & procedures & drivers pass background checks & meet qualifications

	

NR HMO offering transportation; Reform Health Plans

	

Annually by January 1

	

BMHC

	

Exhibit 6, Item A.3.

	

Review & approval of behavioral health services staff & subcontractors for licensure compliance

	

Reform Health Plans & NR HMOs

	

Before providing services

	

BMHC

	

Exhibit 6, Item B.9.

	

Model agreement with community mental health centers

	

Reform Health Plans & NR HMOs

	

Before agreement is executed

	

BMHC

	

Exhibit 6, Item C.3.e.

	

Denied appeals from providers for emergency services claims

	

Plans covering behavioral health

	

Within ten (10) days after Health Plan's final denial

	

BMHC

	

Exhibit 6, Item C.5.a.(3)

	

Medical necessity criteria for community mental health services

	

Plans covering behavioral health

	

Before use and before changes implemented

	

BMHC

	

Exhibit 6, Item L.2.

	

MBHO staff  psychiatrist and model contracts for each specialty type

	

Plans covering behavioral health

	

Before execution

	

BMHC

	

Exhibit 6, Item M.

	

Optional services

	

Plans covering behavioral health

	

Before offering

	

BMHC

	

Exhibit 6, Item R.3.a.

	

Schedule for administrative and program monitoring and clinical record review

	

Plans covering behavioral health

	

Annually by July 1

	

BMHC

	

Exhibit 8, Section VIII, Item B.5.

	

Substitute disease management initiatives

	

CCC

	

Within sixty (60) calendar days of Contract execution

	

BMHC

 

AHCA Contract No. FA905, Amendment No. 3, Page 10 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

	

Contract Section

	

Submission

	

Plan Type

	

Frequency

	

Submit To

	

Exhibit 8, Section VIII, Item A.3.f.

	

Provider satisfaction survey

	

All Reform Health Plans

	

By end of 8th month of Contract

	

BMHC

	

Exhibit 8, Section VIII, Item B.5.b.

	

Policies and procedures and program descriptions for each disease management program

	

All Reform Health Plans

	

Annually, by April 1

	

BMHC

	

Exhibit 8, Section VIII, Item B. 1. e. (5)

	

Caseload maximums for case managers

	

HIV/AIDS specialty plan

	

Before providing services

	

BMHC

	

Exhibit 10, Section X, Item C. 5. a.

	

Discrepancies in ERV

	

FFS Health Plans; CCC

	

Within ten (10) business days of discovery

	

HSD analyst

	

Exhibit 15, Section XV, Item A. 1. a.

	

Plan for transition from FFS to prepaid capitated plan

	

FFS PSNs; CCC

	

Last calendar day of 24th month of Health Plan's initial Reform operation

	

HSD

	

Exhibit 15, Section XV, Item A. 1. b.

	

Conversion application to capitated Health

Plan

	

FFS PSNs; CCC

 

	

By August 1 of 4th year of Reform operation

	

HSD

	

Exhibit 15, Section XV, Item I.

	

Proof of coverage for any non-government subcontractor

	

CCC

	

Within sixty (60) calendar days of execution and before delivery of care

	

BMHC

NR HMO = Non-Reform health maintenance organization, includes Health Plans covering

Frail/Elderly Program services as specified in Attachment I

Ref HMO = Reform health maintenance organization

Ref Cap PSN = Reform capitated provider service network

Ref FFS PSN = Reform Fee-for-Service Provider Service Network

NR Cap PSN = Non-Reform Capitated Provider Service Network

NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network

CCC = Specialty plan for children with chronic conditions

HIV/AIDS = Specialty plan for recipients living with HIV/AIDS

 

	
7.

	
Attachment II, Core Contract Provisions, Section XIII, Method of Payment, the third line of the title, is hereby amended to now read as follows:

 

See Attachment II, Exhibit 13

 

	
8.

	
Attachment II, Core Contract Provisions, Section XIV, Sanctions, Item G., is hereby included as follows:

 

	
  

	
G.   Performance Measure Sanctions

             

	
  

	
The Agency shall sanction the Health Plan for failure to achieve minimum scores on HEDIS performance measures after the first year of poor performance. The Agency may impose monetary sanctions as described below in the event that the PMAP fails to result in performance consistent with the Agency's expected minimum standards, as specified in sub-items 2.a. and 2.b. of this item.

 

 

AHCA Contract No. FA905, Amendment No. 3, Page 11 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

The Agency shall assign performance measures a point value that correlates to the National Committee for Quality Assurance HEDIS National Means and Percentiles. The scores will be assigned according to the table below. Individual performance measures will be grouped and the scores averaged within each group.

 

	

PM Ranking

	

Score

	

>90th percentile

	

6

	

75th-89th percentile

	

5

	

60th-74th percentile

	

4

	

50th-59th percentile

	

3

	

25th- 49th percentile

	

2

	

10th,-24th percentile

	

1

	

<10th percentile

	

0

1.     PMAP Sanctions

 

The Health Plan shall complete a PMAP after the first year of poor performance as described in Attachment II, Section VIII, A.3.c.(5). If the PMAP fails to result in scores above the minimum performance standard, the Health Plan may be assessed monetary sanctions under this section.

 

2.     Monetary sanctions

 

	 	
  

	
a.   The Health Plan may receive a monetary sanction of up to $10,000 for each performance measure group where the group score is two (2) or lower but above zero (0). Performance measure groups are as follows:

 

  (1)      Mental Health and Substance Abuse

 

                        (a)      Follow-Up Hospitalization After Mental Illness (7 day)

 

                        (b)      Antidepressant Medication Management

 

                        (c)      Follow-Up Care for Children Prescribed ADHD Medication

 

  (2)      Well-Child

 

(a)      Childhood Immunization Status

 

(b)      Well-Child Visits in the First 15 Months of Life (6 or more)

 

(c)      Well-Child Visits 3rd, 4th, 5th, and 6th Years of Life

 

(d)      Adolescent Well-Care Visits

(e)      Lead Screening in Children

 

(3)    Other Preventive Care

 

(a)      Breast Cancer Screening

 

(b)      Cervical Cancer Screening

 

(c)      Adults' Access to Preventive/Ambulatory Health Services

(d)      Annual Dental Visits

 

(e)      BMI Assessment 

 

AHCA Contract No. FA905, Amendment No. 3, Page 12 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

(4)      Prenatal/Postpartum

  (a)      Prenatal and Postpartum Care (includes two (2) measures)

  (b)      Frequency of Ongoing Prenatal Care

 

(5)      Chronic Care

 

   (a)      Use of Appropriate Medications for People with Asthma

 

   (b)      Controlling High Blood Pressure

   (c)      Persistence of Beta-Blocker Treatment After a Heart Attack

 

(6)      Diabetes - Comprehensive Diabetes Care (excluding the blood pressure submeasures)

 

	 	
    b.

	
If the Health Plan receives a score of zero (0) on any of the individual measures in the following performance measure groups: Mental Health and Substance Abuse, Chronic Care, or Diabetes; the Health Plan may be sanctioned for individual performance measures, which will result in a sanction of $500 for each member of the denominator not present in the numerator of the performance measure, as defined in the HEDIS manual. If the Health Plan fails to improve these performance measures in subsequent years, the Agency shall impose a sanction of $1,000 per member.

 

	 	
    c.

	
The Agency may amend the performance measure groups with sixty (60) days' advance notice.

 

	
    3.

	
.   Implementation - Performance measure sanctions will be implemented following the phase-in schedule below.

 

    a.      2010 Submission - PMAP assessed for all measures scored at two (2) or below.

b.      2011 Submission - Individual measure sanctions as described in 2.b. above.

        

	
            c. 

	
2012 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 40th percentile

  

	
           d.  

	
2013 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 50th percentile

 

	
 9.

	
     Attachment II, Core  Contract  Provisions,  Section XV,   Financial  Requirements,  Item  D.,  Surplus Requirement, the first sentence, is hereby amended to now read as follows:

 

 In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at all times in the form of cash, investments that mature in less than 180 calendar days and allowable as admitted assets by the Department of Financial Services, and restricted funds of deposits controlled by the Agency (including the Health Plan's insolvency protection account) or the Department of Financial Services, a surplus amount equal to the greater of $1.5 million, ten percent (10%) of total liabilities, or two percent (2%) of the annualized amount of the Health Plan's prepaid revenues.

 

	10.	
 

	
 Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O., Subcontracts, sub-item I.e., is hereby deleted in its entirety and replaced with the following:

 

	 	
c..

	
The Agency encourages use of minority business enterprise subcontractors. See Attachment II, Section VII, Provider Network, Item D., Provider Contract Requirements, for provisions and requirements specific to provider contracts. See Attachment II, Section XVI, Terms and Conditions, 

 

AHCA Contract No. FA905, Amendment No. 3, Page 13 of 14

  

  

  

	 Healthease of Florida, Inc. 	 	 Medicaid HMO Non-Reform Contract

 

Item W., Minority Recruitment and Retention Plan, for other minority recruitment and retention plan requirements. The Health Plan shall provide a monthly Minority Participation Report (see Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the HSD designated minority participation report contact, summarizing the business it does with minority subcontractors or vendors.

 

	
 11.

	
Attachment II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item P., Community Behavioral Health Services Annual 80/20 Expenditure Report (HMOs serving non-Reform populations only), the third sentence is hereby amended to now read as follows:

 

In the event the Health Plan expends less than eighty percent (80%) of the capitation rate, the Health Plan shall return the difference to the Agency no later than April 1st of each Contract year.

 

	
 12..

	
Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral Health Reporting Requirements, sub-item 5., the second sentence is hereby amended to now read as follows:

 

For Health Plans operating less than one (1) year, the Health Plan shall submit this report to BMHC quarterly, forty-five (45) calendar days after the end of the quarter being reported.

 

Unless otherwise stated, this Amendment is effective upon execution by both parties or May 1, 2010 (whichever is later).

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 fourteen (14) 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/ Thomas L. Tran

	  	
SIGNED

BY:

	  	
 

/s/ Thomas W. Arnold

	
NAME:

	  	
Thomas Tran

	  	
NAME:

	  	
Thomas W. Arnold

	
TITLE:

	  	
Chief Financial Officer

	  	
TITLE:

	  	
Secretary

	
DATE:

	  	
April 29, 2010

	  	
DATE:

	  	
5/3/10

 

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

 

AHCA Contract No. FA905, Amendment No. 3, Page 14 of 14

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