Document:

exhibit10-1.htm

    
      
        

      

    

    Back
      to Form 8-K

    Exhibit
      10.1

    

    

    STATE
      OF FLORIDA

    DEPARTMENT
      OF ELDER AFFAIRS

    STANDARD
      CONTRACT

    LONG-TERM
      CARE COMMUNITY DIVERSION PILOT PROJECT

    

    THIS
      CONTRACT is entered into between the State of Florida, Department of
      Elder Affairs, hereinafter referred to as the "department", and Wellcare,
      hereinafter referred to as the "contractor".

    

    I.THE
      Contractor AGREES:

    

    A.To
      provide services according to the conditions specified in Attachment(s)
      I.

    

    B.Federal
      Laws and Regulations

    
      	
               

            	
              1.If
                this contract contains federal funds, the contractor shall comply
                with the
                provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other
                applicable regulations as specified in Attachment
                I.

            

    

    

    
      	
               

            	
              2.
                If this contract contains federal funding in excess of $100,000,
                the contractor shall comply with all applicable standards, orders,
                or
                regulations issued under Section 306 of the Clean Air Act, as amended
                (42
                U.S.C. 1857(h) et seq.), Section 508 of the Clean Water Act, as amended
                (33 U.S.C. 1368 et seq.), Executive Order 11738, and Environmental
                Protection Agency regulations (40 CFR Part 15).  The contractor
                shall report any violations of the above to the department within
                ten (10)
                days of the discovery of any such
                violation.

            

    

    

    
      	
               

            	
              3.If
                this contract contains federal funding the contractor must, prior
                to
                contract execution, complete the Certification Regarding Lobbying
                form,
                Attachment II.  If a Disclosure of Lobbying Activities form,
                Standard Form LLL, is required, it may be obtained from the contract
                manager.  All disclosure forms as required by the Certification
                Regarding Lobbying form must be completed and returned to the contract
                manager no more than 10 days after contract
                execution.

            

    

    

    
      	
               

            	
              4.The
                contractor shall comply with the provisions of the U.S. Department
                of
                Labor, Occupational Safety and Health Administration (OSHA) code,
                29 CFR,
                Part 1910.1030.

            

    

    

    
      	
               

            	
              5.If
                this contract contains federal funding in excess of $100,000, the
                contractor or vendor must, prior to contract execution, complete
                the
                Debarment, Suspension, Ineligibility and Voluntary Exclusion Certification
                form, Attachment III.

            

    

    

    
      	
               

            	
              6.Health
                Insurance Portability and Accountability Act of 1996 (HIPAA) Compliance:
                If the recipient will receive consumer’s protected health
                information as a result of this agreement, then the department recognizes
                that the department and recipient are "Business Associates" of each
                other
                under the terms of HIPAA and, as such, the department and recipient
                will
                enter into a Business Associate agreement separate from this
                agreement.

            

    

    

    C.Civil
      Rights Certification

    
      	
               

            	
              1.The
                contractor gives this assurance in consideration of and for the purpose
                of
                obtaining federal grants, loans, contracts (except contracts of insurance
                or guaranty), property, discounts, or other federal financial assistance
                to programs or activities receiving or benefiting from
                federal

            

    

     

    
      
        
        

      

      
        1

        
          

        

      

      
        
        

      

    

    
      	
               

            	
              financial
                assistance.  The contractor agrees to complete the Civil Rights
                Compliance Questionnaire, DOEA Form 101 A and B, if services are
                provided
                to consumers and if fifteen (15) or more persons are employed. For
                contractors employing less than 15 persons, the department requests
                completion of the Civil Rights Compliance Questionnaire, in accordance
                with the Governor's One Florida Initiative, Executive Order
                99-281.

            

    

    

    
      	
               

            	
              2.The
                contractor assures that it will comply
                with:

            

    

    
      	
               

            	
              a.Title
                VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
                seq., which prohibits discrimination on the basis of race, color,
                or
                national origin in programs and activities receiving or benefiting
                from
                federal financial assistance.

            

    

    

    
      	
               

            	
              b.Section
                504 of the Rehabilitation Act of 1973, as amended,
                29 U.S.C. 794, which prohibits discrimination on the basis of
                handicap in programs and activities receiving or benefiting from
                federal
                financial assistance.

            

    

    

    
      	
               

            	
              c.Title
                IX of the Education Amendments of 1972, as amended,
                20 U.S.C. 1681 et seq., which prohibits discrimination on the
                basis of sex in education programs and activities receiving or benefiting
                from federal financial assistance.

            

    

    

    
      	
               

            	
              d.The
                Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
                which
                prohibits discrimination on the basis of age in programs or activities
                receiving or benefiting from federal financial
                assistance.

            

    

    

    
      	
               

            	
              e.Section
                654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
                42 U.S.C. 9849, which prohibits discrimination on the basis of
                race, creed, color, national origin, sex, handicap, political affiliation
                or beliefs in programs and activities receiving or benefiting from
                federal
                financial assistance.

            

    

    

    
      	
               

            	
              f.The
                Americans with Disabilities Act of 1990, 42 USC 12101, et seq., which
                prohibits discrimination against, and provides equal opportunities
                for
                individuals with disabilities, in employment, public  services,
                and public accommodations.

            

    

    

    
      	
               

            	
              g.All
                regulations, guidelines, and standards as are now or may be lawfully
                adopted under the above statutes.

            

    

    

    
      	
               

            	
              3.The
                contractor shall establish procedures to handle complaints of
                discrimination involving services or benefits through this
                contract.  The contractor shall advise consumers, employees, and
                participants of the right to file a complaint, the right to appeal
                a
                denial or exclusion from the services or benefits from this contract,
                and
                their right to a fair hearing.  Complaints of discrimination
                involving services or benefits through this contract may also be
                filed
                with the Secretary of the department or the appropriate federal or
                state
                agency.

            

    

    

    
      	
               

            	
              4.The
                contractor agrees that compliance with this assurance is a condition
                of
                continued receipt of or benefit from federal financial assistance,
                and
                that it is binding upon the contractor, its successors, transferees,
                and
                assignees for the period during which such assistance is provided.
                The
                contractor further assures that all contractors, subcontractors,
                subgrantees, or others with whom it arranges to provide services
                or
                benefits to participants or employees in connection with any of its
                programs and activities are not discriminating against those participants
                or employees in violation of the above statutes, regulations, guidelines,
                and standards.  In the event of failure to comply, the
                contractor understands that the department may, at its discretion,
                seek a
                court order requiring compliance with the terms of this assurance
                or seek
                other appropriate judicial or administrative relief, including but
                not
                limited to, termination of and denial of further
                assistance.

            

    

    
      
        
        

      

      
        2

        
          

        

      

      
        
        

      

    

    D.Requirements
      of Chapter 287, Florida Statutes

    
      	
               

            	
              1.To
                provide all reports set forth in Attachment I to be received and
                accepted
                by the contract manager.

            

    

    

    
      	
               

            	
              2.To
                comply with the criteria and final date by which such criteria must
                be met
                for completion of this contract as specified in Section I,
                Paragraph V, of this contract.

            

    

    

    
      	
               

            	
              3.To
                allow public access to all documents, papers, letters, or other materials
                subject to the provisions of Chapter 119, Florida Statutes, and made
                or received by the contractor in conjunction with this contract.
                It is
                expressly understood that substantial evidence of the contractor's
                refusal
                to comply with this provision shall constitute a breach of
                contract.

            

    

    

    
      	
               

            	
              4.To
                develop procurement procedures for all services purchased pursuant
                to this
                contract and subcontracts subject to this agreement in accordance
                with
                state and federal regulations that encourages competition and promotes
                a
                diversity of contractors for services for the elder
                consumers.

            

    

    

    E.Withholdings
      and Other Benefits

    
      	
               

            	
              1.The
                contractor is responsible for Social Security and Income Tax withholdings
                of its employees.

            

    

    

    
      	
               

            	
              2.The
                contractor is not entitled to state retirement or leave benefits
                except
                where the contractor is a state
                agency.

            

    

    

    
      	
               

            	
              3.Unless
                justified by the contractor and agreed to by the department in Attachment
                I, the department will not furnish services of support (e.g., office
                space, office supplies, telephone service, secretarial, or clerical
                support) normally available to career service
                employees.

            

    

    

    F.Indemnification

    If
      the
      contractor is a state or local governmental entity, pursuant to subsection
      768.28(18) Florida Statutes, the provisions of this section do not
      apply.

    

    
      	
               

            	
              1.Contractor
                and all subcontractors agree to indemnify, defend, and hold harmless
                the
                department and all of the department's officers, agents, and employees
                from any claim, loss, damage, cost, charge, or expense arising out
                of any
                acts, actions, neglect or omission, action in bad faith, or violation
                of
                federal or state law by the contractor, its agents, employees, or
                subcontractors during the performance of this agreement and all contracts
                incorporating this agreement by reference, whether direct or indirect,
                and
                whether to any person or property to which the department or said
                parties
                may be subject, except neither contractor nor any of its subcontractors
                will be liable under this section for damages arising out of injury
                or
                damage to persons or property directly caused or resulting from the
                sole
                negligence of the department or any of its officers, agents, or
                employees.

            

    

    

    
      	
               

            	
              2.Contractor's
                and subcontractor’s obligation to indemnify, defend, and pay for the
                defense or, at the department's option, to participate and associate
                with
                the department in the defense and trial of any claim and any related
                settlement negotiations, shall be triggered by the department's notice
                of
                claim for indemnification to contractor.  Contractor's and
                subcontractor’s inability to evaluate liability or its evaluation of
                liability shall not excuse contractor's or subcontractor’s duty to defend
                and indemnify the department, upon notice by the
                department.  Notice shall be given by registered or certified
                mail, return receipt requested.  Only an adjudication or
                judgment after the highest appeal is exhausted specifically finding
                the
                department solely negligent shall excuse performance of this provision
                by
                contractors and subcontractors. The contractor shall pay all costs
                and
                fees related to this obligation and its enforcement by the
                department.  The department's failure to notify contractor of a
                claim shall not release contractor of the above duty to
                defend.

            

    

     

    
      
        
        

      

      
        3

        
          

        

      

      
        
        

      

       

    

    
      	
               

            	
              3.It
                is the intent and understanding of the parties that the contractor
                is
                NOT an agent of the department for purposes of
                application of Chapter 768.28, F.S., and is NOT entitled
                or subject to any of the benefits and limitations
                therein.  Contractor expressly agrees to and does hereby waive
                any and all claims or entitlement to any and all application of Chapter
                768.28, F.S., contractor may have or may hereafter acquire by reason
                of
                this agreement or by any interpretation of this agreement and applicable
                law by any court of law equity, or by or through any other dispute
                resolution method or forum, regarding any and all claims that may
                directly
                or indirectly arise from or otherwise involve contractor’s direct or
                indirect involvement, obligations, or benefits under this
                agreement.  Not withstanding the foregoing provisions, nothing
                in this agreement shall serve as a waiver of sovereign immunity,
                or any
                other defense, by the department.  Neither the contractor nor
                any of its subcontractors are employees of the department and shall
                not
                hold themselves out as employees or agents of the department without
                specific authorization from the department.  It is the further
                intent and understanding of the parties that the department does
                not
                control the employment practices of the contractor and shall not
                be liable
                for any wage and hour, employment discrimination, or other labor
                and
                employment claims, which arise against the
                contractor.

            

    

    

    G.Insurance
      and Bonding

    
      	
               

            	
              1.To
                provide adequate liability insurance coverage on a comprehensive
                basis and
                to hold such liability insurance at all times during the existence
                of this
                contract. The contractor accepts full responsibility for identifying
                and
                determining the type(s) and extent of liability insurance necessary
                to
                provide reasonable financial protections for the contractor and the
                consumers to be served under this contract.  Upon the execution
                of this contract, the contractor shall furnish the department written
                verification supporting both the determination and existence of such
                insurance coverage.  Such coverage may be provided by a
                self-insurance program established and operating under the laws of
                the
                State of Florida.  The department reserves the right to require
                additional insurance where
                appropriate.

            

    

    

    
      	
               

            	
              2.To
                furnish an insurance bond from a responsible commercial insurance
                company
                covering all officers, directors, employees and agents of the contractor
                authorized to handle funds received or disbursed under this contract
                in an
                amount commensurate with the funds handled, the degree of risk as
                determined by the insurance company and consistent with good business
                practices.

            

    

    

    
      	
               

            	
              3.If
                the contractor is a state agency or subdivision as defined by
                Chapter 768.28, Florida Statutes, the contractor shall furnish the
                department, upon request, written verification of liability protection
                in
                accordance with Chapter 768.28, Florida Statutes.  Nothing
                herein shall be construed to extend any party's liability beyond
                that
                provided in Chapter 768.28, Florida Statutes. (See also Paragraph
                F
                above.)

            

    

    

    
      
        
        

      

      
        4

        
          

        

      

      
        
        

      

    

     

    H.Abuse,
      Neglect and Exploitation Reporting

    In
      compliance with Chapter 415, Florida Statutes, an employee of the contractor
      who
      knows, or has reasonable cause to suspect, that a child, aged person or disabled
      adult is or has been abused, neglected, or
      exploited, shall immediately report such knowledge or suspicion to the State
      of
      Florida central abuse registry and tracking system on the statewide toll-free
      telephone number (1-800-96ABUSE).

    

    I.Transportation
      Disadvantaged

    If
      consumers are to be transported under this contract, the contractor will comply
      with the provisions of Chapter 427, Florida Statutes, and Rule Chapter 41-2,
      Florida Administrative Code.

    

    J.Purchasing

    
      	
               

            	
              1.PRIDE

            

    

    It
      is
      expressly understood and agreed that any articles which are the subject of,
      or
      are required to carry out this contract shall be purchased from Prison
      Rehabilitative Industries and Diversified Enterprises, Inc. (PRIDE) identified
      under Chapter 946, Florida Statutes, in the same manner and under the procedures
      set forth in subsections 946.515(2) and (4), Florida Statutes. For purposes
      of
      this contract, the person, firm, or other business entity carrying out the
      provisions of this contract shall be deemed to be substituted for the department
      insofar as dealings with PRIDE. This clause is not applicable to any
      subcontractors, unless otherwise required by law. An abbreviated list of
      products/services available from PRIDE may be obtained by contacting PRIDE'S
      Tallahassee branch office at (850) 487-3774 or SunCom 277-3774.

    

    
      	
               

            	
              2.Procurement
                of Products or Materials with Recycled
                Content

            

    

    Additionally,
      it is expressly understood and agreed that any products or materials which
      are
      the subject of, or are required to carry out this contract shall be procured
      in
      accordance with the provisions of Chapter 403.7065 and 287.045, Florida
      Statutes.

    

    
      
        
        

      

      
        5

        
          

        

      

      
        
        

      

    

    
      	
               

            	
              3.Equity
                in Contracting

            

    

    Pursuant
      to Chapter 287.09451, F.S., the department is committed to embracing diversity
      in the provision of services to Florida’s elders and in providing fair and equal
      opportunities for all qualified minority businesses in Florida.  The
      contractor shall report information to the department on utilization of
      certified, and non-certified minority contractors and vendors for all
      subcontractors and vendors receiving funds pursuant to all contracts covered
      by
      this contract.  This report shall be submitted quarterly to the
      department.

    

    K.Publication
      or Statement of State Sponsorship

    
      	
               

            	
              1.As
                required by Chapter 286.25, Florida Statutes, if the contractor or
                subcontractor is a nongovernmental organization which sponsors a
                program
                financed wholly or in part by state funds, including any funds obtained
                through contracts executed in accordance with this agreement, it
                shall in
                publicizing, advertising or describing the sponsorship of the program,
                state:   "Sponsored by Wellcare, and the State of
                Florida, Department of Elder Affairs".  If the sponsorship
                reference is in written material the words "State of Florida, Department
                of Elder Affairs" shall appear in the same size letters and type
                as the
                name of the organization.

            

    

    

    
      	
               

            	
              2.If
                the contractor is a governmental entity or political subdivision
                of the
                state, the department requests compliance with the conditions specified
                above.

            

    

    

    
      	
               

            	
              3.The
                contractor shall not use the words “The State of Florida, Department of
                Elder Affairs” to indicate sponsorship of a program otherwise financed
                unless specific authorization has been obtained by the department
                prior to
                use.

            

    

    

    L.Use
      of Funds for Lobbying Prohibited

    To
      comply
      with the provisions of Chapter 216.347, Florida Statutes, which prohibit the
      expenditure of contract funds for the purpose of lobbying the Legislature,
      a
      judicial branch or a state agency.

    

    

    M.Public
      Entity Crime; Denial or revocation of the right to transact business with public
      entities.

    It
      is the
      intent of the legislature to place the following restrictions on the ability
      of
      persons convicted of public entity crimes to transact business with the
      department per Chapter 287.133, Florida Statutes:

    

    A
      person
      or affiliate who has been placed on the convicted vendor list following a
      conviction for a public entity crime may not submit a bid on a contract to
      provide any goods or services to a public entity, may not submit a bid on a
      contract with a public entity for the construction or repair of a public
      building or public work, may not submit bids on leases of real property to
      a
      public entity, may not be awarded or perform work as a contractor, supplier,
      subcontractor, or consultant under a contract with any public entity, and may
      not transact business with any public entity in excess of the threshold amount
      provided in s. 287.017 for CATEGORY TWO for a period of 36 months from the
      date
      of being placed on the convicted vendor list.  The contractor agrees
      that compliance with this statute is a condition of receipt or benefit from
      state or federal funds and it is binding upon the contractor, and it’s
      successors during the period of this agreement.  The contractor
      further assures that the contractor, it’s officers, directors, senior
      management, partners, employees, or agents, have not been convicted of any
      public entity crimes within the last 36 months. If the contractor or any of
      its
      officers or directors are convicted, pursuant to the definition set forth in
      s.287.133 (1)(b), of a public entity crime during the period of this agreement,
      the contractor shall notify the department immediately. Non-compliance with
      this
      statute shall constitute a breach of contract.

    

    N.Employment

    If
      the
      contractor is a non-governmental organization, it is expressly understood and
      agreed that the contractor will not knowingly employ unauthorized alien
      workers.  Such employment constitutes a violation of the employment
      provisions as determined pursuant to section 274A(e) of the Immigration
      Nationality Act (INA), 8 U.S.C. s.1324 a (e) (section 274A(e). Violation of
      the
      employment provisions as determined pursuant to section 274A(e) shall be grounds
      for unilateral cancellation of this contract.

    

    O.Audits
      and Records

    
      	
               

            	
              1.To
                maintain books, records, and documents (including electronic storage
                media) in accordance with generally accepted accounting procedures
                and
                practices which sufficiently and properly reflect all revenues and
                expenditures of funds provided by the department under this
                contract.  Contractors and subcontractors agree to maintain
                records including paid invoices, payroll registers, travel vouchers,
                copy
                logs, postage logs, time sheets, etc., as supporting documentation
                for
                service cost reports and for administrative expenses itemized for
                reimbursement.  This documentation will be made available upon
                request for monitoring and auditing
                purposes.

            

    

    

    
      	
               

            	
              2.To
                assure that these records shall be subject at all reasonable times
                to
                inspection, review, or audit by state personnel and other personnel
                duly
                authorized by the department, as well as by federal
                personnel.

            

    

    

    
      
        
        

      

      
        6

        
          

        

      

      
        
        

      

    

    
      	
               

            	
              3.To
                maintain and file with the department such progress, fiscal and inventory
                reports as specified in Attachment I, and other reports as the department
                may require within the period of this contract.  Such reporting
                requirements must be reasonable given the scope and purpose of this
                contract.

            

    

     

    
      	
               

            	
              4.To
                provide a financial and compliance audit to the department as specified
                in
                Attachment I and to ensure that all related party transactions are
                disclosed to the auditor.  Additional audit requirements are
                specified in Attachment I.

            

    

    

    
      	
               

            	
              5.To
                include these aforementioned audit and record keeping requirements
                in all
                approved subcontracts and
                assignments.

            

    

    

    
      	
               

            	
              6.The
                contractor agrees to respond to requests for consumer information
                and
                statistical data for research and evaluative purposes when requested
                by
                the department.

            

    

    

    
      	
               

            	
              7.To
                provide to the department all fiscal information regarding services
                contracted to subcontractors pursuant to this agreement using the
                application or format required by the
                department.

            

    

    

    P.Retention
      of Records

    
      	
               

            	
              1.Unless
                otherwise expressly set forth in Attachment I of this contract, the
                contractor agrees to retain all consumer records, financial records,
                supporting documents, statistical records, and any other documents
                (including electronic storage media) pertinent to this contract for
                a
                period of five (5) years after termination of this contract, or if
                an
                audit has been initiated and audit findings have not been resolved,
                the
                records shall be retained until resolution of the audit
                findings.  Any special provisions regarding retention of records
                must be in accord with applicable state or federal law or
                regulation.

            

    

    

    
      	
               

            	
              2.Persons
                duly authorized by the department and federal auditors, pursuant
                to 45
                CFR, Part 74.53(e), and 92.42(e) (1) and (2) shall have full access
                to and
                the right to examine or duplicate any of said records and documents
                during
                said retention period.

            

    

    

    Q.Incident
      Reporting

    
      	
               

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

            

    

    

    
      	
               

            	
              2.The
                contractor will permit persons duly authorized by the department
                to
                inspect any records, papers, documents, facilities, goods and services
                of
                the contractor and subcontractor which are relevant to this agreement
                or
                the mission and statutory authority of the department, and/or interview
                any consumers and employees of the contractor and subcontractor to
                be
                assured of satisfactory performance of the terms and conditions of
                this
                contract.  Following such inspection the department will deliver
                to the contractor a list of its concerns with regard to the manner
                in
                which said goods or services are being provided.  The contractor
                will rectify all noted deficiencies provided by the department within
                the
                time set forth by the department, or provide the department with
                a
                reasonable and acceptable justification for the contractor's failure
                to
                correct the noted deficiencies.  The department shall determine
                whether such failure is reasonable and acceptable.  The
                contractor's failure to correct or justify within a reasonable time
                as
                specified by the department may result in the department taking any
                of the
                actions identified in the Suspension section, or the department deeming
                the contractor’s failure to be a breach of
                contract.

            

    

    

    
      
        
        

      

      
        7

        
          

        

      

      
        
        

      

    

    
      	
               

            	
              3.The
                contractor will notify the department within 48 hours of conditions
                related to subcontractor performance that could impair continued
                service
                delivery.  Reportable conditions may
                include:

            

    

     

    
      	
               

            	
              proposed
                consumer terminations

            

    

    
      	
               

            	
              contractor
                or subcontractor financial
                concerns/difficulties

            

    

    
      	
               

            	
              service
                documentation problems

            

    

    
      	
               

            	
              contract
                non-compliance

            

    

    
      	
               

            	
              service
                quality and consumer complaint
                trends

            

    

    

    Contractors
      will provide the department with a brief summary of the problem(s) and proposed
      corrective action plans and time frames for implementation.

    

    R.Safeguarding
      Information

    Not
      to
      use or disclose any information concerning a contractor of services under this
      contract for any purpose not in conformity with applicable state and federal
      regulations, except upon written consent of the contractor, or the custodial
      parent or legal guardian of the contractor, as authorized by law.

    

    S.Consumer
      Information

    To
      submit
      management, program, and consumer identifiable data, as specified by the
      department in Attachment I.

    

    T.Assignments
      and Subcontracts

    
      	
               

            	
              1.Except
                as otherwise allowed in Attachment I, to neither assign the responsibility
                of this contract to another party nor subcontract for any of the
                work
                contemplated under this contract without prior written approval of
                the
                department.  No such approval by the department of any
                assignment or subcontract shall be deemed in any event or in any
                manner to
                obligate the department beyond the total dollar amount agreed upon
                in this
                contract.  All such assignments or subcontracts shall be subject
                to the conditions of this contract (except Section I, Paragraph J.1.,
                Section II, Paragraph B. and Section I, Paragraph M., [unless the
                subcontractor is a political subdivision of the state]) and to any
                conditions of approval that the department shall deem
                necessary.

            

    

    

    
      	
               

            	
              2.Unless
                otherwise stated in the contract between the contractor and subcontractor,
                payments made by the contractor to the subcontractor must be in accordance
                with Attachment I and other applicable state and federal
                regulations.

            

    

    

    U.Financial
      Reports

    To
      provide financial reports to the department as specified in
      Attachment I.

    

    V.Final
      Invoice

    Any
      payment that may become due under the terms of this contract may be withheld
      until all reports and documentation due from the contractor, and necessary
      adjustments thereto, have been approved by the department.

    

    
      
        
        

      

      
        8

        
          

        

      

      
        
        

      

    

    W.Return
      of Funds

    The
      contractor shall return any overpayment to the agency after either discovery
      by
      the contractor, or notification by the agency, of the overpayment.  In
      the event that the contractor or its independent auditor discovers an
      overpayment has been made, the contractor shall repay said overpayment without
      prior notification from the agency.  In the event that the agency
      first discovers an overpayment has been made, the agency will notify the
      contractor by letter of such a finding.  Such repayment shall be made
      pursuant to all applicable state and federal regulations.

     

    X.Data
      Integrity

    Pursuant
      to the accounting and reporting requirements for federal grants management
      in
      OMB Circulars A-102 and A-110, which require certification of Data Integrity
      for
      any procurement document, the contractor must, prior to execution of this
      agreement, complete the Data Integrity Certification form, Attachment
      VI.

    

    In
      the
      event a data integrity issue results in a delay of service, the contractor
      agrees to execute their agency disaster plan to ensure the delivery of
      service(s) continues.

    

    Y.Conflict
      of Interest

    The
      contractor hereby agrees that it will ensure that its employees, board members,
      management and subcontractors, will avoid any conflict of interest or the
      appearance of a conflict of interest when disbursing or using the funds
      described in this agreement or when contracting with another entity which will
      be paid by the funds described in this agreement.  A conflict of
      interest includes but is not limited to receiving, or agreeing to receive,
      a
      direct or indirect benefit, or anything of value from a contractor, consumer,
      subcontractor, or any person wishing to benefit from the use or disbursement
      of
      these funds.  To avoid a conflict of interest a contractor must ensure
      that all individuals make a disclosure to the department of any relationship
      which may be, or may be perceived to be, as a conflict of interest within thirty
      (30) days of an individual’s original appointment or placement on a board, or if
      the individual is serving as an incumbent, within thirty (30) days of the
      commencement of the contract.

    

    Z.Successors
      and Transferees

    This
      contract and its attachments are binding on the contractor and its successors
      and transferees.

    

     

    

    

    Intentionally
      Left Blank

    

    
      
        
        

      

      
        9

        
          

        

      

      
        
        

      

    

    

    II.THE
      DEPARTMENT AGREES:

    

    A.Contract
      Amount

    To
      pay
      for contracted services according to the conditions of Attachment I in
an amount not to exceed $60 million, subject to the
      availability of funds. The funds awarded to the contractor pursuant to this
      contract consists of the following:

    

    
      	
              Program
                Title

            	
              Year

            	
              Funding
                Source

            	
              CFDA/CSFA#

            	
              Fund
                Amounts

            
	
              Long
                Term Community Diversion Pilot Project

            	
              2007-2008

            	
              General
                revenue-match

            	
              93.777
                & 93.778

            	
              $60
                Million

            

    

    

    The
      State
      of Florida's performance and obligation to pay under this contract is contingent
      upon an annual appropriation by the Legislature. The costs of services paid
      under any other contract or from any other source are not eligible for
      reimbursement under this contract.

    

    B.Contract
      Payment

    Payment
      will be made pursuant to the terms and conditions of Attachment I and any
      applicable state and federal regulations.

    

    C.Vendor
      Ombudsman

    A
      Vendor
      Ombudsman has been established within the Department of Financial
      Services.  The duties of this individual include acting as an advocate
      for vendors who may be experiencing problems in obtaining timely payment(s)
      from
      a state agency.  The Vendor Ombudsman may be contacted at (850)
      413-5516 or by calling the Department of Financial Services Consumer Hotline
      at
      1(800) 343-2762.

    

    

    III.The
      Contractor Agrees to the following special provisions:

    

    
      	
               

            	
              A.Grievance
                and Appeal Procedures

            

    

    If
      this
      contract contains funds for services to elder consumers, the contractor will
      abide by the grievance section in Attachment I and any applicable state and
      federal regulations.

    

    
      	
               

            	
              B.Investigation
                of Allegations

            

    

    Any
      report that implies criminal intent on the part of this contractor or any
      subcontractor and is referred to a governmental or investigatory agency must
      be
      sent to the department. The contractor must investigate allegations regarding
      falsification of client information, service records, payment requests, and
      other related information. If the contractor has reason to believe that the
      allegations will be referred to the State Attorney, a law enforcement agency,
      the United States Attorney’s Office, or other governmental agency, the
      contractor shall notify the Inspector General at the department immediately.
      A
      copy of all documents, reports, notes or other written material concerning
      the
      investigation, whether in the possession of the contractor or subcontractor,
      must be sent to the department’s Inspector General with a summary of the
      investigation and allegations.

    

    C.Disaster

    In
      preparation for the threat of an emergency event as defined in the State of
      Florida Comprehensive Emergency Management Plan, the Department of Elder Affairs
      may exercise authority over a service provider to implement preparedness
      activities to improve the safety of the elderly in the threatened area
and
      to
      secure service provider facilities to minimize the potential impact of the
      event.  These actions will be within the existing roles and
      responsibilities of the service providers.

    

    
      
        
        

      

      
        10

        
          

        

      

      
        
        

      

    

    In
      the
      event the President of the United States or Governor of the State of Florida
      declares a disaster or state of emergency, the Department of Elder Affairs
      may
      exercise authority over the service provider to implement emergency relief
      measures and/or activities.

    

    In
      either
      of these cases, only the Secretary, Deputy Secretary or his/her designee of
      the
      Department of Elder Affairs shall have such authority to order the
      implementation of such measures.  All actions directed by the
      department under this section shall be for the purpose of ensuring the health,
      safety and welfare of the elderly in the potential or actual disaster
      area.

    

    D.Computer
      System Backup and Recovery

    Each
      contractor, among other requirements, must anticipate and prepare for the loss
      of information processing capabilities.  The routine backing up of
      data and software is required to recover from losses or outages of the computer
      system.  Data and software essential to the continued operation of
      contractor functions must be backed up.  The security controls over
      the backup resources shall be as stringent as the protection required of the
      primary resources. It is recommended that a copy of the backed up data be stored
      in a secure, offsite location.  The contractor will submit to the
      department, annually or upon revision, their written policy for backing up
      data
      and software.

     

    IV.THE
      CONTRACTOR AND DEPARTMENT MUTUALLY AGREE:

    

    A.Effective
      Date

    
      	
               

            	
              1.This
                contract shall begin on September 1, 2007, or on the date on which
                the
                contract has been signed by both parties, whichever is
                later.

            

    

    

    
      	
               

            	
              2.This
                contract shall end on August 31,
                2008.

            

    

    

    B.Termination

    1.Termination
      at Will

    This
      contract may be terminated by either party upon no less than sixty (60) calendar
      days notice, without cause, unless a lesser time is mutually agreed upon by
      both
      parties. Said notice shall be delivered by certified mail, return receipt
      requested, or in person with proof of hand delivery. In the event the contractor
      terminates a contract at will the contractor agrees to submit, at the time
      it
      serves notice of intent to terminate, a plan which identifies procedures to
      ensure services to consumers will not be interrupted or suspended by the
      termination.

    
       

      2.Termination
        Because of Lack of Funds 

    

    In
      the
      event funds to finance this contract become unavailable, the agency will notify
      the Contractor in writing within twenty-four (24) hours after the agency learns
      of such unavailability of funds.  Said notice shall be delivered by
      certified mail, return receipt requested, or any expedited delivery service
      that
      provides verification of receipt, or in person with proof of hand
      delivery.  In the event of a fiscal emergency, the department, in
      consultation with the agency may terminate the contract no less than twenty-four
      (24) hours after the contractor has received written notice.  The
      agency shall be the final authority as to the availability of
      funds.

    

    
      
        
        

      

      
        11

        
          

        

      

      
        
        

      

    

    3.Termination
      for Breach

    The
      department may, by written notice to the Contractor, terminate this contract
      if
      the provider fails to cure any material breach within thirty (30) days after
      the
      Contractor receives from the department written notification explaining the
      nature of the material breach; provided however, the department may terminate
      this contract for material breach upon no less than twenty four (24) hours
      written notice to the Contractor if the Contractor has committed a material
      breach of the contract which causes an immediate danger to the public health
      and
      if the Contractor has not cured such breach within the notice period upon no
      less than twenty-four (24) hours notice.  Said notice shall be
      delivered by certified mail, return receipt requested, or in person with proof
      of delivery.  If applicable, the department may employ the default
      provisions in Chapter 60A─1.006(3), Florida Administrative Code.

    

    If
      the
      Contractor does not receive all or a substantial portion of its capitation
      payment within (10) days after it is due, the Contractor shall furnish written
      notification to the department and the Contractor may terminate this contract
      if
      the agency fails to make payment within twenty (20) days after the department’s
      receipt of such notice.

    

    Waiver
      of
      breach of any provisions of this contract shall not be deemed to be a waiver
      of
      any other breach and shall not be construed to be a modification of the terms
      of
      this contract. The provisions herein do not limit the department or agency’s
      right to remedies or damages at law or in equity.

    

    4.Termination
      after Suspension

    If
      the
      department engages any of the suspension provisions contained in Section 1.21
      of
      Attachment I to this contract, the department may, in its sole discretion,
      determine if termination is warranted.

    

    C.Notice
      and Contact

    
      	
               

            	
              1.The
                name, address and telephone number of the contract manager for the
                department for this contract is:

            

    

    Department
      of Elder Affairs

    ATTN:
      Contract Manager

    4040
      Esplanade Way

    Tallahassee,
      FL 32399-7000

    (850)
      414-Direct Number

    

    
      	
               

            	
              2.The
                name, address and telephone number of the representative of the contractor
                responsible for administration of the program under this contract
                is:

            

    

    

    
      	
              Nancy
                Gareau

            

    

    
      	
              Wellcare

            

    

    
      	
              P.O.
                Box 26011

            

    

    
      	
              Tampa,
                FL 33623

            

    

    
      	
              (813)
                865-1816

            

    

    

    
      
        
        

      

      
        12

        
          

        

      

      
        
        

      

    

    
      	
               

            	
              3.In
                the event that different representatives are designated by either
                party
                after execution of this contract, notice of the name and address
                of the
                new representative will be rendered in writing to the other party
                and said
                notification attached to originals of this
                contract.

            

    

    

    D.Renegotiation
      or Modification

    
      	
               

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

            

    

    

    
      	
               

            	
              2.The
                payment made pursuant to this contract shall be governed by the terms
                and
                conditions in Attachment I.

            

    

    

    E.Name,
      Mailing and Street Address of Payee

    
      	
               

            	
              1.The
                name (contractor name as shown on page 1 of this contract) and mailing
                address of the official payee to whom the payment shall be
                made:

            

    

    

    
      	
              Wellcare

            

    

    
      	
              P.O.
                Box 26011

            

    

    
      	
              Tampa,
                FL 33623

            

    

    

    
      	
               

            	
               2.The
                name of the contractor’s contact person and street address where financial
                and administrative records are
                maintained:

            

    

    

    
      	
              Nancy
                Gareau

            

    

    
      	
              Wellcare

            

    

    
      	
              P.O.
                Box 26011

            

    

    
      	
              Tampa,
                FL 33623

            

    

     

    F.All
      Terms and Conditions Included

    

    This
      contract and Attachments I, II, III, IV, and Exhibits A, B, C, D, E, F,
      G, H, I, J, K, and L as referenced, contain all terms and conditions
      agreed upon by the parties. 

     

     

     

    
      
        
        

      

      
        13

        
          

        

      

      
        
        

      

    

     

    IN
      WITNESS WHEREOF, the parties hereto have caused this 110 page
      contract to be executed by their undersigned officials as duly
      authorized.

    

    
      	
              Contractor:
                Wellcare

               

            	
              STATE
                OF FLORIDA DEPARTMENT OF ELDER AFFAIRS

            
	
              SIGNED
                BY:   /s/ Todd S. Farha

            	
              SIGNED
                BY:  /s/   E. D
                Beach       
                

            
	
              NAME:
                Todd Farha

            	
              NAME:
                E. DOUGLAS BEACH

            
	
              TITLE: 
                President & CEO

            	
              TITLE:
                SECRETARY

            
	
              DATE:
                8/23/2007

            	
              DATE:
                8/29/2007

            
	
              FEDERAL
                ID NUMBER: 592583622

              (or
                SS Number for an individual)

            	 
	
              FISCAL
                YEAR ENDING DATE:

            	 
	
              STATE
                AGENCY 29 DIGIT SAMAS CODE:

            	 

    

    

     

    
      
        
        

      

      
        14

        
          

        

      

      
        
        

      

    

    

    

    ATTACHMENT
      I

    

    State
      of Florida

    Department
      of Elder Affairs

    

    Long-Term
      Care Community Diversion Pilot Project

    

    Contract
      No. 2007-2008-01

    

     

    

    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              LONG-TERM
                CARE COMMUNITY DIVERSION PILOT PROJECT

              Table
                of Contents

               

            
	
              SECTION
                1

            	
              GENERAL
                CONTRACT REQUIREMENTS

            	
              5

            
	
              1 1

            	
              Entire
                Agreement; Conflict

            	
              5

            
	
              1 2

            	
              Non-Renewal

            	
              5

            
	
              1 3

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

            	
              5

            
	
              1 4

            	
              Contractor
                Qualifications

            	
              5

            
	
              1 5

            	
              Contract
                Management

            	
              6

            
	
              1 6

            	
              Insolvency
                Protection

            	
              9

            
	
              1 7

            	
              Surplus
                Requirements

            	
              9

            
	
              1 8

            	
              Bonds

            	
              9

            
	
              1 9

            	
              Insurance

            	
              10

            
	
              1 10

            	
              Interest
                and Savings

            	
              10

            
	
              1 11

            	
              Third
                Party Resources

            	
              10

            
	
              1 12

            	
              State
                Ownership

            	
               11

            
	
              1 13

            	
              Ownership
                and Management Disclosure

            	
              11

            
	
              1 14

            	
              Independent
                Provider

            	
               13

            
	
              1 15

            	
              Damages
                from Federal Disallowances

            	
              13

            
	
              1 16

            	
              Offer
                of Gratuities

            	
              13

            
	
              1 17

            	
              Attorneys
                Fees

            	
              13

            
	
              1 18

            	
              Venue
                or Court of Jurisdiction

            	
              13

            
	
              1 19

            	
              Legal
                Action Notification

            	
              13

            
	
              1 20

            	
              Force
                Majeure

            	
              14

            
	
              1 21

            	
              Sanctions

            	
              14

            
	
              1 22

            	
              Applicable
                Laws and Regulations

            	
              15

            
	
              1 23

            	
              Inspection
                and Audit of Financial Records

            	
               16

            
	
              1 24

            	
              Reporting

            	
              16

            
	
              1 25

            	
              Fiscal
                Intermediary

            	
              16

            
	
              1 26

            	
              Subcontracts

            	
              16

            
	
              1 27

            	
              Subcontractor
                Terminations

            	
              20

            
	
              1 28

            	
              Termination

            	
              20

            
	
              1 29

            	
              Assignment

            	
              21

            
	
              SECTION
                2

            	
              RECIPIENT
                ELIGIBILITY TO PARTICIPATE IN THE PROJECT

            	
               22

            
	
              2 1

            	
              Eligibility
                Requirements

            	
               22

            
	
              2 2

            	
              Eligibility

            	
              22

            
	
              2 3

            	
              Persons
                Not Eligible for Enrollment

            	
               22

            
	
              2 4

            	
              Optional
                State Supplementation (OSS)

            	
              23

            
	
              SECTION
                3

            	
              EDUCATIONAL
                MATERIALS and CHOICE COUNSELING

            	
              23

            
	
              3 1  

            	
              Educational
                Materials

            	
              23

            
	
              3 2

            	
              Choice
                Counseling

            	
              23

            
	
              3 3

            	
              Prohibited
                Activities

            	
              23

            
	
              SECTION
                4

            	
              ENROLLMENT
                AND DISENROLLMENT

            	
               24

            
	
              4 1

            	
              Enrollment
                Procedures

            	
              24

            
	
              4 2

            	
              Effective
                Date of Enrollment

            	
              25

            
	
              4 3

            	
              Transition
                Care Planning

            	
              25

            
	
              4 4

            	
              Orientation

            	
               25

            
	
              4 5

            	
              Plan
                of Care

            	
              27

            
	
              4 6

            	
              Integration
                of Care

            	
              29

            
	
              4 7

            	
              Disenrollment

            	
              30

            
	
              4 8

            	
              Disputes
                of Appropriate Enrollments

            	
              31

            
	
              4 9

            	
              Medicaid
                Pending

            	
              31

            

    

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 2

        
          

        

      

      
        
        

      

    

    

    
      	
              SECTION
                5

            	
              ENROLLEE
                RECORDS

            	
              32

            
	
              SECTION
                6

            	
              SERVICE
                PROVISIONS

            	
              33

            
	
              6 1

            	
              General
                Provisions

            	
              33

            
	
              6 2

            	
              Long-Term
                Care Services

            	
              34

            
	
              6 3

            	
              Minimum
                Long-Term Care Service Provider Qualifications

            	
              37

            
	
              6 4

            	
              Acute-Care
                Services

            	
              39

            
	
              6 5

            	
              Acute
                Care Provider Qualifications

            	
              40

            
	
              6 6

            	
              Optional
                Services

            	
              41

            
	
              6 7

            	
              Expanded
                Services

            	
              41

            
	
              6 8

            	
              Availability/Accessibility
                of Services

            	
              41

            
	
              6 9

            	
              Staffing
                Requirements

            	
              41

            
	
              6 10

            	
              Emergency
                Care Requirements

            	
              42

            
	
              6 11

            	
              Out
                of Network Use of Non-Emergency Services

            	
              42

            
	
              6 12

            	
              Adult
                Protective Services

            	
              43

            
	
              SECTION
                7

            	
              UTILIZATION
                MANAGEMENT

            	
              43

            
	
              SECTION
                8

            	
              QUALITY
                ASSURANCE AND IMPROVEMENT REQUIREMENTS

            	
              45

            
	
              8 1

            	
              General

            	
              45

            
	
              8 2

            	
              Quality
                Assurance Program

            	
              45

            
	
              8 3

            	
              Quality
                Assurance Committee

            	
              46

            
	
              8 4

            	
              Quality
                of Care Studies

            	
              46

            
	
              8 5

            	
              Independent
                Medical Review

            	
              47

            
	
              8 6

            	
              Extraordinary
                Reporting

            	
              47

            
	
              SECTION
                9

            	
              GRIEVANCE/APPEALS
                PROCEDURES

            	
              47

            
	
              9 1

            	
              Grievance
                System Requirements

            	
              47

            
	
              9 2

            	
              Appeal
                Process

            	
              48

            
	
              9 3

            	
              Grievance
                Process

            	
              51

            
	
              9 4

            	
              Medicaid
                Fair Hearing System

            	
              51

            
	
              SECTION
                10

            	
              PAYMENT

            	
              52

            
	
              10 1

            	
              Payment
                to Contractor

            	
              52

            
	
              10 2

            	
              Capitation
                Rates

            	
              52

            
	
              10 3

            	
              Payment
                in Full

            	
              53

            
	
              10 4

            	
              Capitation
                Payments

            	
              53

            
	
              10 5

            	
              Payment
                Discrepancies

            	
              53

            
	
              SECTION
                11

            	
              PROGRAM
                REPORTING REQUIREMENTS

            	
              53

            
	
              11 1

            	
              General
                Requirements

            	
              53

            
	
              11 2

            	
              834
                Transactions

            	
              56

            
	
              11 3

            	
              Disenrollment
                Summary Report

            	
              56

            
	
              11 4

            	
              Encounter
                Data Report

            	
              57

            
	
              11 5

            	
              Grievance/Appeals
                Report

            	
              57

            
	
              11 6

            	
              Updated
                Provider Network Listing

            	
              57

            
	
              11 7

            	
              Minority
                Business Enterprise Contract Reporting

            	
              58

            
	
              11 8

            	
              Emergency
                Management Plan

            	
              58

            
	
              11 9

            	
              Enrollee
                Satisfaction Reporting

            	
              58

            
	
              11 10

            	
              Hospice
                Services

            	
              58

            
	
              SECTION
                12

            	
              FINANCIAL
                REPORTING

            	
              58

            
	
              12 1

            	
              General
                Financial Reporting

            	
              58

            
	
              12 2

            	
              Member
                Payment Liability Protection

            	
              58

            
	
              12 3

            	
              Financial
                Reporting Template

            	
              59

            
	
              12 4

            	
              Audited
                Financial Statements

            	
              59

            
	
              12 5

            	
              Unaudited
                Quarterly Financial Statements

            	
              59

            
	
              SECTION
                13

            	
              DEFINITIONS

            	
              69

            

    

    
      	
               

            	
                 

            

    

    

    
      
        
        

      

      
        ATTACHMENT
          I - Page 3

        
          

        

      

      
        
        

      

    

    
 

    
      	
              EXHIBIT
                A

            	
              MULTIPLE
                SIGNATURE VERIFICATION AGREEMENT

            	
              75

            
	
              EXHIBIT
                B

            	
              DISENROLLMENT
                SUMMARY REPORT

            	
              77

            
	
              EXHIBIT
                C

            	
              ENCOUNTER
                DATA REPORTING FORMAT

            	
              78

            
	
              EXHIBIT
                D

            	
              REPORT
                OF GRIEVANCES/APPEALS

            	
              82

            
	
              EXHIBIT
                E

            	
              MINORITY
                BUSINESS ENTERPRISE CONTRACT REPORTING

            	
              83

            
	
              EXHIBIT
                F

            	
              RECONCILIATION
                REPORT

            	
              84

            
	
              EXHIBIT
                G

            	
              DISENROLLMENT
                FORM

            	
              85

            
	
              EXHIBIT
                H

            	
              PROVIDER
                NETWORK AND STAFF LISTING

            	
              86

            
	
              EXHIBIT
                I

            	
              CAPITATION
                RATES

            	
              88

            
	
              EXHIBIT
                J

            	
              PUBLIC
                ENTITY CRIMES

            	
              89

            
	
              EXHIBIT
                K

            	
              DEBARMENT
                AND SUSPENSION

            	
              91

            
	
              EXHIBIT
                L

            	
              HOSPICE
                ENROLLMENT REPORT

            	
              93

            

    

    

    
      
        
        

      

      
        ATTACHMENT
          I - Page 4

        
          

        

      

      
        
        

      

    

    LONG-TERM
      CARE COMMUNITY DIVERSION PILOT PROJECT 

    

    
      	
              
                SECTION
                  1 General Contract Requirements

              

            	
               

            

    

    

    
      	
               

            	
              1.1Conflict

            

    

    

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

    

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

    

    No
      person
      or contractor may use, in connection with any item constituting an
      advertisement, solicitation, circular, book, pamphlet or other communication,
      or
      a broadcast, telecast, or other production, alone or with other words, letters,
      symbols or emblems the words “Medicaid,” or “Department of Elder Affairs,” or
“Agency for Health Care Administration,” except as required in the
      standard contract unless prior written approval is
      obtained from the department.  Specific written authorization from the
      department is required to reproduce, reprint, or distribute any department
      or
      Agency form, application, or publication, for a fee.  State and local
      governments are exempt from this prohibition.  A disclaimer that
      accompanies the inappropriate use of the program or the department or Agency’s
      terms does not provide a defense.  Each piece of mail or information
      constitutes a violation.

    

    1.3Contractor
      Qualifications

    

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

    
      	
               

            	
              A.Have
                a certificate of authority from the Florida Department of Financial
                Services to operate as a health maintenance organization (HMO) pursuant
                to
                Chapter 641 Part I, F.S., and have a health care provider certificate
                from
                the Agency for Health Care Administration (Agency) pursuant to Section
                641.49, F.S., for those counties in the service area in which the
                applicant will apply to provide services
                or;

            

    

    
      	
               

            	
              B.Have
                a license issued pursuant to Chapter 400 or Chapter 429, F.S., and
                meet
                the provisions of an “other qualified provider” set forth in Section
                430.703(7), F.S. and;

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    1.4           Contract
      Management

    

    A.State
      Responsibilities

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

     

     

    
      
        
        

      

      
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    B.Department
      Responsibilities

    
      	
               

            	
              1.Develop,
                analyze, and revise policies and procedures for the project in
                consultation with the Agency.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    C.Contractor
      Responsibilities

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

      	 	b)
              Consider the needs of the enrollees.

      	 	
              c)Are
                adopted in consultation with contracting health care
                professionals.

            

      	 	
              d)Are
                reviewed and updated periodically as appropriate.

              The
                contractor shall disseminate the guidelines to all affected providers
                and, upon request to enrollees and potential
                enrollees.  The decisions for utilization management, enrollee
                education, coverage of services, and other areas to which the guidelines
                apply shall be consistent with the
                guidelines.

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    D.Administrative
      Polices and Procedures Section
      

     

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

    
      	
               

            	
              a)Emergency
                Management Plan

            

    

    
      	
               

            	
              b)Educational
                Materials

            

    

    
      	
               

            	
              c)Initial
                enrollment and Ongoing Eligibility

            

    

    
      	
               

            	
              d)Transition
                Care Planning

            

    

    
      	
               

            	
              e)Orientation

            

    

    
      	
               

            	
              f)Disenrollment

            

    

    
      	
               

            	
              g)Service
                Provisions

            

    

    
      	
               

            	
              h)Network
                Adequacy

            

    

    
      	
               

            	
              i)Sufficient
                staff available 24 hours per day

            

    

    
      	
               

            	
              j)Credentialing
                and Re-Credentialing

            

    

    
      	
               

            	
              k)Plan
                for recruiting and retaining minority health
                vendors

            

    

    
      	
               

            	
              l)Integration
                of Care

            

    

    
      	
               

            	
              m)Plan
                of Care

            

    

    
      	
               

            	
              n)Out
                of network Use of Non-Emergency
                Services

            

    

    
      	
               

            	
              o)Quality
                Assurance Program

            

    

    
      	
               

            	
              p)Quality
                Assurance Committee

            

    

    
      	
               

            	
              q)Extraordinary
                Reporting

            

    

    
      	
               

            	
              r)Utilization
                Management

            

    

    
      	
               

            	
              s)Grievance/Appeals

            

    

    
      	
               

            	
              t)Enrollee
                Records

            

    

    
      	
               

            	
              u)Claims

            

    

    
      	
               

            	
              v)Advance
                Directives

            

    

    
      	
               

            	
              w)Payment
                Discrepancies

            

    

    
      	
               

            	
              x)Reinstatement

            

    

    
      	
               

            	
              y)Subcontract

            

    

    
      	
               

            	
              2.Fraud
                Prevention Polices and
                Procedures

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    3.           Credentialing
      and Re-Credentialing Policies and Procedures

    The
      contractor’s credentialing and re-credentialing policies and procedures shall
      include the following:

    
      	
               

            	
              A.Formal
                delegations and approvals of the credentialing
                process.

            

    

    
      	
               

            	
              B.A
                designated credentialing committee.

            

    

    
      	
               

            	
              C.Identification
                of providers who fall under its scope of
                authority.

            

    

    
      	
               

            	
              D.A
                process, which provides for verification of the following core credential
                information and the subcontractor’s work
                history:

            

    

    
      	
               

            	
              1.The
                subcontractor’s current valid
                license.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.Medicaid
                provider number, if applicable.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              (a)Evidence
                of the subcontractor’s professional liability claims
                history.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              (e)Any
                history of loss or limitation of privileges or disciplinary
                activity.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              2.The
                contractor shall verify the current licensure of the subcontractor
                on the
                HHS Office of the Inspector Generals’ websites on an annual
                basis.

            

    

    
      	
               

            	
              F.The
                contractor shall develop and implement policies and procedures for
                approval of new providers, and imposition of sanctions, termination,
                suspension, or sanctioning of a
                subcontractor.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    4.
      Health Information Systems

    

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

    

    1.5Insolvency
      Protection

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    1.6Surplus
      Requirements

    

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

    

    1.7Bonds

    

    The
      contractor must secure and maintain during the life of the contract a blanket
      fidelity bond from a company doing business in the State of Florida on all
      personnel in its employment and its board of directors.  The bond must
      be issued in the amount of at least $250,000 per occurrence.

     

    
      
        
        

      

      
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    Said
      bond
      must protect the department and Agency from any losses sustained through any
      fraudulent or dishonest act or acts committed by any employees of the provider
      and subcontractors, if any.  The contractor must submit proof of
      coverage within 60 calendar days after execution of the contract and prior
      to
      the delivery of services.  For fidelity bonds to be acceptable, a
      surety company must comply with the provisions of Chapter 624,
      F.S.  The contractor must submit proof of the fidelity bond annually
      during the contract renewal period.

    

    1.8Insurance

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    1.9Interest
      and Savings

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    1.10Third
      Party Resources

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.If
                the contractor has determined that third party liability exists for
                part
                or all of the services provided to an enrollee by a subcontractor
                or
                referral provider, and the third party is reasonably expected to
                make
                payment within 120 calendar days, the contractor may pay the subcontractor
                or referral provider only the amount, if any, by which the subcontractor's
                allowable claim exceeds the amount of the anticipated third party
                payment;
                or, the contractor may assume full responsibility for third party
                collections for service provided through the subcontractor or referral
                provider.

            

    

     

    
      
        
        

      

      
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              D.The
                contractor may not withhold payment for services provided to an enrollee
                if third party liability or the amount of liability cannot be determined,
                or if payment shall not be available within a reasonable time, beyond
                120
                calendar days from the date of
                receipt.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    1.11State
      Ownership

    

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

    

    1.12Ownership
      and Management Disclosure

    

    
      	
               

            	
              A.Federal
                and state laws require full disclosure of ownership, management and
                control of managed care organizations, including other qualified
                providers.  Disclosure must be made on forms prescribed by the
                department for the areas of ownership and control interest business
                transactions (42 CFR 455.105), public entity crimes (Section
                287.133(3)(a), F.S.), and debarment and suspension (52 Fed. Reg.,
                pages
                20360-20369, and Chapter 4707 of the Balanced Budget Act of
                1997).  The forms are available through the department and are
                to be submitted to the department with the initial application and
                then
                resubmitted on an annual basis.  The contractor must disclose
                any changes in management as soon as those occur.  In addition,
                the contractor must submit to the department full disclosure of ownership
                and control at least 60 calendar days before any change in the
                contractor's ownership or control
                occurs.

            

    

    
      	
               

            	
              B.The
                following definitions apply to ownership
                disclosure:

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              G.The
                contract is subject to the provisions of Chapter 112 and Section
                430.03,
                F.S.  The contractor must disclose the name of any officer,
                director, or agent who is an employee of the State of Florida, or
                any of
                its agencies.  Further, the contractor must disclose the name of
                any state employee who owns, directly or indirectly, an interest
                of five
                (5) percent or more in the offeror's firm or any of its
                branches.  The contractor covenants that it presently has no
                interest and shall not acquire any interest, direct or indirect,
                which
                would conflict in any manner or degree with the performance of the
                services hereunder.  The contractor further covenants that in
                the performance of the contract no person having any such known interest
                shall be employed.  No official or employee of the department or
                Agency and no other public official of the State of Florida or the
                federal
                government who exercises any functions or responsibilities in the
                review
                or approval of the undertaking of carrying out the contract must,
                prior to
                completion of this contract, voluntarily acquire any personal interest,
                direct or indirect, in this
                contract.

            

    

    
      
        
        

      

      
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    1.13Independent
      Provider

    

    The
      contractor and any subcontractors’ employees, agents, and officers in the
      performance of this contract, shall act in an independent capacity and not
      as
      officers and employees of the department, Agency, or the State of
      Florida.  It is further expressly agreed that this contract shall not
      be construed as a partnership or joint venture between the contractor or any
      subcontractor and the department, Agency, or the State of Florida.

    

    1.14Damages
      from Federal Disallowances

    

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

    

    1.15Offer
      of Gratuities

    

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

    

    1.16Attorneys’
      Fees

    

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

    

    1.17Venue

    

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

    

    1.18Legal
      Action Notification

    

    The
      contractor must give the department by certified mail immediate written
      notification (no later than 30 calendar days after service of process) of any
      action or suit filed or of any claim made against the contractor by any
      subcontractor, vendor, or other party which results in litigation related to
      this contract for disputes or damages exceeding the amount of
      $50,000.  In addition, the contractor must immediately advise the
      department of the insolvency of a subcontractor or of the filing of a petition
      in bankruptcy by or against a subcontractor.

    

    1.19Force
      Majeure

    

    The
      department and Agency will not be liable for any excess cost to the contractor
      if the department’s or Agency's failure to perform the contract arises out of
      causes beyond the control and without the result of fault or negligence on
      the
      part of the department or Agency.  In all cases, the failure to
      perform must be beyond the control without the fault or negligence of the
      department or Agency. The contractor will not be liable for performance of
      the
      duties and responsibilities of the contract when its ability to perform is
      prevented by causes beyond its control.
      These acts must occur without the fault or negligence of the contractor. These
      include destruction to the facilities due to hurricanes, fires, war, riots,
      and
      other similar acts.  Annually by April 30, the contractor must submit
      to the department for approval an emergency management plan specifying what
      actions the contractor must conduct to ensure the ongoing provisions of health
      services in a natural disaster or man-made emergency.

    

    
      
        
        

      

      
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    1.20Sanctions

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Suspension
                of the contractor’s
                enrollment.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              4.Termination
                pursuant to paragraph IV B (3) of the standard contract, if the contractor
                fails to carry out substantive terms of its contract or fails to
                meet
                applicable requirements in sections 1932, 1903(m) and 1905(t) of
                the
                Social Security Act.  After the department, in consultation with
                the Agency, notifies the contractor that it intends to terminate
                the
                contract, the department, in consultation with the Agency, may give
                the
                contractor’s enrollees written notice of the state's intent to terminate
                the contract and allow the enrollees to disenroll immediately without
                cause.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              (3)The
                sanction is necessary to ensure the health of the contractor’s
                enrollees:

            

    

    
      	
               

            	
              (i)While
                improvements are made to remedy violations under 42 CFR 438.700;
                or

            

    

    
      	
               

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

            

    

    
      	
               

            	
              b)The
                State must impose temporary management (regardless of any other sanction
                that may be imposed) if it finds that a contractor has repeatedly
failed
                to meet substantive requirements in section 1903(m) or section 1932
                of the
                Social Security Act or 42 CFR 438.706.  The State must also
                grant enrollees the right to terminate enrollment without cause,
                as
                described in 42 CFR 438.702(a)(3), and must notify the affected enrollees
                of their right to terminate
                enrollment.

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    1.21Additional
      Applicable Laws and Regulations

    

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

    

    1.22Inspection
      and Audit of Financial Records

    

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

    

    1.23Reporting

    

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

    

    
      
        
        

      

      
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    1.24Fiscal
      Intermediary

    

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

    

    1.25Subcontracts

    The
      contractor is responsible for all work performed under this contract, but may,
      with the written approval of the department, enter into subcontracts for the
      performance of work required under this contract. All subcontracts and
      amendments thereto executed by the contractor must meet the requirements listed
      in this section. All model provider subcontracts must be approved, in writing,
      by the department in advance of implementation and execution of subcontracts.
      All subcontractors must be eligible for participation in the Medicaid program;
      however, the subcontractor is not required to participate in the Medicaid
      program as a provider.  Subcontracts are required with all major
      providers of services and there shall be no provisions prohibiting service
      providers from contracting with other long-term care diversion contractors.
      All
      direct service providers are required to attend and complete Abuse, Neglect
      & Exploitation Training. This training can be given by the department of
      Children and Families, the local area agency on aging, the department, and
      the
      contractor or be accommodated through licensing requirements.  The
      contractor's training materials shall be approved, in advance, by the
      department.   

    

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

    

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

    

    
      	
               

            	
              A.Identification
                of conditions and method of
                payment:

            

    

    All
      subcontract and amendments must meet the following requirements:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.Make
                full disclosure of the method and amount of compensation or other
                consideration to be received from the contractor. The provider must
                not
                charge for any service provided to the recipient at a rate in excess
                of
                the rates established by the contractor’s subcontract with the provider in
                accordance with Section 1128B(d)(1), Social Security Act (enacted
                by
                Section 4704 of the Balanced Budget Act of 1997).  The provider
                may not bill the recipient any amount greater than would be owed
                if the
                entity provided the services
                directly.

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

            	
              5.Physician
                incentive plans must comply with 42 CFR 417.479.  The contractor
                shall make no specific payment directly or indirectly under a physician
                incentive plan to a physician or physician group as an inducement
                to
                reduce or limit medically necessary services furnished to an individual
                enrollee.  Incentive plans must not contain provisions that
                provide incentives, monetary or otherwise, for the withholding of
                medically necessary care.  The contractor must disclose
                information on provider incentive plans listed in 42 CFR 417.479(h)(1)
                and
                42 CFR 417.479(i) at the times indicated in 42 CFR
                417.479(d)-(g).  All such arrangements must be submitted to the
                department for approval, in writing, prior to use.  If any other
                type of withhold arrangement currently exists, it must be omitted
                from all
                subcontracts.

            

    

    
      	
               

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

            

    

    

    B.Provisions
      for monitoring and inspections:

    
      	
               

            	
              1.Provide
                that the department, Agency, and Department of Health and Human Services
                (DHHS) may evaluate through inspection or other means the quality,
                appropriateness and timeliness of services
                performed.

            

    

    
      	
               

            	
              2.Provide
                for inspections of any records pertinent to the contract by the
                department, Agency, and DHHS.

            

    

    
      	
               

            	
              3.Require
                that records be maintained for a period not less than five (5) years
                from
                the close of the contract and retained further if the records are
                under
                review or audit until the review or audit is complete.  (Prior
                approval for the disposition of records must be requested and approved
                by
                the provider if the subcontract is
                continuous.)

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    C.Specification
      of functions of the subcontractor:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.Provide
                for timely access to appointments and
                services.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    D.Protective
      clauses:

    
      	
               

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

            

    

    
      	
               

            	
              2.Require
                compliance with HIPAA privacy and security
                provisions.

            

    

    
      	
               

            	
              3.Require
                an exculpatory clause, which survives subcontract termination including
                breach of subcontract due to insolvency, that assures the enrollees,
                department, Agency, or DHHS may not be held liable for any debts
                of the
                subcontractor in accordance with 42 CFR 447.15. In addition, the
                recipient
                is not liable to the subcontractor for any services for which the
                contractor is liable as specified in Section 641.3154,
                F.S.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              15.Pursuant
                to Section 641.315(2)(b), F.S., specify that the contractor will
                provide
                60 days advance written notice to the subcontractor and the department
                before canceling, without cause, the contract with the
                subcontractor.  However, in a case in which an enrollee’s health
                is subject to imminent danger or a physician’s ability to practice
                medicine is effectively impaired by an action by the Board of Medicine
                or
                other governmental agency, notification must be provided to the department
                immediately.

            

    

    

    
      
        
        

      

      
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              E.The
                contractor must not
                discriminate with respect to participation, reimbursement,
                or       indemnification as to any
                subcontractor who is acting within the scope of the provider’s license, or
                certification under applicable state law, solely on the basis of
                such
                license, or certification, in accordance with Section 4704 of the
                Balanced
                Budget Act of 1997.  This paragraph shall not be construed to
                prohibit a contractor from including subcontractors only to the extent
                necessary to meet the needs of the contractor’s enrollees or from
                establishing any measure designed to maintain quality and control
                costs
                consistent with the responsibilities of the organization.  If
                the contractor declines to include individual subcontractors or groups
                of
                subcontractors in its network, it must give the affected subcontractors
                written notice of thereason for
                its
                decision.

            

    

    

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

    

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

    

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

    

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

    

    
      	
               

            	
              F.Network
                Expansion

            

    

    

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

    

    
      
        
        

      

      
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              1.26Subcontractor
                Termination

            

    

    

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

    

    
      	
               

            	
              1.27Termination

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Continue
                performance under the terms of the contract until the termination
                date.

            

    

    
      	
               

            	
              2.Immediately
                cease enrollment of new enrollees under the
                contract.

            

    

    
      	
               

            	
              3.Immediately
                perform the duties as specified in the approved Termination
                Plan.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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              1.28Assignment

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

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

    

    SECTION
      2  Recipient Eligibility to Participate in the
      Project

    

    
      	
               

            	
              2.1Eligibility
                Requirements

            

    

    

    Recipients
      eligible for project enrollment must be:

    
      	
               

            	
              A.65
                years of age or older.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.Medicaid
                eligible with incomes up to the Institutional Care Program level
                (ICP).

            

    

    
      	
               

            	
              D.Reside
                in the project service
                area.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    

    
      	
               

            	
              2.2Eligibility

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      	
               

            	
              2.3Persons
                Not Eligible for
                Enrollment

            

    

    

    
      	
               

            	
              A.Persons
                residing outside the project service
                area.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      	
               

            	
              2.4Optional
                State Supplementation
                (OSS)

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
        ATTACHMENT
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      SECTION
        3 Educational materials and Choice Counseling

    

     

    
      	
               

            	
              3.1Educational
                Materials 

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      	
               

            	
              3.2Choice
                Counseling

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.The
                qualifications for enrollment in the
                project.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              5.The
                benefits provided under the
                project.

            

    

    
      	
               

            	
              6.Pursuant
                to 42 CFR 438.10(g)(3), the contractor shall provide information
                on the
                contractor’s physician incentive plans or on the contractor’s structure
                and operation to any Medicaid recipient, upon
                request.

            

    

    

    
      	
               

            	
              3.3Prohibited
                Activities

            

    

    

    
      	
               

            	
              A.In
                accordance with 42 CFR 438.104(b)(1)(iv), the entity does not seek
                to
                influence enrollment in conjunction with the sale or offering of
                any
                private insurance.

            

    

    
      	
               

            	
              B.In
                accordance with 42 CFR 438.104(b)(1)(v), the entity does not, directly
                or
                indirectly, engage in door-to-door, telephone, or other cold-call
                marketing activities.

            

    

    
      	
               

            	
              C.In
                accordance with 42 CFR 438.104(b)(2)(i), the entity does not make
                any
                assertion or statement (whether written or oral) that the beneficiary
                must
                enroll with the contractor in order to obtain benefits (Medicaid
                State
                Plan benefits) or in order to not lose benefits (Medicaid State Plan
                benefits).

            

    

    
      	
               

            	
              D.In
                accordance with Section 409.912(21)(b), F.S., and 42 CFR
                438.104(b)(2)(ii), entity does not make any inaccurate false or misleading
                claims that the entity is recommended or endorsed by any federal,
                state or
                county government, the Agency, CMS, department, or any other organization
                which has not certified its endorsement in writing to the
                contractor.

            

    

    

    
      
        
        

      

      
        ATTACHMENT
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    SECTION
      4 ENROLLMENT AND DISENROLLMENT

    
       

      4.1 Enrollment
        Procedures

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.The
                contractor will forward the enrollment information to the Medicaid
                fiscal
                agent in the HIPAA approved format.  This information must be
                transmitted to the fiscal agent by the monthly reporting deadline
                (usually
                the Wednesday preceding the next to last Saturday of the month) in
                order
                to be effective for the subsequent
                month.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Recipient
                address is located in the same county as the contractor’s provider service
                area

            

    

    
      	
               

            	
              2.Recipient
                program codes (should be MS, MMS, or
                MWA)

            

    

    
      	
               

            	
              3.Residing
                in a nursing home

            

    

    
      	
               

            	
              4.Current
                enrollment in a Medicaid HMO

            

    

    
      	
               

            	
              5.Current
                enrollment in the MediPass Program

            

    

    
      	
               

            	
              6.Has
                presence of Medicare Parts A &
B

            

    

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    4.2 Effective
      Date of Enrollment

    

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

    
       

      4.3
        Transition Care Planning

       

    

    
      	
               

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

            

    

    
      	
               

            	
              B.CARES
                staff will notify the contractor, the lead agency, and when appropriate,
                hospital discharge planning staff regarding the need for a transition
                care
                plan. CARES staff will forward, to each of these entities, any information
                collected during the clinical eligibility determination process related
                to
                the person’s health status, functional status, caregiver, social support
                system, living environment and how current service needs are being
                met.

            

    

    
      	
               

            	
              C.By
                the first date of enrollment, (1) the contractor must provide transition
                care services in collaboration with CARES staff and (2) assume
                responsibility for meeting the enrollee’s care needs.  The
                contractor must ensure that enrollment in the project does not interrupt
                or delay the delivery of services needed by the
                enrollee.

            

    

    

    
      
        
        

      

      
        ATTACHMENT
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    4.4 Orientation

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Terms
                and conditions of enrollment including the reinstatement
                process.

            

    

    
      	
               

            	
              2.An
                explanation of the role of the case
                manager.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              9.Information
                regarding the enrollee’s rights and
                responsibilities.

            

    

    
      	
               

            	
              10.Grievance
                and appeals process.

            

    

    
      	
               

            	
              11.Information
                regarding the confidentiality of enrollee
                records.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              a)A
                detailed description of the contractor’s authorization and referral
                process for services.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              c)A
                detailed description of the contractor’s quality assurance
                program.

            

    

    
      	
               

            	
              d)A
                detailed description of the contractor’s credentialing
                process.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
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              e)The
                policies and procedures
                relating to the contractor’s prescription drug benefits
                program.

            

    

    
      	
               

            	
              f)The
                policies and procedures relating to the confidentiality and disclosure
                of
                the enrollee’s medical records.

            

    

    
      	
               

            	
              g)Information
                that enrollees may obtain from the contractor regarding quality
                performance indicators, including aggregate enrollee satisfaction
                data.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              14.Information
                that post-stabilization services are provided without prior authorization
                and other post-stabilization care services rules set forth in 42
                CFR
                422.113(c).

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Provider
                name

            

    

    
      	
               

            	
              2.Service(s)
                provided

            

    

    
      	
               

            	
              3.Provider
                location

            

    

    
      	
               

            	
              4.Provider
                telephone number

            

    

    
      	
               

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

            

    

    
      	
               

            	
               

            

    

    
      	
               

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

            

    

    

    4.5 Plan
      of Care

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              D.The
                plan of care must be based on a comprehensive assessment of the enrollee’s
                health status, physical and cognitive functioning, environment, social
                supports, and end-of-life decisions.  The plan of care must
                clearly identify barriers to the enrollee and caregivers, if
                applicable.  The case manager must discuss barriers and explore
                potential solutions with the enrollee, and caregivers when
                applicable.  The plan of care must detail all interventions
                designed to address specific barriers to independent
                functioning.  The plan may include services provided through the
                enrollee’s own informal network or by volunteers from community social
                service agencies or other organizations such as churches and
                synagogues.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 26

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

            	
              a.The
                enrollee’s name

            

    

    
      	
               

            	
              b.The
                enrollee’s Medicaid ID number

            

    

    
      	
               

            	
              c.Plan
                of Care effective date

            

    

    
      	
               

            	
              d.Plan
                of care review date

            

    

    
      	
               

            	
              e.Covered
                services provided including routine medical and HCBS
                services

            

    

    
      	
               

            	
              f.Begin
                date and end date

            

    

    
      	
               

            	
              g.Providers

            

    

    
      	
               

            	
              h.Amount
                and frequency

            

    

    
      	
               

            	
              i.Case
                manager’s signature

            

    

    
      	
               

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

            

    

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              4.Pursuant
                to 42 CFR 438.208(c)(3) and (c)(4), the contractor must produce a
                plan
                of
                care that addresses the health, social service, and special health
                care
                needs of the enrollee identified through an assessment.  The
                plan of care must be:

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 27

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              G.A
                copy of the plan of care must be forwarded to the enrollee’s primary care
                physician.

            

    

    
      	
               

            	
              H.A
                copy of the plan of care must be forwarded to the department’s CARES
                office within 30 days of
                development.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    4.6 Integration
      of Care

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 28

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    4.7  Disenrollment

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              D.The
                contractor must make
                disenrollment assistance available during business hours. This assistance
                must be available through a toll-free telephone number or face-to-face
                contact. The contractor’s written disenrollment procedure must list the
                staff responsible for this type of
                assistance.

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 29

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

            	
              G.Involuntary
                disenrollments are limited to the following
                reasons:

            

    

    
      	
               

            	
              1.Enrollee
                death.

            

    

    
      	
               

            	
              2.Ineligibility
                for Medicaid.

            

    

    
      	
               

            	
              3.Ineligibility
                for the project.

            

    

    
      	
               

            	
              4.Moving
                outside the project’s service area.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              6.Incarceration.

            

    

    
      	
               

            	
              7.Non-cooperation,
                subject to department approval.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 30

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    4.8
      Disputes of Appropriate Enrollments

    

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

    

    4.9 Medicaid
      Pending

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              I.The
                contractor will submit 834 enrollment transactions for the Medicaid
                Pending individuals to the Medicaid fiscal agent one week prior to
                the
                monthly submission date.  Additionally, the Florida Medicaid
                Management Information System (FMMIS) is designed to process the
                enrollment date retroactive up to a maximum of four (4) months prior
                to
                the first of the month following the CARES eligibility
                determination.  If circumstances require a determination of
                Medicaid eligibility by DCF for a Medicaid Pending individual that
                exceeds
                four months, the request for enrollment must be submitted via the
                manual
                enrollment process.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 31

        
          

        

      

      
        
        

      

    

     

    SECTION
      5  Enrollee Records

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              D.The
                contractor will ensure all subcontracted providers, including medical
                specialists and long-term care providers, properly document the care
                provided to enrollees including, diagnoses, medications, and treatment
                plans.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    SECTION
      6  SERVICE PROVISIONS

    

    General
      Provisions

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 32

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

            	
              D.The
                contractor may provide services beyond those required in this contract
                providing such services are safe, legal, medically prudent, and provided
                equally to any enrollee with similar needs without
                discrimination.  Such extra contractual services must be paid
                from program cost savings and may not be included in encounter data
                as
                reported under Section 11.4.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    6.2Long-Term
      Care Services

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.Assisted
                Living Services:  Personal care services, homemaker services,
                chore services, attendant care, companion services, medication oversight,
                and therapeutic social and recreational programming provided in a
                home-like environment in an assisted living facility licensed pursuant
                to
                Chapter 429 Part I, F.S., in conjunction with living in the
                facility.  This service does not include the cost of room and
                board furnished in conjunction with residing in the
                facility.  This service includes 24-hour on-site response staff
                to meet scheduled or unpredictable needs in a way that promotes maximum
                dignity and independence, and to provide supervision, safety and
                security.  Individualized care is furnished to persons who
                reside in their own living units (which may include dual occupied
                units
                when both occupants consent to the arrangement) which may or may
                not
                include kitchenette and/or living rooms and which contain bedrooms
                and
                toilet facilities.  The resident has a right to
                privacy.  Living units may be locked at the discretion of the
                resident, except when a physician or mental health professional has
                certified in writing that the resident is sufficiently cognitively
                impaired as to be a danger to self or others if given the opportunity
                to
                lock the door.  The facility must have a central dining room,
                living room or parlor, and common activity areas, which may also
                serve as
                living rooms or dining rooms.  The resident retains the right to
                assume risk, tempered only by a person's ability to assume responsibility
                for that risk.  Care must be furnished in a way that fosters the
                independence of each consumer to facilitate aging in
                place.  Routines of care provision and service delivery must be
                consumer-driven to the maximum extent possible, and treat each person
                with
                dignity and respect.  Assisted living services may also
                include:  physical therapy, occupational therapy, speech
                therapy, medication administration, and periodic nursing
                evaluations.  The contractor may arrange for other authorized
                service providers to deliver care to residents of assisted living
                facilities in the same manner as those services would be delivered
                to a
                person in their own home.  The contractor shall be responsible
                for placing enrollees in the appropriate Assisted Living Facility
                setting.   Note:  Assistive Care Services are
                covered under this contract and cannot be billed separately by the
                Assisted Living Facility.

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              R.Physical
                Therapy:  Treatment to restore, improve or maintain impaired
                functions by using activities and chemicals with heat, light, electricity
                or sound, and by massage and active, resistive, or passive exercise
                when
                determined through a multi-disciplinary assessment to improve an
                enrollee’s capability to live safely in the home
                setting.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    6.3Minimum
      Long-Term Care Service Provider Qualifications

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              P.Respite
                Care Providers:  Providers must be employed by a licensed home
                health agency pursuant to Chapter 400, Part III, F.S.; or have a
                certificate of registration issued by the Agency for Health Care
                Administration pursuant to Section 400.509, F.S.; or be a lead agency
                as
                defined in Section 430.203(9), F.S.; or be an Adult Day Care Center
                licensed pursuant to Chapter 429, Part III, F.S.; or be an Assisted
                Living
                Facility licensed pursuant to Chapter 429, Part I, F.S.; or be a
                Nursing
                Facility licensed pursuant to Chapter 400, Part I, F.S.; or be individuals
                contracted by a nurse registry pursuant to Section 400.506, F.S.;
                or be a
                hospice licensed pursuant to Chapter 400, Part IV,
                F.S.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    

    
      
        
        

      

      
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    6.4Acute-Care
      Services

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              F.Inpatient
                Hospital Services:  Medically necessary services, including
                ancillary services, furnished to inpatient enrollees, provided under
                the
                direction of a physician or dentist, in a hospital maintained primarily
                for the care and treatment of patients with disorders other than
                mental
                diseases.  Such services must be provided in accordance with the
                policy and service provisions specified in the Medicaid Hospital
                Coverage and Limitations
                Handbook.

            

    

     

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              I.Prescribed
                Drug Services:  Prescribed drug services for dual eligible
                Medicaid beneficiaries are covered as per the Medicare Modernization
                Act
                (MMA).  However, Section 103(c) of the MMA added §1935(d)(2) to
                the Social Security Act to allow State Medicaid programs to continue
                to
                provide and receive Federal Financial Participation (FFP) for certain
                drugs not included in the Medicare Prescription Drug benefit (Part
                D).
                Drugs excluded from Part D coverage are listed in §1927(d)(2) of the
                Act.  Contractors shall provide certain drugs not included in
                Part D as described in the Medicaid Prescribed Drugs Services and
                Limitations Handbook.   The contractor’s pharmacy
                benefits management program must comply with all applicable federal
                and
                state laws. 

            

    

    
      	
               

            	
              J.Vision
                Services:  Medically necessary eye
                examinations.  Eyeglass repairs and
                adjustments.  Eyeglasses are limited to two pair every 365
                days.  Such services must be provided in accordance with the
                policy and service provisions specified in the Medicaid Vision
                Services Coverage and Limitations Handbook, and must be provided by
                providers licensed under Chapter 484, Part I, or 463,
                F.S..

            

    

    
      	
               

            	
              K.Hospice
                Services:  End of life services provided to enrollees electing
                hospice services.  Services will be provided in accordance with
                the policy and services provisions specified in the Hospice Services
                Coverage and Limitations
                Handbook.

            

    

    

    6.5
      Acute Care Provider Qualifications

    

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

    

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

    
       

      6.6
        Optional Services

    

     

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

    

    6.7
      Expanded Services

    

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

    

    
      
        
        

      

      
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    6.8
      Availability/Accessibility of Services

    

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

    

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

    

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

    

    6.9 
      Staffing Requirements

    

    The
      contractor is responsible for the following staffing requirements:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              G.Sufficient
                support staff to conduct daily business in an orderly manner, including
                having enrollee services staff directly available during business
                hours
                for enrollee services consultation, as determined through management
                and
                medical reviews.

            

    

    
      	
               

            	
              H.The
                contractor must maintain sufficient staff available 24 hours per
                day to
                handle care inquiries.

            

    

    
      	
               

            	
              I.A
                person designated to be responsible for the contractor’s utilization
                control.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    6.10Emergency
      Care Requirements

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    6.11Out
      of Network Use of Non-Emergency Services

    

    Unless
      otherwise specified in this document, when an enrollee uses non-emergency
      services available under the project from a non-subcontracted provider, the
      contractor is not liable for the cost of such utilization unless the contractor
      referred the enrollee to the non-subcontracted provider or authorized such
      out-of-network utilization.  The contractor must provide timely
      approval or denial of authorization of out-of-network use through the assignment
      of a prior authorization number that refers to and documents the
      approval.  A contractor may not require paper authorization as a
      condition of an enrollee receiving treatment if the contractor has an automated
      authorization system.  Written follow-up documentation of the approval
      must be provided to the out-of-network provider within one business day from
      the
      request for approval.  The enrollee is liable for the cost of such
      unauthorized use of contract-covered services from non-subcontracted
      providers.  However,
      in accordance with the Balanced Budget Act of 1997, and pursuant to 42 CFR
      422.100(b)(1)(iii), the plan must also cover post-stabilization services without
      authorization, regardless of whether the enrollee obtains the service within
      or
      outside the plan’s network, for the following situations:

     

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      
        
        

      

      
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    6.12Adult
      Protective Services

    

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

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Adult
                Protective Services Referral Form,

            

    

    
      	
               

            	
              2.Adult
                Safety Assessment of Safety
                Factors,

            

    

    
      	
               

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

            

    

    
      	
               

            	
              4.Court
                Order, if services were court
                ordered,

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    

    
      
        
        

      

      
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    SECTION
      7 UTILIZATION MANAGEMENT

    

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

    

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

    

    
      	
               

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

            

    

    
      	
               

            	
              2.The
                reasons for the action.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

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

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
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              6.For
                expedited service authorization decisions, within the time frames
                specified in 42 CFR 438.210(d).

            

    

    

    SECTION
      8Quality Assurance and Improvement Requirements

    

    8.1General

    

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

    

    8.2Quality
      Assurance Program

    

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

    
      	
               

            	
              A.A
                written description of the quality assurance
                program.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.A
                procedure for quality assurance program
                supervision.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              K.A
                procedure for utilization review.

            

    

    
      	
               

            	
              L.A
                procedure for quality assurance program
                documentation.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              N.A
                continuity of care system.

            

    

    
      	
               

            	
              O.An
                active quality assurance committee.

            

    

    

    
      
        
        

      

      
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    8.3Quality
      Assurance Committee

    

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

    

    The
      quality assurance committee must:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    8.4Quality
      of Care Studies

    

    The
      contractor must conduct quarterly reviews to monitor the quality of care for
      this program.  In accordance with Section 409.912(27)(b) F.S., the
      studies must:

    
      	
               

            	
              A.Target
                specific conditions and health service delivery issues appropriate
                to
                enrollees for focused monitoring and
                evaluation.

            

    

    
      	
               

            	
              B.Use
                clinical care standards or practice guidelines to objectively evaluate
                health services delivery issues and the care the contractor delivers
                or
                fails to deliver for acute and long-term care
                conditions.

            

    

    
      	
               

            	
              C.Use
                quality indicators derived from the clinical care standards or practice
                guidelines to screen and monitor care and services
                delivered.

            

    

    

    The
      reviews must include quarterly monitoring of long-term care records of enrollees
      who have received services during the previous quarter. The contractor’s
      selection of conditions and issues to study should be based on member profile
      data.  There should be a minimum of three quality of care studies.
      Review elements include management of diagnosis, appropriateness and timeliness
      of care, comprehensiveness of and compliance with the plan of care, and evidence
      of special screening
      for, and monitoring of, high-risk persons and conditions.

     

    8.5Independent
      Medical Review

    

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

    

    
      
        
        

      

      
        ATTACHMENT
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    8.6Incident
      Reporting

    

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

    

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

    

    

    SECTION
      9Grievance/Appeals
      Procedures

    

    9.1Grievance
      System Requirements

    

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

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.A
                grievance or appeal involving clinical
                issues.

            

    

     

    
      
        
        

      

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

    
      	
               

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

            

    

    
      	
               

            	
              Office
                of Public Assistance Appeals
                Hearings

            

    

    
      	
               

            	
              1317
                Winewood Boulevard, Building 5, Room
                203

            

    

    
      	
               

            	
              Tallahassee,
                Florida 32399-0700

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.The
                availability of assistance in the filing
                process.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    Agency
      for Health Care Administration

    Bureau
      of Managed Health Care, Building 1, Room 339

    2727
      Mahan Drive, Tallahassee, Florida 32308

    1-888-419-3456

    
      	
               

            	
              6.Notice
                that the contractor must continue enrollee benefits
                if:

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              (d)The
                authorization period has not expired;
                and

            

    

    
      	
               

            	
              (e)The
                enrollee requests extension of
                benefits.

            

    

    

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

    

    
      	
               

            	
              9.2
                Appeal Process

            

    

    

    An
      appeal
      is a request for review of an “action” as defined in Section 13,
      Definitions.  An enrollee may file an appeal, and a provider, acting
      on behalf of the enrollee and with the enrollee’s written consent, may file an
      appeal.  The appeal procedure must be the same for all
      enrollees.

     

    
      	
               

            	
              A.
                Filing Requirements

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
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              B.Contractor
                Duties

            

    

    The
      contractor must:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              6.Continue
                the enrollee's benefits if:

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              c)The
                services were ordered by an authorized
                provider;

            

    

    
      	
               

            	
              d)The
                authorization period has not expired;
                and

            

    

    
      	
               

            	
              e)The
                enrollee requests extension of
                benefits.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    Office
      of Public Assistance Appeals Hearings

    1317
      Winewood Boulevard, Bldg. 5, Room 203,

    Tallahassee,
      Florida 32399-0700

    
      	
               

            	
              c)Notice
                of the right to continue to receive benefits pending a
                hearing.

            

    

    
      	
               

            	
              d)Information
                about how to request the continuation of
                benefits.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
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              11.If
                the contractor continues or reinstates enrollee benefits while the
                appeal
                is pending, the benefits must be continued until one of following
                occurs:

            

    

    
      	
               

            	
              a)The
                enrollee withdraws the appeal.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      	
               

            	
              C.Expedited
                Process

            

    

    

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

    

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              3.Provide
                written notice of disposition.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

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

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

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

            

    

    
      	
               

            	
              4.Fulfill
                all contractor duties listed above.

            

    

    

    
      	
               

            	
              9.3Grievance
                Process

            

    

    

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

    
      	
               

            	
              A.Filing
                Requirements

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      	
               

            	
              B.Contractor
                Duties

            

    

    The
      contractor must:

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

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

    

    
      	
               

            	
              9.4Medicaid
                Fair Hearing System

            

    

    

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

    

    
      	
               

            	
              A.Request
                Requirements

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              B.Contractor
                Duties

            

    

    The
      contractor must:

     

     

    
      
        
        

      

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              (1)
                Within 10 days of the date on the notice of action (Add five (5)
                days if
                the notice is sent via U.S. mail).

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              c)The
                services were ordered by an authorized
                provider;

            

    

    
      	
               

            	
              d)The
                authorization period has not expired;
                and

            

    

    
      	
               

            	
              e)The
                enrollee requests extension of
                benefits.

            

    

    
      	
               

            	
              2.Ensure
                punitive action is not taken against a provider who requests a Medicaid
                fair hearing on the enrollee’s behalf or supports an enrollee’s request
                for a Medicaid fair hearing.

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              2.Ten
                days pass from the date of the contractor’s adverse contractor decision
                and the enrollee has not requested a Medicaid fair hearing with
                continuation of benefits until a Medicaid fair hearing decision is
                reached.  (Add five (5) days if the notice is sent via U.S.
                mail.)

            

    

    
      	
               

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

            

    

    
      	
               

            	
              4.The
                authorization expires or authorized service limits are
                met.

            

    

    

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

    

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

    

    SECTION
      10Payment

    
      	
               

            	
              10.1Payment
                to Contractor

            

    

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

    
      	
               

            	
              10.2Capitation
                Rates

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.In
                accordance with 42 CFR 438.6(c)(1)(i), capitation rates are to be
                developed and certified as actuarially sound, appropriate for the
                populations to be covered, and the services to be furnished under
                the
                contract.

            

    

    

    
      
        
        

      

      
        ATTACHMENT
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              10.3Payment
                in Full

            

    

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

     

    10.4Capitation
      Payments

    
      	
               

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

            

    

    
      	
               

            	
              B.The
                Agency agrees to reflect changes in the Medicaid fee-for-service
                program.  The rate of payment and total dollar amount may be
                adjusted with a properly executed amendment when Medicaid fee-for-service
                expenditure changes have been established through the appropriations
                process and subsequently identified in the Agency’s operating
                budget.  Legislatively mandated changes will take effect on the
                dates specified in the legislation.

            

    

    

    
      	
               

            	
              10.5Payment
                Discrepancies

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    

    SECTION
      11ProgramReporting Requirements

    

    11.1
      General Requirements

    

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

    

    
      	
               

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

            

    

    
      	
               

            	
              1.Individual
                Level - One report is required for each enrollee, e.g., one grievance
                record for each grievance, one record per long-term care
                service.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 53

        
          

        

      

      
        
        

      

    

    
      	
               

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

            

    

    
      	
               

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

            

    

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

     

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

    

    
      	
              Report
                Name

            	
              Level
                of Analysis

            	
              Reporting
                Frequency

            	
              Submission
                Method

            	
              Reporting
                Location

            
	
              834
                Transactions

               

            	
              Location

            	
              Monthly,
                by 4:00 PM on the Wednesday preceding the second to last
                Saturday.

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

            	
              Fiscal
                Agent

            
	
              Supplemental
                834 Transaction

            	
              Location

            	
              Monthly,
                by 4:00 PM on the Wednesday prior to 834 transactions

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

            	
              Fiscal
                Agent

            
	
              Disenrollment
                Summary Report

               

            	
              Location

            	
              Monthly
                within 5 calendar days after the beginning of the reporting
                month

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

            	
              Department

            

    

    
      
        
        

      

      
        ATTACHMENT
          I - Page 54

        
          

        

      

      
        
        

      

    

    
      	
              Report
                Name

            	
              Level
                of Analysis

            	
              Reporting
                Frequency

            	
              Submission
                Method

            	
              Reporting
                Location

            
	
              Encounter
                Data Report

            	
              Individual

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

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

            	
              Department

            
	
              Grievance/Appeals
                Report

            	
              Individual

            	
              Quarterly
                within 5 calendar days of end or reporting calendar
                quarter

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

            	
              Department

            
	
              Updated
                Provider Network and Staff Listing

            	
              Location

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

            	
              Electronic
                Mail (with password protection for HIPAA related information) to
                DiversionReports@elderaffairs.org

              or
                mail via a compact disk or diskette (with password protection for
                HIPAA
                related information)

            	
              Department

            
	
              Minority
                Business Enterprise Contract Reporting

            	
              Contractor

            	
              April
                15, July 5, October 15, January 15

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

            	
              Department

            
	
              Financial
                Statements

            	
              Contractor

            	
              Quarterly,
                within 45 days of end of reporting quarter

            	
              Agency
                Supplied Template on Compact Disc, Diskette or Hard Copy

            	
               Department

               

            
	
              Audited
                Financial Statement

            	
              Contractor

            	
              Annually,
                within 120 days of end of contractor’s fiscal year

            	
              Electronic
                Mail, Compact Disc Diskette or Hard Copy

            	
              Department

            
	
              Emergency
                Management Plan

            	
              Contractor

            	
              Annually,
                April 30

            	
              Electronic
                Mail, Compact Disc, Diskette or Hard Copy

            	
              Department

            
	
              Enrollee
                Satisfaction Survey

            	
              Contractor

            	
              Annually,
                May 15

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

            	
              Department

            

    

     

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 55

        
          

        

      

      
        
        

      

    

     

    
      	
              Report
                Name

            	
              Level
                of Analysis

            	
              Reporting
                Frequency

            	
              Submission
                Method

            	
              Reporting
                Location

            
	
              Insolvency
                Fund Statements

            	
              Contractor

            	
              Monthly
                Statements

            	
              Electronic
                Mail or Hard Copy

            	
              Department

            
	
              Reconciliation
                Report

            	
              Individual

            	
              Within
                five (5) days of receipt of fiscal agent reports and ten (10) days
                of
                receipt of remittance vouchers

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

            	
              Department

            

    

    

    11.2 834
      Transactions

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    

    
      11.3 Disenrollment
        Summary Report

    

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

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

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 56

        
          

        

      

      
        
        

      

      
        11.4 Encounter
          Data Report

      

    

     

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

    

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

    

    11.5 Grievance/Appeals
      Report

    

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

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

    

    11.6 Updated
      Provider Network and Staff Listing

    

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

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

    If
      the
      contractor has not added or terminated a subcontract to its provider network
      within the reporting quarter, a statement to that effect shall be provided
      to
      the department in lieu of an updated Provider Network and Staff
      Listing.

    

    
      
        
        

      

      
        ATTACHMENT
          I - Page 57

        
          

        

      

      
        
        

      

    

     

    11.7
      Minority Business Enterprise Contract Reporting

    

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

    

    11.8
      Emergency Management Plan

    

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

    

    11.9  Enrollee
      Satisfaction Reporting

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

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

    

    11.10   Hospice
      Services

    

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

    

    

    SECTION
      12Financial Reporting

    
       

      12.1 
        General

    

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

    

    12.2 
      Member Payment Liability Protection

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

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 58

        
          

        

      

      
        
        

      

    

     

    
      12.3 
        Financial Reporting Template

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

    
      	
               

            	
              A.Master
                financial sheet - This is the balance sheet, profit and loss statement
                and
                changes in financial position that reflects four (4) quarters plus
                the
                contractor’s fiscal year totals.  Variances have been placed
                within the quarters to track fluctuations on a line-item
                basis.  Ratios have been created to monitor or detect material
                weaknesses in the contractor.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              C.Profit
                and Loss sheets - Contains three (3) sheets to track individual
                performance by commercial, Medicare, and Medicaid product
                lines.

            

    

    
      	
               

            	
              D.Aggregate
                write-in sheets - These four (4) sheets track any information recorded
                on
                the balance sheet or profit and loss statements, which needs further
                explanation.

            

    

    
      	
               

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

            

    

    12.4 
      Audited Financial Statements

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

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

     

    12.5 
      Unaudited Quarterly Financial Statements

    
      	
               

            	
               

            

    

    The
      contractor must submit the following unaudited quarterly financial
      statements:  Balance Sheet, Statement of Revenues,
      Expenses, and Net Worth, and Statement of Changes in Financial
Position
      and Net Worth.

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 59

        
          

        

      

      
        
        

      

    

     

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

            	
              D.If
                additional supporting statements or schedules are added in connection
                with
                providing information on the financial statement, the additions should
                be
                properly keyed to the item being answered (Example - "Current Assets,
                #4").

            

    

    
      	
               

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

            

    

    
      	
               

            	
              F.Minimum
                requirements needed to run the financial report program
                include:  IBM compatible computer with an 80286 processor or
                higher, 3.5@ disk drive; hard disk drive, graphics display monitor
                EGA or
                VGA, 4 Mb of memory, mouse, MS-DOS 3.1 or later and Microsoft Windows
                3.1
                or later, Excel 5.0.

               

            

    

    
      	
               

            	
              1.Balance
                Sheet

            

    

    
      	
               

            	
              (a)Balance
                Sheet Asset Definitions:

            

    

    
      	
               

            	
              1)Current
                Assets - These assets are relatively liquid and usually held for less
                than one year.  Restricted assets for grants, contracts and
                reserves are not included.  Five general types of assets are
                usually included in the current asset
                classification.

            

    

    
      	
               

            	
              i.Cash
                - Money in any form, cash awaiting deposit, balances on deposit in
                checking accounts and certificates of deposit.  Funds with
                availability for current use that are restricted by contract, state
                reserve requirements or other formal arrangements are reported as
                Other
                Assets.  Loan funds held in escrow are reported as Other Assets.
                

            

    

    
      	
               

            	
              ii.Secondary
                Cash Resources - Various investments that are readily marketable, held
                for less than one year or intended for sale within a twelve-month
                period.  Any funds with availability for current use but
                restricted by contract, state requirement or other formal arrangements
                are
                excluded.

            

    

    
      	
               

            	
              iii.Short-Term
                Receivables - Open accounts receivable and notes receivable with
                short-term maturities of less than one
                year.

            

    

    
      	
               

            	
              iv.Short-Term
                Prepayments - Expenses, such as insurance, taxes, rent, paid for in
                advance of use in operations.  These items are usually referred
                to as prepaid expenses.

            

    

    
      	
               

            	
              v.Other
                - Includes inventories that are consumable supplies, such as x-ray,
                laboratory and other operating supplies.  The category includes
                items that will be consumed by the contractor during the current
                period in
                ordinary course of operation and items that are held for resale such
                as
                pharmacy inventories.

            

    

    
      	
               

            	
              2)Other
                Assets - Assets including insolvency requirements, contracts, grants
                and reserves.

            

    

    
      	
               

            	
              3)Property
                and Equipment - Fixed assets including land, building improvements,
                furniture and equipment.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          I - Page 60

        
          

        

      

      
        
        

      

    

     

    
      	
               

            	
              (b)Balance
                Sheet Asset Lines:

            

    

    
      	
               

            	
              1)Cash
                - Cash in the bank or on hand, available for current use and does
                not
                include restricted cash.

            

    

    
      	
               

            	
              2)Short-Term
                Investments - Readily saleable investments acquired with temporarily
                unneeded cash and do not include restricted
                securities.

            

    

    
      	
               

            	
              3)Premiums
                Receivable - Net-Gross amounts collectible from groups or enrollees
                who receive services from the contractor, less the amount accrued
                for
                premiums determined to be uncollectible for the period.  This
                should not include fee-for-service.

            

    

    
      	
               

            	
              4)Interest
                Receivable - Interest earned on investments but not
                received.

            

    

    
      	
               

            	
              5)Other
                Receivables - Net-Gross amounts collectible from sources other than
                enrollees or groups, less the amount accrued for receivables determined
                to
                be uncollectible during the period.  Example:
                fee-for-service.  This should not include restricted
                receivables.

            

    

    
      	
               

            	
              6)Prepaid
                Expenses - Future expenses paid in advance such as unexpired
                insurance.

            

    

    
      	
               

            	
              7)Aggregate
                Write-ins For Current Assets - Enter the total of the write-ins listed
                on the aggregate write-in sheet for current
                assets.

            

    

    
      	
               

            	
              8)Total
                Current Assets - Total of the above
                categories.

            

    

    
      	
               

            	
              9)Restricted
                Assets - Assets restricted for statutory insolvency
                requirements.

            

    

    
      	
               

            	
              10)Restricted
                Funds
                - Assets held for contract (i.e., Medicaid) grants, reserves including
                cash, securities, receivables, and
                other.

            

    

    
      	
               

            	
              11)Loan
                Escrow -
                Funds for which loan notes have been signed by the provider but not
                drawn
                down.  Funds may be held by the provider or an escrow
                agent.

            

    

    
      	
               

            	
              12)Long-Term
                Investments - Investments held for a period longer than twelve
                months.

            

    

    
      	
               

            	
              13)Intangible
                Assets
                and Goodwill Net - Assets of no physical substance.  These
                may include patents, copyrights, licenses, and
                franchises.  Provide gross amount less
                amortization.

            

    

    
      	
               

            	
              14)Aggregate
                Write-ins
                for Other Assets - Enter the total of the write-ins listed on lines
                1501 through 1597.

            

    

    
      	
               

            	
              15)Total
                Other
                Assets - Total of the above
                categories.

            

    

    
      	
               

            	
              16)Land
                - Real
                estate owned by the contractor.

            

    

    
      	
               

            	
              17)Buildings
&
                Improvements - Buildings owned by the contractor and improvements made
                to provider-owned buildings.

            

    

    
      	
               

            	
              18)Construction
                in
                Progress - Buildings or improvements in progress or under
                construction.  These items will be capitalized upon completion
                or utilization.

            

    

    
      	
               

            	
              19)Furniture
                and
                Equipment - Includes medical equipment, office equipment and furniture
                owned by the contractor.

            

    

    
      	
               

            	
              20)Aggregate
                Write-ins
                for Other Equipment - Enter the total of the write-ins listed on the
                aggregate write-in for property and
                equipment.

            

    

     

    
      
        
        

      

      
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              21)Total
                Property and
                Equipment-Net - Total of Property and Equipment categories, less
                Accumulated Depreciation.  The cumulative amount of depreciation
                on property and equipment.  Depreciation is an accounting
                practice recognizing the consumption of the value of a fixed asset
                during
                the asset's useful life.  Depreciation expenses are charged to
                the expense categories representing the cost center to which the
                fixed
                asset is assigned.

            

    

    
      	
               

            	
              22)Total
                Assets -
                Total of Current Assets, Other Assets and Net Property and
                Equipment.

            

    

    
      	
               

            	
              23)Details
                of Write-ins
                Aggregated for Current Assets - Show non-restricted current assets,
                including inventories, not included in the other Current Assets
                categories.

            

    

    
      	
               

            	
              24)Details
                of Write-ins
                Aggregated for Other Assets - Show non-current assets not included in
                the Other Assets categories.

            

    

    
      	
               

            	
              25)Details
                of Write-ins
                Aggregated for Other Equipment - Include automobiles, fixtures, and
                other fixed assets not reported in other Property and Equipment
                categories.

            

    

    

    
      	
               

            	
              (c)Balance
                Sheet Liabilities and Net Worth
                Definitions:

            

    

    
      	
               

            	
              1)Current
                Liabilities - Obligations whose liquidation is reasonably expected to
                occur within one year.  Three main classes or liabilities fall
                within this definition.

            

    

    
      	
               

            	
              2)Obligations
                for goods and services that were acquired for use in the operating
                cycle - These include claims for hospital and physician services and
                accounts payable.

            

    

    
      	
               

            	
              3)Other
                debts that may be expected to require payment within the operating
                cycle
                or one year - This includes short-term notes and the currently
                maturing portion of long-term
                obligations.

            

    

    
      	
               

            	
              4)Revenues
                received and recorded prior to being earned - These advances are often
                described as "deferred revenues."  The obligation to furnish the
                services or to refund the payment is recognized as a
                liability.  These include unearned
                premiums.

            

    

    
      	
               

            	
              5)Other
                Liabilities - Liabilities of a long-term nature; liquidation of
                liabilities is not expected in the current
                year.

            

    

    
      	
               

            	
              6)Net
                Worth -
                Includes ownership or donated capital, restricted funds, reserves,
                and
                earnings or losses.

            

    

    

    
      	
               

            	
              (d)Balance
                Sheet Liabilities and Net Worth
                Lines:

            

    

    
      	
               

            	
              1)Accounts
                Payable - Amounts due to creditors for the acquisition of goods and
                services (trade and vendors rather than health care providers) on
                a credit
                basis.

            

    

    
      	
               

            	
              2) Claims
                Payable (Reported) - Claims reported and booked as
                payables.

            

    

    
      	
               

            	
              3)Accrued
                Inpatient Claims (Not reported) - Hospital and institutional care
                claims incurred but not reported and/or booked as
                payables.

            

    

    
      	
               

            	
              4)Accrued
                Physician Claims (Not reported) - Claims incurred but not reported
                and/or booked as payables for physicians and ancillary (such as lab
                and
                x-ray) services by providers under an arrangement with the prepaid
                health
                plan.  These may include capitation payments to medical groups
                or fees to IPAs.

            

    

     

    
      
        
        

      

      
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              5)Accrued
                Referral Claims (Not reported) - Claims incurred but not reported
                and/or booked as payables for consultants and referrals to providers
                outside a contractor arrangement.  These claims are usually paid
                on a fee-for-service basis.

            

    

    
      	
               

            	
              6)Accrued
                Other Medical (Not Reported) - Other incurred medical expenses but not
                reported and/or booked as payables including emergency room, out-of-area
                services, and payroll.

            

    

    
      	
               

            	
              7)Accrued
                Medical Incentive Pool - Accruals for withholds from IPA’s or
                capitated medical groups and other such arrangements in which the
                provider
                may return incentive funds to
                contractors.

            

    

    
      	
               

            	
              8)Unearned
                Premiums - Income received or booked in advance of the period to which
                it applies.  A liability exists to render service in the
                future.

            

    

    
      	
               

            	
              9)Loans
                and Notes Payable - The principal amount on loans due within one
                year.

            

    

    
      	
               

            	
              10)Aggregate
                Write-Ins
                for Current Liabilities - Enter the total of the write-ins listed on
                the aggregate write-ins for current
                liabilities.

            

    

    
      	
               

            	
              11)Total
                Current
                Liabilities - Total of Current Liability
                Categories.

            

    

    
      	
               

            	
              12)Loans
                and Notes
                - Loans and notes signed by the contractor not including current
                portion   payable.  Include federal
                loans.

            

    

    
      	
               

            	
              13)Statutory
                Liability - Reserve required as a liability by statute (e.g.,
                government purchaser requirements).

            

    

    
      	
               

            	
              14)Aggregate
                Write-ins
                for Other Liabilities - Enter the total of the write-ins listed on the
                aggregate write-ins for other
                liabilities.

            

    

    
      	
               

            	
              15)Total
                Other
                Liabilities - Total of Other Liability
                Categories.

            

    

    
      	
               

            	
              16)Total
                Liabilities - Lines 4 and 8.

            

    

    
      	
               

            	
              17)Donated
                Capital
                - Capital donated to nonprofit organization.  Do not include
                loans.  Describe the nature of donation as well as any
                restrictions on this capital in the notes to financial
                statements.

            

    

    
      	
               

            	
              18)Capital
                - Par
                Value of stock.  Stated amount of owner’s direct equity in
                provider.

            

    

    
      	
               

            	
              19)Paid
                in Surplus
                - Amount over stated value of Line 10.  Reflects actual amount
                in excess of par or stated value.

            

    

    
      	
               

            	
              20)Unassigned
                Surplus - Unassigned Retained Earnings.  Cumulative earnings
                or deficit from operations, net of reserves and restricted
                funds.

            

    

    
      	
               

            	
              21)Aggregate
                Write-ins
                for Other Net Worth Items - Enter the total of the write-ins listed on
                the aggregate write-ins for net
                worth.

            

    

    
      	
               

            	
              22)Total
                Net Worth
                - Total of Lines 9 to 13.

            

    

    
      	
               

            	
              23)Total
                Liabilities
                and Net Worth - Total of Lines 9 and
                15.

            

    

    
      	
               

            	
              24)Details
                of Write-ins
                Aggregated for Current Liabilities - Show current liabilities not
                included in other Current Liabilities categories; include accrued
                payroll
                and taxes.

            

    

    
      	
               

            	
              25)Details
                of Write-ins
                Aggregated for Other Liabilities - Show other liabilities of a
                long-term nature.

            

    

     

    
      
        
        

      

      
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              25)Details
                of Write-ins
                Aggregated for Other Net Worth Items - May include statutory
                reserves, subordinated debt, and accrued interest on subordinated
                debt.

            

    

    

    
      	
               

            	
              2.Statement
                of Revenues, Expenses, and Net
                Worth

            

    

    
      	
               

            	
              (a)Revenue

            

    

    Components
      are broken down to show the sources of income and revenue dependency on public
      or private enrollment bases.  Coordination of Benefits (C.O.B.) and
      Insurance Recoveries are also shown.  Expenses:  Medical,
      Services, Administration and Marketing components are shown.  The
      report includes a contra item for year-end adjustments to the full expenses
      reported and for withholds or incentives claimed.  Report full-accrued
      revenues and expenses as defined below for the period.  Full expenses,
      whether or not the contractor ultimately bears financial responsibility, should
      be shown.  For example, the full hospital and institutional expenses
      are shown in "Inpatient" line.  Offsets to these expenses such as
      C.O.B. and Insurance Recoveries are shown as revenue.  Similarly, full
      physician service expenses are shown with a year end adjustment for withholds
      or
      other offsets returned to the provider as a contra category. Project staff
      should footnote differences in reporting if they are unable to report in lines
      similar to these revenue/expense accounts.

    
      	
               

            	
              (b)Statement
                of Revenues, Expenses, and Net Worth
                Lines

            

    

    
      	
               

            	
              1)Premium
                - Revenue recognized on a prepaid basis from enrollees and groups
                for
                provision of a specified range of health services over a defined
                period of
                time, normally one month.  Also included are premiums from
                Medicare Wrap-Around subscribers for health benefits which supplement
                Medicare coverage.  If advance payments are made to the
                contractor for more than one reporting period, the portion of the
                payment
                that has not yet been earned must be treated as a liability.
                

            

    

    
      	
               

            	
              2)Fee-for-Service
                - Revenue recognized by the contracting entity for provision of health
                services to non-enrollees by contractor providers and to enrollees
                through
                provision of health services excluded from their prepaid benefit
                packages.

            

    

    
      	
               

            	
              3)Co-payments
                - Revenue recognized by the contracting entity from enrollees on
                a
                utilization related basis for certain health services included in
                the HMO
                benefit package.

            

    

    
      	
               

            	
              4)Title
                XVIII Medicare - Revenue as a result of an arrangement between a
                provider and the Centers for Medicare and Medicaid Services for services
                to a Medicare beneficiary.

            

    

    
      	
               

            	
              5)Title
                XIX  Medicaid - Revenue as a result of an arrangement
                between a contractor and a Medicaid state agency for services to
                a
                Medicaid beneficiary.

            

    

    
      	
               

            	
              6)Interest
                - Interest earned from all sources, including the federal loan in
                escrow
                and reserve accounts.

            

    

    
      	
               

            	
              7)C.O.B.
                and Insurance Recoveries - Income from Coordination of Benefits and
                insurance recoveries.

            

    

    
      	
               

            	
              8)Reinsurance
                Recoveries - Income from the settlement of stop-loss (reinsurance)
                claims.

            

    

    
      	
               

            	
              9)Other
                Revenue - Revenue from sources not covered in the previous revenue
                accounts, such as recovery of bad debts or gain on sales of capital
                assets.

            

    

    
      	
               

            	
              10)Total
                Revenue - Total of the above revenue
                accounts.

            

    

     

    
      
        
        

      

      
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              11)Medical
                and Hospital - Expenses for health service delivery including the
                following components:

            

    

    
      	
               

            	
              i.  Physician
                Services - Expenses for physician services provided under contractual
                arrangement to the contractor including the
                following:  salaries, including fringe benefits, paid to
                physicians for delivery of medical services; capitated payments paid
                by
                the contractor to physicians for delivery of medical services to
                contractor subscribers; and fees paid by the contractor to physicians
                on a
                fee-for-service basis for delivery of medical services to contractor
                subscribers.  This includes capitated referrals.  Do
                not include expenses for medical personnel time devoted to administrative
                tasks.

            

    

    
      	
               

            	
              ii.  Other
                Professional Services - Compensation, including fringe benefits, paid
                by the contractor to non-physician providers engaged in the delivery
                of
                services and to personnel engaged in activities in direct support
                of the
                provision of medical services.  This includes dentists,
                psychologists, optometrists, podiatrists, extenders, nurses, clinical
                personnel such as ambulance drivers, technicians, para professionals,
                janitors, quality assurance analysts, administrative supervisors,
                secretaries to medical personnel, and medical record
                clerks.

            

    

    
      	
               

            	
              iii.  Outside
                Referrals - Expenses for services from providers not under provider
                arrangement such as consultations.

            

    

    
      	
               

            	
              iv.  Emergency
                Room, Out-of-Area, Other - Expenses for other non-contracted health
                delivery services incurred by contractor enrollees for which the
                contractor is responsible on a fee-for-service basis.  These
                include emergency room costs and out-of-area emergency physician
                and
                hospital costs.

            

    

    
      	
               

            	
              v.   Occupancy,
                Depreciation and Amortization - Expenses associated with medical
                services including the amount of depreciation and amortization expense
                which is directly associated with the delivery of medical
                services.  The costs of occupancy to the contractor which are
                directly associated with the delivery of medical
                services.  Included in occupancy are costs of using a facility,
                fire and theft insurance, utilities, maintenance, and
                lease.

            

    

    
      	
               

            	
              vi.   Inpatient
                - Inpatient hospital costs of routine and ancillary services
                for   enrollees while confined to an acute care
                hospital.  Does not include out-of-area
                hospitalization.

            

    

    
      	
               

            	
              vii.   Routine
                hospital service- includes regular room and board (including intensive
                care units, coronary care units, and other special inpatient hospital
                units), dietary and nursing services, medical surgical supplies,
                medical
                social services, and the use of certain equipment and facilities
                for which
                the contractor does not customarily make a separate
                charge.

            

    

    
      	
               

            	
              viii.    Ancillary
                services- may also include laboratory, radiology, drugs, delivery room
                and physical therapy services.  Ancillary services may also
                include other special items and services for which charges are customarily
                made in addition to routine service charge.  Charges for
                non-contractor physician services provided in a hospital are included
                in
                this line item only if included as an undefined portion of charges
                by a
                hospital to the contractor.  Include the cost of utilizing
                skilled nursing and intermediate care facilities.  Skilled
                nursing facilities are primarily engaged in providing skilled nursing
                care
                and related services for patients who require medical or nursing
                care or
                rehabilitation service.  Intermediate care facilities are for
                enrollees who do not require the degree of care and treatment which
                a
                hospital or nursing care facility provides, but do require care and
                services above the level of room and
                board.

            

    

     

    
      
        
        

      

      
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              ix.   Reinsurance
                Expenses - Expenses for Reinsurance or "Stop-loss"
                insurance.

            

    

    
      	
               

            	
              x.    Other
                Medical - Costs directly associated with the delivery of medical
                services under contractor arrangement which are not appropriately
                assigned
                to the medical expense categories defined above, e.g., costs of medical
                supplies, medical administration expense (except compensation),
                malpractice insurance, etc. 

            

    

    
      	
               

            	
              xi.   Incentive
                Pool Adjustment - A contra category for adjusting the full medical
                expenses reported.  For example, physician withholds or hospital
                volume discounts returned by or to the provider should be included
                here.  Adjustments should be made only on the annual
                report.

            

      	 	xii.    Total
              Medical and Hospital - Total of the above
              categories.

    

        

    

    
      	
               

            	
              (c)Administration
                - Costs associated with the overall management and operation of the
                contractor including the following
                components:

            

    

    
      	
               

            	
              1)Compensation
                - All expenses for administrative services including compensation
                and
                fringe benefits for personnel time devoted to or in direct support
                of
                administration.  Include expenses for management
                contracts.  Do not include marketing
                expenses.  However, when a management company pays rent,
                insurance, and other non-salary or non-commission payments, these
                amounts
                should not be reported as
                compensation.

            

    

    
      	
               

            	
              2)Interest
                Expenses - Interest on loans paid during
                period.

            

    

    
      	
               

            	
              3)Occupancy,
                Depreciation and Amortization - Expenses associated with
                administrative services including the costs of occupancy to the contractor
                entity which are directly associated with contractor
                administration.  Included in occupancy are costs of using a
                facility, fire and theft insurance, utilities, maintenance, and
                lease.  Do not include expenses for marketing in this
                category.

            

    

    
      	
               

            	
              4)The
                amount of
                depreciation and amortization expense which is directly associated
                with
                administrative services.  Depreciation expense is the
                incremental consumption of the value of a fixed asset during the
                asset's
                useful life.

            

    

    
      	
               

            	
              5)Amortization
                Expense - the cost of certain assets are spread over their estimated
                service lives, e.g., leasehold
                improvements.

            

    

    
      	
               

            	
              6)Marketing
                - Expenses directly related to marketing activities including
                advertising, printing, marketing representative compensation and
                fringe
                benefits, commissions, broker fees, travel, occupancy, and other
                expenses
                allocated to the marketing
                activity.

            

    

    
      	
               

            	
              7)Other
                - Costs which are not appropriately assigned to the health plan
                administration categories defined above.  Included are costs to
                update enrollee records, servicing of enrollee inquiries and complaints,
                claims adjudication and payment, legal, audit, data processing,
                accounting, insurance, bad debts, and all taxes except federal income
                taxes.  Do not include marketing
                expenses.

            

    

    
      
        
        

      

      
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              8)Total
                Administration - Total of the above
                categories.

            

    

    
      	
               

            	
              9)Total
                Expenses - Total of Medical and Hospital and Administration
                Expenses.

            

    

    
      	
               

            	
              10)Income
                (Loss) - Excess or deficiency of total revenues over total
                expenses.

            

    

    
      	
               

            	
              11)Extraordinary
                Item - A nonrecurring gain or loss that meets the following
                criteria:

            

    

    
      	
               

            	
               i.  The
                event must be unusual.  It should be highly abnormal and
                unrelated to, or only incidentally related to, the ordinary activities
                of
                the entity.

            

    

    
      	
               

            	
              ii.
                The event must occur infrequently.  It should be of a type that
                would not reasonably be expected to recur in the foreseeable
                future.

            

    

    
      	
               

            	
              iii.
                The following gains and losses are specifically not
                extraordinary:  write-down or write-off of accounts receivable,
                inventory, or intangible assets; gains or losses from changes in
                the value
                of foreign currency; gains or losses on disposal of a segment of
                a
                business; gains or losses from the disposal of fixed assets; effects
                of a
                strike; and adjustments of accruals on long-term
                contracts.

            

    

    
      	
               

            	
              12)Provision
                for taxes - State and federal taxes for the period (for-profit
                organizations only).

            

    

    
      	
               

            	
              13)Net
                Income (Loss) - Excess or deficiency of total revenues over total
                expenses less state and federal taxes for the
                period.

            

    

    
      	
               

            	
              3.Statement
                of Changes in Financial Position and Net
                Worth

            

    

    This
      report reflects the concept of funds as working capital, rather than the more
      limited cash concept.  Use brackets to show negative
      balances.  Inclusion of statutory reserves as a component of working
      capital is dependent in each situation on the use of the reserve as defined
      by
      the regulatory authority.  The applicable test is whether the reserve
      is available for use in current operations.  This report shows funds
      generated and applied to operations.  Sources and applications of
      funds indicate funds generated (or lost) from operations, as well as other
      sources and applications.  Net worth indicates changes in components
      of net worth over the past year.  Sources of funds used in operations
      including the following:

    

    
      	
               

            	
              (a)Statement
                of Changes in Financial Position and Net Worth
                Lines

            

    

    
      	
               

            	
              1)Net
                Income (Loss) - Report the figure calculated for this
                line.

            

    

    
      	
               

            	
              2)Add
                items not affecting working capital in the current period - depreciation,
                amortization and deferred taxes are expenses not affecting working
                capital.  These expenses are added
                back.

            

    

    
      	
               

            	
              3)Depreciation
                and Amortization

            

    

    
      	
               

            	
              4)Deferred
                Taxes - These are accrued taxes expensed for the period which are
                held
                for payment to the government during a later
                period.

            

    

    
      	
               

            	
              5)Show
                other expenses not affecting working
                capital.

            

    

    
      	
               

            	
              6)Other
                Additions to Working Capital:  Additions are generally from
                borrowing or from liquidating non-current assets and include the
                following:

            

    

    
      	
               

            	
              i.Proceeds
                from borrowing - Additions from borrowing which increase current
                asset
                accounts.

            

    

    
      	
               

            	
              ii.Show
                other additions to working capital.

            

    

    
      	
               

            	
              iii.Total
                Sources of Funds - Total of the above
                categories.

            

    

     

    
      
        
        

      

      
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              7)Applications
                - Uses of Working Capital, usually additions to non-current assets
                or
                reductions in long term liabilities, including the
                following:

            

    

    
      	
               

            	
              i.Additions
                to Property and Equipment - Increase in property and equipment from
                last
                period.

            

    

    
      	
               

            	
              ii.Reductions
                in Long-Term Debt - Decrease in long-term liabilities from last
                period.

            

    

    
      	
               

            	
              iii.Show
                other uses of Working Capital.

            

    

    
      	
               

            	
              iv.Total
                Applications of Funds - Total of the above
                categories.

            

    

    
      	
               

            	
              8)Increase
                (Decrease) in Working Capital - Excess or deficiency of Sources over
                Applications of Funds.

            

    

    
      	
               

            	
              9)Net
                Worth Beginning of Period

            

    

    
      	
               

            	
              10)Increase
                (Decrease) in Donated Capital

            

    

    
      	
               

            	
              11)Increase
                (Decrease) in Capital - (Current year less previous
                year)

            

    

    
      	
               

            	
              12)Increase
                (Decrease) in Reserves and Restricted Funds - (Current year less
                previous
                year)

            

    

    
      	
               

            	
              13)Increase
                (Decrease) in Unassigned Surplus - (Current year less previous
                year)

            

    

    
      	
               

            	
              14)Net
                Worth End of Period

            

    

     

    
      
        
        

      

      
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    SECTION
      13 DEFINITIONS

    The
      following terms as used in this contract, shall be construed and/or interpreted
      as follows, unless the context otherwise expressly requires a different
      construction and/or interpretation.

    Action
      - 42 CFR 438.400 - 1. The denial or limited authorization of a
      requested service, including the type or level of service.  2. The
      reduction, suspension, or termination of a previously authorized
      service.  3. The denial, in whole or in part, of payment for a
      service.  4. The failure to provide services in a timely manner, as
      defined by the state.  5.  The failure of the plan to act
      within the timeframes provided in 42 CFR 438.408(b).  6. For a
      resident of a rural area with only one managed care entity, the denial of a
      Medicaid enrollee's request to exercise his or her right, under 42 CFR
      438.52(b)(2)(ii), to obtain services outside the network 

    

    ADL
      - Activities of Daily Living; include, dressing, grooming, bathing,
      eating, transferring in and out of bed or a chair, walking, climbing stairs,
      toileting, bladder/bowel control, and the wearing and changing of incontinent
      briefs.

    Advance
      Directives- refers to oral and written
      instructions authorizing another to act as one’s agent or attorney regarding
      future medical care. (Examples: Living Will and Durable Power of
      Attorney)

    Adverse
      Determination - Adverse determination means any
      instance in which coverage for the requested service is denied, reduced, or
      terminated.  The contractor’s decision to deny, reduce or terminate
      coverage must be based on the review of whether an admission, availability
      of
      care, continued stay, or other service required in accordance with this contract
      meets the contractor’s requirements for medical necessity, appropriateness,
      health care setting, level of care, or effectiveness.

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

    Ancillary
      Services - Services provided at a hospital
      include, but are not limited to, radiology, pathology, neurology, and
      anesthesiology as specified in the Hospital Coverage and Limitations
      Handbook.

    Appeal
      - 42 CFR 438.400 - A request for review of action.

    Area
      Agency on Aging - an agency designated by the
      department to develop and administer a plan for a comprehensive and coordinated
      system of services for older persons.

    Assessment –an
      individualized comprehensive appraisal of an individual’s medical,
      developmental, mental, social, financial, and environmental status conducted
      by
      a qualified individual for the purpose of determining the need for long term
      care services.  

    Benefits
      - a schedule of medical or social services to be delivered to enrollees
      covered under this contract.

    CMS–
      Centers for Medicare and Medicaid Services.

    Capitation
      Rate - the monthly fee paid by the Agency to the
      contractor for each enrollee enrolled under the contract for the provision
      of
      services during the payment period.

    Care
      Plan - See Plan of Care. 

    CARES
      - Comprehensive Assessment and Review for Long Term Care
      Services.  A nursing home pre-admission assessment program, which
      provides a comprehensive, on-site assessment of individuals seeking admission
      to
      a nursing home under a state assisted program.  The program explores
      all available options to nursing home placement and recommends, and may
      facilitate alternative placements for individuals who are determined able to
      remain in the community.

    CFR
      - Code of Federal Regulations.

     

    
      
        
        

      

      
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    Cold-call
      marketing - Any unsolicited personal contact by
      the contractor or subcontractors with a potential enrollee for the purpose
      of
      marketing.

    Complaints–
      See Grievance

    Contractor
      - the organizational entity serving as the primary contractor and with
      whom this agreement is executed.  The term contractor shall include
      all employees, subcontractors, agents, volunteers, and anyone acting on behalf
      of, in the interest of, or for a contractor.

    Covered
      Services - see Benefits.

    Department
      - Department of Elder Affairs.

    DCF- Department
      of Children and Families

    DHHS
      - United States Department of Health and Human Services.

    Disenrollment
      - the discontinuance of an enrollee's membership in the contractor’s
      plan.  

    Durable
      Medical Equipment - medical equipment that can
      withstand repeated use; is primarily and customarily used to serve a medical
      purpose; is generally not useful in the absence of illness or injury; and is
      appropriate for use in the recipient's home.

    Emergency
      Medical Condition– according to 42 CFR 438.114(a)
      means a medical condition manifesting itself by acute symptoms of sufficient
      severity (including severe pain) that a prudent layperson, who possesses an
      average knowledge of health and medicine, could reasonably expect the absence
      of
      immediate medical attention to result in the following:

    
      	
               

            	
                  (1)
                Placing the health of the individual (or, with respect to
                a
                pregnant woman, the health of the woman or   her unborn
                child) in serious jeopardy.

            

    

        (2)
      Serious impairment to bodily functions.

        (3)
      Serious dysfunction of any bodily organ or part.

    Emergency
      Services - according to 42 CFR 438.114(a) means
      covered inpatient and outpatient services that are as follows:

        (1)
      Furnished by a provider that is qualified to furnish these services
      under this title.

        (2)
      Needed to evaluate or stabilize an emergency medical
      condition.

    Enrollee
      - according to 42 CFR 438.10(a) means a Medicaid recipient who is
      currently enrolled in a MCO as defined in 42 CFR 438.10(a). See
“Member.”

    Enrollment
      - the process by which an eligible Medicaid recipient becomes an
      enrollee in the Long Term Care Community Diversion Pilot Project.

    Existing
      diversion provider - an entity that is
      approved by the department on or before June 30, 2007, to provide services
      to
      consumers through any Long-Term Care Community Diversion Pilot Project
      authorized under Chapter 430.701- 430.709, F.S.. 

    

    Extraordinary
      Reporting – reporting
      of awareness or discovery of conditions that may
      materially affect the contractor’s ability to perform services under this
      contract. 

    Facility
      - any premises (a) owned, leased, used or operated directly or
      indirectly by or for the contractor or its affiliates for purposes related
      to
      this contract; or (b) maintained by a sub-contractor to provide services on
      behalf of the contractor.

    Fair
      Hearing - the opportunity to present one’s case to
      a reviewing authority in accordance with the terms and conditions in 42 CFR
      Part
      431, State Organization and General Administration, Subpart E, and 59G-1.030,
      Florida Administrative Code.

    Fiscal
      Agent - any corporation or other legal entity that
      has contracted with the Agency to receive, process and adjudicate claims under
      the Medicaid program. 

     

    
      
        
        

      

      
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    FMMIS-
      Florida Medicaid Management Information System, Medicaid fiscal agent utilizes
      this system
      for all Medicaid related data and information. 

    Furnished
      - means supplied, given, prescribed, ordered, provided, or directed
      to
      be provided in any manner.

    Grievance  -
      means an expression of dissatisfaction about any matter other than
      an
      action, as "action" is defined in this section.  The term is also used
      to refer to the overall system that includes grievances and appeals
      handled at the contractor level and access to the Medicaid fair hearing
      process.  (Possible subjects for grievances include, but are not
      limited to, the quality of care or services provided, and aspects of
      interpersonal relationships such as rudeness of a contractor or employee, or
      failure to respect the enrollee's rights.)  (42 CFR
      438.2)

    Grievance
      Procedure - the procedure for addressing
      enrollees' grievances.  A grievance is an enrollee’s expression of
      dissatisfaction with any aspect of their care other than the appeal of actions
      (which is an appeal).

    Grievance
      System - the system for reviewing and resolving
      enrollee grievances or appeals.  Components must include a grievance
      process, an appeal process, and access to the Medicaid fair hearing
      system.

    Grievant
      - an enrollee, subcontractor, or other service provider that files a
      grievance with the contractor.

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

    HMO
      - Health Maintenance Organization as certified pursuant to Chapter 64l,
      F.S..

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

    IADL
      - Instrumental Activities of Daily Living; include making and answering
      telephone calls, shopping, transportation ability, preparing meals, laundry,
      light housekeeping, heavy chores, taking medication, and managing
      money.

    ICP
      - The Medicaid Institutional Care Program.

    Ineligible
      Recipient - a Medicaid recipient that does not
      qualify for enrollment in the Long Term Care Community Diversion
      Program.

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

    Lead
      Agency - means an entity designated by an area
      agency on aging and given the authority and responsibility to coordinate
      services for functionally impaired elderly persons.

    Long-Term
      Care Record - a record that includes information
      regarding the medical and long-term care services an enrollee is receiving
      including the plan of care and documentation of case management activities
      including efforts to coordinate and integrate the delivery of all services
      to
      the enrollee.

    Marketing
      - any activity conducted by or on behalf of the contractor where
      information regarding the services offered by the contractor is disseminated
      in
      order to encourage eligible enrollees to enroll or accept any application for
      enrollment in the Long Term Care Community Diversion Program developed under
      this contract.

     

     

    
      
        
        

      

      
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    Medicaid
      - the medical assistance program authorized by Title XIX of the federal
      Social Security Act,
      42
      U.S.C. s.1396 et seq., and regulations there under, as administered in this
      state by the Agency under Chapter 409.901 et seq., F.S.

    Medicaid
      HMO– an HMO as defined in the Medicaid State
      Plan.

    Medically
      Necessary or Medical Necessity - services provided
      in accordance with 42 CFR  438.210(a)(4) and as defined in Section
      59G-1.010(166), F.A.C., to include that medical or allied care, goods, or
      services furnished or ordered must:

    A.
      Meet the following conditions:

    
      	
               

            	
              1.Be
                necessary to protect life, to prevent significant illness or significant
                disability, or to alleviate severe
                pain;

            

    

    
      	
               

            	
              2.Be
                individualized, specific, and consistent with symptoms or confirmed
                diagnosis of the illness or injury under treatment, and not in excess
                of
                the patient’s needs;

            

    

    
      	
               

            	
              3.Be
                consistent with the generally accepted professional medical standards
                as
                determined by the Medicaid program, and not experimental or
                investigational;

            

    

    
      	
               

            	
              4.Be
                reflective of the level of service that can be safely furnished,
                and for
                which no equally effective and more conservative or less costly treatment
                is available, statewide; and

            

    

    
      	
               

            	
              5.Be
                furnished in a manner not primarily intended for the convenience
                of the
                recipient, the recipient’s caretaker, or the
                contractor.

            

    

    
      	
               

            	
              B.  “Medically
                necessary” or “medical necessity” for inpatient hospital services requires
                that those services furnished in a hospital on an inpatient basis
                could
                not, consistent with the provisions of appropriate medical care,
                be
                effectively furnished more economically on an outpatient basis or
                in an
                inpatient facility of a different
                type.

            

    

    
      	
               

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

            

    

    Medicare
      - the medical assistance program authorized by Title XVIII of the
      federal Social Security Act, 42 U.S.C. s. 1395 et seq., and regulations there
      under.

    Nursing
      Facility - an institutional care facility licensed
      under Chapter 395, F.S., or Chapter 400, F.S., that furnishes medical or allied
      inpatient care and services to individuals needing such services.

    Other
      Qualified Provider– a contracted provider who
      meets the qualifications of Chapter 430.703(7), F.S..

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

    Peer
      Review - an evaluation of the professional
      practices of a provider by peers of the provider in order to assess the
      necessity, appropriateness, and quality of care furnished as such care is
      compared to that customarily furnished by the provider's peers and to recognized
      health care standards.

    Plan
      of Care - A plan which describes the service needs
      of each recipient, showing the projected duration, desired frequency, type
      of
      provider furnishing each service, and scope of the services to be
      provided.

    Potential
      Enrollee - according to 42 CFR 438.10(a) means a
      Medicaid recipient who is subject to mandatory enrollment or may voluntarily
      elect to enroll in a given managed care program, but is not yet an enrollee
      of a
      specific managed care program.

     

    
      
        
        

      

      
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    Prepaid
      Health Plan or Plan - the prepaid health care plan
      developed by the contractor in performance of its duties and responsibilities
      under this contract; or a contractual arrangement between the Agency and a
      comprehensive health care contractor for the provision of Medicaid care, goods,
      or services on a prepaid basis to Medicaid recipients.

    Primary
      Care Physician - a Medicaid-participating or
      prepaid health plan-affiliated physician practicing as a general or family
      practitioner, internist, pediatrician, obstetrician, gynecologist, or other
      specialty approved by the Agency, who furnishes primary care and patient
      management services to an enrollee.

    Prior
      Authorization - the act of authorizing specific
      services before they are rendered. 

    Project
      - Long Term Care Community Diversion Program.

    Protocols
      - written guidelines or documentation outlining steps to be followed
      for handling a particular situation, resolving a problem, or implementing a
      plan
      of medical, social, nursing, psycho social, developmental and educational
      services.

    Provider
      - a person or entity who is responsible for or
      directly provides any medical or social services authorized by this
      contract.

    Provider
      Handbook - a document that provides information to
      a Medicaid provider regarding enrollee eligibility, claims submission and
      processing, provider participation, covered care, goods, or services and
      limitations, procedure codes and fees, and other matters related to Medicaid
      program participation.

    Quality
      Assurance - the process of assuring that the
      delivery of health care is appropriate, timely, accessible, available, and
      medically necessary.

    Recipient
      - any individual whom the Department of Children and Families
      determines is eligible, pursuant to federal and state law, to receive medical
      or
      allied care, goods, or services for which the Agency may make payments under
      the
      Medicaid program and is enrolled in the Medicaid program.

    Risk
      - the potential for loss that is assumed by an entity and that may
      arise because the cost of providing care, goods, or services may exceed the
      capitation or other payment made by the Agency to the plan under terms of the
      contract.

    Service
      Area - the designated geographical area within
      which the contractor is authorized by contract to furnish covered services
      to
      enrollees and within which the enrollees reside.

    State
      - State of Florida.

    Subcontract
      - an agreement entered into by a contractor for the provision of
      benefits to enrollees or to perform any administrative function or service
      for
      the contractor specifically related to securing or fulfilling the contractor’s
      obligations under this contract.  Subcontracts include, but are not
      limited to the following:  agreements with all providers of medical or
      ancillary services, unless directly employed by the contractor; management
      or
      administrative agreements; third party billing or other indirect
      administrative/fiscal services, including provision of mailing lists or direct
      mail services; and any contract which benefits any person with a control
      interest in the contractor’s organization.

    Subcontractor
      - any person to which the contractor has contracted or delegated some
      of its functions, services or its obligations under this contract.

    Surplus
      - Net worth, i.e., total assets minus total liabilities. Surplus has
      the same meaning as in Chapter 641.19(19), F.S..  

     

     

    
      
        
        

      

      
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    Third
      Party Resources - an individual, entity, or
      program, excluding Medicaid, that is, may be, could be, should be, or has been
      liable for all or part of the cost of medical services related to any medical
      assistance covered by Medicaid.  An example is an individual’s auto
      insurance company, which typically provides payment of some medical expenses
      related to automobile accidents and injuries.

    Transportation
      - an appropriate means of conveyance furnished to an enrollee to obtain
      services authorized under this contract.

    Transition
      Care Services– services necessary in order to
      safely maintain a person in the community both prior to and after the effective
      date of their enrollment in the project until the initial Plan of Care is
      implemented.

    Transition
      Period - the period of time from the effective
      date of enrollment until the initial Plan of Care is effective.

    Urgent
      Grievance - an adverse determination when the
      standard timeframe of the grievance procedure would seriously jeopardize the
      life or health of an enrollee, or the enrollee’s ability to regain maximum
      function.  

    Violation
      - each determination by the department and/or Agency that a contractor
      failed to act as specified in the contract or in applicable statutes or rules
      governing Medicaid prepaid health plans.  Each day that an ongoing
      violation continues may be considered for the purposes of this contract to
      be a
      separate violation.  In addition, each instance of failing to furnish
      necessary and/or required services or items to enrollees is considered for
      purposes of this contract to be a separate violation.

     

     

    
      
        
        

      

      
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    EXHIBIT
      A

    

    MULTIPLE
      SIGNATURE VERIFICATION AGREEMENT

    

    Account
      Number: ________________

    

    In
      consideration of the mutual promises and undertakings expressed herein, this
      Agreement is entered into between _____________ Bank (“Bank”) and ____________
      Contractor (“Contractor”), effective as of the ______ day of _____________,
      2007.

    

    1.Contractor
      is opening a restricted insolvency protection
      account referenced by number above (“the Account”),
      pursuant to the conditions contained in the Long-Term Care Nursing Home
      Diversion Contract no. 2006-2007-01 entered between Contractor and the State
      of
      Florida, Department of Elder Affairs, (“Department”) dated (Date contract is
      signed).

    

    2.Pursuant
      to its agreement with Department, Contractor desires, and Bank agrees to
      provide, a “hold” on the account so that withdrawals may be made only by
      properly authorized written request, and upon manual examination of the
      requests, which service shall be subject to the terms and restrictions set
      forth
      below.

    

    3.Bank
      will only honor written requests for withdrawals that bear a total of two
      signatures of persons designated by the Department. Department will provide
      to
      Bank examples of the signatures of the authorized representatives.

    

    4.Contractor
      will present the written, properly executed requests for withdrawal of interest
      funds to _________________, at Bank, located at
      ____________________________________._________, Florida, _______, between the
      hours of 8:00 am and 4:00 pm, EST, during banking business days.  The
      request will contain the Account number, the amount of the funds to be
      withdrawn, a description of the payee who shall receive the funds, and the
      signatures of the two authorized representatives, designated in paragraph
      3.

    

    5.Bank
      agrees to verify the signatures; draft the Account for the amount of the
      requested withdrawal, and prepare a Bank Official Check in the withdrawn amount,
      in accordance with the terms of the request.  Bank agrees to undertake
      the above and make the Check available to Contractor no later than the close
      of
      the banking day following the banking day in which the request was presented
      to
      Bank in accordance with Paragraph 4, above.

    

    6.Bank
      shall return to Contractor any request that does not meet the above-described
      requirements.  Bank shall have the sole discretion to determine
      whether the requirements have been met.

    

    7.Pursuant
      to its agreement with Department, Contractor agrees that in the event that
      the
      Department, in consultation with the Agency determines Contractor to be
      insolvent and notifies Bank of its determination, Department may make
      withdrawals on the account solely with the two authorized signatures of
      representatives of the Department, without authorized signatures from
      Contractor.  Bank shall not be responsible or liable for determining
      insolvency.  Bank shall not be required to permit withdrawals upon the
      sole order of Department until written notification is received from Department
      at the address described in Paragraph 4, and Bank has had a reasonable time
      to
      act thereon but in no event later than two (2) business days.

    

    8.Except
      to the extent that Bank is negligent in performing its duties under this
      Agreement, Contractor shall indemnify and hold Bank harmless against any claim,
      loss, liability, damage, cost or expense (including reasonable attorneys’ fees
      incurred by Bank) arising out of or in any way relating to Bank’s compliance
      with the terms of this Agreement.

    

    9.This
      Agreement shall supplement the Bank Deposit Agreement, any corporate or other
      resolution of Contractor relating to the Account, and any other agreements
      or
      terms affecting the Account.  All legal rights and obligations of
      Contractor and Bank under such other documents and pursuant to any applicable
      laws and banking regulations shall remain in effect, except as expressly
      modified by this Agreement.

    

    10.This
      Agreement shall be executed by all currently authorized signors on the Account,
      and it shall continue

     

    
      
        
        

      

      
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    in
      effect
      notwithstanding any subsequent change of authorized signors, and without any
      requirement that it be re-executed or amended.

    

    11.This
      Agreement may be terminated at any time by Bank or Contractor, provided
      Contractor provides Bank written approval from Department, and provided that
      the
      indemnification provision of paragraph 7 above shall continue in effect after
      any such termination with respect to any withdrawals or requests handled by
      Bank
      prior to such termination.  This Agreement shall be binding upon and
      shall inure to the benefit of any successors and assigns of Contractor,
      Department, and Bank.

    

    

    The
      undersigned parties have executed this Agreement through their duly authorized
      representatives as of the date shown above.

     

    
      	BANK	CONTRACTOR
	By:	By:
	 Title:	Title:

    

     

    CONTRACTOR’S
      CERTIFICATION OF AUTHORITY

    

    The
      undersigned hereby certifies that:  (1) (s)he is the Secretary of
      __________ Contractor; and (2) the foregoing Agreement is consistent with any
      corporate or other resolution(s) of Contractor previously or contemporaneously
      provided to Bank.

    

    By:
      ___________________

    Title:
      __________________

    

    Date
      of
      Certification:

    

    AUTHORIZED
      SIGNATURES

    

    DEPARTMENT
      OF ELDER AFFAIRS

    

    
       

      
        	
                ____________________________

                Primary
                  Signature

              	
                ________________________________

                Alternate
                  Signature

              
	Print
                Name:	Print
                Name:
	 Title:	Title:

      

       

    

    

                     

    

    

    Print
      Name:Print Name:

    

    Title:
      _______________________________Title:
      _______________________________

    

     

    
      
        
        

      

      
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           EXHIBIT
      B

    Long-Term
      Care Community Diversion Pilot Project

    Disenrollment
      Summary Report

    

    
      	
                  (Plan
                Name)

               

                 (Reporting
                Month)

               

               

                  Were
                any disenrollments filed
                during this
                reporting
                month?  

                   YES  NO  

            	 
	
               

              DISENROLLMENT

            	 
	 	
              Last
                Name

            	
              First
                Name

            	
              Medicaid
                ID#

            	
              County
                Name

            	
              Provider
                Number

            	
              Disenrollment
                Reason Code*

            	
              Disenrollment
                Reason Occurrence Date

            	 
	
              1

            	 	 	 	 	 	 	 	 
	
              2

            	 	 	 	 	 	 	 	 
	
              3

            	 	 	 	 	 	 	 	 
	
              4

            	 	 	 	 	 	 	 	 
	
              5

            	 	 	 	 	 	 	 	 
	 	 	
                *
                Disenrollment Reason Codes:

            
	 	 	
              EXP
                = Death

            	
              NET
                = Left Provider Network

            	
              VOL
                = Voluntary for Reason Other than Above

            
	 	 	
              ELG
                = Lost Medicaid Eligibility

            	
              CTY
                = Moved Outside of Service Area

            	
              FRD
                = Fraudulent Use of Medicaid or Plan ID Card

            
	 	 	
              INV  =
                Involuntary for Reason Other than Above

            	 	 
	 	 	 	 	 
	 	 	
                SUMMARY

            	 	 
	 	 	
                Total
                Disenrollments:

            	
              __________________

            	 
	 	 	 	 	 

    

    

    
      
        
        

      

      
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    EXHIBIT
      C

    

    Encounter
      Data Reporting Format

    

    Service
      Utilization Reporting

    

    
      	
              The
                plan shall provide recipient-specific service utilization data in
                the
                electronic format as specified below.  The services reported
                represent the comprehensive array of services that might be necessary
                to
                maintain a member at home while avoiding nursing home placement,
                including
                acute and long-term care services.

            

    

    These
      reports must be provided as ASCII, fixed length text files, with two files,
      per recipient, per month. There will be one file for long-term care services
      and one file for acute care services. For example, if a recipient were enrolled
      for an entire quarter, you would have three separate records in each of two
      separate files that are submitted once for the entire quarter. These two files,
      the LTC Services file and the Acute Care Services file, must be submitted once
      every quarter to your DOEA/AHCA contract manager. You will have up to three
      months after the last month in a specific quarter to submit the quarterly
      report.  Contractors must also resubmit acute care services and
      long-term care services updated encounter data for the previous quarter along
      with the current quarter.

    

    If
      no
      units of service are provided in a category or if the category is not applicable
      to you, fill that field with the specified number of spaces (using the spacebar)
      that match that particular field length. Right justify all fields unless noted
      otherwise.  For amount paid, include the sum of Medicaid and Medicare
      crossover claims (deductibles and co-pays for Medicare claims).*  If you have questions about the
      definitions of these services please reference the appropriate Medicaid coverage
      and limitations handbook for Medicaid state plan services. Note: Please do
      not
      use commas between fields and round currency to the nearest dollar
      amount.

    

    The
      contractors shall use the data validation software provided by the department
      to
      generate data validation reports for long-term care and acute care
      services.  All “red flag” items on the data validation reports must be
      corrected or certified by the contractor.  The contractor shall submit
      one password protected zipped file that includes the long-term and acute care
      services data files, validation report files, and if applicable, certification
      files.  The contractor shall adhere to the file-naming format located
      below.

    

    FILE
      1: Long-Term Care Services

    
      	
              Field
                Name

            	
              Description

            	
              Unit
                of Measurement

            	
              Field
                Length

            	
              Start
                Col.

            	
              End
                Col.

            	
              Text/Numeric

            
	
              SSN

            	
              Social
                Security Number (left justify)

            	
              000000000

            	
              9

            	
              1

            	
              9

            	
              Numeric

            
	
              MEDICAID

            	
              Medicaid
                ID Number

            	
              0000000000

            	
              10

            	
              10

            	
              19

            	
              Numeric

            
	
              ENROLL

            	
              Initial
                Date of Program Enrollment

            	
              MMYYYY

            	
              6

            	
              20

            	
              25

            	
              Numeric

            
	
              DISENROL

            	
              Date
                of Disenrollment, if Applicable

            	
              MMYYYY

            	
              6

            	
              26

            	
              31

            	
              Numeric

            
	
              REINST

            	
              Reinstate
                date

            	
              MMYYYY

            	
              6

            	
              32

            	
              37

            	
              Numeric

            
	
              ALF

            	
              ALF
                Resident Indicator

            	
              1=Yes;
                2=No

            	
              1

            	
              38

            	
              38

            	
              Numeric

            
	
              MONTH

            	
              Report
                Month

            	
              MMYYYY

            	
              6

            	
              39

            	
              44

            	
              Numeric

            
	
              ADMINS

            	
              Administrative
                Costs

            	
              Amount
                Paid

            	
              6

            	
              45

            	
              50

            	
              Numeric

            
	
              Long-term
                care

              SERVICES

            	
               

              DESCRIPTION

            	
              UNIT
                OF SERVICE/ COST

            	 	 	 	 
	
              ADCOMP

               

            	
              Adult
                Companion Services

            	
              15
                Minute Unit

            	
              4

            	
              51

            	
              54

            	
              Numeric

            
	
              ADCOMPS

            	
              Adult
                Companion Services

            	
              Amount
                Paid

            	
              6

            	
              55

            	
              60

            	
              Numeric

            
	
              ADAYHLTH

            	
              Adult
                Day Health Services

            	
              15
                Minute Unit

            	
              4

            	
              61

            	
              64

            	
              Numeric

            

    

    

      

    

      
      *
        Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
        enrollees who are also eligible for Medicare.

    

     

    
      
        
        

      

      
        ATTACHMENT
          - Page 78

        
          

        

      

      
        
        

      

    

    
 

    
      	
              ADAYHL$

            	
              Adult
                Day Health Services

            	
              Amount
                Paid

            	
              6

            	
              65

            	
              70

            	
              Numeric

            
	
              ALFSVS

            	
              Assisted
                Living Services

            	
              Days

            	
              2

            	
              71

            	
              72

            	
              Numeric

            
	
              ALFSVS$$

            	
              Assisted
                Living Services

            	
              Amount
                Paid

            	
              6

            	
              73

            	
              78

            	
              Numeric

            
	
              ATTCARE

            	
              Attendant
                Care Services

            	
              15
                Minute Unit

            	
              4

            	
              79

            	
              82

            	
              Numeric

            
	
              ATTCARE$

            	
              Attendant
                Care Services

            	
              Amount
                Paid

            	
              6

            	
              83

            	
              88

            	
              Numeric

            
	
              CASEAID

            	
              Case
                Aide

            	
              15
                Minute Unit

            	
              4

            	
              89

            	
              92

            	
              Numeric

            
	
              CASEAID$

            	
              Case
                Aide

            	
              Amount
                Paid

            	
              6

            	
              93

            	
              98

            	
              Numeric

            
	
              CASEMGMT

            	
              Case
                Management (Internal)

            	
              15
                Minute Unit

            	
              4

            	
              99

            	
              102

            	
              Numeric

            
	
              CASEMGT$

            	
              Case
                Management (Internal)

            	
              Amount
                Paid

            	
              6

            	
              103

            	
              108

            	
              Numeric

            
	
              CHORE

            	
              Chore
                Services

            	
              15
                Minute Unit

            	
              2

            	
              109

            	
              110

            	
              Numeric

            
	
              CHORE$

            	
              Chore
                Services

            	
              Amount
                Paid

            	
              6

            	
              111

            	
              116

            	
              Numeric

            
	
              COM_MH

            	
              Community
                Mental Health

            	
              Visit

            	
              2

            	
              117

            	
              118

            	
              Numeric

            
	
              COM_MH$

            	
              Community
                Mental Health

            	
              Amount
                Paid

            	
              6

            	
              119

            	
              124

            	
              Numeric

            
	
              CNMS_$$

            	
              Consumable
                Medical Supplies

            	
              Amount
                Paid

            	
              6

            	
              125

            	
              130

            	
              Numeric

            
	
              COUNSEL

            	
              Counseling

            	
              15
                Minute Unit

            	
              4

            	
              131

            	
              134

            	
              Numeric

            
	
              COUNSEL$

            	 	
              Amount
                Paid

            	
              6

            	
              135

            	
              140

            	
              Numeric

            
	
              DME_$$

            	
              Durable
                Medical Equipment

            	
              Amount
                Paid

            	
              6

            	
              141

            	
              146

            	
              Numeric

            
	
              ENVIRAA

            	
              Environmental
                Accessibility Adaptations

            	
              Job

            	
              2

            	
              147

            	
              148

            	
              Numeric

            
	
              ENVIRRAA$

            	
              Environmental
                Accessibility Adaptations

            	
              Amount
                Paid

            	
              6

            	
              149

            	
              154

            	
              Numeric

            
	
              ESCORT

            	
              Escort
                Services

            	
              15
                Minute Unit

            	
              4

            	
              155

            	
              158

            	
              Numeric

            
	
              ESCORT$

            	
              Escort
                Services

            	
              Amount
                Paid

            	
              6

            	
              159

            	
              164

            	
              Numeric

            
	
              FAMT_I

            	
              Family
                Training Services (Individual)

            	
              15
                Minute Unit

            	
              2

            	
              165

            	
              166

            	
              Numeric

            
	
              FAMT_I$

            	
              Family
                Training Services (Individual)

            	
              Amount
                Paid

            	
              6

            	
              167

            	
              172

            	
              Numeric

            
	
              FAMT_G

            	
              Family
                Training Services (Group)

            	
              15
                Minute Unit

            	
              2

            	
              173

            	
              174

            	
              Numeric

            
	
              FAMT_G$

            	
              Family
                Training Services  (Group)

            	
              Amount
                Paid

            	
              6

            	
              175

            	
              180

            	
              Numeric

            
	
              FINA­RRS

            	
              Financial
                Assessment/Risk Reduction Services

            	
              15
                Minute Unit

            	
              4

            	
              181

            	
              184

            	
              Numeric

            
	
              FINARR$

            	
              Financial
                Assessment/Risk Reduction Services

            	
              Amount
                Paid

            	
              6

            	
              185

            	
              190

            	
              Numeric

            
	
              FINM_RRS

            	
              Financial
                Maintenance/Risk Reduction Services

            	
              15
                Minute Unit

            	
              4

            	
              191

            	
              194

            	
              Numeric

            
	
              FINM_RR$

            	
              Financial
                Maintenance/Risk Reduction Services

            	
              Amount
                Paid

            	
              6

            	
              195

            	
              200

            	
              Numeric

            
	
              HDMEAL

            	
              Home
                Delivered Meals

            	
              Meal

            	
              2

            	
              201

            	
              202

            	
              Numeric

            
	
              HDMEAL$

            	
              Home
                Delivered Meals

            	
              Amount
                Paid

            	
              6

            	
              203

            	
              208

            	
              Numeric

            
	
              HOMESRVS

            	
              Homemaker
                Services

            	
              15
                Minute Unit

            	
              4

            	
              209

            	
              212

            	
              Numeric

            
	
              HOMESRVC$

            	
              Homemaker
                Services

            	
              Amount
                Paid

            	
              6

            	
              213

            	
              218

            	
              Numeric

            
	
              MH_CM

            	
              Mental
                Health Case Management

            	
              15
                Minute Unit

            	
              4

            	
              219

            	
              222

            	
              Numeric

            
	
              MH_CM$

            	
              Mental
                Health Case Management

            	
              Amount
                Paid

            	
              6

            	
              223

            	
              228

            	
              Numeric

            
	
              SNF

            	
              Nursing
                Facility Services- Long-term

            	
              Days

            	
              2

            	
              229

            	
              230

            	
              Numeric

            
	
              SNF
                $$

            	
              Nursing
                Facility Services-Long-term

            	
              Amount
                Paid

            	
              6

            	
              231

            	
              236

            	
              Numeric

            
	
              NUTR_RRS

            	
              Nutritional
                Assessment/Risk Reduction Services

            	
              15
                Minute Unit

            	
              4

            	
              237

            	
              240

            	
              Numeric

            
	
              NUTR_RR$

            	
              Nutritional
                Assessment/Risk Reduction Services

            	
              Amount
                Paid

            	
              6

            	
              241

            	
              246

            	
              Numeric

            
	
              OT

            	
              Occupational
                Therapy

            	
              15
                Minute Unit

            	
              4

            	
              247

            	
              250

            	
              Numeric

            
	
              OT$

            	
              Occupational
                Therapy

            	 	
              6

            	
              251

            	
              256

            	 
	
              PCS

            	
              Personal
                Care Services

            	
              15
                Minute Unit

            	
              4

            	
              257

            	
              260

            	
              Numeric

            
	
              PC$

            	
              Personal
                Care Services

            	
              Amount
                Paid

            	
              6

            	
              261

            	
              266

            	 
	
              PERS_I

            	
              Personal
                Emergency Response System Installation

            	
              Job

            	
              2

            	
              267

            	
              268

            	
              Numeric

            
	
              PERS_I$

            	
              Personal
                Emergency Response System Installation

            	
              Amount
                Paid

            	
              6

            	
              269

            	
              274

            	
              Numeric

            
	
              PERS_M

            	
              Personal
                Emergency Response System – Maintenance

            	
              Day

            	
              2

            	
              275

            	
              276

            	
              Numeric

            
	
              PERS_M$

            	
              Personal
                Emergency Response System-Maintenance

            	
              Amount
                Paid

            	
              6

            	
              277

            	
              282

            	
              Numeric

            
	
              PEST_I

            	
              Pest
                Control – Initial Visit

            	
              Job

            	
              2

            	
              283

            	
              284

            	
              Numeric

            
	
              PEST_I$

            	
              Pest
                Control-Initial Visit

            	
              Amount
                Paid

            	
              6

            	
              285

            	
              290

            	
              Numeric

            
	
              PEST_M

            	
              Pest
                Control – Maintenance

            	
              Month

            	
              1

            	
              291

            	
              291

            	
              Numeric

            

    

    
 

    
      
        
        

      

      
        ATTACHMENT
          - Page 79

        
          

        

      

      
        
        

      

       

    

    
      	
              PEST_M$

            	
              Pest
                Control- Maintenance

            	
              Amount
                Paid

            	
              6

            	
              292

            	
              297

            	
              Numeric

            
	
              PT

            	
              Physical
                Therapy

            	
              15
                Minute Unit

            	
              4

            	
              298

            	
              301

            	
              Numeric

            
	
              PT$

            	
              Physical
                Therapy

            	
              Amount
                Paid

            	
              6

            	
              302

            	
              307

            	
              Numeric

            
	
              RISKREDU

            	
              Physical
                Risk Assessment and Reduction

            	
              15
                Minute Unit

            	
              4

            	
              308

            	
              311

            	
              Numeric

            
	
              RISKRED$

            	
              Physical
                Risk Assessment and Reduction

            	
              Amount
                Paid

            	
              6

            	
              312

            	
              317

            	
              Numeric

            
	
              PRIVNURS

            	
              Private
                Duty Nursing Services

            	
              15
                Minute Unit

            	
              4

            	
              318

            	
              321

            	
              Numeric

            
	
              PRIVNUR$

            	
              Private
                Duty Nursing Services

            	
              Amount
                Paid

            	
              6

            	
              322

            	
              327

            	
              Numeric

            
	
              PT_R

            	
              Registered
                Physical Therapist

            	
              Visit

            	
              2

            	
              328

            	
              329

            	
              Numeric

            
	
              PT_R$

            	
              Registered
                Physical Therapist

            	
              Amount
                Paid

            	
              6

            	
              330

            	
              335

            	
              Numeric

            
	
              RSPTH

            	
              Respiratory
                Therapy

            	
              15
                Minute Unit

            	
              4

            	
              336

            	
              339

            	
              Numeric

            
	
              RSPTH$

            	
              Respiratory
                Therapy

            	
              Amount
                Paid

            	
              6

            	
              340

            	
              345

            	
              Numeric

            
	
              RESP_HM

            	
              Respite
                Care – In Home

            	
              15
                Minute Unit

            	
              4

            	
              346

            	
              349

            	
              Numeric

            
	
              RESP_HM$

            	
              Respite
                Care- In Home

            	
              Amount
                Paid

            	
              6

            	
              350

            	
              355

            	
              Numeric

            
	
              RESP_FAC

            	
              Respite
                Care – Facility-Based

            	
              Days

            	
              2

            	
              356

            	
              357

            	
              Numeric

            
	
              RESP_FA$

            	
              Respite
                Care- Facility-Based

            	
              Amount
                Paid

            	
              6

            	
              358

            	
              363

            	
              Numeric

            
	
              NURSE

            	
              Skilled
                Nursing

            	
              Visit

            	
              4

            	
              364

            	
              367

            	
              Numeric

            
	
              NURSE$

            	
              Skilled
                Nursing

            	
              Amount
                Paid

            	
              6

            	
              368

            	
              373

            	
              Numeric

            
	
              SPTH

            	
              Speech
                Therapy

            	
              15
                Minute Unit

            	
              4

            	
              374

            	
              377

            	
              Numeric

            
	
              SPTH$

            	
              Speech
                Therapy

            	
              Amount
                Paid

            	
              6

            	
              378

            	
              383

            	
              Numeric

            
	
              TRANSPOR

            	
              Transportation
                Services (not included in Escort  or Adult Day Health
                services)

            	
              Trips

            	
              3

            	
              384

            	
              386

            	
              Numeric

            
	
              TRANSPOR$

            	
              Transportation
                Services (not included in Escort or Adult Day Health
                services)

            	
              Amount
                Paid

            	
              6

            	
              387

            	
              392

            	
              Numeric

            
	
              OTH_UNIT

            	
              Other
                LTC Service not listed (unit)

            	
              Unit/
                Visit

            	
              6

            	
              393

            	
              398

            	
              Numeric

            
	
              DESCR_1

            	
              Description
                of other LTC service

            	 	
              35

            	
              399

            	
              433

            	
              Text

            
	
              OTH_$$

            	
              Other
                LTC service not listed (amount)

            	
              Amount
                Paid

            	
              6

            	
              434

            	
              439

            	
              Numeric

            
	
              DESCR_2

            	
              Description
                of other LTC service

            	 	
              35

            	
              440

            	
              474

            	
              Text

            

    

    

    

    File
      2: Acute Care Services

    

    
      	
              Code

            	
              Field
                Name

            	
              Description

            	
              Unit
                of Measurement

            	
              Field
                Length

            	
              Start
                Col.

            	
              End
                Col.

            	
              Text/Numeric

            
	 	
               

               

              ACUTE

              SERVICES

            	
               

               

               

              DESCRIPTION

            	
               

               

              UNITS
                OF SERVICE/ COST

            	 	 	 	 
	 	
              SSN

            	
              Social
                Security Number (left justify)

            	
              000000000

            	
              9

            	
              1

            	
              9

            	
              Numeric

            
	 	
              MEDICAID

            	
              Medicaid
                ID Number

            	
              0000000000

            	
              10

            	
              10

            	
              19

            	
              Numeric

            
	 	
              MONTH

            	
              Report
                Month

            	
              MMYYYY

            	
              6

            	
              20

            	
              25

            	
              Numeric

            
	 	
              CLINIC

            	
              Clinic
                Services

            	
              Visit

            	
              2

            	
              26

            	
              27

            	
              Numeric

            
	 	
              CLINIC$$

            	
              Clinic
                Services Costs

            	
              Amount
                Paid

            	
              6

            	
              28

            	
              33

            	
              Numeric

            
	 	
              DENTAL

            	
              Dental
                Services

            	
              Visit

            	
              6

            	
              34

            	
              39

            	
              Numeric

            
	 	
              DENTAL$$

            	
              Dental
                Services Costs

            	
              Amount
                Paid

            	
              6

            	
              40

            	
              45

            	
              Numeric

            
	 	
              DIALYSIS

            	
              Dialysis
                Center

            	
              Visit

            	
              2

            	
              46

            	
              47

            	
              Numeric

            
	 	
              DIALYS$$

            	
              Dialysis
                Center Costs

            	
              Amount
                Paid

            	
              6

            	
              48

            	
              53

            	
              Numeric

            
	 	
              ER

            	
              Emergency
                Room Services

            	
              Visit

            	
              2

            	
              54

            	
              55

            	
              Numeric

            
	 	
              ER_$$

            	
              Emergency
                Room Services Costs

            	
              Amount
                Paid

            	
              6

            	
              56

            	
              61

            	
              Numeric

            
	 	
              FQHC

            	
              FQHC
                Services

            	
              Visit

            	
              2

            	
              62

            	
              63

            	
              Numeric

            
	 	
              FQHC_$$

            	
              FQHC
                Services Costs

            	
              Amount
                Paid

            	
              6

            	
              64

            	
              69

            	
              Numeric

            
	 	
              HEAR

            	
              Hearing
                Services including hearing aids

            	
              Amount
                Paid

            	
              6

            	
              70

            	
              75

            	
              Numeric

            
	 	
              INPTSVS

            	
              Inpatient
                Hospital Services

            	
              Day

            	
              3

            	
              76

            	
              78

            	
              Numeric

            
	 	
              INPTSV$$

            	
              Inpatient
                Hospital Services Costs

            	
              Amount
                Paid

            	
              6

            	
              79

            	
              84

            	
              Numeric

            
	 	
              LAB

            	
              Independent
                Laboratory or Portable X-ray Services

            	
              Amount
                Paid

            	
              6

            	
              85

            	
              90

            	
              Numeric

            
	 	
              ARNP

            	
              Nurse
                Practitioner Services

            	
              Visit

            	
              2

            	
              91

            	
              92

            	
              Numeric

            
	 	
              ARNP_$$

            	
              Nurse
                Practitioner Services Costs

            	
              Amount
                Paid

            	
              6

            	
              93

            	
              98

            	
              Numeric

            
	 	
              RX_$$

            	
              Pharmaceuticals

            	
              Amount
                Paid

            	
              6

            	
              99

            	
              104

            	
              Numeric

            

    

    

    
      
        
        

      

      
        ATTACHMENT
          - Page 80

        
          

        

      

      
        
        

      

    

    
      	 	
              PA

            	
              Physical
                Assistant

            	
                         Visit

            	
              2

            	
              105

            	
              106

            	
              Numeric

            
	 	
              PA_$$

            	
              Physical
                Assistant Costs

            	
              Amount
                Paid

            	
              6

            	
              107

            	
              112

            	
              Numeric

            
	 	
              MD

            	
              Physician
                Services

            	
              Visit

            	
              2

            	
              113

            	
              114

            	
              Numeric

            
	 	
              MD_$$

            	
              Physician
                Services Costs

            	
              Amount
                Paid

            	
              6

            	
              115

            	
              120

            	
              Numeric

            
	 	
              OUTPT

            	
              Outpatient
                Hospital Services

            	
              Encounter

            	
              3

            	
              121

            	
              123

            	
              Numeric

            
	 	
              OUTPT_$$

            	
              Outpatient
                Hospital Services Costs

            	
              Amount
                Paid

            	
              6

            	
              124

            	
              129

            	
              Numeric

            
	 	
              PODIATRY

            	
              Podiatry

            	
              Visit

            	
              2

            	
              130

            	
              131

            	
              Numeric

            
	 	
              PODIAT$$

            	
              Podiatry
                Costs

            	
              Amount
                Paid

            	
              6

            	
              132

            	
              137

            	
              Numeric

            
	 	
              RURAL

            	
              Rural
                Health Services

            	
              Visit

            	
              2

            	
              138

            	
              139

            	
              Numeric

            
	 	
              RURAL$$

            	
              Rural
                Health Services Costs

            	
              Amount
                Paid

            	
              6

            	
              140

            	
              145

            	
              Numeric

            
	 	
              SNFREHA

            	
              Skilled
                nursing facility services- rehabilitation

            	
              Days

            	
              2

            	
              146

            	
              147

            	
              Numeric

            
	 	
              SNFREHA$

            	
              Skilled
                nursing facility services- rehabilitation**

            	
              Amount
                Paid

            	
              6

            	
              148

            	
              153

            	
              Numeric

            
	 	
              EYE_$$

            	
              Visual
                Services including eyeglasses

            	
              Amount
                Paid

            	
              6

            	
              154

            	
              159

            	
              Numeric

            
	 	
              OTH_UNIT

            	
              Other
                Acute Service not listed (unit)

            	
              Unit/
                Visit

            	
              6

            	
              160

            	
              165

            	
              Numeric

            
	 	
              OTH_$$

            	
              Other
                Acute service not listed (amount)

            	
              Amount
                Paid

            	
              6

            	
              166

            	
              171

            	
              Numeric

            
	 	
              DESCR_1

            	
              Description
                of other Acute service

            	 	
              35

            	
              172

            	
              206

            	
              Text

            
	 	
              DESCR_2

            	
              Description
                of other Acute service

            	 	
              35

            	
              207

            	
              241

            	
              Text

            

    

    

    

    **Medicare
      Crossovers

    

    

    Encounter
      Data File Naming Format

    Replace
      *** with the contractor’s prearranged 3-character file code, MON with the
      beginning month of the reporting quarter and YY with the reporting
      year.

    

    
      	 	
              Long-Term
                Care Services

            	
              Acute
                Care Services

            
	
              Data
                File

            	
              ***
                MON YY LTC.txt

            	
              ***
                MON YY ACS.txt

            
	
              Validation
                Report

            	
              ***
                MON YY LTC DV.pdf

            	
              ***
                MON YY ACS DV.pdf

            
	
              Certification
                File

              (if
                applicable)

            	
              ***
                MON YY LTC CERT.doc

            	
              ***
                MON YY ACS CERT.doc

            
	
              ZIP
                file

            	
              ***
                MON YY.zip

            

    

    

    
      
        
          
          

        

        
          ATTACHMENT
            - Page 81

          
            

          

        

        
          
          

        

      

    

    

    EXHIBIT
      D

    

    Report
      of Grievances/Appeals

    

    (Plan
      Name)

    
      	 	
                  Were
                any new grievances filed during this reporting
                quarter? YES        

               

            	 	
              NO 

            	 

    

    

    
      	 	 	 	 	 	 	 	 	 	 	 
	 	
              Enrollee's  Last                       Name

            	
              Enrollee's
                First Name

            	
              Enrollee's
                Medicaid ID#

            	
              Enrollee's
                Social Security #

            	
              Grievance

              Type
                *

            	
              Grievance

              Date

            	
              Expedited
                Request?     (Y or N)

            	
              Disposition
                Type **

            	
              Disposition
                Date

            	
               Resolved?

               (Y
                or N)

            
	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              3

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              4

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              5

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

     (Reporting
      Quarter)

    

    Were
      any new appeals filed
      during this reporting
      quarter?  YES        NO   

    
      	 	
              Enrollee's  Last                       Name

            	
              Enrollee's
                First Name

            	
              Enrollee's
                Medicaid ID#

            	
              Enrollee's
                Social Security #

            	
              Appeals
                Type *

            	
              Appeals
                Date

            	
              Expedited
                Request?     (Y or N)

            	
              Disposition
                Type **

            	
              Disposition
                Date

            	
               Resolved?

               (Y
                or N)

            
	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              3

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              4

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              5

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

     

     

    
      	
              *
                Grievance/Appeals Type

            	 	
              **
                Disposition Type

            
	
                1
                = Quality of Care

            	
                          7
                = Enrollment/Disenrollment

            	 	
                 1
                = Reassigned Case Manager

            	
                      7
                = Disenrolled Self

            
	
                2
                = Access to Care

            	
                          8
                = Termination of Contract

            	 	
                 2
                = Service Added to Plan of Care

            	
                      8
                = Disenrolled by plan

            
	
                3
                = Not Medically
                Necessary            svcs

            	
                          9
                = Unauthorized out of plan

            	 	
                 3
                = Service Increased

            	
                      9
                = In QA Review

            
	
                4
                = Excluded Benefit

            	
                        10
                = Unauthorized in-plan svcs

            	 	
                 4
                = Changed to Another Provider

            	
                    10
                = In Grievance/Appeal

                              Process

            
	
                5
                = Billing Dispute

            	
                        11
                = Benefits available in plan

            	 	
                 5
                = Reinstated in Plan

            	
                    11
                = Lost Contact with Enrollee

            
	
                6
                = Contract Interpretation

            	
                        12
                = Other

            	 	
                 6
                = Billing Issue Resolved

            	
                    12
                = Other

            

    

    

    

      
        
          
          

        

        
          ATTACHMENT
            - Page 82

          
            

          

        

        
          
          

        

      

      EXHIBIT
        E

      Minority
        Business Enterprise Contract Reporting

      
        	
                Vendor
                  Name ___________

              	 
	 	 
	
                Quarterly
                  Vendor

              	 
	
                Expenditure
                  Activity

              	 
	 	 
	
                Reporting
                  Timeframe

              	
                Due
                  Date

              
	
                Quarter
                  1 (January thru March)

              	
                April
                  15

              
	
                Quarter
                  2 (April thru June)

              	
                July
                  05

              
	
                Quarter
                  3 (July thru September)

              	
                October
                  15

              
	
                Quarter
                  4 (October thru December)

              	
                January
                  15

              

      

       

       

      
        	
                Subcontractor
                  Name

              	
                Subcontractor
                  Address

              	
                Subcontractor
                  Telephone #

              	
                Subcontractor
                  Federal Identification # or Social Security #

              	
                Total
                  Amount Expended

                With
                  Subcontractor (Current Reporting Quarters Only)

              	
                Total
                  Amount Expended

                With
                  Subcontractor (Prior Reporting Quarters) 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 

      

      
        	
                Completed
                  By:

              	 
	
                Telephone
                  #:

              	 
	
                Completion
                  Date:

              	 

      

      

       

      
        
          
          

        

        
          ATTACHMENT
            - Page 83

          
            

          

        

        
          
          

        

      

     

     

    EXHIBIT
      F

    Long-Term
      Care Community Diversion Pilot Project

    Reconciliation
      Report

    For
      (Contractor name)  (Month/Year)

    

    
      	 	
              Last
                Name

            	
              First
                Name

            	
              Medicaid
                ID Number

            	
              Provider
                Number

            	
              Error
                Code

            	
              Comments

            
	
              1

            	 	 	 	 	 	 
	
              2

            	 	 	 	 	 	 
	
              3

            	 	 	 	 	 	 
	
              4

            	 	 	 	 	 	 
	
              5

            	 	 	 	 	 	 
	
              6

            	 	 	 	 	 	 
	
              7

            	 	 	 	 	 	 
	
              8

            	 	 	 	 	 	 
	
              9

            	 	 	 	 	 	 
	
              10

            	 	 	 	 	 	 

    

    

    

    
      	
              Error
                Codes

            	
              Error
                Summary Description

            	
              Error
                Codes

            	
              Error
                Summary Description

            
	
              01

            	
              Action
                Code Invalid

            	
              14

            	
              Recipient
                Ineligible

            
	
              02

            	
              HMO
                Number Invalid

            	
              15

            	
              Recipient
                Already enrolled

            
	
              03

            	
              HMO
                Number Not Found

            	
              16

            	
              Invalid
                Recipient AID Cat

            
	
              04

            	
              Recipient
                ID Not Found

            	
              17

            	
              Capitation
                Group Not Covered

            
	
              05

            	
              Recipient
                ID Not on File

            	
              18

            	
              Transaction
                Date Invalid

            
	
              06

            	
              Recipient
                Date of Birth Invalid

            	
              19

            	
              Transaction
                Date Incorrect

            
	
              07

            	
              Recipient
                Date of Birth Unmatched

            	
              20

            	
              Outpatient
                Dollars Invalid

            
	
              08

            	
              Recipient
                Has Major Medical

            	
              21

            	
              Inpatient
                Units Invalid

            
	
              09

            	
              HMO
                Not A Medicaid Provider

            	
              22

            	
              Invalid
                Fiscal Year

            
	
              10

            	
              Recipient
                Amount Not Met

            	
              23

            	
              Bad
                Capitation Update

            
	
              11

            	
              Recipient
                Not Enrolled

            	
              24

            	
              Cancelled
                by Choice Counselor

            
	
              12

            	
              Recipient
                Enrolled In Other HMO

            	
              25

            	
              Recipient
                In a Nursing Home

            
	
              13

            	
              Enrollment
                Error

            	 	 

    

     

    

      
        
          
          

        

        
          ATTACHMENT
            - Page 84

          
            

          

        

        
          
          

        

      

      EXHIBIT
        G

      DEPARTMENT
        OF ELDER AFFAIRS

      LONG-TERM
        CARE DIVERSION PILOT PROJECT

      REQUEST
        FOR DISENROLLMENT

      

      
        

        CURRENT
          PROVIDER NAME:  _________________________        COUNTY:
          _____________________________

        

        PROVIDER
          ADDRESS: ___________________________

        

        TELEPHONE
          NUMBER:(           )                                      
  FAX:(           )                                                       

        

      

      

      PARTICIPANT
        NAME: ________________________________________

      

      MEDICAID
        #: __________________________ SS#:  ____________________________DOB:_________________________________

      

      PARTICIPANT
        ADDRESS:______________________________________________________________________________________

      

        COUNTY:_____________________________________

      

      TELEPHONE
        NUMBER:
(           )                                                  
   EFFECTIVE DATE:
        ____________________________________________

      

      COMMENTS:
        ________________________________________________________________________________________________

      

      Does
        enrollee wish to file a grievance?[  ]
        Yes[  ] No

      
        	
                VOLUNTARY
                  (Check All That Apply):

              
	
                 

                □Dissatisfied
                  with services

                □Dissatisfied
                  with plan

                □Moving
                  to out-of-network nursing home

                 

              	
                □Moving
                  to out-of-network ALF

                □No
                  longer wish to participate in diversion program

                □Request
                  new provider

                 

              

      

      

      
        	 	 	 
	
                Signature
                  of Participant or Authorized Representative

              	 	
                Date

              
	 	 	 
	
                If
                  representative, please print name

              	 	
                Please
                  state relationship to participant

                 

              

      

      FOR
        DIVERSION PROVIDER USE ONLY

      
        	
                INVOLUNTARY
                  (Check All That Apply):

              
	
                □Death
                  (Date: ____________________)

                □Not
                  eligible for program

                □Moving
                  out of the service area

                □Fraudulent
                  use of Medicaid ID card

                 

              	
                □Incarceration

                □Non-cooperation,
                  subject to Department approval

                □Other

              

      

      

      
        	 	 	 
	
                Case
                  Manager Signature

              	 	
                Date
                  CARES Office Notified

              
	 	 	 
	
                Program
                  Administrator Signature

              	 	
                CARES
                  Fax Number

              
	
                 

                □REQUEST
                  FOR TRANSFER TO NEW PROVIDER

                 

                NAME
                  OF NEW
                  PROVIDER:  COUNTY: 

                 

              

      

    

    
      
        ATTACHMENT
          - Page 85

        
          

        

      

      
        
        

      

    

    EXHIBIT
      H

    

    
      	
              Provider
                Name

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Street
                Address

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              City,
                FL ZIP

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Phone:

            	
              Plan
                Contact:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              FAX
                :

            	
              Email:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              List
                Date x/xx/xx

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Covered
                Services

            	
              Provider
                Name

            	
              Name
                of Provider Contact

            	
              Phone
                Number

            	
              Street
                Address

            	
              City

            	
              State

            	
              Zip
                Code

            	
              County
                Served

            	
              Comments

            
	
              Adult
                Companion Services

            	 	 	 	 	 	 	 	 	 
	
              Adult
                Companion Services

            	 	 	 	 	 	 	 	 	 
	
              Adult
                Day Health Services

            	 	 	 	 	 	 	 	 	 
	
              Adult
                Day Health Services

            	 	 	 	 	 	 	 	 	 
	
              Assisted
                Living Services

            	 	 	 	 	 	 	 	 	 
	
              Assisted
                Living Services

            	 	 	 	 	 	 	 	 	 
	
              Case
                Management Services

            	 	 	 	 	 	 	 	 	 
	
              Chore
                Services

            	 	 	 	 	 	 	 	 	 
	
              Chore
                Services

            	 	 	 	 	 	 	 	 	 
	
              Consumable
                Medical Supply Services

            	 	 	 	 	 	 	 	 	 
	
              Consumable
                Medical Supply Services

            	 	 	 	 	 	 	 	 	 
	
              Dental

            	 	 	 	 	 	 	 	 	 
	
              Dental

            	 	 	 	 	 	 	 	 	 
	
              Environmental
                Accessibility Adaptation Services

            	 	 	 	 	 	 	 	 	 
	
              Environmental
                Accessibility Adaptation Services

            	 	 	 	 	 	 	 	 	 
	
              Escort
                Services

            	 	 	 	 	 	 	 	 	 
	
              Escort
                Services

            	 	 	 	 	 	 	 	 	 
	
              Family
                Training Services

            	 	 	 	 	 	 	 	 	 
	
              Family
                Training Services

            	 	 	 	 	 	 	 	 	 
	
              Financial
                Assessment/Risk Reduction Services

            	 	 	 	 	 	 	 	 	 
	
              Financial
                Assessment/Risk Reduction Services

            	 	 	 	 	 	 	 	 	 
	
              Hearing

            	 	 	 	 	 	 	 	 	 
	
              Hearing

            	 	 	 	 	 	 	 	 	 
	
              Home
                Delivered Meals

            	 	 	 	 	 	 	 	 	 
	
              Home
                Delivered Meals

            	 	 	 	 	 	 	 	 	 

    

     

    

    
      
        
          
          

        

        
          ATTACHMENT
            - Page 86

          
            

          

        

        
          
          

        

      

    

    

    
      	
              Homemaker
                Services

            	 	 	 	 	 	 	 	 	 
	
              Homemaker
                Services

            	 	 	 	 	 	 	 	 	 
	
              Nursing
                Facility Services

            	 	 	 	 	 	 	 	 	 
	
              Nursing
                Facility Services

            	 	 	 	 	 	 	 	 	 
	
              Nutritional
                Assessment/Risk Reduction Services

            	 	 	 	 	 	 	 	 	 
	
              Nutritional
                Assessment/Risk Reduction Services

            	 	 	 	 	 	 	 	 	 
	
              Occupational
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Occupational
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Personal
                Care Services

            	 	 	 	 	 	 	 	 	 
	
              Personal
                Care Services

            	 	 	 	 	 	 	 	 	 
	
              Personal
                Emergency Response Systems (PERS):

            	 	 	 	 	 	 	 	 	 
	
              Personal
                Emergency Response Systems (PERS):

            	 	 	 	 	 	 	 	 	 
	
              Physical
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Physical
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Respite
                Care Services

            	 	 	 	 	 	 	 	 	 
	
              Respite
                Care Services

            	 	 	 	 	 	 	 	 	 
	
              Speech
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Speech
                Therapy

            	 	 	 	 	 	 	 	 	 
	
              Vision

            	 	 	 	 	 	 	 	 	 
	
              Vision

            	 	 	 	 	 	 	 	 	 
	
              Optional
                Services

            	 	 	 	 	 	 	 	 	 
	
              Transportation
                Services

            	 	 	 	 	 	 	 	 	 
	
              Expanded
                Services

            	 	 	 	 	 	 	 	 	 

    

     

    

      
        	
                Staff
                  Positions

              	
                Staff
                  Name

              	
                Phone
                  Number

              	
                Email

              	
                Fax
                  Number

              
	
                Contract
                  Manager / Plan Administrator

              	 	 	 	 
	
                Case
                  Management Supervisor

              	 	 	 	 
	
                Case
                  Manager

              	 	 	 	 
	
                Data
                  Processing

              	 	 	 	 
	
                Grievance
                  Coordinator

              	 	 	 	 
	
                Medical
                  Director

              	 	 	 	 
	
                Medical
                  Records Coordinator

              	 	 	 	 
	
                Member
                  Services

              	 	 	 	 
	
                Quality
                  Assurance Coordinator

              	 	 	 	 
	
                Training
                  Coordinator

              	 	 	 	 
	
                Utilization
                  Review

              	 	 	 	 

      

    

    
       

      
        ATTACHMENT
          - Page 87

        
          

        

      

      
        
        

      

    

    EXHIBIT  I

    

    Capitation
      Rates

    
      

      

      
        	
                Provider
                  ID

              	
                Provider
                  Name

              	
                County
                  Name

              	
                9/1/07
                  – 8/31/2008 Diversion Capitation Rate

              
	
                015077100

              	
                WellCare

              	
                Orange

              	
                $1,364.51

              
	
                015077101

              	
                WellCare

              	
                Osceola

              	
                $1,364.51

              
	
                015077102

              	
                WellCare

              	
                Seminole

              	
                $1,364.51

              
	
                015077103

              	
                WellCare

              	
                Duval

              	
                $1,425.92

              

      

      
The
        following table lists the initial rates for prospective
        expansions.

    

    

    
      	
              PSA

            	 	
              Counties

            	 	
              2007-2008
                

              Diversion
                

              Capitation
                Rate

            	 
	 	
              1

            	 	
              Escambia,
                Okaloosa, Santa Rosa, and Walton

            	 	$	
              1534.02

            	 
	 	
              2

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

            	 	$	
              1534.02

            	 
	 	
              3

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

            	 	$	
              1564.84

            	 
	 	
              4

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

            	 	$	
              1425.92

            	 
	 	
              5

            	 	
              Pasco
                and Pinellas

            	 	$	
              1590.39

            	 
	 	
              6

            	 	
              Hardee,
                Highlands, Hillsborough, Manatee, and Polk

            	 	$	
              1563.27

            	 
	 	
              7

            	 	
              Brevard,
                Orange, Osceola and Seminole

            	 	$	
              1364.51

            	 
	 	
              8

            	 	
              Charlotte,
                Collier, DeSoto, Glades, Hendry, Lee, and Sarasota

            	 	$	
              1549.66

            	 
	 	
              9

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

            	 	$	
              1531.56

            	 
	 	
              10

            	 	
              Broward

            	 	$	
              1579.69

            	 
	 	
              11

            	 	
              Miami-Dade
                and Monroe

            	 	$	
              1591.75

            	 

    

     

    
      
        
        

      

      
        ATTACHMENT
          - Page 88

        
          

        

      

      
        
        

      

    

    EXHIBIT  J

    

    

    SWORN
      STATEMENT PURSUANT TO CHAPTER 287.133(3)(a),

    FLORIDA
      STATUTES, ON PUBLIC ENTITY CRIMES

    

    THIS
      FORM
      MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
      AUTHORIZED TO ADMINISTER OATHS.

    

    
      	
               

            	
              1.This
                sworn statement is submitted to the Florida Department of Elder
                Affairs by
                Todd S. Farha, President & CEO  for
                WellCare of Florida, Inc. dba WelllCare Senior Partnership whose
                business address is 8735 Henderson Road, Ren 3 Tampa, FL 33634 and,
                if applicable, its Federal Employer Identification Number (FEIN)
                is 
                ___________________If
                the entity has no FEIN, include the Social Security Number of the
                individual signing this sworn statement:
                _____________________________________

            

    

    

    
      	
               

            	
              2.I
                understand that a "public entity crime" as defined in Paragraph
                287.133(1)(g), Florida Statutes, means a violation of any state or
                federal law by a person with respect to and directly related to the
                transaction of business with any public entity or with an agency
                or
                political subdivision of any other state or of the United States,
                including, but not limited to, any bid or contract for goods or services
                to be provided to any public entity or an agency or political subdivision
                of any other state or of the United States and involving antitrust,
                fraud,
                theft, bribery, collusion, racketeering, conspiracy, or material
                representation.

            

    

    

    
      	
               

            	
              3.I
                understand that "convicted" or "conviction" as defined in Paragraph
                287.133(1)(b), Florida Statutes, means a finding of guilt or a
                conviction of a public entity crime, with or without an adjudication
                of
                guilt, in any federal or state trial court of record relating to
                charges
                brought by indictment or information after July 1, 1989, as a result
                of a
                jury verdict, non-jury trial, or entry of a plea of guilty or nolo
                contendere.

            

    

    

    
      	
               

            	
              4.I
                understand that an "affiliate" as defined in Paragraph 287.133(1)(a),
                Florida Statutes, means:

            

    

    

    
      	
               

            	
              a.A
                predecessor or successor of a person convicted of a public entity
                crime;
                or

            

    

    
      	
               

            	
              b.An
                entity under the control of any natural person who is active in the
                management of the entity and who has been convicted of a public entity
                crime.  The term "affiliate" includes those officers, directors,
                executives, partners, shareholders, employees, members, and agents
                who are
                active in the management of the affiliate.  The ownership by one
                person of shares constituting a controlling interest in another person,
                or
                a pooling of equipment or income among persons when not for fair
                market
                value under an arm's length agreement, shall be a prima facie case
                that
                one person controls another person.  A person who knowingly
                enters into a joint venture with a person who has been convicted
                of a
                public entity crime in Florida during the preceding 36 months shall
                be
                considered an affiliate.

            

    

    

    
      	
               

            	
              5.I
                understand that a "person" as defined in Paragraph 287.133(1)(e),
                Florida Statutes, means any natural person or entity organized
                under the laws of any state or of the United States with the legal
                power
                to enter into a binding contract and which bids or applies to bid
                on
                contracts for the provision of goods or services let by a public
                entity,
                or which otherwise transacts or applies to transact business with
                a public
                entity.  The term "person" includes those officers, directors,
                executives, partners, shareholders, employees, members, and agents
                who are
                active in management of an entity.

            

    

    

    
      	
               

            	
              6.Based
                on information and belief, the statement which I have marked below
                is true
                in relation to the entity submitting this sworn
                statement.  (Indicate which statement
                applies.)

            

    

    

          x     
      Neither the entity submitting this sworn statement, nor any of its officers,
      directors, executives, partners, shareholders, employees, members, or agents
      who
      are active in the management of the entity, nor any affiliate of the entity
      has
      been charged with and convicted of a public entity crime subsequent to July
      1,
      1989.

     

               
      The entity submitting this sworn statement, or one or more of its officers,
      directors, executives, partners, shareholders, employees, members, or agents
      who
      are active in the management of the entity, or an affiliate of the entity has
      been charged with and convicted of a public entity subsequent to July 1,
      1989.

    

               
      The entity submitting this sworn statement, or one or more of its officers,
      directors, executives, partners, shareholders, employees, members, or agents
      who
      are active in the management of the entity, or an affiliate of the entity has
      been charged with and convicted of a public entity subsequent to July 1,
      1989.  However, there has been a subsequent proceeding before a
      Hearing Officer of the State of Florida, Division of Administrative Hearings
      and
      the Final Order entered by the Hearing Officer determined that it was not in
      the
      public interest to place the entry submitting this sworn statement on the
      convicted vendor list.  (Attach a copy of the final
      order.)

    

    

    I
      UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
      THE
      PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
      ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR
      IN
      WHICH IT IS FILED.  I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE
      PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD
      PROVIDED IN CHAPTER 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY
      CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.

    

      
      /s/ Todd Farha     

    (signature)

     

    8/23/07 

    (date)

    

    STATE
      OF
      Florida

    

    COUNTY
      OF
      Hillsborough

    

    PERSONALLY
      APPEARED BEFORE ME, the
      undersigned authority, Todd Farha
      who,
      after first being sworn by me, affixed his/her signature in the

    (name
      of
      individual signing)

    

    space
      provided above on this 23 day of August,  2007.

    

     

    
      
        
        

      

      
        ATTACHMENT
          - Page 89

        
          

        

      

      
        
        

      

    

    
 

    
      	 INSTRUCTIONS	
                CONTRACT#2006-2007-01

            
	 
              
              CERTIFICATION
                REGARDING DEBARMENT,
                SUSPENSION, INELIGIBILITY

              AND
                VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS

            	
                  EXHIBIT
                K

            

    

    
      
        

      

    

    

    
      	
               

            	
              1.Each
                recipient or vendor whose contract equals or exceeds $100,000 in
                federal
                monies must sign this debarment certification prior to contract
                execution.  Independent auditors who audit federal programs
                regardless of the dollar amount are required to sign a debarment
                certification form.  Neither the Department of Elder Affairs nor
                its contract recipients or vendors can contract with subrecipients
                if they
                are debarred or suspended by the federal
                government.

            

    

    

    
      	
               

            	
              2.This
                certification is a material representation of fact upon which reliance
                is
                placed when this contract is entered into.  If it is later
                determined that the signed knowingly rendered an erroneous certification,
                the Federal Government may pursue available remedies, including suspension
                and/or debarment.

            

    

    

    
      	
               

            	
              3.The
                recipient or vendor shall provide immediate written notice to the
                contract
                manager at any time the recipient or vendor learns that its certification
                was erroneous when submitted or has become erroneous by reason of
                changed
                circumstances.

            

    

    

    
      	
               

            	
              4.The
                terms “debarred,” “suspended,” “ineligible,” “person,” “principal,” and
                “voluntarily excluded,” as used in this certification, have the meanings
                set out in the Definitions and Coverage sections of rules implementing
                Executive Order 12549 and 45 CFR (Code of Federal Regulations), Part
                76.  You may contact the contract manager for assistance in
                obtaining a copy of those
                regulations.

            

    

    

    
      	
               

            	
              5.The
                recipient or vendor further agrees by submitting this certification
                that,
                it shall not knowingly enter into any subcontract with a person who
                is
                debarred, suspended, declared ineligible, or voluntarily excluded
                from
                participation in this contract unless authorized by the Federal
                Government.

            

    

    

    
      	
               

            	
              6.The
                recipient or vendor further agrees by submitting this certification
                that
                it will require each subrecipient of this contract whose payment
                will
                equal or exceed $100,000 in federal monies, to submit a signed copy
                of
                this certification with each
                contract.

            

    

    

    
      	
               

            	
              7.The
                Department of Elder Affairs and its contract recipients or vendor
                may rely
                upon a certification of a recipient/subrecipients that is not debarred,
                suspended, ineligible, or voluntarily exclude from
                contracting/subcontracting unless it knows that the certification
                is
                erroneous.

            

    

    

    
      	
               

            	
              8.If
                the recipient or vendor is an Area Agency on Aging (AAA), the AAA
                may rely
                upon a certification of a recipient/subrecipient or vendor entity
                that is
                not debarred, suspended, ineligible, or voluntarily
                excluded from
                contracting/subcontracting unless the
                AAA knows that the
                certification is
                erroneous.

            

    

    

    
      	
               

            	
              9.The
                signed certifications of all
                subrecipients or vendors shall
                be kept on file with
                recipient.

            

    

    

    

    DOEA
      FORM
      112A

    (Revised
      May 2002)

     

     

    
      
        
        

      

      
        ATTACHMENT
          - Page 90

        
          

        

      

      
        
        

      

    

    
      
 

      
        	 INSTRUCTIONS	
                 

              
	 
                
                CERTIFICATION
                  REGARDING DEBARMENT,
                  SUSPENSION, INELIGIBILITY

                AND
                  VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS

              	
              

      

      
        
          

        

      

      
This
        certification is required by the regulation implementing Executive Order
        12549,
        Debarment and Suspension, signed February; 18, 1986.  The guidelines
        were published in the May 29, 1987 Federal Register (52 Fed. Reg., pages
        20360-20369).

    

    

    
      	
               

            	
              (1)The
                prospective recipient or
                vendor certifies, by signing this certification, that neither he
                nor his principals is presently debarred, suspended, proposed for
                debarment, declared ineligible, or voluntarily excluded from participation
                in contracting with the Department of Elder Affairs by any federal
                department or agency.

            

    

    

    
      	
               

            	
              (2)Where
                the prospective recipient or vendor is unable
                to
                certify to any of the statements in this certification, such prospective
                recipient or vendor shall attach an explanation to this
                certification.

            

    

    

    Signature  
      /s/   Todd S. Farha      

    

    

    Date:
      8/23/07

    

      
      Todd Farha, President &
CEO            

    Name
      and
      Title of Authorized Individual

    (Print
      or
      type)

    

    WellCare
      of Florida, Inc.

    Name
      of
      Organization

    DOEA
      FORM
      112B

    (Revised
      May 2002)

    

    

    
      
        
        

      

      
        ATTACHMENT
          - Page 91

        
          

        

      

      
        
        

      

    

    

    EXHIBIT
      L

    

    
      	
              HOSPICE
                ENROLLMENT REPORT

            
	 	 	 	 	 
	
              Number
                of new enrollees electing hospice by month

            
	 	 	 	 	 
	 	 	 	 	 
	
              Contractor
                _______________________________

            	 
	 	 	 	 	 
	
              Month
                of _____________________

            	 	 
	 	 	 	 	 
	 	
              County

            	
              Number
                of new enrollees

            	
              For
                Profit

            	
              Not
                for Profit

            
	
              1

            	 	 	 	 
	
              2

            	 	 	 	 
	
              3

            	 	 	 	 
	
              4

            	 	 	 	 
	
              5

            	 	 	 	 
	
              6

            	 	 	 	 
	
              7

            	 	 	 	 
	
              8

            	 	 	 	 
	
              9

            	 	 	 	 
	
              10

            	 	 	 	 
	
              11

            	 	 	 	 
	
              12

            	 	 	 	 
	
              13

            	 	 	 	 
	
              14

            	 	 	 	 
	
              15

            	 	 	 	 
	
              16

            	 	 	 	 
	
              17

            	 	 	 	 
	
              18

            	 	 	 	 
	
              19

            	 	 	 	 
	
              20

            	 	 	 	 
	
              21

            	 	 	 	 
	
              22

            	 	 	 	 
	
              23

            	 	 	 	 
	
              24

            	 	 	 	 
	
              25

            	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	
              Submitted
                by:____________________________

            	 
	 	 	 	 	 
	
              Submit
                to your contract manager by the 15 days after the reporting
                month.

            

    

     

    
      
        
        

      

      
        ATTACHMENT
          - Page 92

        
          

        

      

      
        
        

      

    

    ATTACHMENT
      II

    

    CERTIFICATION
      REGARDING LOBBYING

     CERTIFICATION
      FOR CONTRACTS, GRANTS, LOANS AND

    COOPERATIVE
      AGREEMENT

    

    The
      undersigned certifies, to the best of his or her knowledge and belief,
      that:

    

    
      	
               

            	
              (1)No
                federal appropriated funds have been paid or will be paid, by or
                on behalf
                of the undersigned, to any person for influencing or attempting to
                influence an officer or employee of any state or federal agency,
                a member
                of congress, an officer or employee of congress, an employee of a
                member
                of congress, or an officer or employee of the state legislator, in
                connection with the awarding of any federal grant, the making of
                any
                federal loan, the entering into of any cooperative agreement, and
                the
                extension, continuation, renewal, amendment, or modification of any
                federal contract, grant, loan, or cooperative
                agreement.

            

    

    

    
      	
               

            	
              (2)If
                any funds other than federal appropriated funds have been paid or
                will be
                paid to any person for influencing or attempting to influence an
                officer
                or employee of any agency, a member of congress, an officer or employee
                of
                congress, or an employee of a member of congress in connection with
                this
                federal contract, grant, loan, or cooperative agreement, the undersigned
                shall complete and submit Standard Form-LLL, "Disclosure Form to
                Report
                Lobbying," in accordance with its
                instructions.

            

    

    

    
      	
               

            	
              (3)The
                undersigned shall require that the language of this certification
                be
                included in the award documents for all sub-awards at all tiers (including
                subcontracts, sub-grants, and contracts under grants, loans and
                cooperative agreements) and that all sub-recipients shall certify
                and
                disclose accordingly.

            

    

    

    This
      certification is a material representation of fact upon which reliance was
      placed when this transaction was made or entered into.  Submission of
      this certification is a prerequisite for making or entering into this
      transaction imposed by section 1352, Title 31, U.S. Code.  Any person
      who fails to file the required certification shall be subject to a civil penalty
      of not less than $10,000 and not more than $100,000 for each such
      failure.

    

    
      Signature  
        /s/   Todd S. Farha     

      

      Date:
        8/23/07

      

        
        Todd
        Farha                    

      Nameof
        Authorized Individual

      (Print
        or
        type)

       

      XQ744   

      Application
        or Contract Number

      

      WellCare
        of Florida, Inc. P.O Box 26011, Tampa, FL 33623   

      Name
        of
        Organization

      DOEA
        FORM
        112B

      (Revised
        May 2002)

       

      
        
          
          

        

        
          ATTACHMENT
            II -Page 1

          
            

          

        

        
          
          

        

      

    

    ATTACHMENT  III

    CERTIFICATION
      REGARDING DATA INTEGRITY COMPLIANCE

    
      	
               

            	
              FOR
                CONTRACTS, GRANTS, LOANS
                AND

            

    

    COOPERATIVE
      AGREEMENTS

    

    

    The
      undersigned, an authorized representative of the recipient named in the contract
      or agreement to which this form is an attachment, hereby certifies
      that:

    

    
      	
               

            	
              (1)The
                recipient and any sub-recipients of services under this contract
                have
                financial management systems capable of providing certain information,
                including: (1) accurate, current, and complete disclosure of the
                financial
                results of each grant-funded project or program in accordance with
                the
                prescribed reporting requirements; (2) the source and application
                of funds
                for all contract supported activities; and (3) the comparison of
                outlays
                with budgeted amounts for each award.  The inability to process
                information in accordance with these requirements could result in
                a return
                of grant funds that have not been accounted for
                properly.

            

    

    

    
      	
               

            	
              (2)Management
                Information Systems used by the recipient, sub-recipient(s), or any
                outside entity on which the recipient is dependent for data that
                is to be
                reported, transmitted or calculated, have been assessed and verified
                to be
                capable of processing data accurately, including year-date dependent
                data.
                For those systems identified to be non-compliant, recipient(s) will
                take
                immediate action to assure data
                integrity.

            

    

    

    
      	
               

            	
              (3)If
                this contract includes the provision of hardware, software, firmware,
                microcode or imbedded chip technology, the undersigned warrants that
                these
                products are capable of processing year-to-date dependent data accurately.
                All versions of these products offered by the recipient (represented
                by
                the undersigned) and purchased by the State will be verified for
                accuracy
                and integrity of data prior to
                transfer.

            

    

    

    In
      the
      event of any decrease in functionality related to time and date related codes
      and internal subroutines that impede the hardware or software programs from
      operating properly, the recipient agrees to immediately make required
      corrections to restore hardware and software programs to the same level of
      functionality as warranted herein, at no charge to the State, and without
      interruption to the ongoing business of the state, time being of the
      essence.

    

    
      	
               

            	
              (4)The
                recipient and any sub-recipient(s) of services under this contract
                warrant
                their policies and procedures include a disaster plan to provide
                for
                service delivery to continue in case of an emergency including emergencies
                arising from data integrity compliance
                issues.

            

    

    

    The
      recipient shall require that the language of this certification be included
      in
      all subcontracts, subgrants, and other agreements and that all sub-contractors
      shall certify compliance accordingly.

    

    This
      certification is a material representation of fact upon which reliance was
      placed when this transaction was made or entered into.  Submission of
      this certification is a prerequisite for making or entering into this
      transaction imposed by OMB Circulars A-102 and A-110.

     

    
      
        	
                WellCare
                  of Florida, Inc. bda WellCare Senior Partnership, 8735 Henderson
                  Road
                  Tampa, FL 33634

              
	
                Name
                  and Address of Recipient

                 

              	 	 
	
                   /s/   Todd
                  S. Farha    

              	
                President
                  & CEO

              	
                8/23/07

              
	
                Signature

                 

              	
                Title

              	
                Date

              
	
                Todd
                  S. Farha

              	 	 
	
                Name
                  of Authorized Signor

              	 	 

      

       

    

    

    
      
        
        

      

      
        ATTACHMENT
          III -Page 1

        
          

        

      

      
        
        

      

    

    ATTACHMENT  IV

    

    AGREEMENT
      TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID
      PENDING

    
      	
              _______

            	
              No,
                contractor does not elect to provide services to individuals designated
                as
                Medicaid Pending.

            

    

    
      	
              _______

            	
              Yes,
                contractor elects to provide services to individuals designated as
                Medicaid Pending.

            

    

    

    By
      checking YES above, contractor agrees to provide services to individuals
      referred to them by CARES who have been designated as Medicaid Pending in
      accordance with Section 430.705(5), Florida Statutes.  The contractor
      will meet all conditions of this contract and the following:

    

    
      	
               

            	
              a.The
                contractor is responsible for compliance with all pertinent insurance
                laws
                and regulations prior to providing services to Medicaid Pending
                individuals.

            

    

    
      	
               

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

            

    

    
      	
               

            	
              c.The
                contractor may assist Medicaid pending individuals through the Medicaid
                financial eligibility process by submitting the ACCESS Florida Application
                (online or hardcopy) to the Department of Children and Families and
                when
                contacted by DCF, forward at a minimum the following documentation:
                Financial Release (CF ES 2613), CARES’ level of care decision (Form 603)
                and the Certification of Enrollment Status (HCBS) (CF-AA
                2515).  Applications may be completed and submitted online at
                the following
                website:  www.myflorida.com/accesssflorida

            

    

    
      	
               

            	
              d.Once
                the individual is determined financially eligible, the contractor
                must
                notify CARES and provide a copy of the Notice of Case Action within
                two
                business days of receipt.

            

    

    
      	
               

            	
              e.The
                contractors will be responsible for submitting 834 enrollment transactions
                to the Medicaid fiscal agent one week prior to the regular submission
                date
                for only the Medicaid pending individuals.  The enrollment date
                will be retroactive to the first of the month following the CARES
                eligibility determination, not to exceed four (4)
                months.  

            

    

    
      	
               

            	
              f.Services
                must be in place on the first of the month following the CARES eligibility
                determination.

            

    

    
      	
               

            	
              g.The
                contractor will be paid the capitation rate for services rendered
                retroactive to the first of the month following the CARES eligibility
                determination, not to exceed four (4) months.  The
                contractor shall make available, on request from the department,
                proof of
                services, which meet the timeframes listed
                above.    

            

    

    
      	
               

            	
              h.Payment
                will be made once full financial eligibility has been
                determined.

            

    

    
      	
               

            	
              i.In
                the event the individual is
                determined not to be financially eligible by the Department of Children
                & Families, the contractor must notify CARES and can seek
                reimbursement from the individual in accordance with the Medicaid
                Coverage
                and Limitations Handbooks and the associated fee
                schedules.

            

    

    

    Signature
      /s/  Todd S.
      Farha          

    

    Date
      8/23/2007

    

    Todd
      S. Farha, President & CEO

    Name
      and
      Title of Authorized Individual (Print or type)

     

    
      

      
        
          
          

        

        
          ATTACHMENT
            IV -Page 1EX-10.1

Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care

AHCA CONTRACT NO. FA614

AMENDMENT NO. 4

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

	1.	 	Attachment I, Scope of Services, is hereby amended to include Exhibit II-D, Fourth Revised
Capitation Rates, attached hereto and made a part of the Contract. All references in the
Contract to Exhibit II-C, Third Revised Capitation Rates, shall hereinafter also refer to
Exhibit II-D, Fourth Revised Capitation Rates, as appropriate.

	2.	 	Attachment I, Scope of Services, is hereby amended to include Exhibit III-A, September 1,
2007-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, September 1, 2006 — August 31,
2007 HMO Rates, shall hereinafter also refer to Exhibit III-A, September 1, 2007- August 31,
2008 Medicaid Non-Reform HMO Capitation Rates, as appropriate.

	3.	 	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section V, Covered Services, Item
C, Expanded Services, sub-item 2 is hereby deleted in its entirety and replaced with the
following:

2. The following is a list of the Health Plan’s Expanded Services:

a. Adult basic dental benefits, such as cleanings, simple fillings, and/or
extractions.

	 	b.	 	Up to $25 credit per household each month for selected
over-the-counter drugs and/or health supplies.

	 	c.	 	Respite Care services — Annual maximum of not more than
an initial home health visit by an R.N. and eight (8) follow-up visits by an
aide. Follow-up visits are four (4) hours in length. Maximum of sixteen (16)
hours in a given month and thirty-two (32) hours per year.

	 	d.	 	Circumcisions for newborns (routine newborn circumcision
up to twelve (12) weeks of age).

	4.	 	This Amendment shall have an effective date of September 1, 2007, 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.

AHCA Contract No. FA614, Amendment No. 4, Page 1 of 2

AHCA Form 2100-0002 (Rev. NOV03)

1

Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care

IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which
includes all attachments hereto) to be executed by their officials thereunto duly authorized.

	 	 	 	 	 
	AMERIGROUP FLORIDA, INC.STATE OF FLORIDA, AGENCY FOR
	D/B/A/ AMERIGROUP COMMUNITY CAREHEALTH CARE ADMINISTRATION
	SIGNED

BY:

	 	 	 	SIGNED

BY:
	NAME:William McHugh .......................
	 	NAME:Andrew C. Agwunobi, M.D
	 
	 	 
	TITLE: CEO

	 	 	 	TITLE:Secretary
	 

	 	 	 	 
	DATE:

	 	 	 	DATE:
	List of attachments included as part of this Amendment:

	Specify

Type

	 	Letter/Number

        .............
	 	

Description
	 

	 	 
	 	 
	Exhibit

Exhibit

	 	II-D

III-A
	 	Fourth Revised Capitation Rates (1 Page)

September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO

Capitation Rates (5 Pages)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form 2100-0002 (Rev. NOV03)

Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care

EXHIBIT II-D

FOURTH REVISED CAPITATION RATES

Table 4 — General Capitation Rates plus Mental Health Rates plus Transportation:

	 	 	 	 	 
	Area 3 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Hernando
	 	 	015005350	 
	Lake
	 	 	015005341	 
	Area 5 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Pasco
	 	 	015005304	 
	Pinellas
	 	 	015005305	 
	Area 6 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Hillsborough
	 	 	015005300	 
	Polk
	 	 	015005307	 
	Manatee
	 	 	015005318	 
	Area 7 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Orange
	 	 	015005308	 
	Seminole
	 	 	015005313	 
	Osceola
	 	 	015005314	 
	Brevard
	 	 	015005336	 
	Area 8 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Lee
	 	 	015005302	 
	Sarasota
	 	 	015005306	 
	Area 9 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Palm Beach
	 	 	015005310	 
	Area 10 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Broward
	 	 	015005311	 
	Area 11 Counties:
	 	 	 	 
	County:
	 	Provider Number:
	Miami-Dade
	 	 	015005312	 

AHCA Contract No. FA614, Exhibit II-D, Page 1 of 1

AHCA Form 2100-0002 (Rev. NOV03)

2

AHCA Contract No. FA614, Exhibit III-A, Page 1 of 5
HMO CapRates—200709-200808 08/10/2007

EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

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

	 	 	 	 	 	 	 	 	 
	TABLE 1	 	 	 	 	 	 	 	 
	General Rates:

	 	

	 	

	 	

	 	

	
 
	 	TANF
	 	SSI-N
	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	011,131.99202.30

021,131.99202.30

031,296.42233.58

041,128.87203.75

051,260.50227.66

061,111.64201.87

071,129.81204.44

081,059.95192.36

091,098.82197.96

101,119.46203.01

111,448.96260.41

	 	105.58

105.58

122.13

106.78

119.09

106.04

107.10

100.83

103.63

106.51

136.24
	 	66.22

66.22

77.48

67.92

75.94

68.10

68.40

64.75

65.91

68.32

86.18
	 	135.19

135.19

156.47

136.68

152.59

135.60

137.11

129.15

132.56

136.20

174.38
	 	72.29

72.29

84.50

74.01

82.61

74.02

74.43

70.40

71.62

74.23

94.02
	 	265.45

265.45

308.68

269.88

301.42

269.07

271.08

255.88

261.85

270.06

343.72
	 	167.89

167.89

196.24

171.79

191.81

171.81

172.77

163.25

166.57

172.18

218.26
	 	347.47

347.47

408.68

358.59

400.30

360.32

361.05

342.35

346.99

360.84

453.77
	 	10,081.87

10,081.87

11,326.29

10,675.98

11,774.49

10,832.05

11,163.75

9,491.26

10,597.24

13,743.01

14,396.52
	 	1,458.88

1,458.88

1,656.79

1,563.58

1,721.01

1,590.31

1,640.70

1,388.78

1,556.56

2,028.53

2,111.55
	 	435.95

435.95

495.12

467.86

514.94

475.95

490.80

415.62

465.60

606.68

631.62
	 	201.26

201.26

233.33

220.87

241.96

225.91

233.68

196.24

221.41

290.75

299.15
	 	222.08

222.08

256.55

242.36

266.53

247.84

256.10

215.38

242.54

319.15

329.01
	 	716.10

716.10

826.59

781.86

857.42

799.09

824.52

694.16

781.98

1,026.77

1,058.44
	 	703.88

703.88

816.63

772.10

846.21

790.01

815.86

685.42

773.10

1,016.73

1,046.51
	 	271.50

271.50

273.34

330.41

230.22

284.19

327.20

192.02

205.98

256.37

336.08
	 	138.14112.37

138.14112.37

129.66105.80

133.72109.08

127.48104.72

124.63101.81

128.73105.41

118.95 97.25

127.97104.76

143.41117.45

198.00160.77
	TABLE 2

General + Mental Health Rates:

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	
 
	 	 	 	 	 	TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	1,132.01

1,132.02

1,296.43

1,128.88

1,260.51

1,111.66

1,129.83

1,059.96

1,098.84

1,119.48

1,448.98
	 	202.32

202.33

233.59

203.76

227.67

201.89

204.46

192.37

197.98

203.03

260.43
	 	107.22

108.49

123.45

108.15

120.30

107.89

108.88

102.09

105.18

108.43

137.86
	 	77.91

86.47

86.66

77.48

84.61

81.34

81.08

73.55

76.72

81.68

97.47
	 	146.11

148.60

162.55

143.01

160.70

147.98

148.96

134.98

139.72

145.05

181.86
	 	83.21

85.70

90.58

80.34

90.72

86.40

86.28

76.23

78.78

83.08

101.50
	 	269.89

268.86

310.23

271.49

304.71

274.10

275.90

257.36

263.67

272.31

345.62
	 	172.33

171.30

197.79

173.40

195.10

176.84

177.59

164.73

168.39

174.43

220.16
	 	351.22

350.43

410.02

359.98

403.08

364.57

365.12

343.63

348.57

362.79

455.42
	 	10,081.95

10,082.03

11,326.36

10,676.09

11,774.54

10,832.12

11,163.81

9,491.33

10,597.31

13,743.10

14,396.60
	 	1,458.96

1,459.04

1,656.86

1,563.69

1,721.06

1,590.38

1,640.76

1,388.85

1,556.63

2,028.62

2,111.63
	 	443.39

449.74

501.38

477.61

519.96

482.47

496.92

421.62

471.93

615.03

638.59
	 	249.30

280.06

269.08

276.60

274.37

268.01

273.18

230.52

257.55

338.45

338.94
	 	266.06

267.29

277.06

274.33

296.20

286.38

292.26

235.05

263.28

346.52

351.84
	 	797.48

768.77

850.48

819.11

912.32

870.40

891.44

717.07

806.13

1,058.65

1,085.04
	 	734.86

728.75

827.91

789.69

867.11

817.15

841.33

696.24

784.51

1,031.78

1,059.07
	 	271.71

291.70

280.19

354.96

232.95

285.50

329.79

198.87

212.83

263.22

343.31
	 	149.79

153.14

138.64

150.49

140.29

128.51

139.24

132.17

137.56

151.46

206.05
	 	124.02

127.37

114.78

125.85

117.53

105.69

115.92

110.47

114.35

125.50

168.82

3

AHCA Contract No. FA614, Exhibit III-A, Page 2
of 5 HMO—CapRates—200709-200808 08/10/2007

EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

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

	 	 	 	 	 	 	 
	TABLE 3	 	 	 	 	 	 
	General + MH + Dental Rates:

	 	

	 	

	 	

	TANF

	 	SSI-N
	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	011,132.02202.33109.31

021,132.03202.34110.58

031,296.44233.60126.52

041,128.89203.77110.20

051,260.52227.69123.77

061,111.67201.90110.53

071,129.84204.47111.04

081,059.97192.38105.11

091,098.85197.99108.10

101,119.49203.04111.29

111,448.99260.44141.58

	 	82.23

90.79

93.00

81.71

91.76

86.79

85.54

79.80

82.75

87.56

105.13
	 	150.59

153.08

169.14

147.39

168.12

153.63

153.58

141.46

145.98

151.15

189.81
	 	86.99

89.48

96.13

84.03

96.98

91.17

90.17

81.69

84.06

88.23

108.20
	 	271.74

270.71

313.24

274.30

311.90

277.72

278.43

260.37

264.42

274.13

347.23
	 	173.97

172.94

200.46

175.89

201.49

180.05

179.84

167.40

169.94

176.05

221.59
	 	354.63

353.84

415.57

365.17

416.36

371.26

369.79

349.19

351.80

366.16

458.40
	 	10,081.95

10,082.03

11,326.37

10,676.09

11,774.55

10,832.13

11,163.81

9,491.34

10,597.31

13,743.11

14,396.61
	 	1,458.97

1,459.05

1,656.88

1,563.70

1,721.08

1,590.40

1,640.77

1,388.87

1,556.64

2,028.64

2,111.65
	 	445.59

451.94

504.76

479.82

524.88

485.64

500.03

424.74

474.66

618.77

642.83
	 	253.12269.40

283.88270.63

274.93282.17

280.43277.68

282.89303.65

273.51291.19

278.58296.97

235.93239.77

262.28267.41

344.93352.19

346.28358.26
	 	800.35

771.64

854.04

822.42

919.87

874.82

894.55

720.67

807.81

1,060.76

1,088.67
	 	738.28

732.17

832.15

793.64

876.10

822.42

845.04

700.54

786.52

1,034.30

1,063.40
	 	272.21

292.20

280.73

356.97

237.38

287.34

331.41

200.35

213.56

265.27

347.71
	 	152.10

155.45

141.72

153.57

148.63

133.29

142.40

135.32

139.40

154.03

210.11
	 	125.50

128.85

116.76

127.83

122.88

108.76

117.95

112.48

115.53

127.15

171.42
	TABLE 4

General + MH + Transportation Rates:

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	
 
	 	 	 	 TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	1,137.56

1,137.57

1,303.13

1,133.91

1,264.71

1,115.71

1.133.77

1,065.54

1,104.22

1,123.27

1,452.24
	 	203.71

203.72

235.26

205.01

228.72

202.90

205.44

193.77

199.32

203.97

261.24
	 	108.08

109.35

124.49

108.93

120.95

108.52

109.49

102.95

106.02

109.01

138.36
	 	78.43

86.99

87.29

77.95

85.01

81.72

81.45

74.07

77.23

82.04

97.78
	 	148.03

150.52

164.87

144.75

162.15

149.38

150.32

136.91

141.58

146.35

182.98
	 	84.47

86.96

92.09

81.48

91.67

87.31

87.17

77.49

79.99

83.94

102.24
	 	272.98

271.95

313.95

274.28

307.04

276.35

278.09

260.46

266.66

274.42

347.43
	 	174.71

173.68

200.67

175.56

196.90

178.58

179.28

167.12

170.70

176.05

221.56
	 	354.40

353.61

413.86

362.87

405.49

366.89

367.38

346.83

351.65

364.96

457.29
	 	10,125.36

10,125.44

11,381.17

10,720.46

11,809.84

10,866.95

11,201.13

9,532.67

10,640.50

13,782.23

14,425.98
	 	1,486.99

1,487.07

1,692.25

1,592.34

1,743.85

1,612.87

1,664.85

1,415.54

1,584.51

2,053.89

2,130.60
	 	449.03

455.38

508.50

483.38

524.54

487.00

501.77

427.00

477.55

620.11

642.40
	 	251.78

282.54

272.20

279.13

276.38

270.00

275.30

232.88

260.02

340.69

340.62
	 	272.18

273.41

284.79

280.59

301.18

291.30

297.53

240.88

269.38

352.05

355.99
	 	817.47

788.76

875.73

839.55

928.58

886.44

908.63

736.11

826.01

1,076.67

1,098.57
	 	751.37

745.26

848.76

806.56

880.53

830.40

855.51

711.96

800.93

1,046.66

1,070.25
	 	278.48

298.47

288.81

361.93

238.83

290.82

335.43

204.95

219.75

270.52

348.23
	 	163.52

166.87

158.48

166.27

154.32

140.11

151.37

146.97

153.37

169.12

218.56
	 	132.78

136.13

127.44

135.91

126.48

113.09

123.67

119.92

124.43

136.76

176.80

4

AHCA Contract No. FA614, Exhibit III-A, Page 3 of 5
HMO CapRates—200709-200808 08/10/2007

EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

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

	 	 	 	 	 	 	 
	TABLE 5	 	 	 	 	 	 
	General + Transportation Rates:

	 	

	 	

	 	

	TANF

	 	SSI-N
	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	011,137.54203.69

021,137.54203.69

031,303.12235.25

041,133.90205.00

051,264.70228.71

061,115.69202.88

071,133.75205.42

081,065.53193.76

091,104.20199.30

101,123.25203.95

111,452.22261.22

	 	106.44

106.44

123.17

107.56

119.74

106.67

107.71

101.69

104.47

107.09

136.74
	 	66.74

66.74

78.11

68.39

76.34

68.48

68.77

65.27

66.42

68.68

86.49
	 	137.11

137.11

158.79

138.42

154.04

137.00

138.47

131.08

134.42

137.50

175.50
	 	73.55

73.55

86.01

75.15

83.56

74.93

75.32

71.66

72.83

75.09

94.76
	 	268.54

268.54

312.40

272.67

303.75

271.32

273.27

258.98

264.84

272.17

345.53
	 	170.27

170.27

199.12

173.95

193.61

173.55

174.46

165.64

168.88

173.80

219.66
	 	350.65

350.65

412.52

361.48

402.71

362.64

363.31

345.55

350.07

363.01

455.64
	 	10,125.28

10,125.28

11,381.10

10,720.35

11,809.79

10,866.88

11,201.07

9,532.60

10,640.43

13,782.14

14,425.90
	 	1,486.91

1,486.91

1,692.18

1,592.23

1,743.80

1,612.80

1,664.79

1,415.47

1,584.44

2,053.80

2,130.52
	 	441.59

441.59

502.24

473.63

519.52

480.48

495.65

421.00

471.22

611.76

635.43
	 	203.74

203.74

236.45

223.40

243.97

227.90

235.80

198.60

223.88

292.99

300.83
	 	228.20

228.20

264.28

248.62

271.51

252.76

261.37

221.21

248.64

324.68

333.16
	 	736.09

736.09

851.84

802.30

873.68

815.13

841.71

713.20

801.86

1,044.79

1,071.97
	 	720.39

720.39

837.48

788.97

859.63

803.26

830.04

701.14

789.52

1,031.61

1,057.69
	 	278.27

278.27

281.96

337.38

236.10

289.51

332.84

198.10

212.90

263.67

341.00
	 	151.87

151.87

149.50

149.50

141.51

136.23

140.86

133.75

143.78

161.07

210.51
	 	121.13

121.13

118.46

119.14

113.67

109.21

113.16

106.70

114.84

128.71

168.75
	TABLE 6

General + Dental Rates:

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	TANF

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	 	 	 	 	SSI-B
	 	SSI-AB
	 	

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	1,132.00

1,132.00

1,296.43

1,128.88

1,260.51

1,111.65

1,129.82

1,059.96

1,098.83

1,119.47

1,448.97
	 	202.31

202.31

233.59

203.76

227.68

201.88

204.45

192.37

197.97

203.02

260.42
	 	107.67

107.67

125.20

108.83

122.56

108.68

109.26

103.85

106.55

109.37

139.96
	 	70.54

70.54

83.82

72.15

83.09

73.55

72.86

71.00

71.94

74.20

93.84
	 	139.67

139.67

163.06

141.06

160.01

141.25

141.73

135.63

138.82

142.30

182.33
	 	76.07

76.07

90.05

77.70

88.87

78.79

78.32

75.86

76.90

79.38

100.72
	 	267.30

267.30

311.69

272.69

308.61

272.69

273.61

258.89

263.60

271.88

345.33
	 	169.53

169.53

198.91

174.28

198.20

175.02

175.02

165.92

168.12

173.80

219.69
	 	350.88

350.88

414.23

363.78

413.58

367.01

365.72

347.91

350.22

364.21

456.75
	 	10,081.87

10,081.87

11,326.30

10,675.98

11,774.50

10,832.06

11,163.75

9,491.27

10,597.24

13,743.02

14,396.53
	 	1,458.89

1,458.89

1,656.81

1,563.59

1,721.03

1,590.33

1,640.71

1,388.80

1,556.57

2,028.55

2,111.57
	 	438.15

438.15

498.50

470.07

519.86

479.12

493.91

418.74

468.33

610.42

635.86
	 	205.08

205.08

239.18

224.70

250.48

231.41

239.08

201.65

226.14

297.23

306.49
	 	225.42

225.42

261.66

245.71

273.98

252.65

260.81

220.10

246.67

324.82

335.43
	 	718.97

718.97

830.15

785.17

864.97

803.51

827.63

697.76

783.66

1,028.88

1,062.07
	 	707.30

707.30

820.87

776.05

855.20

795.28

819.57

689.72

775.11

1,019.25

1,050.84
	 	272.00

272.00

273.88

332.42

234.65

286.03

328.82

193.50

206.71

258.42

340.48
	 	140.45

140.45

132.74

136.80

135.82

129.41

131.89

122.10

129.81

145.98

202.06
	 	113.85

113.85

107.78

111.06

110.07

104.88

107.44

99.26

105.94

119.10

163.37

5

AHCA Contract No. FA614, Exhibit III-A, Page 4 of 5
HMO—CapRates—200709-200808 08/10/2007

EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

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

	 	 	 	 	 	 	 
	TABLE 7	 	 	 	 	 	 
	General + Dental + Transportation Rates:

	 	

	 	

	 	

	TANF

	 	SSI-N
	 	SSI-B
	 	SSI-AB

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	011,137.55203.70108.5371.06141.59

021,137.55203.70108.5371.06141.59

031,303.13235.26126.2484.45165.38

041,133.91205.01109.6172.62142.80

051,264.71228.73123.2183.49161.46

061,115.70202.89109.3173.93142.65

071,133.76205.43109.8773.23143.09

081,065.54193.77104.7171.52137.56

091,104.21199.31107.3972.45140.68

101,123.26203.96109.9574.56143.60

111,452.23261.23140.4694.15183.45

	 	77.33

77.33

91.56

78.84

89.82

79.70

79.21

77.12

78.11

80.24

101.46
	 	270.39

270.39

315.41

275.48

310.94

274.94

275.80

261.99

266.59

273.99

347.14
	 	171.91

171.91

201.79

176.44

200.00

176.76

176.71

168.31

170.43

175.42

221.09
	 	354.06

354.06

418.07

366.67

415.99

369.33

367.98

351.11

353.30

366.38

458.62
	 	10,125..28

10,125.28

11,381.10

10,720.35

11,809.79

10,866.88

11,201.07

9,532.60

10,640.43

13,782.14

14,425.90
	 	1,486.92

1,486.92

1,692.20

1,592.24

1,743.82

1,612.82

1,664.80

1,415.49

1,584.45

2,053.82

2,130.54
	 	443.79

443.79

505.6

475.84

524.44

483.65

498.76

424.12

473.95

615.50

639.67
	 	203.74

203.74

242.30

227.23

252.49

233.40

241.20

204.01

228.61

299.47

308.17
	 	228.20

228.20

269.39

251.97

278.96

257.57

266.08

225.93

252.77

330.35

339.58
	 	736.09

736.09

855.40

805.61

881.23

819.55

844.82

716.80

803.54

1,046.90

1,075.60
	 	723.81

723.81

841.72

792.92

868.62

808.53

833.75

705.44

791.53

1,034.13

1,062.02
	 	278.77

278.77

282.50

339.39

240.53

291.35

334.46

199.58

213.63

265.72

345.40
	 	154.18

154.18

152.58

152.58

149.85

141.01

144.02

136.90

145.62

163.64

214.57
	 	122.61

122.61

120.44

121.12

119.02

112.28

115.19

108.71

116.02

130.36

171.35
	TABLE 8

General + Mental Health + Dental + Transportation Rates:

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	TANF

	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	 	 	 	 	SSI-B
	 	SSI-AB
	 	

Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	1,137.57

1,137.58

1,303.14

1,133.92

1,264.72

1,115.72

1,133.78

1,065.55

1,104.23

1,123.28

1,452.25
	 	203.72

203.73

235.27

205.02

228.74

202.91

205.45

193.78

199.33

203.98

261.25
	 	110.17

111.44

127.56

110.98

124.42

111.16

111.65

105.97

108.94

111.87

142.08
	 	82.75

91.31

93.63

82.18

92.16

87.17

85.91

80.32

83.26

87.92

105.44
	 	152.51

155.00

171.46

149.13

169.57

155.03

154.94

143.39

147.84

152.45

190.93
	 	88.25

90.74

97.64

85.17

97.93

92.08

91.06

82.95

85.27

89.09

108.94
	 	274.83

273.80

316.96

277.09

314.23

279.97

280.62

263.47

268.41

276.24

349.04
	 	176.35

175.32

203.34

178.05

203.29

181.79

181.53

169.79

172.25

177.67

222.99
	 	357.81

357.02

419.41

368.06

418.77

373.58

372.05

352.39

354.88

368.33

460.27
	 	10,125.36

10,125.44

11,381.18

10,720.46

11,809.85

10,866.96

11,201.13

9,532.68

10,640.50

13,782.24

14,425.99
	 	1,487.00

1,487.08

1,692.27

1,592.35

1,743.87

1,612.89

1,664.86

1,415.56

1,584.52

2,053.91

2,130.62
	 	451.23

457.58

511.88

485.59

529.46

490.17

504.88

430.12

480.28

623.85

646.64
	 	255.60

286.36

278.05

282.96

284.90

275.50

280.70

238.29

264.75

347.17

347.96
	 	275.52

276.75

289.90

283.94

308.63

296.11

302.24

245.60

273.51

357.72

362.41
	 	820.34

791.63

879.29

842.86

936.13

890.86

911.74

739.71

827.69

1,078.78

1,102.20
	 	754.79

748.68

853.00

810.51

889.52

835.67

859.22

716.26

802.94

1,049.18

1,074.58
	 	278.98

298.97

289.35

363.94

243.26

292.66

337.05

206.43

220.48

272.57

352.63
	 	165.83

169.18

161.56

169.35

162.66

144.89

154.53

150.12

155.21

171.69

222.62
	 	134.26

137.61

129.42

137.89

131.83

116.16

125.70

121.93

125.61

138.41

179.40

6

EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

	 	 	 
	Area

Area 1

Area 2

Area 3

Area 4

Area 5

Area 6

Area 7

Area 8

Area 9

Area 10

Area 11

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

Corresponding Counties

Escambia, Okaloosa, Santa Rosa, Walton

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

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

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

Pasco, Pinellas

Hardee, Highlands, Hillsborough, Manatee, Polk

Brevard, Orange, Osceola, Seminole

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

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

Broward

Dade, Monroe

Created on August 10, 2007

AHCA Contract No. FA614, Exhibit III-A, Page 5 of 5
HMO CapRates_200709-200808 08/10/2007

7

Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care

IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which
includes all attachments hereto) to be executed by their officials thereunto duly authorized.

	 	 	 	 	 
	AMERIGROUP FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR
	D/B/A/ AMERIGROUP COMMUNITY C	 	HEALTH CARE ADMINISTRATION
	SIGNED

BY:

	 	/S/ William McHugh
	 	SIGNED

BY:
	 

	 	 
	 	 
	NAME: William McHugh

	 	 	 	NAME: Andrew C. Agwunobi, M.D
	 

	 	 	 	 
	TITLE:. CEO

	 	 	 	TITLE: Secretary
	 

	 	 	 	 
	DATE: 8-31-07

	 	 	 	DATE:
	 

	 	 	 	 

List of attachments included as part of this Amendment:

	 	 	 	 	 
	Specify

	 	Letter/
	 	

	Type

	 	Number
	 	Descnption
	 

	 	 
	 	 
	Exhibit

	 	II-D
	 	Fourth Revised Capitation Rates (1 Page)
	Exhibit

	 	III-A
	 	September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO
	
 
	 	 	 	Capitation Rates (5 Pages)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form
2100-0002 (Rev. NOV03)

8

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