Document:

Exhibit 4.2

WARRANT AGREEMENT

          THIS AGREEMENT, dated as of this _____ day of September 2006, by and between Waccamaw Bankshares, Inc., a North Carolina corporation (the “Company”) and First-Citizens Bank & Trust Company, Raleigh, North Carolina (the “Transfer Agent”).

          WHEREAS, the Company in connection with its offering (the “Offering”) of up to six hundred fifty six thousand one hundred ninety six (656,196) shares of its no par value common stock (the “Common Stock”) is issuing an aggregate of up to six hundred fifty six thousand one hundred ninety-six warrants (the “Warrants”) to purchase the Company’s Common Stock, such that one Warrant shall be issued for each share of the Company’s Common Stock sold in the Offering.

          WHEREAS, the Company desires to appoint the Transfer Agent to act on its behalf in connection with (i) the issuance, transfer and exchange of the certificates representing the Warrants (the “Warrant Certificates”), (ii) the exercise of the Warrants by the holders thereof (together with any registered successors or assigns, the “Holders”) and (iii) the adjustment of the Warrants in certain events as contained herein;

          NOW, THEREFORE, the parties hereto hereby agree as follows:

          1.          APPOINTMENT OF TRANSFER AGENT. The Company hereby appoints the Transfer Agent as its agent to issue the Warrant Certificates subject to resignation or replacement as provided herein.  The Transfer Agent agrees to accept such appointment, subject to the terms and conditions as set forth herein and to issue, transfer and exchange the Warrant Certificates pursuant to the terms as provided for herein and to issue the certificates representing the appropriate number of shares of Common Stock (or other consideration) upon exercise of the Warrants.  

          2.          ISSUANCE OF WARRANT CERTIFICATES.

                       2.1.          Form of Warrant Certificate.  All Warrants shall be issued substantially in the form of the Warrant Certificate annexed hereto as Exhibit A.  The terms of any such Certificate are incorporated herein by reference.

                       2.2.          Execution of Warrants.  No Warrants shall have been duly and validly issued until a Holder has received a Warrant Certificate executed by the chairman or president of the Company and the secretary or treasurer of the Company and such Certificate is countersigned by an authorized officer of the Transfer Agent.  Any Warrant Certificates may be executed by the officers of the Company by means of a facsimile signature.  The Transfer Agent shall maintain the register of all Holders.

                       2.3.          Maximum Number of Warrants.  The Company hereby authorizes the Transfer Agent to issue an aggregate of up to six hundred fifty-six thousand one hundred ninety six (656,196) Warrants pursuant to the terms hereof subject to adjustment as hereafter provided in Section 5 hereof.

                       2.4.          Initial Holders.  The Company shall deliver to the Transfer Agent a list of the names of the persons who shall be the initial Holders of the Warrants and the number of Warrants to which each such person is entitled.  The Transfer Agent is hereby authorized by the Company to promptly issue Warrant Certificates for up to six hundred fifty-six thousand one hundred ninety six 656,196) Warrants upon receipt of the written request of the Company, which shall include the list referred to in the preceding sentence.  The Company shall deliver to the Transfer Agent, along with this Warrant Agreement, a sufficient number of duly executed Warrant Certificates.  The Warrant Certificates shall be completed and countersigned by the Transfer Agent and
promptly mailed or delivered to the Holders as identified on the list described above pursuant to the terms hereof.  When requested by the Transfer Agent, from time to time hereafter, the Company will execute additional Warrant Certificates in blank for the Transfer Agent to issue hereunder.

          3.          RIGHTS OF A HOLDER. Subject to adjustment as provided herein, each Warrant shall evidence the right to purchase one share of the Company’s Common Stock at the purchase price of $24.00 (the “Purchase Price”).  Following the Expiration Date, as defined in Section 4.1 below, the Warrant shall be null and void.

          4.          EXERCISE OR TRANSFER OF WARRANT.

                       4.1.          Exercise Period.  The Warrants may be exercised at any time commencing after September 30, 2006 (the “Initial Exercise Date”) but not later than 5:00 P.M., Eastern Time, on September 30, 2009 (the “Expiration Date”).  If the Expiration Date is not a Business Day, it shall automatically be extended to 5:00 P.M. on the next day which is a Business Day.  Business Day means any day other than a Saturday, Sunday, or holiday on which banks in North Carolina are authorized by law to close.

                       4.2.          Means of Exercise.  In order to exercise a Warrant, the Holder must present and surrender the Warrant Certificate to the Company at its office, with the election to exercise section duly executed and it must be accompanied by payment in full, in the form of cash, by certified or official bank check payable to the order of the Company or its successor, or any other form acceptable to the Company, of the aggregate Purchase Price for the number of shares of Common Stock specified in such Election to Exercise Form.

                       4.3.          Issuance of Common Stock.  Upon the direction of the Company, the Transfer Agent shall promptly deliver or cause to be delivered a certificate or certificates evidencing the shares of Common Stock purchased when any Warrant is validly exercised.  Upon receipt of any Warrant Certificate by the Company, at its office, in proper form for exercise and accompanied by payments as herein provided, the Holder shall be deemed to be the holder of record of the shares of Common Stock issuable upon such exercise, notwithstanding that the stock transfer books of the Company shall then be closed or that certificates representing such shares of Common Stock shall not then be actually delivered to the Holder.  For that purpose, the Company will immediately
give notice to the Transfer Agent of any such exercise of a Warrant by a Holder.

                       4.4.          Transfer.  Upon surrender of a Warrant Certificate at the principal office of the Transfer Agent, by the Holder thereof in person or by an attorney duly authorized in writing, with the election to transfer section properly completed and duly executed, such Warrant Certificate may be transferred or exchanged without payment of any service charge, for another Warrant Certificate or Warrant Certificates of like tenor, evidencing in the aggregate the number of Warrants evidenced by the Warrant Certificates so surrendered and registered in the name or names as requested by the then registered owner thereof or by an attorney duly authorized in writing.  Warrants transferred pursuant to such Section shall be accompanied by a proper payment of any
applicable transfer taxes. 

                       4.5.          Simultaneous Exercise and Transfer.  Holders electing to exercise Warrants and simultaneously transfer Warrants evidenced by the same Warrant Certificate shall submit the Warrant Certificates to the Company in accordance with Section 4.2 hereof.  Thereafter, the Company shall direct the Transfer Agent in accordance with Section 4.3 hereof to deliver certificates representing shares of Common Stock purchased upon the valid exercise of any such Warrant, and deliver to the Transfer Agent the Warrant Certificate for transfer pursuant to Section 4.4 hereof. 

          5.          ADJUSTMENT OF PURCHASE PRICE AND NUMBER OF SHARES PURCHASABLE AND OTHER TERMS IN CERTAIN EVENTS. 

                       5.1.          The Purchase Price and the resulting number of shares of Common Stock issuable under each Warrant shall be subject to adjustment as follows:

	
  
 
  	
  
(a)
  	
  
If the Company after the date of issuance of a   Warrant, but before its exercise:
  
	 
 
 	 
 
 	 
 
 
	
  
 
  	
  
 
  	
  
(1)  declares   a dividend or any other distribution payable in shares of its Common Stock otherwise than out of earnings or   earned surplus;
  
	 
 
 	 
 
 	 
 
 
	
  
 
  	
  
 
  	
  
(2)  subdivides its outstanding shares of   Common Stocks into a greater number of shares;
  
	 
 
 	 
 
 	 
 
 
	
  
 
  	
  
 
  	
  
(3)  combines its outstanding shares of Common   Stock into a smaller number of shares;
  
	 
 
 	 
 
 	 
 
 
	
  
 
  	
  
 
  	
  
(4)  issues by reclassification of its shares   of Common Stock any shares of capital stock of the Company (other than a   change in par value or from par value to no par value or from no par value to   par value); or
  
	 
 
 	 
 
 	 
 
 
	
   
  	
  
 
  	
  
(5)  issues rights, options or warrants   entitling holders of shares of Common Stock to subscribe for shares of Common   Stock at less than the current market price, if any;
  

the number of shares of Common Stock issuable under each Warrant immediately prior to such action shall be adjusted (calculated to the nearest tenth of a share of Common Stock) so that the Holder of each Warrant may receive the number of shares of Common Stock of the Company to which it would have been entitled upon such action if such holder had so exercised the Warrant immediately prior thereto.  In this case, the Purchase Price shall also be adjusted (calculated to the nearest whole cent) by multiplying the Purchase Price in effect immediately prior to an adjustment in accordance with 5.1(a)(1) through (5) hereof by the inverse of the factor used to make such adjustment.  An adjustment made pursuant to this Section 5 shall become effective immediately after the record date for the determination of owners of Common Stock entitled thereto in the case of a dividend or distribution, and shall become effective immediately after the effective date in the
case of a subdivision, combination, reclassification, or issuance of rights, options or warrants retroactive to the record date, if any, for such event.

          (b)          No payment or adjustment shall be made by or on behalf of the Company on account of any cash dividends on the Common Stock issued upon any exercise of a Warrant which was declared for payment to the holders of Common Stock of record as of a date prior to the date on which such Warrant is exercised.

          (c)          For the purpose of this Section 5.1, the term “shares of Common Stock” shall mean (x) the class of stock designated as the Common Stock at the date of this Warrant, or (y) any other class of stock resulting from successive changes or reclassifications of such shares consisting solely of changes in par value, from no par value to par value or from par value to no par value. In the event that at any time, as a result of an adjustment made pursuant to this Section 5, the Holder shall become entitled to purchase any shares of the Company other than shares of Common Stock, thereafter the number of such other shares so purchasable upon exercise of each Warrant and the Purchase Price of such shares shall be subject to adjustment from time to time in a manner and on terms as nearly equivalent as practicable to the provisions with respect to
the shares of Common Stock contained in this Section 5.1.

          5.2.          Liquidation, Dissolution or Winding Up.  Notwithstanding any other provisions hereof, in the event of the liquidation, dissolution, or winding up of the affairs of the Company (other than in connection with a merger or sale or conveyance of all or substantially all of its assets outside of the ordinary course of business), the right to exercise each Warrant shall terminate and expire at the close of business on the last full business day before the earliest date fixed for the payment of any distributable amount on the Common Stock.  The Company shall cause a notice to be mailed to each Holder at least 20 days prior to the applicable record date for such payment stating the date on which such liquidation, dissolution or winding up is expected to become effective, and the date on which it is expected that holders of shares
of Common Stock of record shall be entitled to exchange their shares of Common Stock for securities or other property or assets (including cash) deliverable upon such liquidation, dissolution or winding up, and that each Holder may exercise outstanding Warrants during such 20 day period and, thereby, receive consideration in the liquidation on the same basis as other previously outstanding shares of the same class as the shares acquired upon exercise.  The Company’s failure to give notice required by this Section 5.2 or any defect therein shall not affect the validity of such liquidation, dissolution or winding up.

          5.3.          Merger, Consolidation, etc.

                          (a)          In case of any merger of the Company into any other entity or sale or conveyance of all or substantially all of its assets outside of the ordinary course of business (such merger, share exchange, sale or conveyance, or any other reorganization in which the Company is not the surviving entity, a “Change”) then, as a condition of such Change, lawful and adequate provisions shall be made whereby the Holders shall thereafter have the right to receive upon payment of the Purchase Price in effect immediately prior to such Change, upon the basis and upon the terms and conditions specified in this Agreement (including but not limited to all provisions contained in this Section 5), and in lieu of the shares of the Company’s Common Stock
purchasable upon the exercise of the Warrants, such shares of stock, securities, cash or assets which such Holder would have been entitled to receive after the happening of such Change had such Warrant been exercised immediately prior to such Change.  The provisions of this Section 5.3 shall similarly apply to successive Changes.  The Company shall cause a notice to be mailed to each Holder at least 20 days prior to the applicable record date for the Change covered by this Section 5.3(a) and shall provide notice of the Change and shall set forth the first and last date on which the Holder may exercise outstanding Warrants.  The Company’s failure to give the notice required by this Section 5.3(a) or any defect therein shall not affect the validity of the Change covered by this Section 5.3(a).

                          (b)          Notwithstanding the foregoing, if as a result of such Change, holders of the Company Common Stock shall receive consideration other than solely in shares of stock or other securities in exchange for their Company Common Stock, the Company may, at its option, fulfill its obligation hereunder by causing the Notice required by Section 5.3(a) hereof to include notice to Holders of the opportunity to exercise their Warrants before the applicable record date for the Change, and thereby receive consideration in the Change, on the same basis as other previously outstanding shares of the same class as the shares acquired upon exercise.  If the notice specified in the preceding sentence is provided to Holders, Warrants not exercised in accordance with
this Section 5.3(b) before consummation of the Change shall be canceled and become null and void on the effective date of the Change.  The notice provided by the Transfer Agent pursuant to this Section 5.3(b) shall include a description of the terms of this Agreement providing for cancellation of the Warrants in the event that Warrants are not exercised by the prescribed date.  The Company’s failure to give any notice required by this Section 5.3(b) or any defect therein shall not affect the validity of any such Change.

          5.4.          Duty to Make Fair Adjustments in Certain Cases.  If any event occurs as to which in the opinion of the Board of Directors of the Company the other provisions of this Section 5 are not strictly applicable or if strictly applicable would not fairly protect the purchase rights of the Holders in accordance with the essential intent and principles of this Agreement, then the Board of Directors shall make an adjustment in the application of such provisions, in accordance with such essential intent and principles, as to protect the purchase rights of the Holders.  Notwithstanding the foregoing, the issuance of Common Stock or any securities convertible into Common Stock by the Company either for cash or in a merger, sale of assets, exchange or acquisition shall not, by itself, constitute a basis for requiring any adjustment in the
Warrants unless specifically enumerated herein.

          5.5.          Good Faith Determination.  Any determination as to whether an adjustment or limitation of exercise is required pursuant to this Section 5 (and the amount of any adjustment), shall be binding upon the Holders and the Company if made in good faith by the Board of Directors of the Company.

          5.6.          Notice of Adjustment.  Whenever the number of shares of Common Stock purchasable upon the exercise of the Warrants or the Purchase Price is adjusted, the Company shall promptly file in the custody of its Secretary or an Assistant Secretary at its principal office and with the Transfer Agent, an officer’s certificate setting forth the number of shares of Common Stock purchasable upon the exercise of the Warrants, the Purchase Price after such adjustment, a statement, in reasonable detail, of the facts requiring such adjustment and the computation by which such adjustment was made.  Each such officer’s certificate shall be made available at all reasonable times for inspection by the Holders, and at the expense and direction of the Company the Transfer Agent shall, forthwith after each such adjustment, promptly mail a
copy of such certificate to such Holders by first class mail, postage prepaid.  The Company’s failure to give the notice required by this Section 5.6 or any defect therein shall not affect the validity of such action listed under this Section 5.6.

          5.7.          No Change of Warrant Necessary.  Irrespective of any adjustment in the Purchase Price or in the number or kind of shares issuable upon exercise of the Warrants, the Warrant Certificates may continue to express the same price and number and kind of shares as are stated in the Warrant Certificates as initially issued.

          6.             SHARES TO BE FULLY PAID; RESERVATION OF SHARES.  The Company covenants and agrees for the benefit of the Holders:

                          6.1.          That all shares of Common Stock which may be issued upon the exercise of the rights represented by the Warrant Certificates will, upon issue and payment of the aggregate Purchase Price therefor, be duly authorized, validly issued, fully paid and non-assessable and free and clear of all liens and encumbrances, with no personal liability attaching to the ownership thereof.

                          6.2.          That during the period within which the rights represented by the Warrant Certificates may be exercised, the Company will at all times have authorized and reserved for the purpose of issue upon exercise of the rights evidenced by the Warrant Certificates, a sufficient number of shares of Common Stock to provide for the exercise of the rights represented by the Warrant Certificates.

                          6.3.          That the Company will take all such action as may be necessary to ensure that the shares of Common Stock issuable upon the exercise of the Warrants may be so issued without violation of any applicable federal or state law or regulation. 

                          6.4.          That the shares of Common Stock issuable upon exercise of the Warrants shall be registered under the Securities Act of 1933 and shall register or qualify such Common Stock in every state where such registration or qualification shall be required under the applicable state securities or Blue Sky laws; and

                          6.5          That the Company shall use its best efforts to list the Warrants for trading on the NASDAQ Capital Market as soon as practicable.

          7.          LOSS OF WARRANT CERTIFICATE.  Upon receipt by the Transfer Agent of evidence satisfactory to it of the loss, theft, destruction or mutilation of a Warrant Certificate, and (i) in the case of such loss, theft or destruction, of reasonably satisfactory indemnification and bonding, or (ii) if mutilated, upon surrender and cancellation of such Warrant Certificate, the Transfer Agent, upon the request and instruction of the Company, shall execute and deliver a new Warrant Certificate of like tenor.  Any such new Warrant Certificate executed and delivered shall constitute an additional contractual obligation on the part of the Company, whether or not the Warrant Certificate so lost, stolen, destroyed or mutilated shall be at any time enforceable by anyone.

          8.          NO ISSUANCE OF FRACTIONAL INTERESTS IN COMMON STOCK.  The Company shall not be required to issue fractional shares of Common Stock on the exercise of the Warrants. If any fraction of a share of Common Stock would be issuable upon the exercise of the Warrants (or any specified portion thereof), the Company shall pay an amount in cash equal to the product of (a) such fraction and (b) the fair market value of the Common Stock, as determined in good faith by the Board of Directors of the Company, on the Business Day prior to the date the Warrant is exercised.

          9.          NO RIGHTS AS STOCKHOLDERS; CERTAIN NOTICES AND REPORTS TO HOLDERS.  Except as specifically provided in this Agreement, nothing contained in this Agreement or in the Warrant Certificates shall be construed as conferring upon the Holders or any transferees the right to vote or to receive dividends or to receive notice as stockholders in respect of any meeting of stockholders for the election of directors of the Company or any other matter, or any rights whatsoever as stockholders of the Company. If, however, between the date hereof and the Expiration Date (or if earlier the occurrence of any event specified in Section 5.2 or 5.3(b) terminating the Warrants), any of the following events shall occur:

                       (a)          the Company shall declare any cash dividend upon its shares of Common Stock payable at a rate more than 50% in excess of the rate of the last cash dividend theretofore paid; or

                       (b)          the Company shall declare any dividend payable in any securities upon its shares of Common Stock, other than a dividend payable in Common Stock or make any distribution (other than a regular cash dividend out of undistributed net income) to the holders of its shares of Common Stock; or

                       (c)          the Company shall distribute any rights, options or warrants to the holders of shares of Common Stock; or

                       (d)          a capital reorganization or reclassification of the Company’s capital stock shall be proposed;

then in any one or more of said events, the Company shall give to the Holders at least twenty days prior written notice of the date fixed as a record date or the date of closing the transfer books for the determination of the stockholders entitled to receive such dividend or distribution. Any such notice shall also specify, in the case of any such dividend or distribution, the date on which holders of shares of Common Stock are entitled thereto. Failure to mail such notice or any defect therein or in the mailing thereof shall not affect the validity of any action taken in connection with such dividend or distribution.

          10.          AGREEMENT OF HOLDERS.  Every Holder of a Warrant, by his acceptance thereof, consents and agrees with the Company, the Transfer Agent and every other Holder of a Warrant that:

                         (a)          Warrants are not transferable except as provided herein; and

                         (b)          The Company and the Transfer Agent may deem and treat the person in whose name the Warrant Certificate is registered as the Holder and as the absolute, true and lawful owner of the Warrants represented thereby for all purposes, and neither the Company nor the Transfer Agent shall be affected by any notice or knowledge to the contrary.

          11.          DUTIES OF TRANSFER AGENT.  The Transfer Agent acts hereunder as agent and in a ministerial capacity for the Company, and its duties shall be determined solely by the provisions hereof.  The Transfer Agent shall not, by issuing and delivering Warrant Certificates or by any other act hereunder be deemed to make any representations as to the validity, value or authorization of the Warrant Certificates or the Warrants represented thereby or of any securities or other property delivered upon exercise of any Warrant or whether any stock issued upon exercise of any Warrant is fully paid and nonassessable.

                         The Transfer Agent shall not at any time be under any duty or responsibility to any Holder of Warrant Certificates to make or cause to be made any adjustment of the Purchase Price provided in this Agreement, or to determine whether any fact exists which may require any such adjustments, or with respect to the nature or extent of any such adjustment, when made, or with respect to the method employed in making the same.  It shall not (i) be liable for any recital or statement of facts contained herein or for any action taken, suffered or omitted by it in reliance on any Warrant Certificate or other document or instrument believed by it in good faith to be genuine and to have been signed or presented by the proper party or parties, (ii) be responsible for any failure on the part of the Company to comply with any of its
covenants and obligations contained in this Agreement or in any Warrant Certificate, or (iii) be liable for any act or omission in connection with this Agreement except for its own gross negligence or willful misconduct.

                         Further, neither the Transfer Agent nor its officers, employees, directors, agents or affiliates shall:  (a) be liable for any good faith action, omission, or error in judgment in performing the Transfer Agent’s duties under this Agreement, but shall be liable only for losses caused by the Transfer Agent’s gross negligence or willful malfeasance in the performance of its duties under this Agreement; (b) in any event be liable for any special, speculative or consequential damages, even if advised of the possibility of such damages, or for any punitive damages; (c) be liable for any loss arising from any act or failure to act by any third party, including a failure to follow the Transfer Agent’s instructions or to honor its demands, or from any delay or difficulty arising from applicable rules,
regulations, procedures, or requirements; (d) be liable for any loss arising from, or failure to perform when performance is rendered unfeasible, or significantly more costly, by causes beyond the Transfer Agent’s control, including equipment, communications and transportation failures and interruptions, governmental orders and actions, war or military action, civil unrest or commotion, catastrophes, strikes or other labor disturbances, or natural disasters; (e) be liable for loss or deemed in violation of any provision of this Agreement or applicable law if, promptly after the discovery of the mistake, the Transfer Agent takes whatever actions may be practical under the circumstances to remedy the mistake, or if the Transfer Agent is unable to correct a mistake due to the Company’s failure to act; (f) be subject to liability for acting in accordance with the Company’s instructions or arising from any other exercise of authority by the Company; or (g) have any responsibility for
providing legal or tax advice.  Any liability of the Transfer Agent to the Company shall be limited to the lesser of the total fees charged the Company by Transfer Agent in the preceding five years under this Agreement or the actual damages recoverable by the Company under this Agreement.  

                         The Transfer Agent may seek the advice of legal counsel to the Company, or, in its discretion, of the Transfer Agent’s own legal counsel, with respect to the meaning and construction of, or its rights and duties under, this Agreement, and the Company shall pay, or reimburse the Transfer Agent for, the fees and expenses charged by any such counsel.  The Transfer Agent may at any time initiate an action or proceeding for the determination of any question which may arise, or for instructions concerning any matter as to which the Transfer Agent is uncertain of its rights or duties, and the Company shall pay, or reimburse the Transfer Agent for, the expenses of any such action or proceeding.  The Transfer Agent shall have no liability for any act or omission taken or made by it in good faith pursuant to the
advice of legal counsel, or for following the instructions of any court, or for any liability caused by delay or inaction pending such advice or instructions.  The Transfer Agent shall have no obligation to prosecute, defend, or otherwise participate in any action or proceeding unless it is advanced sufficient funds and/or indemnified, to its satisfaction, for the expenses or liabilities that may arise from such action or proceeding. 

                         The Company shall provide Transfer Agent with notices and detailed information about actions it directs or instructs Transfer Agent to take.  The Company’s instructions shall be given reasonably in advance and in reasonable detail, and in accordance with any procedural requirements of this Agreement.   Transfer Agent shall be entitled to rely on, and be fully protected in acting on, any directions or instructions from the Company.  Any notice, statement, instruction, request, direction, order or demand of the Company shall be sufficiently evidenced by an instrument signed by the President, any Vice President, its Secretary, or Assistant Secretary, (unless other evidence in respect thereof is herein specifically prescribed).  Transfer Agent may, however, but shall not be required to, accept
and act upon instructions given orally (in person or on the telephone), or by telegram, facsimile, electronic mail or other means which Transfer Agent reasonably believes to be genuine and authorized, but Transfer Agent shall not be liable for acting upon such instructions or purported instructions.  The Transfer Agent shall not be liable for any action taken, suffered or omitted by it in accordance with such notice, statement, instruction, request, direction, order or demand believed by it to be genuine.  The Company will cooperate reasonably with Transfer Agent to enable Transfer Agent to carry out the Company’s directions or instructions and otherwise perform its duties under this Agreement.  

                         The Transfer Agent may resign its duties and be discharged from all liabilities and further duties hereunder (except liabilities arising as a result of the Transfer Agent’s own gross negligence or willful misconduct), after giving 30 days’ prior written notice to the Company.  At least 15 days prior to the date such resignation is to become effective, the Transfer Agent shall cause a copy of such notice of resignation to be mailed to the Holder of each Warrant Certificate at the Company’s expense. Upon such resignation, or any inability of the Transfer Agent to act as such hereunder, the Company shall appoint a new Transfer Agent in writing.  The Company shall have complete discretion in the naming of a new Transfer Agent, who may be an affiliate, subsidiary or department of the Company, or any
person used by the Company as transfer agent for the Common Stock.  If the Company shall fail to make such appointment within a period of 15 days after it has been notified in writing of such resignation by the resigning Transfer Agent, then the Holder of any Warrant Certificate may apply to any court of competent jurisdiction for the appointment of a new Transfer Agent.

                         The Company may, upon notice to the Holders, remove and replace the Transfer Agent as the Company’s agent for purposes of the Warrant Certificate under this Agreement.

                         After acceptance in writing of an appointment by a new transfer agent is received by the Company, such new transfer agent shall be vested with the same powers, rights, duties and responsibilities as if it had been originally named herein as the Transfer Agent, without any further assurance, conveyance, act or deed. Any former Transfer Agent hereby agrees to cooperate with and deliver all records and Warrant Certificates to the new transfer agent at the direction of the new transfer agent and the Company.

                         Not later than the effective date of an appointment of a new transfer agent by the Company, the Company shall file notice with the resigning or terminated Transfer Agent and shall forthwith cause a copy of such notice to be mailed to each Holder.

                         Any corporation into which the Transfer Agent or any new transfer agent may be converted or merged or any corporation resulting from any consolidation to which the Transfer Agent or any new transfer agent shall be a party or any corporation succeeding to the trust business of the Transfer Agent shall be a successor transfer agent under this Agreement without any further act. Any such successor transfer agent shall promptly cause notice of its succession as transfer agent to be mailed to the Company and to each Holder.

                         Nothing herein shall preclude the Transfer Agent from acting in any other capacity for the Company.

          12.          INDEMNIFICATION AND SAVE HARMLESS. The Company agrees to indemnify the Transfer Agent and hold it harmless against any and all losses, expenses and liabilities, including judgments, counsel fees and reasonable costs, for anything done or omitted by the Transfer Agent in the execution of its duties and powers hereunder except losses, expenses and liabilities arising as a result of the Transfer Agent’s gross negligence or willful misconduct. The rights of indemnification and obligations to hold harmless created in this Section shall survive any termination of this Agreement. Upon request, the Company will furnish the Transfer Agent with a surety bond to secure such liability, damage, or expense.

          13.          FEES AND EXPENSES OF TRANSFER AGENT. As compensation for its services under this Agreement, the Company shall pay to Transfer Agent a fee equal to $2.50 per Holder per year, which fee shall in no event be less than $2,000 per year. The Company shall additionally reimburse Transfer Agent for its out-of-pocket expenses incurred in rendering those services, which expenses may include, but are not necessarily limited to, costs of printing, supplies, postage, travel, telephone and telecopier use, and couriers, and fees and expenses of counsel and third-parties employed by Transfer Agent. The Company will make timely payment of fees and/or expenses when invoiced by Transfer Agent. Transfer Agent may immediately terminate this Agreement if the Company fails to make such payments within thirty (30) calendar days of an invoice date, and
Company shall be additionally liable to Transfer Agent for all reasonable costs of collection, including but not limited to interest, court costs and attorneys’ fees.

          14.          MODIFICATION OF AGREEMENT.  The Transfer Agent and the Company may by supplemental agreement make any changes or corrections in this Agreement: (i) that they shall deem appropriate to cure any ambiguity or to correct any defective or inconsistent provision or manifest mistake or error herein contained; or (ii) that they may deem necessary or desirable and which shall not adversely affect the purchase or other material rights of the Holders of Warrant Certificates.  This Agreement shall not otherwise be modified, supplemented or amended in any respect except with the consent in writing of the Holders of Warrant Certificates representing not less than 50% of the Warrants then outstanding, but no such amendment, modification or supplement which changes the number or nature of the securities purchasable upon the exercise of
any Warrant, the Purchase Price or accelerates the Expiration Date, shall be made without the consent in writing of each and every Holder (but no consent shall be required for such changes as are specifically prescribed by this Agreement as originally executed).

          15.          MISCELLANEOUS.

                         15.1.          Entire Agreement.  This Agreement and the form of Warrant Certificate annexed hereto as Exhibit A contains the entire Agreement between the parties hereto with respect to the transactions contemplated by this Agreement and supersedes all prior negotiations, arrangements or understandings with respect thereto.

                         15.2.          Counterparts.  This Agreement may be executed in one or more counterparts, all of which shall be considered one and the same agreement and each of which shall be deemed an original.

                         15.3.          Governing Law.  This Agreement shall be governed by the laws of the State of North Carolina, without giving effect to the principles of conflicts of laws thereof.

                         15.4.          Descriptive Headings.  The descriptive headings of this Agreement are for convenience only and shall not control or affect the meaning or construction of any provision of this Agreement.

                         15.5.          Notices.  Any notice or other communications required hereunder to be given to a Holder shall be in writing and shall be sufficiently given, if mailed (first class, postage prepaid), or personally delivered, addressed in the name and at the address of such Holder appearing from time to time on the records of the Transfer Agent. Notices or other communications to the Company shall be deemed to have been sufficiently given if delivered by hand or mailed to the Company at its then principal office, Attention: President, or at such other address as the Company shall have designated by written notice to the Transfer Agent. Notices or other communications to the Transfer Agent shall be deemed to have been sufficiently given if delivered by hand or
mailed (first class, postage prepaid) to its then principal office. Notice by mail shall be deemed given when deposited in the mail, postage prepaid.

                         15.6          Successors and Assigns.  The terms and conditions of this Agreement shall inure to the benefit of and be binding upon the respective successors and assigns of the Company and the Transfer Agent.

          IN WITNESS WHEREOF, the Company and the Transfer Agent have executed this Agreement by their duly authorized officers as of the date first set forth above.

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Waccamaw Bankshares, Inc.
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
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[Name]
  	
  
 
  
	
  
 
  	
  
[Title]
  	
  
 
  
	
  
[Corporate Seal]
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
First-Citizens Bank & Trust Company
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
By:
  	
  
 
  
	
   
  	
  
 
  	
  

  
	
  
 
  	
  
[Name]
  	
  
 
  
	
  
 
  	
  
[Title]
  	
  
 
  
	
  
[Corporate Seal]
  	
  
 
  	
  
 
  

	
  
CUSIP #    __________________
  	
  
___________________   WARRANTS
  
	
  
No. W _____________________
  	
  
 
  

Waccamaw Bankshares, Inc.
 WARRANTS TO PURCHASE COMMON STOCK
 VOID FOR ANY PURPOSE AFTER 5:00 PM, EASTERN TIME, ON _______, 2009

          This Certificate certifies that, for value received, ____________________________________________________________________________________________________________ or registered assigns, is the registered holder of the number of warrants (the “Warrants”) set forth above.  Each Warrant entitles the registered holder thereof to receive from Waccamaw Bankshares, Inc., a North Carolina corporation with its principal office at 110 North J. K. Powell Boulevard, Whiteville, North Carolina 28472 (the “Corporation”), on and after the issuance date one (1) fully paid and nonassessable share of the common stock, no par value, of the Corporation (the “Common Stock”), at the purchase price of $24.00 (the “Purchase Price”) upon surrender of this Warrant Certificate, with the form of election to purchase set forth on the reverse hereof properly completed and duly executed
and payment of the Purchase Price at the principal office of the Corporation as provided in the Warrant Agreement (the “Warrant Agreement”) by and between the Corporation and First-Citizens Bank & Trust Company (the “Transfer Agent”), a copy of which may be obtained from the Corporation, by a written request from the registered holder hereof or which may be inspected by any registered holder or his or her agent at the principal office of the Corporation.  Payment of the Purchase Price may be made at the option of the registered holder in cash, by certified or official bank check payable to the order of the Corporation or by any other means acceptable to the Corporation.

          The Purchase Price and the number of shares of Common Stock purchasable upon exercise of the Warrants set forth above are based on the Common Stock of the Corporation outstanding as of the issuance date of this Warrant Certificate and are subject to adjustment provided in Section 5 of the Warrant Agreement.

          Upon surrender of this Warrant Certificate and payment of the Purchase Price, the Corporation shall issue and cause to be delivered to the registered holder of this Warrant Certificate a certificate for the number of shares of Common Stock issuable for the Warrants then being exercised.

          No Warrant may be exercised after 5:00 P.M., Eastern Time, on September 30, 2009 (the “Expiration Date”).  If such date is not a Business Day as defined in the Warrant Agreement, the Expiration date shall mean 5:00 P.M., Eastern Time, the next following Business Day.  The Expiration Date may be accelerated as provided in the Warrant Agreement under certain specifically defined circumstances upon notice to the registered holder hereof.  To the extent not exercised and delivered to the Transfer Agent by the Expiration Date, the Warrants shall be null and void.

          The further provisions of this Warrant Certificate are set forth on the reverse hereof, and the further provisions of the Warrant Agreement shall for all purposes have the same effect as if set forth fully at this place.  

          This Warrant Certificate is not valid unless countersigned by the Transfer Agent.

          IN WITNESS WHEREOF, Waccamaw Bankshares, Inc. has caused this Warrant Certificate to be duly executed under its corporate seal.

	
  
Countersigned:
  	
  
 
  	
  
 
  	
  
 
  
	
  First-Citizens Bank & Trust   Company
  	
  
 
  	
  
Waccamaw Bankshares, Inc.
  
	
  
 
  	
  
as Transfer Agent
  	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
   
 	
  
 
  	
  
 
  	
  
 
  
	
  
By: 
  	
  
 
  	
  
 
  	
  
By: 
  	
  
 
  
	
  
 
  	
  

  	
  
 
  	
  
 
  	
  

  
	
   
  	
  
Authorized Signature
  	
  
 
  	
  
 
  	
  
Chairman
  
	
  
 
  	
  
 
  	
  
 
  	
  
 
  	
  
 
  
	
  
Dated:
  	
  
 
  	
  
 
  	
  
By:
  	
  
 
  
	
  
 
  	
  

  	
  
 
  	
  
 
  	
  

  
	
  
 
  	
  
 
  	
  
 
  	
  
 
  	
  
Secretary
  
	
   
  	
  
 
  	
  
 
  	
  
 
  	
  
 
  
	
  
(SEAL)
  

Waccamaw Bankshares, Inc.

          This Warrant Certificate and each Warrant represented hereby are issued pursuant to and are subject in all respects to the terms and conditions set forth in the Warrant Agreement, which is incorporated herein by reference.
Please refer to the Warrant Agreement for a description of the rights, limitations of rights, obligations, duties and immunities hereunder of the Transfer Agent, the Corporation and the registered holders of the Warrants. In the event the registered holders do not comply with the terms of the Warrant Agreement, the Warrants shall immediately become null and void.

          The Warrant Agreement provides that upon the occurrence of certain events, the Purchase Price set forth on the face hereof may, under certain conditions, be adjusted. If the Purchase Price is adjusted, the Warrant Agreement provides that the Purchase Price in effect immediately prior to such event shall be adjusted so that the registered holder of each Warrant may receive the number of shares of Common Stock of the Corporation to which it would have been entitled upon such action if such registered holder had so exercised the Warrant immediately prior to the event. No fractional shares of Common Stock will be issued upon exercise of the Warrant. If any fraction of a share of Common Stock would be issuable upon the exercise of the Warrants (or any specified portion thereof), the Corporation shall pay an amount in cash equal to the product of (a) such fraction and (b) the fair market value of the Common
Stock, as determined in good faith by the Board of Directors of the Corporation, on the Business Day prior to the date the Warrant is exercised. 

          Upon surrender of this Warrant Certificate and similar Warrant Certificates at the principal office of the Transfer Agent, by the registered holder hereof in person or by an attorney duly authorized in writing, such Warrant Certificates may be transferred or exchanged in the manner and subject to the limitations provided in the Warrant Agreement, for another Warrant Certificate or Warrant Certificates of like tenor, evidencing in the aggregate the number of Warrants evidenced by the Warrant Certificates so surrendered and registered in the name or names as requested by the then registered owner thereof or by an attorney duly authorized in writing. In the case of the exercise of less than all the Warrants represented hereby, the registered holder shall be entitled to receive upon surrender of this Warrant Certificate another Warrant Certificate or Warrant Certificates for the balance of the Warrants
evidenced by this Warrant Certificate.  In the case of a simultaneous exercise of Warrants and a transfer of Warrants, the Warrant Certificates shall first be submitted to the Corporation.

          Prior to the exercise of any Warrant represented hereby, the registered holder shall not be entitled to any rights of a stockholder of the Corporation, including, without limitation, the right to vote or to receive dividends or other distributions, and shall not be entitled to receive any notice of any proceedings of the Corporation, except as provided in the Warrant Agreement. 

          The Corporation and the Transfer Agent shall treat the registered holder as the absolute owner hereof and of each Warrant represented hereby for all purposes and shall not be affected by any notice to the contrary.

          This Warrant Certificate shall be governed by and construed in accordance with the laws of the State of North CarolinaExhibit 10.1

    
      

    

    Back to Form 8-K

     

    Exhibit
      10.1

     

    

      Contract
        No. FA615

      

      STATE
        OF FLORIDA

      AGENCY
        FOR HEALTH CARE ADMINISTRATION

      STANDARD
        CONTRACT

      

      THIS
        CONTRACT is
        entered into between the State of Florida,
        AGENCY FOR HEALTH CARE ADMINISTRATION,
        hereinafter referred to as the “Agency”,
        whose
        address is 2727 Mahan Drive, Tallahassee, Florida 32308, and WELLCARE
        OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN
        OF FLORIDA,
        hereinafter referred to as the “Vendor”
        or
“Health Plan”,
        whose
        address is 8735
        Henderson Road, Renaissance 1,
        Tampa,
        Florida
        33634, a
Florida
        For-Profit Corporation, to
        provide Health
        Care Services to Medicaid Beneficiaries.

      

      
        	I.  	
                THE
                  VENDOR HEREBY AGREES:

              

      

      

      A. General
        Provisions

      

      
        	 	 	
                1.

              	
                To
                  provide services according to the terms and conditions set forth
                  in this
                  Contract, Attachment
                  I,
                  Scope of Services, and Attachment
                  II,
                  Medicaid Prepaid Health Plan Model Contract and all other attachments
                  named herein which are attached hereto and incorporated by
                  reference.

              

      

      

      
        	2.  	
                To
                  perform as an independent vendor and not as an agent, representative,
                  or
                  employee of the Agency.

              

      

      

      
        	3.  	
                To
                  recognize that the State of Florida, by virtue of its sovereignty,
                  is not
                  required to pay any taxes on the services or goods purchased under
                  the
                  terms of this Contract.

              

      

      

      
        	B.  	
                Federal
                  Laws and Regulations

              

      

      

      
        	 	 	
                1.

              	
                If
                  this Contract contains federal funds, the Vendor shall comply with
                  the
                  provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other
                  applicable regulations as specified in Attachments
                  I and
                  II.

              

      

      

      
        	 	 	
                2.

              	
                If
                  this Contract contains federal funding in excess of $100,000, the
                  Vendor
                  must, upon Contract execution, complete the Certification Regarding
                  Lobbying form, Attachment
                  IV.
                  If
                  a Disclosure of Lobbying Activities form, Standard Form LLL, is
                  required,
                  it may be obtained from the Agency’s Contract Manager. All disclosure
                  forms as required by the Certification Regarding Lobbying form
                  must be
                  completed and returned to the Agency’s Contract
                  Manager.

              

      

      

      
        	 	 	
                3.

              	
                Pursuant
                  to 45 CFR, Part 76, if this Contract contains federal funding in
                  excess of
                  $25,000, the Vendor must, upon Contract execution, complete the
                  Certification Regarding Debarment, Suspension, Ineligibility, and
                  Voluntary Exclusion Contracts/Subcontracts, Attachment
                  V.

              

      

      

      
        	C.  	
                Audits
                  and Records

              

      

      

      
        	 	
                1.

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

              

      

      

      

      
        	 	
                2.

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

              

      

      

      
        	 	
                3.

              	
                To
                  maintain and file with the Agency such progress, fiscal and inventory
                  reports as specified in Attachment
                  II,
                  and other reports as the Agency may require within the period of
                  this
                  Contract. In addition, access to relevant computer data and applications
                  which generated such reports should be made available upon
                  request.

              

      

      

      
        	 	
                4.

              	
                To
                  ensure that all related party transactions are disclosed to the
                  Agency
                  Contract Manager. Additional audit requirements are specified in
                  Attachment
                  II,
                  Special Provisions, Section
                  XII. 

              

      

      

      
        	 	 	
                5.

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

              

      

      

      
        	D.  	
                Retention
                  of Records

              

      

      

      
        	 	 	
                1.

              	
                To
                  retain all financial records, supporting documents, statistical
                  records,
                  and any other documents (including electronic storage media) pertinent
                  to
                  performance under this Contract for a period of five (5) years
                  after
                  termination of this Contract, or if an audit has been initiated
                  and audit
                  findings have not been resolved at the end of five (5) years, the
                  records
                  shall be retained until resolution of the audit
                  findings.

              

      

      

      2.Persons
        duly authorized by the Agency and federal auditors, pursuant to 45 CFR, Part
        74
        and/or 45 CFR, Part 92, shall have full access to and the right to examine
        any
        of said records and documents.

      

      3.The
        rights of access in this section must not be limited to the required retention
        period but shall last as long as the records are retained.

      

      
        	E.  	
                Monitoring

              

      

      

      
        	 	 	
                1.

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

              

      

      

      
        	 	 	
                2.

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

              

      

      

      
        	F.  	
                Indemnification

              

      

      

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

      

      G. Insurance

      

      
        	 	 	
                1.

              	
                To
                  the extent required by law, the Vendor will be self-insured against,
                  or
                  will secure and maintain during the life of the Contract, Worker’s
                  Compensation Insurance for all his employees connected with the
                  work of
                  this project and, in case any work is subcontracted, the Vendor
                  shall
                  require the subcontractor similarly to provide Worker’s Compensation
                  Insurance for all of the latter’s employees unless such employees engaged
                  in work under this Contract are covered by the Vendor’s self insurance
                  program. Such self insurance or insurance coverage shall comply
                  with the
                  Florida Worker’s Compensation law. In the event hazardous work is being
                  performed by the Vendor under this Contract and any class of employees
                  performing the hazardous work is not protected under Worker’s Compensation
                  statutes, the Vendor shall provide, and cause each subcontractor
                  to
                  provide, adequate insurance satisfactory to the Agency, for the
                  protection
                  of his employees not otherwise
                  protected.

              

      

      

      
        	 	
                2.

              	
                The
                  Vendor shall secure and maintain Commercial General Liability insurance
                  including bodily injury, property damage, personal & advertising
                  injury and products and completed operations. This insurance will
                  provide
                  coverage for all claims that may arise from the services and/or
                  operations
                  completed under this Contract, whether such services and/or operations
                  are
                  by the Vendor or anyone directly, or indirectly employed by him.
                  Such
                  insurance shall include a Hold Harmless Agreement in favor of the
                  State of
                  Florida and also include the State of Florida as an Additional
                  Named
                  Insured for the entire length of the Contract. The Vendor is responsible
                  for determining the minimum limits of liability necessary to provide
                  reasonable financial protections to the Vendor and the State of
                  Florida
                  under this Contract.

              

      

      

      
        	 	
                3.

              	
                All
                  insurance policies shall be with insurers licensed or eligible
                  to transact
                  business in the State of Florida. The Vendor’s current certificate of
                  insurance shall contain a provision that the insurance will not
                  be
                  canceled for any reason except after thirty (30) days written notice
                  to
                  the Agency’s Contract Manager.

              

      

      

      H. Assignments
        and Subcontracts

      

      To
        neither assign the responsibility of this Contract to another party nor
        subcontract for any of the work contemplated under this Contract without
        prior
        written approval of the Agency.
        No
        such approval by the Agency of any assignment or subcontract shall be deemed
        in
        any event or in any manner to provide for the incurrence of any obligation
        of
        the Agency in addition to the total dollar amount agreed upon in this Contract.
        All such assignments or subcontracts shall be subject to the conditions of
        this
        Contract and to any conditions of approval that the Agency shall deem
        necessary.

      

      I. Financial
        Reports

      

      To
        provide financial reports to the Agency as specified in Attachment
        II.

      

      J. Return
        of Funds

      

      To
        return
        to the Agency any overpayments due to unearned funds or funds disallowed
        pursuant to the terms of this Contract that were disbursed to the Vendor
        by the
        Agency. The Vendor shall return any overpayment to the Agency within forty
        (40)
        calendar days after either discovery by the Vendor, its independent auditor,
        or
        notification by the Agency, of the overpayment.

      

      K. Purchasing

      

      1. P.R.I.D.E.

      

      It
        is
        expressly understood and agreed that any articles which are the subject of,
        or
        required to carry out this Contract shall be purchased from the corporation
        identified under Chapter 946, Florida Statutes, if available, in the same
        manner
        and under the same procedures set forth in Section 946.515(2), (4), Florida
        Statutes; and for purposes of this Contract the person, firm or other business
        entity carrying out the provisions of this Contract shall be deemed to be
        substituted for this agency insofar as dealings with such corporation are
        concerned.

      

      The
        “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
        ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:

      

      P.R.I.D.E.

      2720-G
        Blair Stone Road

      Tallahassee,
        Florida 32301

      (850)
        487-3774

      Toll
        Free: 1-800-643-8459

      Website:
        www.pridefl.com

      

      
        	 	
                2.

              	
                RESPECT
                  of Florida

              

      

      

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

      

      The
        "nonprofit agency” identified is RESPECT of Florida which may be contacted
        at:

      

      
        	
                RESPECT
                  of Florida.

                2475
                  Apalachee Parkway, Suite 205

                Tallahassee,
                  Florida 32301-4946

                (850)
                  487-1471

                Website:
                  www.respectofflorida.org

              

      

      

      
        	
              	
                3. 
                  

              	
                Procurement
                  of Products or Materials with Recycled
                  Content

              

      

      

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

      L. Civil
        Rights Requirements/Vendor Assurance

      

      The
        Vendor assures that it will comply with:

      

      
        	 	 	
                1.

              	
                Title
                  VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
                  seq., which prohibits discrimination on the basis of race, color,
                  or
                  national origin.

              

      

      
        	 	 	
                2.

              	
                Section
                  504 of the Rehabilitation Act of 1973, as amended,
                  29 U.S.C. 794, which prohibits discrimination on the basis of
                  handicap.

              

      

      
        	 	 	
                3.

              	
                Title
                  IX of the Education Amendments of 1972, as amended,
                  20 U.S.C. 1681 et seq., which prohibits discrimination on the
                  basis of sex.

              

      

      
        	 	 	
                4.

              	
                The
                  Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
                  which
                  prohibits discrimination on the basis of
                  age.

              

      

      
        	 	 	
                5.

              	
                Section
                  654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
                  42 U.S.C. 9849, which prohibits discrimination on the basis of
                  race, creed, color, national origin, sex, handicap, political affiliation
                  or beliefs.

              

      

      
        	 	 	
                6.

              	
                The
                  Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
                  discrimination on the basis of disability and requires reasonable
                  accommodation for persons with
                  disabilities.

              

      

      
        	 	 	
                7.

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

              

      

      

      The
        Vendor agrees that compliance with this assurance constitutes a condition
        of
        continued receipt of or benefit from funds provided through this Contract,
        and
        that it is binding upon the Vendor, its successors, transferees, and assignees
        for the period during which services are provided. The Vendor further assures
        that all contractors, subcontractors, subgrantees, or others with whom it
        arranges to provide services or benefits to participants or employees in
        connection with any of its programs and activities are not discriminating
        against those participants or employees in violation of the above statutes,
        regulations, guidelines, and standards.

      

      M. Discrimination

      

      An
        entity
        or affiliate who has been placed on the discriminatory vendor list may not
        submit a bid, proposal, or reply on a contract to provide any goods or services
        to a public entity; may not submit a bid, proposal, or reply on a contract
        with
        a public entity for the construction or repair of a public building or public
        work; may not submit bids, proposals, or replies on leases of real property
        to a
        public entity; may not be awarded or perform work as a contractor, supplier,
        subcontractor, or consultant under a contract with any public entity; and
        may
        not transact business with any public entity. The Florida Department of
        Management Services is responsible for maintaining the discriminatory vendor
        list and intends to post the list on its website. Questions regarding the
        discriminatory vendor list may be directed to the Florida Department of
        Management Services, Office of Supplier Diversity at (850)
        487-0915.

      

      N. Requirements
        of Section 287.058, Florida Statutes

      

      
        	 	
                1.

              	
                To
                  submit bills for fees or other compensation for services or expenses
                  in
                  sufficient detail for a proper pre-audit and post-audit
                  thereof.

              

      

      

      
        	 	 	
                2.

              	
                Where
                  applicable, to submit bills for any travel expenses in accordance
                  with
                  Section 112.061, Florida
                  Statutes.

              

      

      

      
        	 	
                3.

              	
                To
                  provide units of deliverables, including reports, findings, and
                  drafts, in
                  writing and/or in an electronic format agreeable to both parties,
                  as
                  specified in Attachment
                  I
                  and Attachment
                  II, to
                  be received and accepted by the Contract Manager prior to
                  payment.

              

      

      

      
        	 	
                4.

              	
                To
                  comply with the criteria and final date by which such criteria
                  must be met
                  for completion of this Contract as specified in Section III, Paragraph
                  A.
                  of this Contract.

              

      

      

      
        	 	
                5.

              	
                To
                  allow public access to all documents, papers, letters, or other
                  material
                  made or received by the Vendor in conjunction with this Contract,
                  unless
                  the records are exempt from Section 24(a) of Article I of the State
                  Constitution and Section 119.07(1), Florida Statutes. It is expressly
                  understood that substantial evidence of the Vendor's refusal to
                  comply
                  with this provision shall constitute a breach of
                  Contract.

              

      

      

      O. Sponsorship

      

      As
        required by Section 286.25, Florida Statutes, if the Vendor is a
        nongovernmental organization which sponsors a program financed wholly or
        in part
        by state funds, including any funds obtained through this Contract, it shall,
        in
        publicizing, advertising or describing the sponsorship of the program,
        state:

      

      "Sponsored
        by WELLCARE
        OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN
        OF FLORIDA and
        the
        State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION".

      

      If
        the
        sponsorship reference is in written material, the words "State of Florida,
        AGENCY FOR HEALTH CARE ADMINISTRATION" shall appear in the same size letters
        or
        type as the name of the organization.

      

      P. Final
        Invoice

      

      The
        Vendor must submit the final invoice for payment to the Agency no more than
        90
        days
        after the Contract ends or is terminated. If the Vendor fails to do so, all
        right to payment is forfeited and the Agency will not honor any requests
        submitted after the aforesaid time period. Any payment due under the terms
        of
        this Contract may be withheld until all reports due from the Vendor and
        necessary adjustments thereto have been approved by the Agency.

      

      
        	 	
                Q.

              	
                Use
                  Of Funds For Lobbying
                  Prohibited

              

      

      

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

      

      R. Public
        Entity Crime

      

      A
        person
        or affiliate who has been placed on the convicted vendor list following a
        conviction for a public entity crime may not be awarded or perform work as
        a
        contractor, supplier, subcontractor, or consultant under a contract with
        any
        public entity, and may not transact business with any public entity in excess
        of
        the threshold amount provided in Section 287.017, Florida Statutes, for category
        two, for a period of 36 months from the date of being placed on the convicted
        vendor list.

      

      S. Health
        Insurance Portability and Accountability Act

       

      To
        comply
        with the Department of Health and Human Services Privacy Regulations in the
        Code
        of Federal Regulations, Title 45, Sections 160 and 164, regarding disclosure
        of
        protected health information as specified in Attachment
        III.

      

      T. Confidentiality
        of Information

      

      Not
        to
        use or disclose any confidential information, including social security numbers
        that may be supplied under this Contract pursuant to law, and also including
        the
        identity or identifying information concerning a Medicaid recipient or services
        under this Contract for any purpose not in conformity with state and federal
        laws, except upon written consent of the recipient, or his/her
        guardian.

      

      U. Employment

      

      To
        comply
        with Section 274A (e) of the Immigration and Nationality Act. The Agency
        shall
        consider the employment by any contractor of unauthorized aliens a violation
        of
        this Act. If the Vendor knowingly employs unauthorized aliens, such violation
        shall be cause for unilateral cancellation of this Contract. The Vendor shall
        be
        responsible for including this provision in all subcontracts with private
        organizations issued as a result of this Contract.

      

      V. Vendor
        Performance

      

      Penalties
        or sanctions for unsatisfactory performance under this Contract are specified
        in
Attachment
        I and
        Attachment
        II,
        if
        applicable.

      

      II. THE
        AGENCY HEREBY AGREES:

      

      A. Contract
        Amount

      

      To
        pay
        for contracted services according to the conditions of Attachment
        I
        in an
        amount not to exceed $1,218,028,875.00,
        subject
        to the availability of funds. The State of Florida's performance and obligation
        to pay under this Contract is contingent upon an annual appropriation by
        the
        Legislature. 

      

      B. Contract
        Payment

      

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

      

      III. THE
        VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

      

      A. Effective/End
        Date

      

      This
        Contract shall begin upon execution by both parties or September
        1, 2006,
        (whichever
        is later) and end August
        31, 2009,
        inclusive.

      

      B. Termination

      

      1. Termination
        at Will

      

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

      

      2. Termination
        Due To Lack of Funds

      

      In
        the
        event funds to finance this Contract become unavailable, the Agency may
        terminate the Contract upon no less than twenty-four (24) hours written notice
        to the Vendor. Said notice shall be delivered by certified mail, return receipt
        requested, or in person with proof of delivery. The Agency shall be the final
        authority as to the availability of funds.

      

      3. Termination
        for Breach

      

      Unless
        the Vendor's breach is waived by the Agency in writing, the Agency may, by
        written notice to the Vendor, terminate this Contract upon no less than
        twenty-four (24) hours written notice. Said notice shall be delivered by
        certified mail, return receipt requested, or in person with proof of delivery.
        If applicable, the Agency may employ the default provisions in
        Chapter 60A-1.006(4), Florida Administrative Code.

      

      Waiver
        of
        breach of any provisions of this Contract shall not be deemed to be a waiver
        of
        any other breach and shall not be construed to be a modification of the terms
        of
        this Contract. The provisions herein do not limit the Agency's right to remedies
        at law or to damages.

      

      C. Contract
        Managers

      

      
        	 	 	
                1.

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

              

      

      

      G.
        Douglas Harper

      Agency
        for Health Care Administration

      2727
        Mahan Drive, MS# 50

      Tallahassee,
        FL 32308

      (850)
        487-2355

       

      
        	2.  	
                The
                  Vendor’s Contract Manager’s name, address and telephone number for this
                  Contract is as follows:

              

      

      

      Imtiaz
        "MT" Sattaur

      WellCare
        of Florida, Inc. 

      d/b/a
        Staywell Health Plan
        of Florida

      8735
        Henderson Road, Renaissance 1

      Tampa,
        FL 33634

      (813)
        290-6279

      

      
        	 	 	
                3.

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

              

      

      

      D. Renegotiation
        or Modification

      

      
        	 	 	
                1.

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

              

      

      

      
        	 	 	 	
                2.

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

              

      

      
E. Name,
        Mailing and Street Address of Payee

      

      
        	 	 	
                1.

              	
                The
                  name (Vendor name as shown on Page 1 of this Contract) and mailing
                  address
                  of the official payee to whom the payment shall be
                  made:

              

      

      

      WellCare
        of Florida, Inc.

      d/b/a
        Staywell Health Plan
        of Florida

      8735
        Henderson Road, Renaissance 1

      Tampa,
        FL 33634

      

      
        	 	
                2.

              	
                The
                  name of the contact person and street address where financial and
                  administrative records are
                  maintained:

              

      

      

      Paul
        L. Behrens

      8735
        Henderson Road, Renaissance 1

      Tampa,
        FL 33634

      

      F. All
        Terms and Conditions

      

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

              

      

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      IN
        WITNESS THEREOF,
        the
        parties hereto have caused this three-hundred twelve (312) page Contract,
        which
        includes any referenced attachments, to be executed by their undersigned
        officials as duly authorized. This Contract is not valid until signed
and
        dated by
        both parties.

      

      
        	
                WELLCARE
                  OF FLORIDA, INC.

                D/B/A
                  STAYWELL HEALTH PLAN 

                OF
                  FLORIDA

              	
                STATE
                  OF FLORIDA, AGENCY FOR

                HEALTH
                  CARE ADMINISTRATION

              
	 	 	 	 	 
	
                SIGNED
                  BY:

              	 /s/ 
                Paul Behrens        	
                SIGNED
                  BY:

              	  
                /s/  Christa Calamas        
                	 
	 	 	 	 	 
	
                NAME:

              	
                  
                  Paul Behrens

              	
                NAME:

              	
                 
                  Christa Calamas

              	 
	 	 	 	 	 
	
                TITLE:

              	
                 
                  SVP and Chief Financial Officer

              	
                TITLE:

              	
                  
                  Secretary

              	 
	 	 	 	 	 
	
                DATE:

              	 
8/31/06	
                DATE:

              	 
9/1/06	 
	 	 	 	 	 

      

      

      FEDERAL
        ID NUMBER (or SS Number for an individual): 59-2583622

      

      VENDOR
        FISCAL YEAR ENDING DATE: 12/31

      

      List
        of
        attachments/exhibits included as part of this Contract:

       

      Attachment I Scope
        of
        Services (9 Pages)

      Attachment II Medicaid
        Prepaid Health Plan Model Contract (288) Pages

      Attachment III Business
        Associate Agreement (3 Pages)

      Attachment IV Lobbying
        Certification (1 Page)

      Attachment V Debarment
        Certification (1 Page)

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      

        ATTACHMENT
          I

        SCOPE
          OF SERVICES

        

        

        
          	
                  A.

                	
                  Manner
                    of Service (s)
                    Provision:

                

        

        

        Policies
          and Procedures

        

        The
          Health Plan shall comply with all provisions of this Contract and any subsequent
          amendments, and shall act in good faith in the performance of the Contract's
          provisions. The Health Plan shall develop, maintain and implement written
          policies and procedures covering all provisions of this Contract. All policies
          and procedures shall be prior-approved by the Agency in writing. The Health
          Plan
          agrees that failure to comply with all provisions of this Contract shall
          result
          in the assessment of penalties and/or termination of this Contract, in
          whole or
          in part, as set forth in this Contract.

        

        

        B. Method
          of Payment:

        

        1. General

        

        Notwithstanding
          the payment amounts which may be computed with the rate tables specified
          in
          Exhibit III, the sum of total capitation payments under this Contract shall
          not
          exceed the total Contract amount of $1,218,028,875.00.
          

        

        
          	 	
                  a.

                	
                  The
                    Health Plan shall be paid capitation payments for each Agency
                    Service
                    Area, based upon Exhibit II, Table 4, attached hereto.
                    

                

        

        

        
          	 	
                  c.

                	
                  All
                    payments made to the Health Plan shall be in accordance with
                    this section
                    (Section B, Method of Payment) and Attachment II, Section XIII,
                    Method of
                    Payment.

                

        

        

        2. Enrollment
          Levels

        

        The
          Agency assigns the Health Plan an authorized maximum Enrollment level for
          each
          operational county. The authorized maximum Enrollment level is in effect
          on
          September 1, 2006, or upon Contract execution, whichever is later. 

        

        
          	a.  	
                  The
                    Agency must approve, in writing, any increase in the Health Plan’s maximum
                    Enrollment level for each operational county and subpopulation
                    to be
                    served, as applicable. Such approval shall not be unreasonably
                    withheld,
                    and shall be based upon the Health Plan’s satisfactory performance of
                    terms of the Contract and upon the Agency’s approval of the Health Plan’s
                    administrative and service resources, as specified in this Contract,
                    in
                    support of each Enrollment level. 

                

        

        

        
          	b.  	
                  Exhibit
                    I, Table 1, attached hereto, indicates the Health Plan’s maximum
                    authorized Enrollment levels for each Medicaid Reform county
                    and each
                    applicable authorized eligibility category.

                

        

        

        3. Health
          Plan Capitation Rate 

        

        Exhibit
          II, Table 4 provides the capitation rates respective to the authorized
          areas of
          operation, as identified in subsection B, Method of Payment, Item 2, above.
          The
          Capitation Rate payment shall be in accordance with Attachment II, Section
          XIII,
          Payment Methodology.

        

        4. Capitation
          Rate Tables

        

        Exhibit
          III lists the Capitation Rates for the Health Plan’s authorized Service
          Areas.

        

        

        REMAINDER
          OF PAGE INTENTIONALLY LEFT BLANK

        
          
             

            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        EXHIBIT
          1

        

        

        MAXIMUM
          ENROLLMENT LEVELS

        

        TABLE
          1

        ENROLLMENT
          LEVELS

        

        
          	
                  County

                	
                  Maximum
                    Enrollment Level

                
	
                  Brevard

                	
                  14,000

                
	
                  Broward

                	
                  25,000

                
	
                  Dade

                	
                  25,000

                
	
                  Hernando

                	
                  15,000

                
	
                  Hillsborough

                	
                  28,000

                
	
                  Lee

                	
                  15,000

                
	
                  Manatee

                	
                  12,000

                
	
                  Palm
                    Beach

                	
                  15,000

                
	
                  Pasco

                	
                  7,000

                
	
                  Pinellas

                	
                  15,000

                
	
                  Polk

                	
                  25,000

                
	
                  Orange

                	
                  38,000

                
	
                  Osceola

                	
                  12,000

                
	
                  Sarasota

                	
                  6,000

                
	
                  Seminole

                	
                  6,000

                

        

        

        

        REMAINDER
          OF PAGE INTENTIONALLY LEFT BLANK

        

        

        
          
             

            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        EXHIBIT
          II

        CAPITATION
          RATES

        

        A. Table
          4 -
          General Capitation Rates plus Mental Health Rates plus
          Transportation:

        

        Area
          3 Counties: 

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Hernando

                	
                  015016901

                

        

        

        Area
          5 Counties: 

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Pasco

                	
                  015016903

                
	
                  Pinellas

                	
                  015016904

                

        

        

        Area
          6 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Hillsborough

                	
                  015016902

                
	
                  Polk

                	
                  015016905

                
	
                  Manatee

                	
                  015016912

                

        

        

        Area
          7 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Orange

                	
                  015016906

                
	
                  Seminole

                	
                  015016908

                
	
                  Osceola

                	
                  015016907

                
	
                  Brevard

                	
                  015016913

                

        

        

        Area
          8 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Lee

                	
                  015016911

                
	
                  Sarasota

                	
                  015016914

                

        

        

        Area
          9 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Palm
                    Beach

                	
                  015016910

                

        

        

        Area
          10 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Broward

                	
                  015016900

                

        

        

        Area
          11 Counties:

        

        
          	
                  County

                	
                  Provider
                    Number

                
	
                  Miami-Dade

                	
                  015016909

                

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

    

     

    

      
        	
                EXHIBIT
                  III

              	 
	
                September
                  1, 2006- August 31, 2007 HMO RATES

              
	
                (MEDICAID
                  Non-Reform HMO CAPITATION RATES)

              
	
                By
                  Area , Age and Eligibility Category 

              
	
                Effective
                  from September 1, 2006 thru August 31, 2007

              
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  1

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  Rates:

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 TANF

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE

                 (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  

                (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	
                 

              	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
                 

              	 	 
	
                01

              	
                984.41

              	
                187.77

              	
                94.20

              	
                59.28

              	
                124.19

              	
                65.47

              	
                240.45

              	
                153.59

              	
                321.77

              	
                9,105.00

              	
                1,514.90

              	
                418.36

              	
                193.71

              	
                221.49

              	
                689.79

              	
                663.38

              	
                224.43

              	
                81.78

              	
                72.80

              	
                 

              
	
                02

              	
                984.41

              	
                187.77

              	
                94.20

              	
                59.28

              	
                124.19

              	
                65.47

              	
                240.45

              	
                153.59

              	
                321.77

              	
                9,105.00

              	
                1,514.90

              	
                418.36

              	
                193.71

              	
                221.49

              	
                689.79

              	
                663.38

              	
                224.43

              	
                81.78

              	
                72.80

              	
                 

              
	
                03

              	
                1,119.04

              	
                215.12

              	
                108.14

              	
                68.68

              	
                142.53

              	
                75.76

              	
                277.34

              	
                177.97

              	
                374.11

              	
                9,838.59

              	
                1,650.55

              	
                455.86

              	
                214.24

              	
                243.93

              	
                761.80

              	
                733.75

              	
                222.99

              	
                76.64

              	
                68.22

              	
                 

              
	
                04

              	
                977.46

              	
                188.43

              	
                94.81

              	
                60.52

              	
                124.94

              	
                66.54

              	
                243.67

              	
                156.49

              	
                329.66

              	
                9,496.04

              	
                1,594.91

              	
                440.11

              	
                207.52

              	
                236.40

              	
                737.11

              	
                710.51

              	
                281.10

              	
                80.69

              	
                71.81

              	
                 

              
	
                05

              	
                1,067.14

              	
                205.69

              	
                103.55

              	
                66.12

              	
                136.51

              	
                72.78

              	
                266.02

              	
                170.99

              	
                360.08

              	
                10,493.86

              	
                1,761.79

              	
                486.26

              	
                229.33

              	
                261.00

              	
                813.88

              	
                784.20

              	
                227.89

              	
                75.00

              	
                66.73

              	
                 

              
	
                06

              	
                952.19

              	
                184.52

              	
                93.11

              	
                59.80

              	
                122.69

              	
                65.63

              	
                239.77

              	
                154.53

              	
                326.30

              	
                9,506.98

              	
                1,600.98

              	
                441.82

              	
                209.34

              	
                238.56

              	
                743.00

              	
                716.54

              	
                266.50

              	
                71.11

              	
                63.33

              	
                 

              
	
                07

              	
                995.57

              	
                192.16

              	
                96.69

              	
                61.72

              	
                127.53

              	
                68.03

              	
                248.61

              	
                159.82

              	
                336.93

              	
                9,869.04

              	
                1,664.31

              	
                459.14

              	
                218.22

              	
                247.85

              	
                773.41

              	
                746.36

              	
                258.48

              	
                74.69

              	
                66.44

              	
                 

              
	
                08

              	
                891.16

              	
                172.27

              	
                86.81

              	
                55.56

              	
                114.42

              	
                61.12

              	
                223.35

              	
                143.81

              	
                303.33

              	
                8,573.17

              	
                1,440.41

              	
                397.64

              	
                187.66

              	
                213.40

              	
                665.88

              	
                641.84

              	
                199.48

              	
                70.72

              	
                62.90

              	
                 

              
	
                09

              	
                959.78

              	
                184.64

              	
                92.88

              	
                59.08

              	
                122.41

              	
                65.01

              	
                238.25

              	
                152.88

              	
                321.72

              	
                9,678.19

              	
                1,630.65

              	
                450.09

              	
                213.75

              	
                242.41

              	
                757.35

              	
                730.08

              	
                187.44

              	
                75.59

              	
                67.24

              	
                 

              
	
                10

              	
                949.98

              	
                183.45

              	
                92.43

              	
                59.18

              	
                121.83

              	
                65.12

              	
                237.80

              	
                153.08

              	
                322.61

              	
                12,128.14

              	
                2,049.58

              	
                566.06

              	
                269.77

              	
                306.61

              	
                956.09

              	
                922.33

              	
                227.28

              	
                85.14

              	
                75.76

              	
                 

              
	
                11

              	
                1,250.56

              	
                239.79

              	
                120.51

              	
                76.32

              	
                158.78

              	
                84.09

              	
                308.55

              	
                197.83

              	
                415.51

              	
                13,040.05

              	
                2,192.54

              	
                605.29

              	
                286.46

              	
                325.12

              	
                1,014.84

              	
                978.59

              	
                283.70

              	
                121.23

              	
                107.80

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  2

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + Mental Health Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                
                  TANF

                

              	
                 

              	
                 

              	
                 

              	
                 

              	
              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                984.43

              	
                187.79

              	
                95.93

              	
                71.39

              	
                136.48

              	
                77.76

              	
                244.40

              	
                157.54

              	
                325.26

              	
                9,105.08

              	
                1,514.98

              	
                430.15

              	
                264.67

              	
                289.33

              	
                793.42

              	
                700.39

              	
                227.58

              	
                94.88

              	
                85.90

              	
                 

              
	
                02

              	
                984.43

              	
                187.79

              	
                96.79

              	
                78.05

              	
                138.03

              	
                79.31

              	
                243.59

              	
                156.73

              	
                324.95

              	
                9,105.09

              	
                1,514.99

              	
                432.97

              	
                271.86

              	
                269.95

              	
                740.56

              	
                685.53

              	
                246.33

              	
                96.76

              	
                87.78

              	
                 

              
	
                03

              	
                1,119.05

              	
                215.13

              	
                109.27

              	
                76.84

              	
                148.55

              	
                81.78

              	
                278.71

              	
                179.34

              	
                375.49

              	
                9,838.63

              	
                1,650.59

              	
                462.53

              	
                249.94

              	
                266.07

              	
                784.99

              	
                743.87

              	
                230.86

              	
                84.31

              	
                75.89

              	
                 

              
	
                04

              	
                977.47

              	
                188.44

              	
                96.10

              	
                69.88

              	
                131.84

              	
                73.44

              	
                245.24

              	
                158.06

              	
                331.24

              	
                9,496.10

              	
                1,594.97

              	
                450.87

              	
                265.05

              	
                272.08

              	
                774.49

              	
                726.81

              	
                300.20

              	
                98.57

              	
                89.69

              	
                 

              
	
                05

              	
                1,067.15

              	
                205.70

              	
                104.70

              	
                74.42

              	
                142.63

              	
                78.90

              	
                267.41

              	
                172.38

              	
                361.49

              	
                10,493.90

              	
                1,761.83

              	
                492.59

              	
                263.20

              	
                282.00

              	
                835.88

              	
                793.80

              	
                232.83

              	
                83.72

              	
                75.45

              	
                 

              
	
                06

              	
                952.21

              	
                184.54

              	
                95.20

              	
                74.40

              	
                137.52

              	
                80.46

              	
                244.53

              	
                159.29

              	
                330.50

              	
                9,507.04

              	
                1,601.04

              	
                451.42

              	
                267.12

              	
                293.80

              	
                827.38

              	
                746.67

              	
                267.56

              	
                74.98

              	
                67.20

              	
                 

              
	
                07

              	
                995.59

              	
                192.18

              	
                98.58

              	
                75.44

              	
                137.65

              	
                78.15

              	
                250.91

              	
                162.12

              	
                339.25

              	
                9,869.10

              	
                1,664.37

              	
                468.64

              	
                269.01

              	
                279.35

              	
                806.41

              	
                760.75

              	
                264.02

              	
                87.29

              	
                79.04

              	
                 

              
	
                08

              	
                891.17

              	
                172.28

              	
                87.87

              	
                63.26

              	
                120.10

              	
                66.80

              	
                224.64

              	
                145.10

              	
                304.63

              	
                8,573.21

              	
                1,440.45

              	
                403.68

              	
                219.96

              	
                233.43

              	
                686.87

              	
                650.99

              	
                205.52

              	
                83.04

              	
                75.22

              	
                 

              
	
                09

              	
                959.79

              	
                184.65

              	
                94.38

              	
                69.92

              	
                130.40

              	
                73.00

              	
                240.06

              	
                154.69

              	
                323.55

              	
                9,678.23

              	
                1,630.69

              	
                457.28

              	
                252.19

              	
                266.25

              	
                782.32

              	
                740.97

              	
                192.43

              	
                85.84

              	
                77.49

              	
                 

              
	
                10

              	
                950.00

              	
                183.47

              	
                94.50

              	
                74.19

              	
                132.90

              	
                76.19

              	
                240.31

              	
                155.59

              	
                325.15

              	
                12,128.19

              	
                2,049.63

              	
                574.97

              	
                317.41

              	
                336.15

              	
                987.04

              	
                935.83

              	
                232.19

              	
                91.90

              	
                82.52

              	
                 

              
	
                11

              	
                1,250.58

              	
                239.81

              	
                122.43

              	
                90.20

              	
                169.02

              	
                94.33

              	
                310.87

              	
                200.15

              	
                417.86

              	
                13,040.10

              	
                2,192.59

              	
                613.63

              	
                331.07

              	
                352.78

              	
                1,043.82

              	
                991.23

              	
                291.36

              	
                127.80

              	
                114.37

              	
                 

              
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  3

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + MH + Dental Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
                 

              	
                 

              	
                 

              	
                 

              	
                TANF 

              	
                 

              	
                 

              	
                 

              	
                 

              	
              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE

                 (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                984.43

              	
                187.80

              	
                98.41

              	
                76.67

              	
                142.09

              	
                82.41

              	
                245.26

              	
                158.28

              	
                326.24

              	
                9,105.08

              	
                1,515.00

              	
                432.51

              	
                268.70

              	
                292.89

              	
                795.68

              	
                702.46

              	
                227.77

              	
                96.63

              	
                86.76

              	
                 

              
	
                02

              	
                984.43

              	
                187.80

              	
                99.27

              	
                83.33

              	
                143.64

              	
                83.96

              	
                244.45

              	
                157.47

              	
                325.93

              	
                9,105.09

              	
                1,515.01

              	
                435.33

              	
                275.89

              	
                273.51

              	
                742.82

              	
                687.60

              	
                246.52

              	
                98.51

              	
                88.64

              	
                 

              
	
                03

              	
                1,119.05

              	
                215.14

              	
                112.34

              	
                83.37

              	
                155.49

              	
                87.52

              	
                281.35

              	
                181.61

              	
                378.51

              	
                9,838.63

              	
                1,650.61

              	
                465.60

              	
                255.18

              	
                270.70

              	
                788.49

              	
                747.08

              	
                231.90

              	
                87.26

              	
                77.34

              	
                 

              
	
                04

              	
                977.47

              	
                188.45

              	
                98.28

              	
                74.52

              	
                136.78

              	
                77.53

              	
                247.57

              	
                160.06

              	
                333.90

              	
                9,496.10

              	
                1,594.99

              	
                453.16

              	
                268.97

              	
                275.55

              	
                777.64

              	
                729.71

              	
                301.57

              	
                101.51

              	
                91.14

              	
                 

              
	
                05

              	
                1,067.16

              	
                205.72

              	
                108.38

              	
                82.24

              	
                150.94

              	
                85.79

              	
                275.45

              	
                179.28

              	
                370.68

              	
                10,493.91

              	
                1,761.87

              	
                497.23

              	
                271.12

              	
                289.01

              	
                842.94

              	
                800.28

              	
                237.48

              	
                92.44

              	
                79.75

              	
                 

              
	
                06

              	
                952.21

              	
                184.55

              	
                97.98

              	
                80.32

              	
                143.81

              	
                85.67

              	
                248.64

              	
                162.82

              	
                335.19

              	
                9,507.05

              	
                1,601.07

              	
                454.57

              	
                272.52

              	
                298.58

              	
                832.70

              	
                751.55

              	
                270.73

              	
                80.85

              	
                70.09

              	
                 

              
	
                07

              	
                995.59

              	
                192.19

              	
                100.95

              	
                80.49

              	
                143.01

              	
                82.60

              	
                253.93

              	
                164.71

              	
                342.70

              	
                9,869.10

              	
                1,664.39

              	
                471.63

              	
                274.11

              	
                283.87

              	
                810.02

              	
                764.07

              	
                266.03

              	
                90.77

              	
                80.76

              	
                 

              
	
                08

              	
                891.17

              	
                172.29

              	
                90.51

              	
                68.89

              	
                126.08

              	
                71.75

              	
                227.84

              	
                147.84

              	
                308.28

              	
                8,573.21

              	
                1,440.47

              	
                406.25

              	
                224.35

              	
                237.32

              	
                691.37

              	
                655.12

              	
                207.65

              	
                87.12

              	
                77.23

              	
                 

              
	
                09

              	
                959.79

              	
                184.66

              	
                97.52

              	
                76.58

              	
                137.48

              	
                78.87

              	
                242.05

              	
                156.40

              	
                325.82

              	
                9,678.23

              	
                1,630.71

              	
                460.05

              	
                256.93

              	
                270.44

              	
                784.62

              	
                743.09

              	
                193.17

              	
                88.23

              	
                78.67

              	
                 

              
	
                10

              	
                950.00

              	
                183.48

              	
                97.54

              	
                80.65

              	
                139.77

              	
                81.87

              	
                242.34

              	
                157.32

              	
                327.46

              	
                12,128.20

              	
                2,049.66

              	
                578.71

              	
                323.81

              	
                341.82

              	
                989.96

              	
                938.51

              	
                234.27

              	
                94.95

              	
                84.02

              	
                 

              
	
                11

              	
                1,250.59

              	
                239.83

              	
                126.08

              	
                97.97

              	
                177.28

              	
                101.17

              	
                312.69

              	
                201.72

              	
                419.94

              	
                13,040.11

              	
                2,192.62

              	
                617.59

              	
                337.84

              	
                358.76

              	
                1,047.74

              	
                994.82

              	
                294.22

              	
                131.90

              	
                116.39

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  4

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + MH + Transportation Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 TANF

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE

                 (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                989.41

              	
                189.41

              	
                97.06

              	
                72.23

              	
                138.71

              	
                79.17

              	
                248.03

              	
                159.83

              	
                329.39

              	
                9,129.34

              	
                1,535.05

              	
                440.25

              	
                267.63

              	
                294.48

              	
                813.36

              	
                714.87

              	
                239.52

              	
                112.65

              	
                93.54

              	
                 

              
	
                02

              	
                989.41

              	
                189.41

              	
                97.92

              	
                78.89

              	
                140.26

              	
                80.72

              	
                247.22

              	
                159.02

              	
                329.08

              	
                9,129.35

              	
                1,535.06

              	
                443.07

              	
                274.82

              	
                275.10

              	
                760.50

              	
                700.01

              	
                258.27

              	
                114.53

              	
                95.42

              	
                 

              
	
                03

              	
                1,124.90

              	
                217.03

              	
                110.60

              	
                77.82

              	
                151.16

              	
                83.44

              	
                282.97

              	
                182.02

              	
                380.34

              	
                9,868.98

              	
                1,675.69

              	
                475.17

              	
                253.66

              	
                272.53

              	
                809.95

              	
                761.99

              	
                241.15

              	
                110.17

              	
                87.01

              	
                 

              
	
                04

              	
                981.69

              	
                189.81

              	
                97.06

              	
                70.59

              	
                133.73

              	
                74.63

              	
                248.31

              	
                160.00

              	
                334.75

              	
                9,525.59

              	
                1,619.35

              	
                463.16

              	
                268.67

              	
                278.36

              	
                798.72

              	
                744.42

              	
                307.55

              	
                122.56

              	
                100.01

              	
                 

              
	
                05

              	
                1,070.82

              	
                206.90

              	
                105.54

              	
                75.03

              	
                144.28

              	
                79.94

              	
                270.09

              	
                174.06

              	
                364.54

              	
                10,513.00

              	
                1,777.63

              	
                500.55

              	
                265.53

              	
                286.05

              	
                851.58

              	
                805.21

              	
                239.28

              	
                100.41

              	
                82.63

              	
                 

              
	
                06

              	
                956.09

              	
                185.80

              	
                96.08

              	
                75.05

              	
                139.25

              	
                81.56

              	
                247.35

              	
                161.07

              	
                333.72

              	
                9,527.20

              	
                1,617.71

              	
                459.82

              	
                269.59

              	
                298.08

              	
                843.95

              	
                758.71

              	
                273.49

              	
                90.97

              	
                74.07

              	
                 

              
	
                07

              	
                998.64

              	
                193.18

              	
                99.28

              	
                75.95

              	
                139.01

              	
                79.01

              	
                253.13

              	
                163.52

              	
                341.78

              	
                9,889.65

              	
                1,681.36

              	
                477.19

              	
                271.52

              	
                283.71

              	
                823.30

              	
                773.02

              	
                269.96

              	
                103.51

              	
                86.01

              	
                 

              
	
                08

              	
                896.29

              	
                173.95

              	
                89.03

              	
                64.12

              	
                122.39

              	
                68.25

              	
                228.37

              	
                147.45

              	
                308.88

              	
                8,596.82

              	
                1,459.97

              	
                413.52

              	
                222.85

              	
                238.44

              	
                706.27

              	
                665.08

              	
                214.93

              	
                101.16

              	
                83.01

              	
                 

              
	
                09

              	
                964.64

              	
                186.23

              	
                95.47

              	
                70.73

              	
                132.56

              	
                74.37

              	
                243.58

              	
                156.91

              	
                327.57

              	
                9,702.53

              	
                1,650.78

              	
                467.40

              	
                255.16

              	
                271.41

              	
                802.29

              	
                755.47

              	
                198.62

              	
                107.13

              	
                86.64

              	
                 

              
	
                10

              	
                953.74

              	
                184.69

              	
                95.35

              	
                74.82

              	
                134.57

              	
                77.25

              	
                243.04

              	
                157.31

              	
                328.25

              	
                12,156.21

              	
                2,072.80

              	
                586.63

              	
                320.83

              	
                342.12

              	
                1,010.07

              	
                952.55

              	
                239.40

              	
                118.00

              	
                93.74

              	
                 

              
	
                11

              	
                1,253.13

              	
                240.64

              	
                123.00

              	
                90.63

              	
                170.16

              	
                95.05

              	
                312.73

              	
                201.33

              	
                419.99

              	
                13,058.07

              	
                2,207.46

              	
                621.12

              	
                333.27

              	
                356.60

              	
                1,058.59

              	
                1,001.97

              	
                296.79

              	
                144.07

              	
                121.37

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 
	
                TABLE
                  5

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + Transportation Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
                 

              	
                 

              	
                 

              	
                 

              	
                
                  TANF

                

              	
                 

              	
                 

              	
                 

              	
                 

              	
              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE

                 (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE 
                  (14-20)

              	
                AGE 
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                989.39

              	
                189.39

              	
                95.33

              	
                60.12

              	
                126.42

              	
                66.88

              	
                244.08

              	
                155.88

              	
                325.90

              	
                9,129.26

              	
                1,534.97

              	
                428.46

              	
                196.67

              	
                226.64

              	
                709.73

              	
                677.86

              	
                236.37

              	
                99.55

              	
                80.44

              	
                 

              
	
                02

              	
                989.39

              	
                189.39

              	
                95.33

              	
                60.12

              	
                126.42

              	
                66.88

              	
                244.08

              	
                155.88

              	
                325.90

              	
                9,129.26

              	
                1,534.97

              	
                428.46

              	
                196.67

              	
                226.64

              	
                709.73

              	
                677.86

              	
                236.37

              	
                99.55

              	
                80.44

              	
                 

              
	
                03

              	
                1,124.89

              	
                217.02

              	
                109.47

              	
                69.66

              	
                145.14

              	
                77.42

              	
                281.60

              	
                180.65

              	
                378.96

              	
                9,868.94

              	
                1,675.65

              	
                468.50

              	
                217.96

              	
                250.39

              	
                786.76

              	
                751.87

              	
                233.28

              	
                102.50

              	
                79.34

              	
                 

              
	
                04

              	
                981.68

              	
                189.80

              	
                95.77

              	
                61.23

              	
                126.83

              	
                67.73

              	
                246.74

              	
                158.43

              	
                333.17

              	
                9,525.53

              	
                1,619.29

              	
                452.40

              	
                211.14

              	
                242.68

              	
                761.34

              	
                728.12

              	
                288.45

              	
                104.68

              	
                82.13

              	
                 

              
	
                05

              	
                1,070.81

              	
                206.89

              	
                104.39

              	
                66.73

              	
                138.16

              	
                73.82

              	
                268.70

              	
                172.67

              	
                363.13

              	
                10,512.96

              	
                1,777.59

              	
                494.22

              	
                231.66

              	
                265.05

              	
                829.58

              	
                795.61

              	
                234.34

              	
                91.69

              	
                73.91

              	
                 

              
	
                06

              	
                956.07

              	
                185.78

              	
                93.99

              	
                60.45

              	
                124.42

              	
                66.73

              	
                242.59

              	
                156.31

              	
                329.52

              	
                9,527.14

              	
                1,617.65

              	
                450.22

              	
                211.81

              	
                242.84

              	
                759.57

              	
                728.58

              	
                272.43

              	
                87.10

              	
                70.20

              	
                 

              
	
                07

              	
                998.62

              	
                193.16

              	
                97.39

              	
                62.23

              	
                128.89

              	
                68.89

              	
                250.83

              	
                161.22

              	
                339.46

              	
                9,889.59

              	
                1,681.30

              	
                467.69

              	
                220.73

              	
                252.21

              	
                790.30

              	
                758.63

              	
                264.42

              	
                90.91

              	
                73.41

              	
                 

              
	
                08

              	
                896.28

              	
                173.94

              	
                87.97

              	
                56.42

              	
                116.71

              	
                62.57

              	
                227.08

              	
                146.16

              	
                307.58

              	
                8,596.78

              	
                1,459.93

              	
                407.48

              	
                190.55

              	
                218.41

              	
                685.28

              	
                655.93

              	
                208.89

              	
                88.84

              	
                70.69

              	
                 

              
	
                09

              	
                964.63

              	
                186.22

              	
                93.97

              	
                59.89

              	
                124.57

              	
                66.38

              	
                241.77

              	
                155.10

              	
                325.74

              	
                9,702.49

              	
                1,650.74

              	
                460.21

              	
                216.72

              	
                247.57

              	
                777.32

              	
                744.58

              	
                193.63

              	
                96.88

              	
                76.39

              	
                 

              
	
                10

              	
                953.72

              	
                184.67

              	
                93.28

              	
                59.81

              	
                123.50

              	
                66.18

              	
                240.53

              	
                154.80

              	
                325.71

              	
                12,156.16

              	
                2,072.75

              	
                577.72

              	
                273.19

              	
                312.58

              	
                979.12

              	
                939.05

              	
                234.49

              	
                111.24

              	
                86.98

              	
                 

              
	
                11

              	
                1,253.11

              	
                240.62

              	
                121.08

              	
                76.75

              	
                159.92

              	
                84.81

              	
                310.41

              	
                199.01

              	
                417.64

              	
                13,058.02

              	
                2,207.41

              	
                612.78

              	
                288.66

              	
                328.94

              	
                1,029.61

              	
                989.33

              	
                289.13

              	
                137.50

              	
                114.80

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  6

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + Dental Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
              	
                 

              	
                 

              	
                 

              	
                
                  TANF

                

              	
                 

              	
                 

              	
                 

              	
                 

              	
                
                

              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                984.41

              	
                187.78

              	
                96.68

              	
                64.56

              	
                129.80

              	
                70.12

              	
                241.31

              	
                154.33

              	
                322.75

              	
                9,105.00

              	
                1,514.92

              	
                420.72

              	
                197.74

              	
                225.05

              	
                692.05

              	
                665.45

              	
                224.62

              	
                83.53

              	
                73.66

              	
                 

              
	
                02

              	
                984.41

              	
                187.78

              	
                96.68

              	
                64.56

              	
                129.80

              	
                70.12

              	
                241.31

              	
                154.33

              	
                322.75

              	
                9,105.00

              	
                1,514.92

              	
                420.72

              	
                197.74

              	
                225.05

              	
                692.05

              	
                665.45

              	
                224.62

              	
                83.53

              	
                73.66

              	
                 

              
	
                03

              	
                1,119.04

              	
                215.13

              	
                111.21

              	
                75.21

              	
                149.47

              	
                81.50

              	
                279.98

              	
                180.24

              	
                377.13

              	
                9,838.59

              	
                1,650.57

              	
                458.93

              	
                219.48

              	
                248.56

              	
                765.30

              	
                736.96

              	
                224.03

              	
                79.59

              	
                69.67

              	
                 

              
	
                04

              	
                977.46

              	
                188.44

              	
                96.99

              	
                65.16

              	
                129.88

              	
                70.63

              	
                246.00

              	
                158.49

              	
                332.32

              	
                9,496.04

              	
                1,594.93

              	
                442.40

              	
                211.44

              	
                239.87

              	
                740.26

              	
                713.41

              	
                282.47

              	
                83.63

              	
                73.26

              	
                 

              
	
                05

              	
                1,067.15

              	
                205.71

              	
                107.23

              	
                73.94

              	
                144.82

              	
                79.67

              	
                274.06

              	
                177.89

              	
                369.27

              	
                10,493.87

              	
                1,761.83

              	
                490.90

              	
                237.25

              	
                268.01

              	
                820.94

              	
                790.68

              	
                232.54

              	
                83.72

              	
                71.03

              	
                 

              
	
                06

              	
                952.19

              	
                184.53

              	
                95.89

              	
                65.72

              	
                128.98

              	
                70.84

              	
                243.88

              	
                158.06

              	
                330.99

              	
                9,506.99

              	
                1,601.01

              	
                444.97

              	
                214.74

              	
                243.34

              	
                748.32

              	
                721.42

              	
                269.67

              	
                76.98

              	
                66.22

              	
                 

              
	
                07

              	
                995.57

              	
                192.17

              	
                99.06

              	
                66.77

              	
                132.89

              	
                72.48

              	
                251.63

              	
                162.41

              	
                340.38

              	
                9,869.04

              	
                1,664.33

              	
                462.13

              	
                223.32

              	
                252.37

              	
                777.02

              	
                749.68

              	
                260.49

              	
                78.17

              	
                68.16

              	
                 

              
	
                08

              	
                891.16

              	
                172.28

              	
                89.45

              	
                61.19

              	
                120.40

              	
                66.07

              	
                226.55

              	
                146.55

              	
                306.98

              	
                8,573.17

              	
                1,440.43

              	
                400.21

              	
                192.05

              	
                217.29

              	
                670.38

              	
                645.97

              	
                201.61

              	
                74.80

              	
                64.91

              	
                 

              
	
                09

              	
                959.78

              	
                184.65

              	
                96.02

              	
                65.74

              	
                129.49

              	
                70.88

              	
                240.24

              	
                154.59

              	
                323.99

              	
                9,678.19

              	
                1,630.67

              	
                452.86

              	
                218.49

              	
                246.60

              	
                759.65

              	
                732.20

              	
                188.18

              	
                77.98

              	
                68.42

              	
                 

              
	
                10

              	
                949.98

              	
                183.46

              	
                95.47

              	
                65.64

              	
                128.70

              	
                70.80

              	
                239.83

              	
                154.81

              	
                324.92

              	
                12,128.15

              	
                2,049.61

              	
                569.80

              	
                276.17

              	
                312.28

              	
                959.01

              	
                925.01

              	
                229.36

              	
                88.19

              	
                77.26

              	
                 

              
	
                11

              	
                1,250.57

              	
                239.81

              	
                124.16

              	
                84.09

              	
                167.04

              	
                90.93

              	
                310.37

              	
                199.40

              	
                417.59

              	
                13,040.06

              	
                2,192.57

              	
                609.25

              	
                293.23

              	
                331.10

              	
                1,018.76

              	
                982.18

              	
                286.56

              	
                125.33

              	
                109.82

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  7

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + Dental + Transportation Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                
                

              	
                 

              	
                 

              	
                 

              	 TANF	
                 

              	
                 

              	
                 

              	
                 

              	
              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE 
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  

                (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                989.39

              	
                189.40

              	
                97.81

              	
                65.40

              	
                132.03

              	
                71.53

              	
                244.94

              	
                156.62

              	
                326.88

              	
                9,129.26

              	
                1,534.99

              	
                430.82

              	
                200.70

              	
                230.20

              	
                711.99

              	
                679.93

              	
                236.56

              	
                101.30

              	
                81.30

              	
                 

              
	
                02

              	
                989.39

              	
                189.40

              	
                97.81

              	
                65.40

              	
                132.03

              	
                71.53

              	
                244.94

              	
                156.62

              	
                326.88

              	
                9,129.26

              	
                1,534.99

              	
                430.82

              	
                200.70

              	
                230.20

              	
                711.99

              	
                679.93

              	
                236.56

              	
                101.30

              	
                81.30

              	
                 

              
	
                03

              	
                1,124.89

              	
                217.03

              	
                112.54

              	
                76.19

              	
                152.08

              	
                83.16

              	
                284.24

              	
                182.92

              	
                381.98

              	
                9,868.94

              	
                1,675.67

              	
                471.57

              	
                223.20

              	
                255.02

              	
                790.26

              	
                755.08

              	
                234.32

              	
                105.45

              	
                80.79

              	
                 

              
	
                04

              	
                981.68

              	
                189.81

              	
                97.95

              	
                65.87

              	
                131.77

              	
                71.82

              	
                249.07

              	
                160.43

              	
                335.83

              	
                9,525.53

              	
                1,619.31

              	
                454.69

              	
                215.06

              	
                246.15

              	
                764.49

              	
                731.02

              	
                289.82

              	
                107.62

              	
                83.58

              	
                 

              
	
                05

              	
                1,070.82

              	
                206.91

              	
                108.07

              	
                74.55

              	
                146.47

              	
                80.71

              	
                276.74

              	
                179.57

              	
                372.32

              	
                10,512.97

              	
                1,777.63

              	
                498.86

              	
                239.58

              	
                272.06

              	
                836.64

              	
                802.09

              	
                238.99

              	
                100.41

              	
                78.21

              	
                 

              
	
                06

              	
                956.07

              	
                185.79

              	
                96.77

              	
                66.37

              	
                130.71

              	
                71.94

              	
                246.70

              	
                159.84

              	
                334.21

              	
                9,527.15

              	
                1,617.68

              	
                453.37

              	
                217.21

              	
                247.62

              	
                764.89

              	
                733.46

              	
                275.60

              	
                92.97

              	
                73.09

              	
                 

              
	
                07

              	
                998.62

              	
                193.17

              	
                99.76

              	
                67.28

              	
                134.25

              	
                73.34

              	
                253.85

              	
                163.81

              	
                342.91

              	
                9,889.59

              	
                1,681.32

              	
                470.68

              	
                225.83

              	
                256.73

              	
                793.91

              	
                761.95

              	
                266.43

              	
                94.39

              	
                75.13

              	
                 

              
	
                08

              	
                896.28

              	
                173.95

              	
                90.61

              	
                62.05

              	
                122.69

              	
                67.52

              	
                230.28

              	
                148.90

              	
                311.23

              	
                8,596.78

              	
                1,459.95

              	
                410.05

              	
                194.94

              	
                222.30

              	
                689.78

              	
                660.06

              	
                211.02

              	
                92.92

              	
                72.70

              	
                 

              
	
                09

              	
                964.63

              	
                186.23

              	
                97.11

              	
                66.55

              	
                131.65

              	
                72.25

              	
                243.76

              	
                156.81

              	
                328.01

              	
                9,702.49

              	
                1,650.76

              	
                462.98

              	
                221.46

              	
                251.76

              	
                779.62

              	
                746.70

              	
                194.37

              	
                99.27

              	
                77.57

              	
                 

              
	
                10

              	
                953.72

              	
                184.68

              	
                96.32

              	
                66.27

              	
                130.37

              	
                71.86

              	
                242.56

              	
                156.53

              	
                328.02

              	
                12,156.17

              	
                2,072.78

              	
                581.46

              	
                279.59

              	
                318.25

              	
                982.04

              	
                941.73

              	
                236.57

              	
                114.29

              	
                88.48

              	
                 

              
	
                11

              	
                1,253.12

              	
                240.64

              	
                124.73

              	
                84.52

              	
                168.18

              	
                91.65

              	
                312.23

              	
                200.58

              	
                419.72

              	
                13,058.03

              	
                2,207.44

              	
                616.74

              	
                295.43

              	
                334.92

              	
                1,033.53

              	
                992.92

              	
                291.99

              	
                141.60

              	
                116.82

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                TABLE
                  8

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                General
                  + Mental Health + Dental + Transportation Rates: 

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              	
                 

              	
                 

              	
                 

              	
                
                  TANF

                

              	
                 

              	
                 

              	
                 

              	
                 

              	
              	
                 

              	
                
                  SSI-N

                

              	
                 

              	
                 

              	
                SSI-B

              	
                SSI-AB

              	
                 

              
	
                Area

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE
                  (14-20)

              	
                AGE
                  (21-54)

              	
                AGE
                  (55+)

              	
                BTHMO

                +2MO

              	
                3MO-11MO

              	
                AGE
                  

                (1-5)

              	
                AGE
                  

                (6-13)

              	
                AGE

                 (14-20)

              	
                AGE
                  

                (21-54)

              	
                AGE
                  (55+)

              	
                 

              	
                AGE
                  

                (65-)

              	
                AGE
                  (65+)

              	
                 

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                Female

              	
                Male

              	
                Female

              	
                Male

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                01

              	
                989.41

              	
                189.42

              	
                99.54

              	
                77.51

              	
                144.32

              	
                83.82

              	
                248.89

              	
                160.57

              	
                330.37

              	
                9,129.34

              	
                1,535.07

              	
                442.61

              	
                271.66

              	
                298.04

              	
                815.62

              	
                716.94

              	
                239.71

              	
                114.40

              	
                94.40

              	
                 

              
	
                02

              	
                989.41

              	
                189.42

              	
                100.40

              	
                84.17

              	
                145.87

              	
                85.37

              	
                248.08

              	
                159.76

              	
                330.06

              	
                9,129.35

              	
                1,535.08

              	
                445.43

              	
                278.85

              	
                278.66

              	
                762.76

              	
                702.08

              	
                258.46

              	
                116.28

              	
                96.28

              	
                 

              
	
                03

              	
                1,124.90

              	
                217.04

              	
                113.67

              	
                84.35

              	
                158.10

              	
                89.18

              	
                285.61

              	
                184.29

              	
                383.36

              	
                9,868.98

              	
                1,675.71

              	
                478.24

              	
                258.90

              	
                277.16

              	
                813.45

              	
                765.20

              	
                242.19

              	
                113.12

              	
                88.46

              	
                 

              
	
                04

              	
                981.69

              	
                189.82

              	
                99.24

              	
                75.23

              	
                138.67

              	
                78.72

              	
                250.64

              	
                162.00

              	
                337.41

              	
                9,525.59

              	
                1,619.37

              	
                465.45

              	
                272.59

              	
                281.83

              	
                801.87

              	
                747.32

              	
                308.92

              	
                125.50

              	
                101.46

              	
                 

              
	
                05

              	
                1,070.83

              	
                206.92

              	
                109.22

              	
                82.85

              	
                152.59

              	
                86.83

              	
                278.13

              	
                180.96

              	
                373.73

              	
                10,513.01

              	
                1,777.67

              	
                505.19

              	
                273.45

              	
                293.06

              	
                858.64

              	
                811.69

              	
                243.93

              	
                109.13

              	
                86.93

              	
                 

              
	
                06

              	
                956.09

              	
                185.81

              	
                98.86

              	
                80.97

              	
                145.54

              	
                86.77

              	
                251.46

              	
                164.60

              	
                338.41

              	
                9,527.21

              	
                1,617.74

              	
                462.97

              	
                274.99

              	
                302.86

              	
                849.27

              	
                763.59

              	
                276.66

              	
                96.84

              	
                76.96

              	
                 

              
	
                07

              	
                998.64

              	
                193.19

              	
                101.65

              	
                81.00

              	
                144.37

              	
                83.46

              	
                256.15

              	
                166.11

              	
                345.23

              	
                9,889.65

              	
                1,681.38

              	
                480.18

              	
                276.62

              	
                288.23

              	
                826.91

              	
                776.34

              	
                271.97

              	
                106.99

              	
                87.73

              	
                 

              
	
                08

              	
                896.29

              	
                173.96

              	
                91.67

              	
                69.75

              	
                128.37

              	
                73.20

              	
                231.57

              	
                150.19

              	
                312.53

              	
                8,596.82

              	
                1,459.99

              	
                416.09

              	
                227.24

              	
                242.33

              	
                710.77

              	
                669.21

              	
                217.06

              	
                105.24

              	
                85.02

              	
                 

              
	
                09

              	
                964.64

              	
                186.24

              	
                98.61

              	
                77.39

              	
                139.64

              	
                80.24

              	
                245.57

              	
                158.62

              	
                329.84

              	
                9,702.53

              	
                1,650.80

              	
                470.17

              	
                259.90

              	
                275.60

              	
                804.59

              	
                757.59

              	
                199.36

              	
                109.52

              	
                87.82

              	
                 

              
	
                10

              	
                953.74

              	
                184.70

              	
                98.39

              	
                81.28

              	
                141.44

              	
                82.93

              	
                245.07

              	
                159.04

              	
                330.56

              	
                12,156.22

              	
                2,072.83

              	
                590.37

              	
                327.23

              	
                347.79

              	
                1,012.99

              	
                955.23

              	
                241.48

              	
                121.05

              	
                95.24

              	
                 

              
	
                11

              	
                1,253.14

              	
                240.66

              	
                126.65

              	
                98.40

              	
                178.42

              	
                101.89

              	
                314.55

              	
                202.90

              	
                422.07

              	
                13,058.08

              	
                2,207.49

              	
                625.08

              	
                340.04

              	
                362.58

              	
                1,062.51

              	
                1,005.56

              	
                299.65

              	
                148.17

              	
                123.39

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Area

              	 	
                Corresponding
                  Counties

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Area
                  1

              	 	
                Escambia,
                  Okaloosa, Santa Rosa, Walton

              	 	 
	
                Area
                  2

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

              	 	 
	
                Area
                  3

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

              	 	 	 
	
                Area
                  4

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

              	 	 	 
	
                Area
                  5

              	 	
                Pasco,
                  Pinellas

              	 	 	 	 	 	 	 	 	 	 
	
                Area
                  6

              	 	
                Hardee,
                  Highlands, Hillsborough, Manatee, Polk

              	 	 
	
                Area
                  7

              	 	
                Brevard,
                  Orange, Osceola, Seminole

              	 	 	 	 
	
                Area
                  8

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

              	 	 	 	 	 
	
                Area
                  9

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

              	 	 	 
	
                Area
                  10

              	 	
                Broward

              	 	 	 	 
	
                Area
                  11

              	 	
                Dade,
                  Monroe

              	 	 	 	 	 	 	 	 	 	 	 
	
                created
                  on august 11, 2006

              	 	 	 	 	 	 	 	 	 	 

      

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ATTACHMENT
      II

    

    Medicaid
      Prepaid Health Plan Model Contract

    

    

    

    
      
        
          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
        

      

    

     

    
      Table
        of Contents

      

       

      Section
        I
        Definitions and Acronyms

       

      
        	 	
                A.

              	
                Definitions

              	 

      

      
        	 	
                B.

              	
                Acronyms

              	 

      

       

      Section
        II General Overview

       

      
        	 	
                A.

              	
                Purpose

              	 

      

      
        	 	
                B.

              	
                Responsibilities
                  of the State of Florida (State) and the Agency for Health Care
                  Administration (Agency)

              	 

      

      
        	 	
                C
                  .

              	
                General
                  Responsibilities of the Health Plan

              	 

      

       

      Section
        III Eligibility and Enrollment

       

      
        	 	
                A.

              	
                Eligibility

              	 

      

      
        	 	
                B.

              	
                Enrollment

              	 

      

      
        	 	
                C.

              	
                Disenrollment

              	 

      

       

      Section
        IV Enrollee Services and Marketing

       

      
        	 	
                A.

              	
                Enrollee
                  Services

              	 

      

      
        	 	
                B.

              	
                Marketing

              	 

      

       

      Section
        V
        Covered Services

       

      
        	 	
                A.

              	
                Covered
                  Services

              	 

      

      
        	 	
                B.

              	
                Optional
                  Services

              	 

      

      
        	 	
                C.

              	
                Expanded
                  Services

              	 

      

      
        	 	
                D.

              	
                Excluded
                  Services

              	 

      

      
        	 	
                E.

              	
                Moral
                  or Religious Objections

              	 

      

      
        	 	
                F.

              	
                Coverage
                  Provisions

              	 

      

       

      Section
        VI Behavioral Health Care

       

      
        	 	
                A.

              	
                General
                  Provisions

              	 

      

      
        	 	
                B.

              	
                Service
                  Requirements

              	 

      

      
        	 	
                C.

              	
                Behavioral
                  Health Managed Care Local Advisory Group

              	 

      

      
        	 	
                D.

              	
                Community
                  Behavioral Health Services Annual 80/20 Expenditure Report

              	 

      

       

      Section
        VII Provider Network

       

      
        	 	
                A.

              	
                General
                  Provisions

              	 

      

      
        	 	
                B.

              	
                Primary
                  Care Providers

              	 

      

      
        	 	
                C.

              	
                Minimum
                  Standards

              	 

      

      
        	 	
                D.

              	
                Appointment
                  Waiting Times and Geographic Access Standards

              	 

      

      
        	 	
                E.

              	
                Behavioral
                  Health Services

              	 

      

      
        	 	
                F.

              	
                Specialists
                  and Other Providers

              	 

      

      
        	 	
                G.

              	
                Continuity
                  of Care

              	 

      

      
        	 	
                H.

              	
                Network
                  Changes

              	 

      

       

      Section
        VIII Quality Management

       

      
        	 	
                A.

              	
                Quality
                  Improvement

              	 

      

      
        	 	
                B.

              	
                Utilization
                  Management (UM)

              	 

      

       

      Section
        IX

       

       

      Grievance
        System

       

      
        	 	
                A.

              	
                General
                  Requirements

              	 

      

      
        	 	
                B.

              	
                The
                  Grievance Process

              	 

      

      
        	 	
                C.

              	
                The
                  Appeal Process

              	 

      

      
        	 	
                D.

              	
                Medicaid
                  Fair Hearing System

              	 

      

       

      Section
        X
        Administration and Management

       

      
        	 	
                A.

              	
                General
                  Provisions

              	 

      

      
        	 	
                B.

              	
                Staffing

              	 

      

      
        	 	
                C.

              	
                Provider
                  Contract Requirements

              	 

      

      
        	 	
                D.

              	
                Provider
                  Termination

              	 

      

      
        	 	
                E.

              	
                Provider
                  Services

              	 

      

      
        	 	
                F.

              	
                Medical
                  Records Requirements

              	 

      

      
        	 	
                G.

              	
                Claims
                  Payment

              	 

      

      
        	 	
                H.

              	
                Encounter
                  Data

              	 

      

      
        	 	
                I.

              	
                Fraud
                  Prevention

              	 

      

       

      Section
        XI Information Management and Systems

       

      
        	 	
                A.

              	
                General
                  Provisions

              	 

      

      
        	 	
                B.

              	
                Data
                  and Document Management Requirements

              	 

      

      
        	 	
                C.

              	
                System
                  and Data Integration Requirements

              	 

      

      
        	 	
                D.

              	
                Systems
                  Availability, Performance and Problem Management
                  Requirements

              	 

      

      
        	 	
                E.

              	
                System
                  Testing and Change Management Requirements

              	 

      

      
        	 	
                F.

              	
                Information
                  Systems Documentation Requirements

              	 

      

      
        	 	
                G.

              	
                Reporting
                  Requirements - Specific to Information Management and Systems Functions
                  and Capabilities - and Technological Capabilities

              	 

      

      
        	 	
                H.

              	
                Other
                  Requirements

              	 

      

      
        	 	
                I.

              	
                Compliance
                  with Standard Coding Schemes

              	 

      

      
        	 	
                J.

              	
                Data
                  Exchange and Formats and Methods Applicable to Health
                  Plans

              	 

      

       

      Section
        XII Reporting Requirements

       

      
        	 	
                A.

              	
                Health
                  Plan Reporting Requirements

              	 

      

      
        	 	
                B.

              	
                Enrollment/Disenrollment
                  Reports:

              	 

      

      
        	 	
                C.

              	
                Grievance
                  System

              	 

      

      
        	 	
                D.

              	
                Provider
                  Reporting

              	 

      

      
        	 	
                E.

              	
                Marketing
                  Representative Report

              	 

      

      
        	 	
                F.

              	
                Critical
                  Incidents

              	 

      

      
        	 	
                G.

              	
                Hernandez
                  Settlement Agreement (HSA) Report

              	 

      

      
        	 	
                H.

              	
                Performance
                  Measure Report

              	 

      

      
        	 	
                I.

              	
                Financial
                  Reporting

              	 

      

      
        	 	
                J.

              	
                Suspected
                  Fraud Reporting

              	 

      

      
        	 	
                K.

              	
                Information
                  Systems Availability and Performance Report

              	 

      

      
        	 	
                L.

              	
                Claims
                  Inventory Summary Report

              	 

      

      
        	 	
                M.

              	
                Child
                  Health Check-Up Reports

              	 

      

      
        	 	
                N.

              	
                Pharmacy
                  Encounter Data

              	 

      

      
        	 	
                O.

              	
                Transportation
                  Services

              	 

      

      
        	 	
                P.

              	
                Enrollee
                  Satisfaction Survey Summary

              	 

      

      
        	 	
                Q.

              	
                Stakeholders’
                  Satisfaction Survey Summary

              	 

      

      
        	 	
                R.

              	
                Behavioral
                  Health Services Grievance and Appeals Reporting
                  Requirements

              	 

      

      
        	 	
                S.

              	
                Critical
                  Incident Reporting

              	 

      

      
        	 	
                T.

              	
                Required
                  Staff/Providers

              	 

      

      
        	 	
                U.

              	
                FARS/CFARS

              	 

      

      
        	 	
                V.

              	
                Behavioral
                  Health Encounter Report

              	 

      

      
        	 	
                W.

              	
                Behavioral
                  Health Pharmacy Encounter Data Report

              	 

      

      
        	 	
                X.

              	
                Minority
                  Participation Report

              	 

      

       

      Section
        XIII Method of Payment

       

      
        	 	
                A.

              	
                Fixed
                  Price Unit Contract

              	 

      

      
        	 	
                B.

              	
                Child
                  Health Check-Up Incentive Program

              	 

      

      
        	 	
                C.

              	
                Capitation
                  Rate

              	 

      

      
        	 	
                D.

              	
                Errors

              	 

      

      
        	 	
                E.

              	
                Member
                  Payment Liability Protection

              	 

      

      
        	 	
                F.

              	
                Co-payments

              	 

      

      
        	 	
                G.

              	
                Enrollment
                  Levels

              	 

      

      
        	 	
                H.

              	
                Transition
                  to Medicaid Reform

              	 

      

      
        	 	
                I.

              	
                Cost
                  Effectiveness

              	 

      

       

      Section
        XIV Sanctions

       

      
        	 	
                A.

              	
                General
                  Provisions

              	 

      

      
        	 	
                B.

              	
                Specific
                  Sanctions

              	 

      

       

      Section
        XV Financial Requirements

       

      
        	 	
                A.

              	
                Insolvency
                  Protection

              	 

      

      
        	 	
                B.

              	
                Insolvency
                  Protection Account Waiver

              	 

      

      
        	 	
                C.

              	
                Surplus
                  Start Up Account

              	 

      

      
        	 	
                D.

              	
                Surplus
                  Requirement

              	 

      

      
        	 	
                E.

              	
                Interest

              	 

      

      
        	 	
                F.

              	
                Inspection
                  and Audit of Financial Records

              	 

      

      
        	 	
                G.

              	
                Physician
                  Incentive Plans

              	 

      

      
        	 	
                H.

              	
                Third
                  Party Resources

              	 

      

      
        	 	
                I.

              	
                Fidelity
                  Bonds

              	 

      

       

      Section
        XVI Terms and Conditions

       

      
        	 	
                A.

              	
                Agency
                  Contract Management

              	 

      

      
        	 	
                B.

              	
                Applicable
                  Laws and Regulations

              	 

      

      
        	 	
                C.

              	
                Assignment

              	 

      

      
        	 	
                D.

              	
                Attorney's
                  Fees

              	 

      

      
        	 	
                E.

              	
                Conflict
                  of Interest

              	 

      

      
        	 	
                F.

              	
                Contract
                  Variation

              	 

      

      
        	 	
                G.

              	
                Court
                  of Jurisdiction or Venue

              	 

      

      
        	 	
                H.

              	
                Damages
                  for Failure to Meet Contract Requirements

              	 

      

      
        	 	
                I.

              	
                Disputes

              	 

      

      
        	 	
                J.

              	
                Force
                  Majeure

              	 

      

      
        	 	
                K.

              	
                Legal
                  Action Notification

              	 

      

      
        	 	
                L.

              	
                Licensing

              	 

      

      
        	 	
                M.

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

              	 

      

      
        	 	
                N.

              	
                Offer
                  of Gratuities

              	 

      

      
        	 	
                O.

              	
                Subcontracts

              	 

      

      
        	 	
                P.

              	
                Hospital
                  Provider Contracts

              	 

      

      
        	 	
                Q.

              	
                Termination
                  Procedures

              	 

      

      
        	 	
                R.

              	
                Waiver

              	 

      

      
        	 	
                S.

              	
                Withdrawing
                  Services from a County

              	 

      

      
        	 	
                T.

              	
                MyFloridaMarketPlace
                  Vendor Registration

              	 

      

      
        	 	
                U.

              	
                MyFloridaMarketplace
                  Vendor Registration and Transaction Fee Exemption

              	 

      

      
        	 	
                V.

              	
                Ownership
                  and Management Disclosure

              	 

      

      
        	 	
                W.

              	
                Minority
                  Recruitment and Retention Plan

              	 

      

      
        	 	
                X.

              	
                Independent
                  Provider

              	 

      

      
        	 	
                Y.

              	
                General
                  Insurance Requirements

              	 

      

      
        	 	
                Z.

              	
                Worker's
                  Compensation Insurance

              	 

      

      
        	 	
                AA.

              	
                State
                  Ownership

              	 

      

      
        	 	
                BB.

              	
                Disaster
                  Plan

              	 

      

    
      
        
          

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
        

      

    

    Section
      I

     

    Definitions
      and Acronyms

     

    

    
      	
              A.

            	
              Definitions

            

    

    

    The
      following terms as used in this Contract shall be construed and/or interpreted
      as follows, unless the Contract otherwise expressly requires a different
      construction and/or interpretation. 

    

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

    

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

    

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

    

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

    

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

    

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

    

    Agent—
An
      entity that contracts with the State to perform administrative functions,
      including but not limited to: Fiscal Agent activities; outreach and education,
      eligibility and Enrollment activities; Systems and Technical support.

    

    Ancillary
      Provider—
A
      Provider of ancillary medical services who has contracted with a Health Plan
      to
      provide ancillary medical services to the Health Plan's Enrollees.

    

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

    

    Automatic
      Assignment (or Auto-Assign)—
The
      Enrollment of an eligible Medicaid Recipient, for whom Enrollment is mandatory,
      in a Health Plan chosen by AHCA or its Agent, and/or the assignment of a new
      Enrollee to a PCP chosen by the Health Plan. 

    

    Appeal—
A
      request for review of an Action, pursuant to 42 CFR 438.400(b).

    

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

    

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

    

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

    

    Behavioral
      Health Care Provider—
A
      licensed mental health professional, such as a "Clinical Psychologist," or
      registered nurse qualified due to training or competency in mental health care,
      who is responsible for the provision of mental health care to patients, or
      a
      physician licensed under Chapters 458 or 459, F.S., who is under contract to
      provide Behavioral Health Services to Enrollees.

    

    Benefits—
A
      schedule of health care services to be delivered to Enrollees covered by the
      Health Plan as set forth in Section V and Section VI of this Contract.

    

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

    

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

    

    Calendar
      Days—
All
      seven (7) days of the week. 

    

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

    

    Case
      Management—
A
      process which assesses, plans, implements, coordinates, monitors and evaluates
      the options and services required to meet an Enrollee's health needs using
      communication and all available resources to promote quality cost-effective
      outcomes. Proper Case Management occurs across a continuum of care, addressing
      the ongoing individual needs of an Enrollee rather than being restricted to
      a
      single practice setting.

    

    Cause—
Special
      reasons that allow Mandatory Enrollees to change their Health Plan option
      outside their Open Enrollment period. May also be referred to as “Good
      Cause.”

    

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

    

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

    

    Child
      Health Check-Up Program (CHCUP) —
A
      comprehensive and preventative health examinations provided on a periodic basis
      that are aimed at identifying and correcting medical conditions in
      Children/Adolescents. Policies and procedures are described in the Child Health
      Check-Up Services Coverage and Limitations Handbook.

    

    Children/Adolescents—
      Enrollees under the age of 21.

    

    Children
      & Families Services Program Office—
Also
      referred to as the Children & Families Safety & Preservation Program
      Office, located in the DCF; the State agency responsible for overseeing programs
      that identify and protect abused and neglected Children and attempt to prevent
      domestic violence.

    

    Choice
      Counselor/Enrollment Broker—
The
      State’s contracted or designated entity that performs functions related to
      outreach, education, counseling, Enrollment, and Disenrollment of Potential
      Enrollees into a Health Plan. 

    

    Choice
      Counseling Specialists—
      Certified individuals authorized by an Agency-approved process who provide
      one-on-one information to Medicaid Recipients, to assist the Medicaid Recipients
      in choosing the Health Plan that best meets their health care needs and those
      of
      their family. 

    

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

    

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

     

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

    

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

    

    Contract
      Period
      - The
      term of the contract from September 1, 2006 through August 31, 2009.

    

    Contract
      Year -
      The
      period of time from September 1 through August 31 of each calendar
      year.

    

    Contracting
      Officer — The
      Secretary of the Agency or his/her delegate.

    

    Cost
      Effective —
The
      Health Plan’s per-member, per-month costs to the State, including, but not
      limited to, FFS costs, administrative costs, and case-management fees, must
      be
      no greater than the State's costs associated with capitated Health
      Plans.

    

    County
      Health Department (CHD)—
CHDs
      are organizations administered by the Department of Health for the purpose
      of
      providing health services as defined in Chapter 154, F.S., which include the
      promotion of the public's health, the control and eradication of preventable
      diseases, and the provision of primary health care for special
      populations.

    

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

    

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

    

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

    

    Direct
      Ownership Interest —
      The
      ownership of stock, equity in capital or any interest in the profits of the
      disclosing entity. A disclosing entity is defined as a Medicaid provider or
      supplier, or other entity that furnishes services or arranges for furnishing
      services under Medicaid, or health related services under the social services
      program.

    

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

    

    Disease
      Management - A
      system
      of coordinated health care intervention and communication for populations with
      conditions in which patient self-care efforts are significant. Disease
      Management supports the physician or practitioner/patient relationship and
      plan
      of care; emphasized prevention of exacerbations and complications utilizing
      evidence-based practice guidelines and patient empowerment strategies, and
      evaluates clinical, humanistic and economic outcomes on an ongoing basis with
      the goal of improving overall health.

    

    Disenrollment—
The
      Agency approved discontinuance of an Enrollee's Enrollment in a Health
      Plan.

    

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

    

    Downward
      Substitution of Care—
The
      use
      of less restrictive, lower cost services than otherwise might have been
      provided, that are considered clinically acceptable and necessary to meet
      specified objectives outlined in an Enrollee's plan of treatment, provided
      as an
      alternative to higher cost services. For services related to mental health,
      Downward Substitution of Care may include care provided by private practice
      psychologists and social workers, psycho-social rehabilitation, Medicaid
      community mental health services or Medicaid mental health targeted Case
      Management, and other services considered clinically appropriate, more
      cost-effective and less restrictive. 

    

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

    

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

    

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

    

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

    

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

    

    Emergency
      Transportation
      - The
      provision of Emergency Transportation Services in accordance with Section
      409.908(13)(d)(4), F.S.

    

    Encounter
      Data
      - A
      record of Covered Services provided to Enrollees of a Health Plan. An Encounter
      is an interaction between a patient and Provider (health plan, rendering
      physician, pharmacy, lab, etc.) who delivers services or is professionally
      responsible for services delivered to a patient.

    

    Enrollee—
A
      Medicaid Recipient currently enrolled in the Health Plan.

    

    Enrollment—
The
      process by which an eligible Medicaid Recipient becomes an Enrollee in a Health
      Plan.

    

    Enrollee
      Suicide Attempt—
An
      act
      which clearly reflects an attempt by an Enrollee to cause his or her own death,
      which results in bodily injury requiring medical treatment by a licensed health
      care professional.

    

    Expanded
      Services—
A
      Health Plan Covered Service for which the Health Plan receives no direct payment
      from the Agency.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    Florida
      Medicaid Management Information System (FMMIS)—
      The
      information system used to process Florida Medicaid claims and payments to
      Health Plans, and to produce management information and reports relating to
      the
      Florida Medicaid program. This system is used to maintain Medicaid eligibility
      data and provider enrollment data.

    

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

    

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

    

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

    

    Good
      Cause—
See
      Cause.

    

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

    

    Grievance
      Procedure—
The
      procedure for addressing Enrollees' grievances.

    

    Grievance
      System—
The
      system for reviewing and resolving Enrollee Grievances and Appeals. Components
      must include a Grievance process, an Appeal process and access to the Medicaid
      Fair Hearing system.

    

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

    

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

    

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

    

    Health
      Maintenance Organization (HMO)—
An
      organization or entity licensed in accordance with Section 641 of the Florida
      Statutes or in accordance with the Florida Medicaid State plan definition of
      an
      HMO. 

    

    Health
      Plan—
An
      entity that integrates financing and management with the delivery of health
      care
      services to an enrolled population. It employs or contracts with an organized
      system of Providers, which deliver services and frequently shares financial
      risk. For the purposes of this Contract, a Health Plan has also contracted
      with
      the Agency to provide Medicaid services under the Florida Medicaid Reform
      program, and includes health maintenance organizations authorized under chapter
      641 of the Florida Statutes, exclusive provider organizations as defined in
      chapter 627 of the Florida Statutes, health insurers authorized under chapter
      624 of the Florida Statutes, and Provider Service Networks as defined in Section
      409.912, Florida Statutes. 

    

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

    

    Hospital
      Services Agreement—
The
      agreement between the Health Plan and a Hospital to provide medical services
      to
      the Health Plan's Enrollees.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    Mandatory
      Assignment—
The
      process the Agency uses to assign Potential Enrollees to a Health Plan. The
      Agency automatically assigns those Mandatory Potential Enrollees who did not
      voluntarily choose a Health Plan.

    

    Market
      Area—
The
      geographic area in which the Health Plan is authorized to market and/or conduct
      pre-enrollment activities.

    

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

    

    Marketing
      Representative — A
      person
      who provides information, pre-enrollment assistance, or otherwise promotes a
      Health Plan. Marketing Representatives shall be limited to licensed insurance
      agents. 

    

    Medicaid
      Area — The
      specific counties designated by the Agency.

    

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

    

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

    

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

    

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

    

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

    

    
      	 	
              1.

            	
              Meet
                the following conditions:

            

    

    

    
      	 	
              a.

            	
              Be
                necessary to protect life, to prevent significant illness or significant
                disability or to alleviate severe
                pain;

            

    

    

    
      	 	
              b.

            	
              Be
                individualized, specific and consistent with symptoms or confirm
                diagnosis
                of the illness or injury under treatment and not in excess of the
                patient's needs;

            

    

    

    
      	 	
              c.

            	
              Be
                consistent with the generally accepted professional medical standards
                as
                determined by the Medicaid program, and not be experimental or
                investigational;

            

    

    

    
      	 	
              d.

            	
              Be
                reflective of the level of service that can be furnished safely and
                for
                which no equally effective and more conservative or less costly treatment
                is available statewide; and

            

    

    

    
      	 	
              e.

            	
              Be
                furnished in a manner not primarily intended for the convenience
                of the
                Enrollee, the Enrollee's caretaker or the
                provider.

            

    

    

    
      	 	
              2.

            	
              Medically
                Necessary or Medical Necessity for those services furnished in a
                Hospital
                on an inpatient basis cannot, 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.

            

    

    

    
      	 	
              3.

            	
              The
                fact that a provider has prescribed, recommended or approved medical
                or
                allied goods or services does not, in itself, make such care, goods
                or
                services Medically Necessary, a Medical Necessity or a Covered
                Service/Benefit.

            

    

    

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

    

    Meds
      AD—
Those
      recipients up to 88% of FPL with assets up to $5,000 for an individual and
      $6,000 for a couple without Medicare and those with Medicare that are not
      receiving institutional care, hospice care, or home and community based
      services.

    

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

    

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

    

    Non-Covered
      Service—
A
      service that is not a Covered Service/Benefit of the Medicaid State Plan or
      of
      the Health Plan.

    

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

    

    Open
      Enrollment—
The
      sixty (60) day period before the end of an Enrollee's Enrollment year, during
      which an Enrollee may choose to change Health Plans for the following Enrollment
      year. 

    

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

    

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

    

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

    

    Peer
      Review—
An
      evaluation of the professional practices of a provider by the provider's peers
      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.

    

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

    

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

    

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

    

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

    

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

    

    Portable
      X-Ray Equipment—
X-ray
      equipment transported to a setting other than a hospital, Clinic or office
      of a
      physician or other Licensed Practitioner of the Healing Arts.

    

    Post-Stabilization
      Care Services—
Covered
      Services related to an Emergency Medical Condition that are provided after
      an
      Enrollee is stabilized in order to maintain the condition, or to improve or
      resolve the Enrollee's condition pursuant to 42 CFR 422.113.

    

    Potential
      Enrollee — Pursuant
      to 42 CFR 438.10(a), an eligible Medicaid Recipient who is subject to Mandatory
      Assignment or may voluntarily elect to enroll in a given Health Plan, but is
      not
      yet an Enrollee of a specific Health Plan. 

    

    Pre-Enrollment —
The
      provision of Marketing and educational materials to a Medicaid Recipient and
      assistance in completing the Request for Benefit Information (RBI).

    

    Pre-Enrollment
      Application—
See
      Request for Benefit Information.

    

    Prepaid
      Health Plan—
A
      Health Plan reimbursed on a prepaid basis. (see Health Plan)

    

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

    

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

    

    Primary
      Care Provider
      (PCP)—
A
      Health Plan staff or contracted physician practicing as a general or family
      practitioner, internist, pediatrician, obstetrician, gynecologist, advanced
      registered nurse practitioners, physician assistants or other specialty approved
      by the Agency, who furnishes Primary Care and patient management services to
      an
      Enrollee. See Sections 641.19, 641.31 and 641.51, F.S. 

    

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

    

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

    

    Provider — A
      person
      or entity that is eligible to provide Medicaid services and has a contractual
      agreement with the Health
      Plan to provide Medicaid services.
      

    

    Provider
      Contract — An
      agreement between the Health Plan and a health care Provider as described above.
      

    

    Provider
      Service Network
      (PSN) — A
      network
      established or organized and operated by a health care provider, or group of
      affiliated health care providers, including minority physician networks and
      emergency room diversion programs that meet the requirements of Section
      409.91211, F.S., which
      provides a substantial proportion of the health care items and services under
      a
      contract directly through the provider or affiliated group of providers and
      may
      make arrangements with physicians or other health care professionals, health
      care institutions, or any combination of such individuals or institutions to
      assume all or part of the financial risk on a prospective basis for the
      provision of basic health services by the physicians, by other health
      professionals, or through the institutions. The health care providers must
      have
      a controlling interest in the governing body of the provider service
      network organization.
      

     

    Public
      Event—
An
      event sponsored for the public or segment of the public by two (2) or more
      actively participating organizations, one (1) of which may be a health
      organization.

    

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

    

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

    

    Quality
      Improvement (QI) —
      The
      process of monitoring and assuring that the delivery of health care services
      are
      available, accessible, timely, Medically Necessary, and provided in sufficient
      quantity, of acceptable Quality, within established standards of excellence,
      and
      appropriate for meeting the needs of the Enrollees. 

     

    Quality
      Improvement Program (QIP) —
      The
      process of assuring the delivery of health care is appropriate, timely,
      accessible, available and Medically Necessary.

    

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

     

    Request
      for Benefit Information (RBI)—
The
      form completed by a Potential Enrollee with the assistance of a Health Plan
      representative and submitted by the Health Plan to the Choice
      Counselor/Enrollment Broker to initiate the receipt of information for the
      Enrollment process. Also known as Pre-Enrollment Application.

    

    Residential
      Services —
      As
      applied to DJJ, refers to the out-of-home placement for use in a level 4, 6,
      8
      or 10 facility as a result of a delinquency disposition order. Also referred
      to
      as a Residential Commitment Program.

    

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

    

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

    

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

    

    Sales
      Activities —
      Actions
      performed by an agent of any Health Plan, including the acceptance of
      Pre-Enrollment Application Requests for Benefit Information, for the purpose
      of
      Enrollment of Potential Enrollees.

    

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

    

    Service
      Area—
The
      designated geographical area within which the Health Plan is authorized by
      the
      Contract to furnish Covered Services to Enrollees.

    

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

    

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

    

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

    

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

    

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

    

    State —
      State of
      Florida.

    

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

    

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

    

    Subscriber
      Assistance Program
      - An
      external grievance program available to Medicaid Recipients that will allow
      an
      additional avenue to resolve a Grievance or Appeal.

    

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

     

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

    

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

    

    Systems —
      See
      Information Systems.

    

    Temporary
      Assistance to Needy Families (TANF)—
Public
      financial assistance provided to low-income families.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    Well
      Care Visit—
A
      routine medical visit for one (1) of the following: CHCUP visit, family
      planning, routine follow-up to a previously treated condition or illness, adult
      physicals or any other routine visit for other than the treatment of an
      illness.

    

    
      	
              B.

            	
              Acronyms

            

    

    

    ADL
      — Activities
      of Daily Living

     

    ADM—
      Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
      Children & Families (aka SAMH — listed below)

     

    ALF—
      Assisted Living Facility

     

    APD—
Agency
      for People with Disabilities

     

    BBA
      —
      Balanced Budget Act of 1997

     

    CAP
      — Corrective
      Action Plan

     

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

     

    CDC
      — Centers
      for Disease Control

     

    CHD
      — County
      Health Department

     

    CMS
      — Centers
      for Medicare & Medicaid Services

     

    CFR
      — Code
      of
      Federal Regulations

     

    CHCUP
      — Child
      Health Check-Up Program

     

    CPT—
      Physicians’ Current Procedural Terminology

     

    DCF—
      Department of Children & Families

     

    DFS
      -
      Department of Financial Services

     

    DHHS—
United
      States Department of Health & Human Services

     

    DOH—
      Department of Health

     

    DJJ—
      Department of Juvenile Justice

     

    DEA—
Drug
      Enforcement Administration

     

    DME—
Durable
      Medical Equipment

     

    EDI
      —
      Electronic Data Interchange 

     

    EDT
      -
      Eastern Daylight Time

     

    EPSDT—
Early
      and Periodic Screening, Diagnosis & Treatment Program

     

    EQR
      —
      External Quality Review

     

    EQRO—
      External Quality Review Organization

     

    EST—
Eastern
      Standard Time

     

    FAC—
Florida
      Administrative Code

     

    FFS—
      Fee-for-Service

     

    FQHC—
      Federally Qualified Health Center

     

    FTE—
Full
      Time Equivalent Position

     

    HIPAA—
Health
      Insurance Portability & Accountability Act

     

    HMO—
Health
      Maintenance Organization

     

    IBNR
      -
      Incurred but not reported

     

    LEIE—
List
      of
      Excluded Individuals & Entities

     

    MBHO—
Managed
      Behavioral Health Organization

     

    ODBC
      —
Open
      Database Connectivity

     

    PCCB
      - Per
      capita capitation benchmark

     

    PCP—
Primary
      Care Physician

     

    QI
      -
      Quality
      Improvement

     

    QIP—
Quality
      Improvement Program

     

    RBI
      -
      Request for Benefit Information

     

    RFP—
Request
      for Proposal

     

    RHC—
Rural
      Health Clinic

     

    SAMH—
      Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
      Children & Families (aka ADM — listed above)

     

    SFTP—
Secure
      File Transfer Protocol

     

    SOBRA—
Sixth
      Omnibus Budget Reconciliation Act

     

    SQL
      —
      Structured Query Language

     

    SSI
      —
      Supplemental Security Income

     

    UM
      —
      Utilization Management

     

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

     

    
      
        

         

        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      II

     

    General
      Overview 

     

    

     

    
      	
              A.

            	
              Purpose

            

    

    

    This
      Contract is an agreement between the Agency and the Health Plan for the
      provision of pre-paid Medicaid services.

    

    
      	
              B.

            	
              Responsibilities
                of the State of Florida (State) and the Agency for Health Care
                Administration (Agency)

            

    

    

    
      	1.  	
              The
                Agency will be responsible for administering the Medicaid program,
                including all aspects of Medicaid Reform. The Agency will administer
                contracts, monitor Health Plan performance, and provide oversight
                in all
                aspects of the Health Plan’s
                operations.

            

    

    

    
      	2.  	
              The
                State has sole authority for determining eligibility for Medicaid
                and
                whether Medicaid Recipients are mandated to enroll in, may enroll
                in, or
                may not enroll in Medicaid Reform.

            

    

    

    
      	3.  	
              The
                Agency or its Agent will review the Florida Medicaid Management
                Information System (FMMIS) file daily and will send written notification
                and information to all Potential Enrollees. A Potential Enrollee
                will have
                thirty (30) Calendar Days to select a Health Plan.
                

            

    

    

    
      	4.  	
              The
                Agency or its Agent will Auto-Assign Medicaid Recipients who do not
                select
                a Medicaid health plan during their choice period to a health plan
                using a
                pre-established algorithm.

            

    

    

    
      	5.  	
              Enrollment
                in the Health Plan, whether chosen or Auto-Assigned, is effective
                at 12:01
                a.m. on the first (1st) Calendar Day of the month following Potential
                Enrollee selection or Auto-Assignment, for those Potential Enrollees
                who
                choose or are Auto-Assigned to the Health Plan on or between the
                first
                (1st) Calendar Day of the month and the Penultimate Saturday of the
                month.
                For those Enrollees who choose or are Auto-Assigned to the Health
                Plan
                between the Sunday after the Penultimate Saturday and before the
                last
                Calendar Day of the month, Enrollment in the Health Plan will be
                effective
                on the first (1st) Calendar Day of the second (2nd) month after choice
                or
                Auto-assignment.

            

    

    

    
      	6.  	
              The
                Agency or its Agent will notify the Health Plan of an Enrollee’s selection
                or assignment to the Health Plan. 

            

    

    

    
      	7.  	
              The
                Agency or its Agent will send a written confirmation notice to Enrollees
                identifying the chosen or Auto-Assigned Health Plan. If the Enrollee
                has
                not chosen a PCP, the confirmation notice will advise the Enrollee
                that
                the Health Plan will assign a PCP. Notice to the Enrollee will be
                made in
                writing and sent via Surface Mail. Notice to the Health Plan will
                be made
                via file transfer. 

            

    

    

    
      	8.  	
              Conditioned
                on continued eligibility, Mandatory Enrollees will have a Lock-In
                period
                of twelve (12) consecutive months. After an initial ninety (90) day
                change
                period, Mandatory Enrollees will only be able to disenroll from the
                Health
                Plan for Cause. The Agency or its Agent will notify Enrollees at
                least
                once every twelve (12) months, and at least sixty (60) Calendar Days
                prior
                to the date the Lock-In period ends (the Open Enrollment period),
                that
                they have the opportunity to change health plans. Enrollees who do
                not
                make a choice will be deemed to have chosen to remain with their
                current
                health plan, unless the current health plan no longer participates
                in
                Medicaid Reform. In this case, the Enrollee will be Auto-Assigned
                to a new
                health plan.

            

    

    

    
      	9.  	
              The
                Agency or its Agent will automatically re-enroll an Enrollee into
                the
                health plan in which he or she was most recently enrolled if the
                Enrollee
                has a temporary loss of eligibility, defined for purposes of this
                Contract
                as less than sixty (60) Calendar Days. In this instance, for Mandatory
                Potential Enrollees, the Lock-In period will continue as though there
                had
                been no break in eligibility, keeping the original twelve (12) month
                period. 

            

    

    

    
      	10.  	
              If
                a temporary loss of eligibility has caused the Enrollee to miss the
                Open
                Enrollment period, the Agency or its Agent will enroll the Enrollee
                in the
                health plan in which he or she was enrolled prior to the loss of
                eligibility. The Enrollee will have ninety (90) Calendar Days to
                disenroll
                without Cause.

            

    

    

    
      	11.  	
              The
                State will issue a Medicaid identification (ID) number to a newborn
                upon
                notification from the Health Plan, the hospital, or other authorized
                Medicaid provider, consistent with the unborn activation process.
                

            

    

    

    
      	12.  	
              The
                Agency or its Agent will notify Enrollees of their right to request
                Disenrollment as follows:

            

    

    

    
      	 	
              a.

            	
              For
                Cause at any time; or

            

    

    

    
      	 	
              b.

            	
              Without
                Cause, at the following times:

            

    

    

    
      	 	
              (1)

            	
              During
                the ninety (90) days following the Enrollee's initial Enrollment,
                or the
                date the Agency or its Agent sends the Enrollee notice of the enrollment,
                whichever is later;

            

    

    

    
      	 	
              (2)

            	
              At
                least every twelve (12) months;

            

    

    

    
      	 	
              (3)

            	
              If
                the temporary loss of Medicaid eligibility has caused the Enrollee
                to miss
                the Open Enrollment period; 

            

    

    

    
      	(4)  	
              When
                the Agency or its Agent grants the Enrollee the right to terminate
                Enrollment without Cause. The Agency or its Agent determines the
                Enrollee's right to terminate Enrollment without Cause on a case-by-case
                basis. 

            

    

    

    
      	13.  	
              The
                Agency or its Agent will process all Disenrollments from the Health
                Plan.
                The Agency or its Agent will make final determinations about granting
                Disenrollment requests and will notify the Health Plan via file transfer
                and the Enrollee via Surface Mail of any Disenrollment
                decision.

            

    

    

    
      	14.  	
              When
                Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
                Disenrollment shall be immediate. 

            

    

    

    
      	15.  	
              The
                Agency will conduct periodic monitoring of the Health Plan’s operations
                for compliance with the provisions of the Contract and applicable
                federal
                and State laws and regulations.

            

    

    

    
      	
              C
                .

            	
              General
                Responsibilities of the Health Plan 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all provisions of this Contract and
                its
                amendments, if any, and shall act in good faith in the performance
                of the
                Contract's provisions. The Health Plan shall develop and maintain
                written
                policies and procedures to implement all provisions of this Contract.
                The
                Health Plan agrees that failure to comply with all provisions of
                this
                Contract shall result in the assessment of penalties and/or termination
                of
                the Contract, in whole or in part, as set forth in this
                Contract.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall comply with all pertinent Agency rules in effect
                throughout the duration of the
                Contract.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall comply with all current Florida Medicaid Handbooks
                ("Handbooks") as noticed in the Florida Administrative Weekly ("FAW"),
                or
                incorporated by reference in rules relating to the provision of services
                set forth in Section V, Covered Services, and Section VI, Behavioral
                Health Care, except where the provisions of the Contract alter the
                requirements set forth in the Handbooks promulgated in the Florida
                Administrative Code (FAC). In addition, the Health Plan shall comply
                with
                the limitations and exclusions in the Handbooks, unless otherwise
                specified by this Contract. In no instance may the limitations or
                exclusions imposed by the Health Plan be more stringent than those
                specified in the Handbooks. The Health Plan shall furnish services
                in an
                amount, duration and scope that are no more restrictive than the
                services
                provided in the non-Medicaid Reform FFS program and that may reasonably
                be
                expected to achieve the purpose for which the services are furnished.
                The
                Health Plan shall not arbitrarily deny or reduce the amount, duration
                or
                scope of a required service solely because of the diagnosis, type
                of
                illness, or condition. 

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan may offer Expanded Services, as described in Section
                V,
                Covered Services to Enrollees, in addition to the required services
                and
                Quality Enhancements. The Health Plan shall define with specificity
                its
                Expanded Services in regards to amount, duration and scope, and obtain
                approval, in writing, by the Agency prior to
                implementation.

            

    

    

    
      	 	
              5.

            	
              This
                Contract including all attachments and exhibits, represents the entire
                agreement between the Health Plan and the Agency and supersedes all
                other
                contracts between the parties when it is executed by duly authorized
                signatures of the Health Plan and the Agency. Correspondence and
                memoranda
                of understanding do not constitute part of this Contract. In the
                event of
                a conflict of language between the Contract and the attachments,
                the
                provisions of the Contract shall govern. The Agency reserves the
                right to
                clarify any contractual relationship in writing and such clarification
                shall govern. Pending final determination of any dispute over any
                Agency
                decision, the Health Plan shall proceed diligently with the performance
                of
                its duties as specified under the Contract and in accordance with
                the
                direction of the Agency's Division of
                Medicaid.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall have a Quality Improvement program that ensures
                enhancement of quality of care and emphasizes improving the quality
                of
                patient outcomes. The Agency may restrict the Health Plan’s Enrollment
                activities if the Health Plan does not meet acceptable Quality Improvement
                and performance indicators, based on HEDIS reports and other outcome
                measures to be determined by the Agency. Such restrictions may include,
                but shall not be limited to, the termination of Mandatory
                Assignments.

            

    

    

    
      	 	
              7.

            	
              The
                Health Plan must demonstrate that it has adequate knowledge of Medicaid
                programs, provision of health care services, medical claims data,
                and the
                capability to design and implement cost savings methodologies. The
                Health
                Plan must demonstrate the capacity for financial analyses, as necessary
                to
                fulfill the requirements of this Contract. Additionally, the Health
                Plan
                must meet all requirements for doing business in the State of
                Florida.

            

    

     

    
      	 	
              8.

            	
              The
                Health Plan may be required to provide to the Agency or its Agent
                information or data that is not specified under this Contract. In
                such
                instances, and at the direction of the Agency, the Health Plan shall
                fully
                cooperate with such requests and furnish all information in a timely
                manner, in the format in which it is requested. The Health Plan shall
                have
                at least thirty (30) Calendar Days to fulfill such ad
                hoc
                requests.

            

    

    

    
      	 	
              9.

            	
              The
                Health Plan shall fully cooperate with, and provide necessary data
                to, the
                Agency and its Agent for the design, management, operations and monitoring
                of the Enhanced Benefits Program.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan shall provide care management services and monitor utilization
                of services through the prior authorization of claims for Covered
                Services
                for its Enrollees.

            

    

    

    
      	 	
              11.

            	
              The
                Health Plans shall collect and submit Encounter Data for each Contract
                Year in the format required by the Agency and within the time frames
                specified by the Agency. An encounter guide along with technical
                assistance will be forthcoming. At a minimum the Health Plans shall
                be
                responsible for the following:

            

    

    

    
      	a.  	
              Health
                Plans shall collect and submit to the Agency or its designee, Enrollee
                service level encounter data for all Covered
                Services;

            

    

    

    
      	b.  	
              Encounter
                data shall be submitted following HIPAA standards, namely the ANSI
                X12N
                837 Transaction formats (P - Professional, I - Institutional, and
                D -
                Dental), and the National Council for Prescription Drug Programs
                NCPDP
                format (for Pharmacy services); and

            

    

    

    
      	 	
              c.

            	
              All
                Covered Services rendered to Enrollees shall result in the creation
                of an
                encounter record.

            

    

    

     

    

    

    REMAINDER
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    Section
      III

     

    Eligibility
      and Enrollment

     

    

    
      	
              A.

            	
              Eligibility

            

    

    

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

    

    
      	1.  	
              Eligible
                Populations 

            

    

    

    
      	 	
              a.

            	
              The
                categories of eligible Medicaid Recipients authorized to be enrolled
                in
                the Health Plan are: 

            

    

    

    
      	 	
              (1)

            	
              Low
                Income Families and Children;

            

    

    

    
      	 	
              (2)

            	
              Sixth
                Omnibus Budget Reconciliation Act (SOBRA)
                Children;

            

    

    

    
      	 	
              (3)

            	
              Supplemental
                Security Income (SSI) Medicaid
                Only;

            

    

    

    
      	 	
              (4)

            	
              SSI
                Medicare, Part B only;

            

    

    

    
      	 	
              (5)

            	
              SSI
                Medicare, Parts A and B;

            

    

    

    
      	 	
              (6)

            	
              Medicaid
                Recipients who are residents in ALFs and are not enrolled in an ALF
                waiver
                program;

            

    

    

    
      	 	
              (7)

            	
              Refugees;

            

    

    

    
      	 	
              (8)

            	
              The
                Meds AD population;

            

    

    

    
      	 	
              (9)

            	
              Individuals
                with Medicare coverage (e.g., dual eligible individuals) who are
                not
                enrolled in a Medicare Advantage Plan;

            

    

    

    
      	 	
              (10)

            	
              Title
                XXI MediKids are eligible for Enrollment in the Health Plan in accordance
                with Section 409.8132, F.S. Except as otherwise specified in this
                Contract, Title XXI MediKids eligible participants are entitled to
                the
                same conditions and services as currently eligible Title XIX Medicaid
                Recipients; and 

            

    

    

    
      	 	
              (11)

            	
              Women
                enrolled in the Health Plan who change eligibility categories to
                the SOBRA
                eligibility category due to pregnancy remain eligible for Enrollment
                in
                the Health Plan.

            

    

    

    
      	2.  	
              Ineligible
                Populations

            

    

    

    
      	 	 	
              a.

            	
              The
                following categories describe Medicaid Recipients who are not eligible
                to
                enroll in a Health Plan: 

            

    

    

    
      	 	
              (1)

            	
              Pregnant
                women who have not enrolled in Medicaid Reform prior to the effective
                date
                of their SOBRA eligibility;

            

    

    

    
      	 	
              (2)

            	
              Medicaid
                Recipients who, at the time of application for Enrollment and/or
                at the
                time of Enrollment, are domiciled or residing in an institution,
                including:

            

    

    

    (a) Nursing
      facilities (and have been CARES assessed); 

    

    (b) Sub-acute
      inpatient psychiatric (SIPP) facilities, 

    

    
      	 	
              (c)

            	
              Intermediate
                care facility for persons with developmental disabilities
                (ICF-DD);

            

    

    

    (d) State
      hospitals; or 

    

    (e) Correctional
      institutions.

    

    
      	 	
              (3)

            	
              Medicaid
                Recipients whose Medicaid eligibility was determined through the
                medically
                needy program.

            

    

    

    
      	 	
              (4)

            	
              Qualified
                Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries
                (SLMBs), or Qualified Individuals at Level 1
                (QI-1s);

            

    

    

    
      	 	
              (5)

            	
              Medicaid
                Recipients who have other creditable health-care coverage, such as
                TriCare
                or a private health maintenance organization
                (HMO);

            

    

    

    (6) Medicaid
      Recipients who reside in the following:

    

    
      	 	
              (a)

            	
              Residential
                commitment programs/facilities operated through the Department of
                Juvenile
                Justice (DJJ);

            

    

    

    
      	 	
              (b)

            	
              Residential
                group care operated by the Family Safety & Preservation Program of the
                DCF;

            

    

    

    
      	 	
              (c)

            	
              Children's
                residential treatment facilities purchased through the Substance
                Abuse
                & Mental Health District ("SAMH") Offices of the DCF (also referred
                to
                as Purchased Residential Treatment Services -
                "PRTS");

            

    

    

    
      	 	
              (d)

            	
              SAMH
                residential treatment facilities licensed as Level I and Level II
                facilities; and

            

    

    

    
      	 	
              (e)

            	
              Residential
                Level I and Level II substance abuse treatment programs. See
                Sections 65D-30.007(2)(a) and (b),
                F.A.C.

            

    

    

    
      	 	
              (7)

            	
              Medicaid
                Recipients participating in the Family Planning
                waiver;

            

    

    

    
      	 	
              (8)

            	
              Children/Adolescents
                with chronic conditions who are enrolled in Children’s Medical Services
                (CMS);

            

    

    

    
      	 	
              (9)

            	
              Women
                eligible for Medicaid due to breast and/or cervical
                cancer;

            

    

    

    
      	 	
              (10)

            	
              Individuals
                eligible under a hospice-related eligibility group;
                

            

    

    

    
      	 	
              (11)

            	
              Medicaid
                Recipients who are members of the Florida Assertive Community Treatment
                Team (FACT team);

            

    

    

    
      	 	
              (12)

            	
              Medicaid
                Recipients who are receiving services through a hospice program,
                the
                Medicaid AIDS waiver (Project AIDS Care) program, a prescribed pediatric
                extended care center;

            

    

    
      	 	
              (13)

            	
              Medicaid
                Recipients who are also members of a Medicare-funded health maintenance
                organization (HMO);

            

    

    

    
      	 	
              (14)

            	
              Medicaid
                Recipients whose Medicaid eligibility has been determined through
                the
                medically needy program; or

            

    

    

    
      	 	
              (15)

            	
              Family
                Planning waiver beneficiaries.

            

    

    

    
      	
              B.

            	
              Enrollment

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    
      	 	
              a.

            	
              Only
                Medicaid Recipients who are included in the eligible population and
                living
                in counties with authorized Health Plans are eligible to enroll and
                receive services from the Health
                Plan.

            

    

    

    
      	 	
              b.

            	
              The
                Agency or its Agent shall be responsible for Enrollment, including
                Enrollment into a Health Plan, Disenrollment, and outreach and education
                activities. The Health Plan shall coordinate with the Agency and
                its Agent
                as necessary for all Enrollment and Disenrollment
                functions.

            

    

    

    
      	 	
              c.
                

            	
              The
                Health Plan shall accept Medicaid Recipients without restriction
                and in
                the order in which they enroll. The Health Plan shall not discriminate
                against Medicaid Recipients on the basis of religion, gender, race,
                color,
                age, or national origin, and shall not use any policy or practice
                that has
                the effect of discriminating on the basis of religion, gender, race,
                color, or national origin, or on the basis of health, health status,
                pre-existing condition, or need for health care
                services.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall accept new Enrollees through-out the Contract period
                up
                to the authorized maximum enrollment levels approved in Attachment
                I.
                

            

    

    

    
      	2.  	
              Enrollment
                with a Primary Care Provider
                (PCP)

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall offer each Enrollee a choice of PCPs. After making
                a
                choice, each Enrollee shall have a single
                PCP.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall assign a PCP to those Enrollees who did not choose
                a PCP
                at the time of Health Plan selection. The Health Plan shall take
                into
                consideration the Enrollee's last PCP (if the PCP is known and available
                in the Health Plan's network), closest PCP to the Enrollee's home
                address,
                ZIP code location, keeping Children/Adolescents within the same family
                together, age (adults versus Children/Adolescents) and gender
                (OB/GYN).

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall provide written notice of the following via Surface
                Mail
                to the Enrollee, by the first day of the Enrollee’s enrollment or within
                five (5) Calendar Days following the availability of the Enrollment
                file
                from the Agency or its Agent, whichever is
                later:

            

    

    

    
      	 	
              (1)

            	
              The
                actual date of Enrollment, and the name, telephone number and address
                of
                the Enrollee’s PCP assignment;

            

    

    

    (2) The
      Enrollee's ability to choose a different PCP;

    

    
      	 	
              (3)

            	
              An
                explanation that a provider directory has been mailed separately
                with
                other member materials; and

            

    

    

    
      	 	
              (4)

            	
              The
                procedures for changing PCPs, including provision of the Health Plan’s
                toll-free member services telephone number,
                etc.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall permit Enrollees to change PCPs at any time.
                

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall assign all Enrollees that are reinstated after
                a
                temporary loss of eligibility to the PCP who was treating them prior
                to
                loss of eligibility, unless the Enrollee specifically requests another
                PCP, the PCP no longer participates in the Health Plan or is at capacity,
                or the Enrollee has changed geographic
                areas.

            

    

    

    
      	3.  	
              Newborn
                Enrollment

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall utilize the unborn activation process to facilitate
                enrollment and shall be responsible for newborns from the date they
                are
                enrolled in the Health Plan. 

            

    

    

    
      	 	
              b.

            	
              Upon
                unborn activation, the newborn shall be enrolled in the Health Plan
                in
                which his/her mother was enrolled during the next enrollment cycle.
                

            

    

    

    
      	 	
              c.

            	
              Newborn
                Enrollment shall occur through the following
                procedures:

            

    

    

    
      	 	
              (1)

            	
              Upon
                identification of an Enrollee's pregnancy, the Health Plan shall
                immediately notify DCF of the pregnancy and any relevant information
                known
                (i.e., due date and gender). The Health Plan must provide this
                notification by completing the DCF-ES 2039 Form and submitting the
                completed form to DCF. The Health Plan shall indicate its name and
                number
                as the entity initiating the referral. The DCF-ES 2039 form is located
                on
                the Medicaid web site: 

            

    

     

    http://www.fdhc.state.fl.us/Medicaid/Newborn

    

    
      	 	
              (2)

            	
              DCF
                will generate a Medicaid ID number and the unborn child will be added
                to
                the Medicaid file. This information will be transmitted to the Medicaid
                Fiscal Agent. The Medicaid ID number will remain inactive until after
                the
                child is born.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall comply with all requirements set forth by the Agency
                or
                its Agent related to Unborn Activation (see Policy Transmittal 06-02,
                Unborn Activation Process). To ensure the prompt enrollment of Newborns,
                the Health Plan shall ensure that the form DCF-ES 2039 (Form 2039)
                is
                completed and submitted, via electronic submission, to the local
                DCF
                Economic Self-Sufficiency Services Office immediately upon the birth
                of
                the child. If the Hospital is not a participating Hospital, the Health
                Plan must complete and transmit the Form 2039 to DCF. With regard
                to
                participating Hospitals, as part of its participating Hospital contract,
                the Health Plan must include a clause that states whether the Health
                Plan
                or the participating Hospital will complete and transmit Form 2039
                to DCF
                for all Newborns.

            

    

    

    
      	 	
              (4)

            	
              Upon
                notification that a pregnant Enrollee has presented to the Hospital
                for
                delivery, the Health Plan shall inform the Hospital, the pregnant
                Enrollee’s attending physician and the newborn’s attending and consulting
                physicians that the newborn is an Enrollee only if the Health Plan
                has
                verified that the newborn has an unborn record on the system that
                is
                awaiting activation. At this time the Health Plan shall initiate
                the
                Unborn Activation process.

            

    

    

    
      	 	
              (5)

            	
              Upon
                activation, the newborn shall be enrolled in the Health Plan in which
                his/her mother was enrolled during the month of birth.
                

            

    

    

    
      	4.  	
              Enrollment
                Cessation

            

    

    

    The
      Health Plan may request that the Agency halt or reduce Enrollment temporarily
      if
      continued full Enrollment would exceed its capacity to provide required services
      under the Contract. The
      Agency may also limit Health Plan Enrollments when such action is considered
      to
      be in the Agency's best interest in accordance with the provisions of this
      Contract. 

    

    5. Enrollment
      Notice

    

    By
      the
      first day of the Enrollee’s enrollment or within five (5) Calendar Days
      following receipt of the Enrollment file from Medicaid or its Agent, whichever
      is later,
      the
      Health Plan shall mail the
      following information to all new Enrollees:

    

    
      	 	
              a.

            	
              Notification
                that Enrollees can change their Health Plan selection, subject to
                Medicaid
                limitations.

            

    

    

    
      	 	
              b.

            	
              Enrollment
                materials regarding PCP choice as described in Section III.B., including
                the Provider Directory.

            

    

    

    c. New
      Enrollee Materials as described in Section IV.

    

    
      	
              C.

            	
              Disenrollment

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    
      	 	
              a.

            	
              If
                the Contract is renewed, the Enrollment status of all Enrollees shall
                continue uninterrupted.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall ensure that it does not restrict the Enrollee's
                right to
                disenroll voluntarily in any way. 

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan or its agents shall not provide or assist in the completion
                of
                a Disenrollment request or assist the Agency’s contracted Choice
                Counselor/Enrollment Broker in the Disesnrollment
                process.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall ensure that Enrollees that are disenrolled and
                wish to
                file an appeal have the opportunity to do so. All Enrollees shall
                be
                afforded the right to file an appeal except for the following reasons
                for
                Disenrollment: 

            

    

    

    
      	 	
              (1)

            	
              Moving
                out of the Service Area; 

            

    

    

    
      	 	
              (2)

            	
              Loss
                of Medicaid eligibility; and 

            

    

    

    
      	 	
              (3)

            	
              Enrollee
                death.

            

    

    

    
      	 	
              e.

            	
              An
                Enrollee may submit to the Agency or its Agent a request to disenroll
                from
                the Health Plan without Cause during the ninety (90) Calendar Day
                change
                period following the date of the Enrollee's initial Enrollment with
                the
                Health Plan, or the date the Agency or its Agent sends the Enrollee
                notice
                of the Enrollment, whichever is later. An Enrollee may request
                Disenrollment without Cause every twelve (12) months
                thereafter.

            

    

    

    
      	 	
              f.

            	
              The
                effective date of an approved Disenrollment shall be the last Calendar
                Day
                of the month in which Disenrollment was made effective by the Agency
                or
                its Agent, but in no case shall Disenrollment be later than the first
                (1st) Calendar Day of the second (2nd) month following the month
                in which
                the Enrollee or the Health Plan files the Disenrollment request.
                If the
                Agency or its Agent fails to make a Disenrollment determination within
                this timeframe, the Disenrollment is considered approved.
                

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall keep a daily written log or electronic documentation
                of
                all oral and written Enrollee Disenrollment requests and the disposition
                of such requests. The log shall include the following:
                

            

    

    

    
      	 	
              (1)

            	
              The
                date the request was received by the Health
                Plan;

            

    

    

    
      	 	
              (2)

            	
              The
                date the Enrollee was referred to the Agency's Choice Counselor/Enrollment
                Broker or the date of the letter advising the Enrollee of the
                Disenrollment procedure, as appropriate;
                and

            

    

    

    
      	 	
              (3)

            	
              The
                reason that the Enrollee is requesting
                Disenrollment.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan shall send to the Agency or its Agent a monthly summary
                report
                of all submitted Disenrollment requests. This report must specify
                the
                reason for such Disenrollment requests. It shall be reconciled to
                the
                Health Plan Enrollment Report processed by the Agency or its Agent
                for the
                applicable month and shall be reviewed by the Agency or its Agent
                for
                compliance with acceptable reasons for Disenrollment. The Agency
                may
                reinstate Enrollment for any Enrollee whose reason for Disenrollment
                is
                not consistent with established
                guidelines.

            

    

    

    
      	2.  	
              Cause
                for Disenrollment 

            

    

    

    
      	 	
              a.

            	
              An
                Enrollee may request Disenrollment from the Health Plan for Cause
                at any
                time. Such request shall be submitted to the Agency or its Agent.
                The
                following reasons constitute Cause for Disenrollment from the Health
                Plan:

            

    

    

    
      	 	
              (1)

            	
              The
                Enrollee moves out of the county, or the Enrollee’s address is incorrect
                and the Enrollee does not live in the
                county;

            

    

    

    
      	 	
              (2)

            	
              The
                Provider is no longer with the Health
                Plan;

            

    

    

    
      	 	
              (3)

            	
              The
                Enrollee is excluded from
                enrollment;

            

    

    

    
      	 	
              (4)

            	
              A
                substantiated marketing violation
                occurred;

            

    

    

    
      	 	
              (5)

            	
              The
                Enrollee is prevented from participating in the development of his/her
                treatment plan;

            

    

    

    
      	 	
              (6)

            	
              The
                Enrollee has an active relationship with a provider who is not on
                the
                Health Plan's network, but is in the network of another health
                plan;

            

    

    

    
      	 	
              (7)

            	
              The
                Enrollee is enrolled in the wrong Health Plan as determined by the
                Agency;

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan no longer participates in the
                county;

            

    

    

    
      	 	
              (9)

            	
              The
                State has imposed intermediate sanctions upon the Health Plan, as
                specified in 42 CFR 438.702(a)(3);

            

    

    

    
      	 	
              (10)

            	
              The
                Enrollee needs related services to be performed concurrently, but
                not all
                related services are available within the Health Plan network; or,
                the
                Enrollee's PCP has determined that receiving the services separately
                would
                subject the Enrollee to unnecessary
                risk;

            

    

    

    
      	 	
              (11)

            	
              The
                Health Plan does not, because of moral or religious objections, cover
                the
                service the Enrollee seeks;

            

    

    

    
      	 	
              (12)

            	
              The
                Enrollee missed his/her Open Enrollment due to a temporary loss of
                eligibility, defined as sixty (60) days or less;
                or

            

    

    

    
      	 	
              (13)

            	
              Other
                reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor
                quality of care; lack of access to services covered under the Contract;
                inordinate or inappropriate changes of PCPs; service access impairments
                due to significant changes in the geographic location of services;
                lack of
                access to Providers experienced in dealing with the Enrollee’s health care
                needs; or fraudulent Enrollment. 

            

    

    

    
      	3.  	
              Involuntary
                Disenrollment

            

    

    

    
      	 	
              a.

            	
              With
                proper written documentation, the following are acceptable reasons
                for
                which the Health Plan shall submit Involuntary Disenrollment requests
                to
                the Agency or its Choice Counselor/Enrollment Broker, as specified
                by the
                Agency:

            

    

    

    
      	 	
              (1)

            	
              Enrollee
                has moved out of the Service Area;

            

    

    

    
      	 	
              (2)

            	
              Enrollee
                death;

            

    

    

    
      	 	
              (3)

            	
              Determination
                that the Enrollee is ineligible for Enrollment based on the criteria
                specified in this Contract in Section III.A.3, Excluded Populations;
                and

            

    

    

    
      	 	
              (4)

            	
              Fraudulent
                use of the Enrollee ID card. 

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall promptly submit such Disenrollment requests to
                the
                Agency or its Choice Counselor/Enrollment Broker, as specified by
                the
                Agency. In no event shall the Health Plan submit the Disenrollment
                request
                at such a date as would cause the Disenrollment to be effective later
                than
                forty-five (45) Calendar Days after the Health Plan’s receipt of the
                reason for Involuntary Disenrollment. The Health Plan shall ensure
                that
                Involuntary Disenrollment documents are maintained in an identifiable
                Enrollee record.

            

    

    

    
      	 	
              c.

            	
              If
                the Health Plan submitted the Disenrollment request for one of the
                above
                reasons, the Health Plan shall verify that the information is
                accurate.

            

    

    

    
      	 	
              d.

            	
              If
                the Health Plan discovers that an ineligible Enrollee has been enrolled,
                then it shall request Disenrollment of the Enrollee and shall notify
                the
                Enrollee in writing that the Health Plan is requesting Disenrollment
                and
                the Enrollee will be disenrolled in the next Contract month, or earlier
                if
                necessary. Until the Enrollee is Disenrolled, the Health Plan shall
                be
                responsible for the provision of services to that
                Enrollee.

            

    

    

    
      	 	
              e.

            	
              On
                a monthly basis, the Health Plan shall review its ongoing Enrollment
                report (FLMR 8200-R0004) to ensure that all Enrollees are residing
                in the
                same county in which they were enrolled. The Health Plan shall update
                the
                records for all Enrollees who have moved from one county to another,
                but
                are still residing in the Health Plan’s Service Area, and provide the
                Enrollee with a new Provider Directory for that county. For Enrollees
                with
                out-of-county addresses on the Enrollment report, the Health Plan
                shall
                notify the Enrollee in writing that the Enrollee should contact the
                Choice
                Counselor/Enrollment Broker or Medicaid Options, depending on whether
                the
                Enrollee moves into a Reform or Non-Reform County, respectively,
                to choose
                another Health Plan, or other managed care option available in the
                Enrollee’s new county, and that the Enrollee will be Disenrolled as a
                result of the Enrollee's contact with the Choice Counselor/Enrollment
                Broker or Medicaid Options.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan may submit an Involuntary Disenrollment request to the
                Agency
                or its Choice Counselor/Enrollment Broker, as specified by the Agency,
                after providing to the Enrollee at least one (1) verbal warning and
                at
                least one (1) written warning of the full implications of his or
                her
                failure of actions:

            

    

    

    
      	 	
              (1)

            	
              For
                an Enrollee who continues not to comply with a recommended plan of
                health
                care. Such requests must be submitted at least sixty (60) Calendar
                Days
                prior to the requested effective
                date.

            

    

    

    
      	 	
              (2)

            	
              For
                an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
                to the extent that his or her Enrollment in the Health Plan seriously
                impairs the organization's ability to furnish services to either
                the
                Enrollee or other Enrollees. This Section does not apply to Enrollees
                with
                mental health diagnoses if the Enrollee’s behavior is attributable to the
                mental illness.

            

    

    

    
      	 	
              g.

            	
              The
                Agency may approve such requests provided that the Health Plan documents
                that attempts were made to educate the Enrollee regarding his/her
                rights
                and responsibilities, assistance which would enable the Enrollee
                to comply
                was offered through Case Management, and it has been determined that
                the
                Enrollee’s behavior is not related to the Enrollee’s medical or behavioral
                condition. All requests will be reviewed on a case-by-case basis
                and
                subject to the sole discretion of the Agency. Any request not approved
                is
                final and not subject to dispute or
                appeal.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan shall not request Disenrollment of an Enrollee due
                to:

            

    

    

    
      	(1)  	
              Health
                diagnosis;

            

    

    

    
      	(2)  	
              Adverse
                changes in an Enrollee’s health
                status;

            

    

    

    
      	(3)  	
              Utilization
                of medical services;

            

    

    

    
      	(4)  	
              Diminished
                mental capacity;

            

    

    

    
      	(5)  	
              Pre-existing
                medical condition;

            

    

    

    
      	(6)  	
              Uncooperative
                or disruptive behavior resulting from the Enrollee’s special needs (with
                the exception of C.4.f.2 above);

            

    

    

    
      	(7)  	
              Attempt
                to exercise rights under the Health Plan's Grievance System;
                or

            

    

    

    
      	(8)  	
              Request
                of one (1) PCP to have an Enrollee assigned to a different Provider
                out of
                the Health Plan.

            

    

    

    REMAINDER
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    Section
      IV

     

    Enrollee
      Services and Marketing

     

    

     

    
      	
              A.

            	
              Enrollee
                Services

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall have written policies and procedures for the provision
                of Enrollee Services, as specified in this Contract. Such policies
                and
                procedures shall be submitted to the Agency for
                approval.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall ensure that Enrollees are aware of their rights
                and
                responsibilities, the role of PCPs, how to obtain care, what to do
                in an
                emergency or urgent medical situation, how to request a Grievance,
                Appeal
                or Medicaid Fair Hearing, how to report suspected Fraud and Abuse,
                procedures for obtaining required Behavioral Health Services, including
                any additional Health Plan phone numbers to be used for obtaining
                services, and all other requirements and Benefits of the Health Plan.
                

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall have the capability to answer Enrollee inquiries
                via
                written materials, telephone, electronic transmission, and face-to-face
                communication.

            

    

    

    
      	 	
              d.

            	
              Mailing
                envelopes for Enrollee materials shall contain a request for address
                correction. For Enrollees whose Enrollee Materials are returned to
                the
                Health Plan as undeliverable, the Health Plan shall use and maintain
                in a
                file a record of all of the following methods to contact the Enrollee:
                

            

    

    

    
      	 	
              (1)

            	
              Telephone
                contact at the telephone number obtained from the local telephone
                directory, directory assistance, city directory, or other
                directory;

            

    

    

    
      	 	
              (2)

            	
              Telephone
                contact with DCF and Families Economic Self-Sufficiency Services
                Office
                staff to determine if they have updated address information and telephone
                number; and

            

    

    

    
      	 	
              (3)

            	
              Routine
                checks (at least once a month for the first three (3) months of
                Enrollment) on services or claims authorized or denied by the Health
                Plan
                to determine if the Enrollee has received services, and to locate
                updated
                address and telephone number
                information.

            

    

    

    
      	 	
              e.

            	
              New
                Enrollee materials are not required for a former Enrollee who was
                disenrolled because of the loss of Medicaid eligibility and who regains
                his/her eligibility within sixty (60) days and is automatically reinstated
                as a Health Plan Enrollee. In addition, unless requested by the Enrollee,
                new Enrollee materials are not required for a former Enrollee subject
                to
                Open Enrollment who was disenrolled because of the loss of Medicaid
                eligibility, who regains his/her eligibility within sixty (60) days
                of
                his/her managed care enrollment, and is reinstated as a Health Plan
                Enrollee. A notation of the effective date of the reinstatement on
                the
                most recent application or conspicuously in the Enrollee's administrative
                file. Enrollees, who were previously enrolled in a Health Plan, lose
                and
                regain eligibility after sixty (60) days, will be treated as new
                Enrollees.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall notify, in writing, each person who is to be reinstated,
                of the effective date of the reinstatement and the assigned Primary
                Care
                Provider. The notifications shall distinguish between Enrollees subject
                to
                Open Enrollment and Enrollees not subject to Open Enrollment and
                shall
                include information regarding change procedures for Cause, or general
                Health Plan change procedures through the Agency’s toll-free Choice
                Counselor/Enrollment Broker telephone number, as appropriate. The
                notification shall also instruct the Enrollee to contact the Health
                Plan
                if a new Enrollee card and/or a new Enrollee handbook are needed.
                The
                Health Plan shall provide such notice to each affected Enrollee by
                the
                first (1st) Calendar Day of the month following the Health Plan’s receipt
                of the notice of reinstatement.

            

    

    

    
      	2.  	
              Requirements
                for Written Materials

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall make all written materials available in alternative
                formats and in a manner that takes into consideration the Enrollee's
                special needs, including those who are visually impaired or have
                limited
                reading proficiency. The Health Plan shall notify all Enrollees and
                Potential Enrollees that information is available in alternative
                formats
                and how to access those formats.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall make all written material available in English,
                Spanish,
                and all other appropriate foreign languages. The appropriate foreign
                languages comprise all languages in the Health Plan Service Area
                spoken by
                approximately five percent (5%) or more of the total population.
                The
                Health Plan shall provide, free of charge, interpreters for Potential
                Enrollees or Enrollees whose primary language is a foreign
                language.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall provide Enrollee information in accordance with
                42 CFR
                438.10, which addresses information requirements related to written
                and
                oral information provided to Enrollees, including: languages, format,
                Health Plan features such as benefits, Service Area, Provider network
                and
                physician incentive plans, Enrollment and Disenrollment rights and
                responsibilities, the Grievance System, Advance Directives. The Health
                Plan shall notify Enrollees on at least an annual basis of their
                right to
                request and obtain information in accordance with the above
                regulations.

            

    

    

    
      	 	
              d.

            	
              All
                written materials shall be at or near the fourth (4th)
                grade comprehension level. Suggested reference materials to determine
                whether the Health Plan’s written materials meet this requirement
                are:

            

    

    

    
      	 	
              (1)

            	
              Fry
                Readability Index;

            

    

    

    
      	 	
              (2)

            	
              PROSE
                The Readability Analyst (software developed by Education Activities,
                Inc.);

            

    

    

    
      	 	
              (3)

            	
              Gunning
                FOG Index;

            

    

    

    
      	 	
              (4)

            	
              McLaughlin
                SMOG Index;

            

    

    

    
      	 	
              (5)

            	
              The
                Flesch-Kincaid Index; or

            

    

    

    
      	 	
              (6)

            	
              Other
                software approved by the Agency.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall provide written notice to the Agency of any changes
                to
                any written materials provided to Enrollees. Written materials shall
                be
                provided to the Agency at least forty-five (45) Calendar Days prior
                to the
                effective date of the change. Written notice of such changes shall
                be
                provided to Enrollees at least thirty (30) days prior to the effective
                date of the change.

            

    

    

    
      	 	
              f.

            	
              All
                written materials, including any materials for the Health Plan Web
                site,
                shall be submitted to the Agency for written approval prior to being
                distributed.

            

    

    

    
      	3.  	
              New
                Enrollee Materials 

            

    

    

    
      	 	
              a.

            	
              By
                the first day of the assigned Enrollee’s Enrollment or within five (5)
                Calendar Days following receipt of the Enrollment file from Medicaid
                or
                its Agent, whichever is later,
                the Health Plan shall mail to the new Enrollee the Enrollee Handbook,
                the
                Provider Directory, the Enrollee Identification and the following
                additional materials:

            

    

    

    
      	 	
              (1)

            	
              A
                request for the following information to be updated: Enrollee’s name,
                address (home and mailing), county of residence, and telephone number;
                

            

    

    

    
      	 	
              (2)

            	
              A
                completed, signed and dated release form authorizing the Health Plan
                to
                release medical information to the federal and State governments
                or their
                duly appointed agents; and, current behavioral health care provider
                information;

            

    

    

    
      	 	
              (3)

            	
              A
                notice that Enrollees who lose eligibility and are disenrolled shall
                be
                automatically re-Enrolled in the Health Plan if eligibility is regained
                within 180 days;

            

    

    

    
      	 	
              (4)

            	
              Each
                mailing shall include a postage paid, pre-addressed return envelope;
                and
                

            

    

    

    
      	 	
              (5)

            	
              The
                initial mailing may be combined with the PCP assignment notification.
                The
                Health Plan shall document each mailing in the Health Plan’s
                records.

            

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      	4.  	
              Enrollee
                Handbook Requirements 

            

    

    

    
      	 	
              a.

            	
              The
                Enrollee services handbook shall include the following information:
                

            

    

    

    
      	 	
              (1)

            	
              Table
                of Contents;

            

    

    

    
      	 	
              (2)

            	
              Terms
                and conditions of Enrollment including the reinstatement process;
                

            

    

    

    
      	 	
              (3)

            	
              Description
                of the Open Enrollment process;

            

    

    

    
      	 	
              (4)

            	
              Description
                of services provided, including limitations and general restrictions
                on
                Provider access, exclusions and out-of-network use;
                

            

    

    

    
      	 	
              (5)

            	
              Procedures
                for obtaining required services, including second opinions, and
                authorization requirements, including those services available without
                Prior Authorization; 

            

    

    

    
      	 	
              (6)

            	
              Toll-free
                telephone number of the appropriate Area Medicaid Office;
                

            

    

    

    
      	 	
              (7)

            	
              Emergency
                Services and procedures for obtaining services both in and out of
                the
                Health Plan’s Service Area, including, an explanation that Prior
                Authorization is not required for Emergency Services, the locations
                of any
                emergency settings and other locations at which Providers and Hospitals
                furnish Emergency Services and Post-Stabilization Care Services and
                use of
                the 911 telephone system, or its equivalent;

            

    

    

    
      	 	
              (8)

            	
              The
                extent to which, and how, after-hours and emergency coverage is provided,
                and that the Enrollee has a right to use any Hospital or other setting
                for
                Emergency Care;

            

    

    

    
      	 	
              (9)

            	
              Procedures
                for Enrollment, including Enrollee rights and protections;
                

            

    

    

    
      	 	
              (10)

            	
              A
                notice advising Enrollees how to change PCPs;

            

    

    

    
      	 	
              (11)

            	
              Grievance
                System components and procedures; 

            

    

    

    
      	 	
              (12)

            	
              Enrollee
                rights and procedures for Disenrollment, including the toll-free
                telephone
                number for the Agency’s contracted Choice Counselor/Enrollment Broker;
                

            

    

    

    
      	 	
              (13)

            	
              Procedures
                for filing a request for Disenrollment for Cause;
                

            

    

    

    
      	 	
              (14)

            	
              Information
                regarding Newborn enrollment, including the mother’s responsibility to
                notify the Health Plan and the mother’s DCF case worker of the Newborn’s
                birth and selection of a PCP; 

            

    

    

    
      	 	
              (15)

            	
              Enrollee
                rights and responsibilities, including the extent to which, and how,
                Enrollees may obtain services from out-of-network providers and the
                right
                to obtain family planning services from any participating Medicaid
                provider without Prior Authorization for such services, and other
                provisions in accordance with 42 CFR 438.100;

            

    

    

    
      	 	
              (16)

            	
              Information
                on emergency transportation and non-emergency transportation, counseling
                and referral services available under the Health Plan, and how to
                access
                these services; 

            

    

    

    
      	 	
              (17)

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

            

    

    

    
      	 	
              (18)

            	
              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); 

            

    

    

    
      	 	
              (19)

            	
              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;
                

            

    

    

    
      	 	
              (20)

            	
              Information
                regarding health care Advance Directives pursuant to Chapter 765,
                F.S.,
                and 42 CFR 422.128; 

            

    

    

    
      	 	
              (21)

            	
              Cost
                sharing for the Enrollee, if any; 

            

    

    

    
      	 	
              (22)

            	
              Instructions
                explaining how Enrollees may obtain information from the Health Plan
                regarding quality performance indicators, including Enrollee information;
                

            

    

    

    
      	 	
              (23)

            	
              How
                and where to access any benefits that are available under the State
                Plan,
                but not covered under the Contract, including cost
                sharing;

            

    

    

    
      	 	
              (24)

            	
              Any
                restrictions on the Enrollee's freedom of choice among network Providers;
                

            

    

    

    
      	 	
              (25)

            	
              A
                release document for each Enrollee authorizing the Health Plan to
                release
                medical information to the federal and State governments or their
                duly
                appointed Agents;

            

    

    

    
      	 	
              (26)

            	
              A
                notice that clearly states that the Enrollee may select an alternative
                Behavioral Health Care Case Manager or direct service provider within
                the
                Health Plan, if one is available;

            

    

    

    
      	 	
              (27)

            	
              A
                description of Behavioral Health Services provided, including limitations,
                exclusions and out-of-network use;

            

    

    

    
      	 	
              (28)

            	
              An
                explanation that Enrollees may choose to have all family members
                served by
                the same PCP or they may choose different PCPs;

            

    

    

    
      	 	
              (29)

            	
              A
                description of Emergency Behavioral Health Services procedures both
                in and
                out of the Health Plan's Service Area;

            

    

    

    
      	 	
              (30)

            	
              Information
                to assist the Enrollee in assessing a potential behavioral health
                problem;

            

    

    

    
      	 	
              (31)
                

            	
              Procedures
                for reporting Fraud, Abuse and Overpayment;
                and

            

    

    

    
      	 	
              (32)

            	
              Information
                regarding HIPAA relative to the Enrollee’s personal health information
                (PHI). 

            

    

    

    
      	 	
              b.

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

            

    

    

    
      	 	
              c.

            	
              Written
                information regarding Advance Directives provided by the Health Plan
                must
                reflect changes in State law as soon as possible, but no later than
                ninety
                (90) days after the effective date of the
                change.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan, in its Enrollee handbook and provider manual, shall
                clearly
                specify required procedural steps in the Grievance Procedure, including
                the address, telephone number and office hours of the Grievance staff.
                The
                Health Plan shall specify phone numbers for a grievant to call to
                present
                a Grievance or to contact the Grievance staff. Each phone number
                shall be
                toll-free within the grievant’s geographic area and provide reasonable
                access to the Health Plan without undue delays. The Grievance System
                must
                provide an adequate number of phone lines to handle incoming Grievances
                and Appeals.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall make information available upon request regarding
                the
                structure and operation of the Health Plan and any physician incentive
                plans, as set forth in 42 CFR
                438.10(g)(3).

            

    

    

    
      	5.  	
              Provider
                Directory

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall mail a Provider Directory to all new Enrollees,
                including Enrollees who reenrolled after the Open Enrollment period.
                The
                Health Plan shall provide the most recently printed Provider Directory
                and
                include an addendum listing those physicians, etc., no longer providing
                services to Enrollees of the Health Plan and those physicians, etc.,
                that
                have entered into an agreement to provide services to Enrollees of
                the
                Health Plan since the Health Plan published the most recently printed
                Provider Directory. In lieu of the Provider Directory addendum, the
                Health
                Plan may enclose a letter, in Times New Roman font, and at the
                fourth-grade reading level (as is required of all documents mailed
                to
                Enrollees) stating that the most recent listing of Providers is available
                by calling the Health Plan at its toll-free telephone number and
                at the
                Health Plan's website and provide the Internet address that will
                take the
                Enrollee directly to the online Provider Directory, without having
                to go
                to the Health Plan's home page or any other website as a prerequisite
                to
                viewing the online Provider Directory. The Health Plan must obtain
                the
                Agency's prior written approval of the
                letter.

            

    

    

    
      	 	
              b.

            	
              The
                Provider Directory shall include the names, locations, office hours,
                telephone numbers of, and non-English languages spoken by, current
                Health
                Plan Providers. The Provider Directory shall include, at a minimum,
                information relating to PCPs, specialists, pharmacies, hospitals,
                certified nurse midwives and licensed midwives, and Ancillary Providers.
                The Provider Directory shall also identify Providers that are not
                accepting new patients.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall maintain an online Provider Directory. The Health
                Plan
                shall update the online Provider Directory on, at least, a monthly
                basis.
                The Health Plan shall file an attestation to this effect with the
                Bureau
                of Managed Health Care and the Bureau of Health Systems
                Development.

            

    

    

    
      	 	
              d.

            	
              If
                the Health Plan elects to use a more restrictive pharmacy network
                than the
                network available to Medicaid Recipients enrolled in the Medicaid
                FFS
                program, then the Provider Directory must include the names of the
                participating pharmacies. If all pharmacies are part of a chain and
                are
                within the Health Plan's Service Area under contract with the Health
                Plan,
                the Provider Directory need only list the chain
                name.

            

    

    

    
      	 	
              e.

            	
              In
                accordance with section 1932(b)(3) of the Social Security Act, the
                Provider Directory shall include a statement that some Providers
                may not
                perform certain services based on religious or moral
                beliefs.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall arrange the Provider Directory as follows:
                

            

    

    

    
      	 	
              (1)

            	
              Providers
                are listed in alphabetical order, showing the Provider's name and
                specialty; 

            

    

    

    
      	 	
              (2)

            	
              Providers
                are listed by specialty, in alphabetical order;
                and

            

    

    

    
      	 	
              (3)

            	
              Behavioral
                Health Providers are listed by provider
                type.

            

    

    

    
      	6.  	
              Enrollee
                ID Card

            

    

    

    
      	 	
              a.

            	
              Immediately
                upon the Enrollee’s enrollment with the Health Plan, the Health Plan shall
                mail, via Surface Mail, an Enrollee Identification (ID) Card. The
                Enrollee
                ID Card shall include, at a
                minimum:

            

    

    

    
      	 	
              (1)

            	
              The
                Enrollee's name and Medicaid ID
                number;

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's name, address and Enrollee services number;
                and

            

    

    

    
      	 	
              (3)

            	
              A
                telephone number that a non-contracted provider may call for billing
                information.

            

    

    

    
      	7.  	
              Toll-Free
                Help Line

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall operate a toll-free telephone help line. Such help
                line
                shall respond to all areas of Enrollee
                inquiry.

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan has authorization requirements for prescribed drug
                services and is subject to the Hernandez Settlement Agreement (HSA),
                the
                Health Plan may allow the telephone help line staff to act as Hernandez
                Ombudsman, pursuant to the terms of the HSA, so long as the Health
                Plan
                maintains a Hernandez Ombudsman Log. The Health Plan may maintain
                the
                Hernandez Ombudsman Log as part of the Health Plan’s telephone help line
                log, so long as the Health Plan can access the Hernandez Ombudsman
                Log
                information separately for reporting purposes. The log shall contain
                information as described in Section V.D.13, Prescribed Drug
                Services.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall have telephone call policies and procedures that
                shall
                include requirements for staffing, personnel, hours of operation,
                call
                response times, maximum hold times, and maximum abandonment rates,
                monitoring of calls via recording or other means, and compliance
                with
                standards. 

            

    

    

    
      	 	
              d.

            	
              The
                telephone helpline shall handle calls from non-English speaking Enrollees,
                as well as calls from Enrollees who are hearing impaired.
                

            

    

    

    
      	 	
              e.

            	
              The
                telephone help line shall be fully staffed between the hours of 8:00
                a.m.
                and 7:00 p.m., EDT or EST, as appropriate, Monday through Friday,
                excluding State holidays. The telephone help line staff shall be
                trained
                to respond to Enrollee questions in all areas, including but not
                limited
                to, Covered Services, the Provider network, and non-emergency
                transportation. 

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall develop performance standards and monitor telephone
                help
                line performance by recording calls and employing other monitoring
                activities. Such standards shall be submitted and approved by the
                Agency.
                At a minimum, the standards shall require that, measured on a monthly
                basis: 

            

    

    

    
      	 	
              (1)

            	
              One
                hundred percent (100%) of all calls are answered within four (4)
                rings
                (these calls may be placed in a
                queue);

            

    

    

    
      	 	
              (2)

            	
              The
                wait time in the queue shall not exceed three (3)
                minutes;

            

    

    

    
      	 	
              (3)

            	
              The
                Blocked Call rate does not exceed one percent (1%); and
                

            

    

    

    
      	 	
              (4)

            	
              The
                rate of Abandoned Calls does not exceed five percent (5%).
                

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall have an automated system available between the
                hours of
                8:00 p.m. and 7:00 a.m., EDT or EST, as appropriate, Monday through
                Friday
                and at all hours on weekends and holidays. This automated system
                must
                provide callers with operating instructions on what to do in case
                of an
                emergency and shall include, at a minimum, a voice mailbox for callers
                to
                leave messages. The Health Plan shall ensure that the voice mailbox
                has
                adequate capacity to receive all messages. A Health Plan Representative
                shall return all messages on the next Business
                Day.

            

    

    

    
      	8.  	
              Cultural
                Competency

            

    

    

    
      	 	
              a.

            	
              In
                accordance with 42 CFR 438.206, the Health Plan shall have a comprehensive
                written Cultural Competency Plan describing how the Health Plan will
                ensure that services are provided in a culturally competent manner
                to all
                Enrollees, including those with limited English proficiency. The
                Cultural
                Competency Plan must describe how the Providers, Health Plan employees,
                and systems will effectively provide services to people of all cultures,
                races, ethnic backgrounds, and religions in a manner that recognizes,
                values, affirms, and respects the worth of the individual Enrollees
                and
                protects and preserves the dignity of each
                Enrollee.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan may distribute a summary of the Cultural Competency Plan
                to
                network Providers if the summary includes information on how the
                Provider
                may access the full Cultural Competency Plan on the Health Plan’s website.
                This summary shall also detail how the Provider can request a hard-copy
                from the Health Plan at no charge to the
                Provider.

            

    

    

    
      	9.  	
              Translation
                Services

            

    

    

    The
      Health Plan is required to provide oral translation services of information
      to
      any Enrollee who speaks any non-English language regardless of whether an
      Enrollee speaks a language that meets the threshold of a prevalent non-English
      language. The Health Plan is required to notify its Enrollees of the
      availability of oral interpretation services and to inform them of how to access
      oral interpretation services. There shall be no charge to the Enrollee for
      translation services.

    

    
      	
              B.

            	
              Marketing

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    
      	 	
              a.

            	
              For
                each new Contract period, the Health Plan shall submit to the Agency
                for
                written approval, pursuant to Section 409.912, F.S., its Marketing
                plan
                and all Marketing and Request for Benefit Information (RBI) materials
                no
                later than sixty (60) Calendar Days prior to Contract renewal, and
                for any
                changes in Marketing and RBI materials during the re-contracting
                and
                renewal period, no later than sixty (60) Calendar Days prior to
                implementation. The Marketing materials shall be distributed in the
                Health
                Plan’s entire Service Area in accordance with Section 4707 of the Balanced
                Budget Act of 1997 (BBA).

            

    

    

    
      	 	
              b.

            	
              Marketing
                materials include, but are not limited to, all solicitation materials,
                forms, brochures, fact sheets, posters, lectures, Medicaid recruitment
                materials and presentations, Request for Benefit Information forms
                (previously known as pre-enrollment applications),
                etc.

            

    

    

    
      	 	
              c.

            	
              To
                announce a specific event, the Health Plan shall submit a request
                to
                market pursuant to Section IV.B.4, Approval Process, of this Contract,
                and
                shall include the announcement of the event that will be given out
                to the
                public.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall be responsible for developing and implementing
                a written
                plan designed to solicit Enrollment from Potential Enrollees and
                to
                control the actions of its Marketing staff. All of the Marketing
                policies
                set forth in this Contract apply to staff, Subcontractors, Health
                Plan
                volunteers and all persons acting for, or on behalf of, the Health
                Plan.
                All materials developed shall be governed by the requirements set
                forth in
                this Section. Additionally, the Health Plan is vicariously liable
                for any
                Marketing violations of its employees, agents or
                Subcontractors.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall limit its Market Area to residents of the Service
                Area
                and shall not market to residents of a Service Area not approved
                by the
                Agency.

            

    

    

    
      	2.  	
              Prohibited
                Activities

            

    

     

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

            	
              In
                accordance with Sections 409.912 and 409.91211, F.S., practices that
                are
                discriminatory, including, but not limited to, attempts to discourage
                Enrollment or reenrollment on the basis of actual or perceived health
                status;

            

    

    

    
      	 	
              (2)

            	
              Direct
                or indirect Cold Call Marketing for solicitation of Medicaid Recipients,
                either by door-to-door, telephone or other means, in accordance with
                Section 4707 of the Balanced Budget Act of 1997, and section 409.912,
                F.S.
                

            

    

    

    
      	 	
              (3)

            	
              Overly
                aggressive solicitation, such as repeated telephoning, continued
                recruitment after an offer for Enrollment is declined by a Medicaid
                Recipient, or similar techniques. Health Plan representatives shall
                not
                directly solicit Potential Enrollees for the purpose of enrolling
                in the
                Health Plan, except as provided in Section IV.B.3., Permitted Activities.
                

            

    

    

    
      	 	
              (4)

            	
              In
                accordance with Section 409.912, F.S., activities that could mislead
                or
                confuse Medicaid Recipients or Potential Enrollees, or misrepresent
                the
                Health Plan, its Marketing Representatives, or the Agency. No fraudulent,
                misleading, or misrepresentative information shall be used in Marketing,
                including information regarding other governmental programs. Statements
                that could mislead or confuse include, but are not limited to, any
                assertion, statement or claim (whether written or oral)
                that:

            

    

    

    
      	 	
              (a)

            	
              The
                Medicaid Recipient must enroll in the Health Plan in order to obtain
                Medicaid, or in order to avoid losing Medicaid benefits;
                

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan is endorsed by any federal, State or county government,
                the
                Agency, or CMS, or any other organization which has not certified
                its
                endorsement in writing to the Health
                Plan;

            

    

    

    
      	 	
              (c)

            	
              Marketing
                Representatives are employees or representatives of the federal,
                State or
                county government, or of anyone other than the Health Plan or the
                organization by whom they are
                reimbursed;

            

    

    

    
      	 	
              (d)

            	
              The
                State or county recommends that a Medicaid Recipient enroll with
                the
                Health Plan; and/or

            

    

    

    
      	 	
              (e)

            	
              A
                Medicaid Recipient will lose benefits under the Medicaid program
                or any
                other health or welfare benefits to which the Recipient is legally
                entitled, if the Medicaid Recipient does not enroll with the Health
                Plan.

            

    

    

    
      	 	
              (5)

            	
              In
                accordance with section 409.912, F.S., granting or offering of any
                monetary or other valuable consideration for Enrollment, except as
                authorized by Section 409.912,
                F.S.;

            

    

    

    
      	 	
              (6)

            	
              Offers
                of insurance, such as but not limited to, accidental death, dismemberment,
                disability or life insurance;

            

    

    

    
      	 	
              (7)

            	
              Enlisting
                the assistance of any employee, officer, elected official or agent
                of the
                State in recruitment of Medicaid Recipients, except as authorized
                in
                writing by the Agency;

            

    

    

    
      	 	
              (8)

            	
              Offers
                of material or financial gain to any persons soliciting, referring
                or
                otherwise facilitating Medicaid Recipient Enrollment, except for
                authorized licensed Marketing Representatives. The Health Plan shall
                ensure that only licensed Marketing Representatives market the Health
                Plan
                to Medicaid Recipients;

            

    

    

    
      	 	
              (9)

            	
              Giving
                away promotional items in excess of one dollar ($1.00) retail value
                to
                attract attention. Items to be given away shall bear the Health Plan's
                name and shall only be given away at Health Fairs or other general
                Public
                Events. In addition, such promotional items must be offered to the
                general
                public and shall not be limited to Medicaid Recipients who indicate
                they
                will enroll in the Health Plan;

            

    

    

    
      	 	
              (10)

            	
              In
                accordance with Section 409.912, F.S., Marketing to Medicaid Recipients
                in
                State offices unless approved in writing and approved by the affected
                State Agency when solicitation occurs in the office of another State
                Agency. The Agency shall ensure that Marketing Representatives stationed
                in State offices market to Medicaid Recipients only in designated
                areas
                and in such a way as to not interfere with the Medicaid Recipients'
                activities in the State office. The Health Plan shall not use any
                other
                State facility, program, or procedure in the recruitment of Medicaid
                Recipients except as authorized in writing by the Agency. Request
                for
                approval of activities at State offices must be submitted to the
                Agency at
                least thirty (30) Calendar Days prior to the
                activity;

            

    

    

    
      	 	
              (11)

            	
              Marketing
                face-to-face to assigned Enrollees or Medicaid Recipients unless
                the
                Enrollee or Recipient contacts the Health Plan and requests information.
                Upon such request the Health Plan shall notify the Choice
                Counselor/Enrollment Broker of such request, and the Health Plan
                shall
                keep documentation of such contacts and visits in the Enrollee’s file;
                

            

    

    

    
      	 	
              (12)

            	
              Providing
                any gift, commission, or any form of compensation to the Choice
                Counselor/Enrollment Broker, including the Choice Counselor/Enrollment
                Broker's full-time, part-time or temporary employees and Subcontractors;
                

            

    

    

    
      	 	
              (13)

            	
              The
                Health Plan shall not market, prior to the Enrollment, the incentives
                that
                shall be offered to the Enrollee as described in Section VIII.B.7.,
                Incentive Programs. Marketing representatives may describe the programs
                (not the incentives) that shall be offered (e.g., prenatal classes).
                The
                Health Plan may inform Enrollees once they are actually enrolled
                in the
                Health Plan about the specific incentives available;
                or

            

    

    

    
      	 	
              (14)

            	
              All
                activities included in section 641.3903, F.S.

            

    

    

    
      	3.  	
              Permitted
                Activities

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan may engage in the following activities under the supervision
                and with the written approval of the Agency:

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan upon written approval of the Agency, may have a marketer
                in
                Provider offices as long as the Provider approves and the marketer
                provides information to the Potential Enrollee only upon request.
                In
                addition, the Health Plan and the Provider shall not require the
                Potential
                Enrollee to visit the marketer, nor shall the marketer approach the
                Potential Enrollee. No Sales Activities shall be allowed in Provider
                offices. 

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan may leave Agency approved referral cards in Provider
                offices,
                at Public Events and Health Fairs. These cards may be completed by
                Potential Enrollees and delivered to the Health Plan or turned in
                at the
                Provider office. Information on the card is limited to the name,
                address
                and telephone number of the Potential Enrollee and space for signature.
                A
                space to note a contact time may be provided. A follow up visit to
                the
                Potential Enrollee’s home may not occur prior to the referral being logged
                by the Health Plan’s regional or headquarters Enrollee services office.
                Twenty-four (24) hours or the next Business Day shall elapse after
                the
                request is logged before the home visit may
                occur.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan may market at State offices, Health Fairs and Public
                Events
                and contact thereafter, in person, Potential Enrollees who request
                further
                information about the Health Plan, in accordance with Section 4707
                of the
                BBA. The Health Plan shall submit, for review and approval by the
                Agency,
                its intent to market at Health Fairs and Public Events at least two
                (2)
                weeks prior to the event. The Health Plan shall obtain complete disclosure
                of information, in a format to be approved by the Agency, from each
                organization participating in a Health Fair or Public Event prior
                to the
                event. The information disclosure is only required when the Health
                Plan is
                the primary organizer of the Health Fair or Public Event. If the
                Health
                Plan has been invited by a community organization to be a sponsor
                of an
                event, the Health Plan shall provide the Agency with a copy of the
                invitation in lieu of the information disclosure. All disclosure
                information shall be sent to the Agency with the Health Plan’s request for
                approval of the event.

            

    

    

    
      	 	
              (4)

            	
              The
                main purpose of a Health Fair or a Public Event shall not be Medicaid
                Health Plan marketing, but Medicaid Health Plan marketing may be
                provided
                at these events, subject to Agency rules and
                oversight.

            

    

    

    
      	 	
              (5)

            	
              Upon
                the effective date of Enrollment, Health Plan marketing staff or
                other
                Health Plan staff may visit Enrollees in order to obtain completed
                new
                Enrollee materials. All such visits must be documented in the Enrollee's
                file.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan may leave Agency approved written materials (brochures
                or
                posters, etc.) in Provider Offices, at Public Events, and at Health
                Fairs.

            

    

    

    
      	 	
              (7)

            	
              Marketing
                face-to-face to Potential Enrollees may be allowed if the Potential
                Enrollee contacts the Health Plan’s headquarters or regional Enrollee
                services office directly to request a home visit. The Health Plan
                shall
                not allow the visit to the Potential Enrollee’s home to occur before the
                next Business Day or twenty-four (24) hours have elapsed since the
                request
                for the visit. The Health Plan must be able to provide evidence to
                the
                Agency that the twenty-four (24) hour or next Business Day requirement
                has
                been met. The Health Plan will be required, upon request by the Agency,
                to
                provide a log that shows how initial contact with the Potential Enrollee
                was made. Only Agency registered Marketing Representatives shall
                be
                allowed to make home visits. Each Health Plan shall make available
                to the
                Agency, as requested, a report of the number of home visits made
                by each
                Agency registered Marketing Representative to Potential Enrollee’s
                homes.

            

    

    

    
      	4.  	
              Approval
                Process

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall submit a detailed description of its Marketing
                plan and
                copies of all Marketing materials, the Health Plan or its Subcontractors’
                plan to distribute, to the Agency for prior approval. This requirement
                includes, but is not limited to: posters, brochures, websites, and
                any
                materials that contain statements regarding the Health Plan’s Covered
                Services and Provider network-related materials. Neither the Health
                Plan
                nor its Subcontractors shall distribute any Marketing materials without
                prior written approval from the
                Agency.

            

    

    

    
      	 	
              b.

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

            

    

    

    
      	 	
              (1)

            	
              A
                Health Plan shall submit its bi-monthly Marketing schedule to the
                Agency,
                two (2) weeks in advance of each month. The Marketing Schedule may
                be
                revised if a Health Plan provides notice to the Agency one (1) week
                prior
                to the Public Event or the Health Fair. The Agency may expedite this
                process as needed.

            

    

    

    
      	 	
              (2)

            	
              The
                Agency will approve or deny the Health Plan's bi-monthly Marketing
                schedule and revision request no later than five (5) Business Days
                from
                receipt of the schedule and/or revision request.
                

            

    

    

    
      	 	
              (3)

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

            

    

    

    
      	 	
              (4)

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

            

    

    

    
      	 	
              (5)

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

            

    

    

    
      	5.  	
              Provider
                Compliance

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall ensure its health care Providers comply with the
                following Marketing requirements:

            

    

    

    
      	 	
              (1)

            	
              Health
                care Providers may give out Health Plan brochures at Health Fairs
                or in
                their own offices comparing the Benefits of different Health Plans
                with
                which they contract. However, they cannot orally compare Benefits
                among
                Health Plans, unless Marketing Representatives from each Health Plan
                are
                present.

            

    

    

    
      	 	
              (2)

            	
              Health
                care Providers may co-sponsor events, such as Health Fairs and
                cooperatively market and advertise with the Health Plan in indirect
                ways;
                such as television, radio, posters, fliers, and print
                advertisement.

            

    

    

    
      	 	
              (3)

            	
              Health
                care Providers may announce a new affiliation with a Health Plan
                or give a
                list of Health Plans with which they contract to their
                patients.

            

    

    

    
      	 	
              (4)

            	
              Health
                care Providers shall not furnish lists of their Medicaid Recipients
                to
                Health Plans with which they contract, or any other entity, nor can
                Providers furnish other Health Plans' membership lists to any Health
                Plan,
                nor can Providers take applications in their
                offices.

            

    

    

    
      	6.  	
              Marketing
                Representatives

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall not Subcontract with any brokerage firm or independent
                agent for purposes of Marketing.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall be required to register each Marketing Representative
                with the Agency. The registration shall consist of providing the
                Agency
                with the representative's name, address, telephone number, cellular
                telephone number, DFS license number, the names of all Medicaid health
                plans with which the Marketing Representative was previously employed,
                and
                the name of the Medicaid health plan with which the Marketing
                Representative is presently employed.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall provide the Agency, on a monthly basis, information
                on
                terminations of all Marketing Representatives. The Health Plan shall
                maintain and make available to the Agency upon request evidence of
                current
                licensure and contractual agreements with all Marketing Representatives
                used by the Health Plan to recruit Medicaid Recipients.
                

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall report to DFS and the Agency any Marketing
                Representative who violates any requirements of this Contract, within
                fifteen (15) Calendar Days of knowledge of such
                violation.

            

    

    

    
      	 	
              e.

            	
              While
                Marketing, Marketing Representatives shall wear picture identification
                that includes their DFS license number and identifies the Health
                Plan
                represented.

            

    

    

    
      	 	
              f.

            	
              The
                Marketing Representative shall inform the Medicaid Recipient that
                the
                Representative is not an employee of the State and is not a Choice
                Counseling Specialist, but is a Representative of the Health
                Plan.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall not pay commission compensation, or shall recoup
                commissions paid, to Marketing Representatives for new Enrollees
                whose
                voluntary Disenrollment is effective within the first (1st) three
                (3)
                months of their initial Enrollment, unless the Disenrollment is due
                to the
                Enrollee moving out of the county in which the Health Plan has been
                authorized to operate. In addition, the Health Plan shall not pay
                commission compensation, or shall recoup commission paid, to Marketing
                Representatives for excluded Medicaid Recipients, per Section III.A.2,
                Ineligible Populations, who were enrolled in error. A Marketing
                Representative's total monthly commission cannot exceed forty percent
                (40%) of the Marketing Representative's total monthly compensation,
                excluding benefits.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan shall instruct and provide initial and periodic training
                to
                its Marketing Representatives regarding the Marketing provisions
                of this
                Contract.

            

    

    

    
      	 	
              i.

            	
              The
                Health Plan shall implement procedures for background and reference
                checks
                for use in its Marketing Representative hiring
                practices.

            

    

    

    
      	7.  	
              Request
                for Benefit Information (RBI)
                Activities

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall refer Potential Enrollees interested in enrolling
                in the
                Health Plan to the Choice Counselor/Enrollment
                Broker.

            

    

    

    
      	 	
              b.

            	
              In
                accordance with Section 409.912, F.S., and Agency guidelines, and
                upon
                approval of the Agency, the Health Plan may assist Potential Enrollees
                in
                obtaining information through the completion of an RBI, previously
                known
                as a pre-enrollment application for
                information.

            

    

    

    
      	 	
              c.

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

            

    

    

    
      	 	
              (1)

            	
              Name;

            

    

    

    
      	 	
              (2)

            	
              Address
                (home and mailing);

            

    

    

    
      	 	
              (3)

            	
              County
                of residence; 

            

    

    

    
      	 	
              (4)

            	
              Telephone
                number;

            

    

    

    
      	 	
              (5)

            	
              Date
                of Application;

            

    

    

    
      	 	
              (6)

            	
              Applicant’s
                signature or signature of parent or guardian;
                and

            

    

    

    
      	 	
              (7)

            	
              Marketing
                Representative’s signature and DFS license
                number.

            

    

    

    
      	 	
              d.

            	
              At
                the time of completion of the RBI, the Health Plan shall furnish
                the
                Potential Enrollee with a copy of the completed
                RBI.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall accept RBIs only from Potential Enrollees who reside
                within the authorized Service Area. In addition, the Health Plan
                shall use
                the provider number associated with the county in which the Potential
                Enrollee resides.

            

    

    

    
      	 	
              f.

            	
              If
                the Voluntary Potential Enrollee is recognized to be in foster care
                by the
                Health Plan, and is dependent, prior to Enrollment, the Health Plan
                must
                receive written authorization from (1) a parent, (2) a legal guardian,
                or
                (3) DCF or DCF’s delegate. If a parent is unavailable, the Health Plan
                shall obtain authorization from DCF. The RBI shall include information
                that the Potential Enrollee is in foster
                care.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall provide a reasonable written explanation of the
                Health
                Plan Benefits to the Potential Enrollee prior to accepting the RBI.
                The
                Health Plan shall explain to all Potential Enrollees that the family
                may
                choose to have all members served by the same PCP or they may choose
                different PCPs based on each Enrollee’s needs. The information must comply
                with 42 CFR 438.10.

            

    

    

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    Section
      V

     

    Covered
      Services 

     

    

    
      	
              A.

            	
              Covered
                Services 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall ensure the provision of services in sufficient
                amount,
                duration and scope to be reasonably expected to achieve the purpose
                for
                which the services are furnished and shall ensure the provision of
                the
                following covered services as defined and specified in this Contract.
                The
                Health Plan shall not arbitrarily deny or reduce the amount, duration,
                or
                scope of a required service solely because of the diagnosis, type
                of
                illness or condition. The Health Plan may place appropriate limits
                on a
                service on the basis of such criteria as Medical Necessity or for
                utilization control, consistent with the terms of this Contract,
                provided
                the services furnished can be reasonably expected to achieve their
                purpose.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan is responsible for ensuring that all provider, service
                and
                product standards specified in the Agency's Medicaid Services Coverage
                & Limitations Handbooks and the Health Plan's own provider handbooks
                are incorporated into the Health Plan's participation agreements
                by
                reference. Exceptions exist where different standards are specified
                elsewhere in this Contract, if the standard is waived in writing
                by the
                Division of Medicaid on a case-by-case basis, when the Medicaid
                Recipient's medical needs would be equally or better served in an
                alternative care setting, or when using alternative therapies or
                devices
                within the prevailing medical
                community.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan must require out-of-network providers to coordinate with
                respect to payment and must ensure that cost to the Enrollee is no
                greater
                than it would be if the Covered Services were furnished within the
                network.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall ensure the provision of the following Covered
                Services:

            

    

    

    
      	
              Child
                Health Check-Up

            	
              Inpatient
                Hospital Services

            
	
              Community
                Mental Health Services.

            	
              Mental
                Health Targeted Case Management

            
	
              Family
                Planning Services

            	
              Outpatient
                Hospital and Emergency Services

            
	
              Freestanding
                Dialysis Centers

            	
              Physician
                Services

            
	
              Hearing
                Services

            	
              Prescribed
                Drug Services

            
	
              Home
                Health Services and Durable Medical Equipment

            	
              Therapy
                Services

            
	
              Independent
                Laboratory and X-Ray Services 

            	
              Visual
                Services

            
	
              Behavioral
                Health Services

            	 

    

    

    
      	
              B.

            	
              Optional
                Services

            

    

    

    
      	 	
              1.

            	
              These
                following services are rendered within Medicaid guidelines at the
                option
                of the Health Plan and the Agency as described
                below:

            

    

    

    
      	 	
               Covered

            	
                Not
                Covered

            
	 Dental Services	 	
               X

            
	 Transportation Services	
               X

            	 

    

     

    

    
      	
              C.

            	
              Expanded
                Services

            

    

    

    
      	 	
              1.

            	
              The
                following services are defined as Expanded Services that may be offered
                by
                the Health Plan following the Agency’s written
                approval:

            

    

    

    
      	 	
              a.

            	
              Services
                in excess of the amount, duration and scope of those listed in Section
                V,
                Covered Services;

            

    

    

    
      	 	
              b.

            	
              Services
                and benefits not listed in Section V, Covered
                Services;

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan may offer, upon written Agency approval, an over-the-counter
                expanded drug benefit, not to exceed twenty-five dollars ($25.00)
                per
                household, per month. Such benefits shall be limited to nonprescription
                drugs containing a national drug code ("NDC") number, first aid supplies
                and birth control supplies. Such benefits must be offered directly
                through
                the Health Plan's fulfillment house or through a Subcontractor. The
                Health
                Plan shall make payments for the over-the-counter drug benefit directly
                to
                the Subcontractor, if applicable.

            

    

    

    
      	 	
              2.

            	
              The
                following is a list of the Health Plan’s Expanded
                Services:

            

    

    

    
      	 	 	
              a.
                Annual comprehensive oral exam, x-rays (one per year), 2 cleanings
                per
                year, silver amalgam fillings, one peridontic deep cleaning per year,
                2
                peridontic scaling and root planning per
                year;

            

    

    

    
      	 	 	
              b.
                Unlimited eye exams and eyeglasses, if medically
                necessary;

            

    

    

    
      	 	 	
              c.
                Up to $25 credit per household each month for selected over the counter
                drugs and/or health supplies;

            

    

    

    
      	 	 	
              d.
                Free approved round trip transportation to medical appointments;
                

            

    

    

    
      	 	 	
              e.
                Hearing exam and one hearing aid every three years, if medically
                necessary
                (hearing aid only).

            

    

    

    
      	 	 	
              f.
                Circumcision up to 1 year.

            

    

    

    
      	
              D.

            	
              Excluded
                Services 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan is not obligated to provide any services not specified
                in this
                Contract. Enrollees who require services available through Medicaid
                but
                not covered by this Contract shall receive the services through the
                Medicaid fee-for-service reimbursement system. In such cases, the
                Health
                Plan's responsibility is limited to case coordination and referral.
                Therefore, the Health Plan shall determine the need for the services
                and
                refer the Enrollee to the appropriate service provider. The Health
                Plan
                may request assistance from the local Medicaid Field Office for referral
                to the appropriate service setting.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall consult the DCF office to identify appropriate
                methods
                of assessment and referral for those Enrollees requiring long-term
                care
                institutional services, institutional services for persons with
                developmental disabilities or state hospital services. The Health
                Plan is
                responsible for transition and referral of these Enrollees to appropriate
                service providers, including helping the Enrollees to obtain an attending
                physician. The Plan shall disenroll all Enrollees requiring these
                services
                in accordance with Section III.C.3.a.(3) of this
                Contract.

            

    

    

    
      	
              E.

            	
              Moral
                or Religious Objections

            

    

    

    
      	 	
              1.

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

            

    

    

    
      	 	
              a.

            	
              The
                Agency within one hundred and twenty (120) Calendar Days prior to
                adopting
                the policy with respect to any service;
                and

            

    

    

    
      	 	
              b.

            	
              Enrollees
                within thirty (30) Calendar Days prior to adopting the policy with
                respect
                to any service.

            

    

    

    
      	
              F.

            	
              Coverage
                Provisions 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall provide the following services in accordance with
                the
                provisions herein, and in accordance with the Florida Medicaid Coverage
                and Limitations Handbooks and the Florida Medicaid State Plan. The
                Health
                Plan shall comply with all State and federal laws pertaining to the
                provision of such services.

            

    

    

    
      	 	
              2.

            	
              Advance
                Directives

            

    

    

    
      	 	
              a.

            	
              In
                compliance with 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128, the Health
                Plan
                shall written policies and procedures for Advance Directives, including
                health Advance Directives. Such Advance Directives shall be included
                in
                each Enrollee's Medical Record. The Health Plan shall provide these
                policies and procedures to all Enrollee's eighteen (18) years of
                age and
                older and shall advise Enrollees
                of:

            

    

    

    
      	 	
              (1)

            	
              Their
                rights under State law, including the right to accept or refuse medical
                or
                surgical treatment and the right to formulate Advance Directives;
                and

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's written policies respecting the implementation of those
                rights, including a statement of any limitation regarding the
                implementation of Advance Directives as a matter of
                conscience.

            

    

    

    
      	 	
              b.

            	
              The
                information must include a description of State law and must reflect
                changes in State law as soon as possible, but no later than ninety
                (90)
                Calendar Days after the effective
                change.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan's information must inform Enrollees that complaints may
                be
                filed with the State's complaint
                hotline.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall educate its staff about its policies and procedures
                on
                Advance Directives, situations in which Advance Directives may be
                of
                benefit to Enrollees, and their responsibility to educate Enrollees
                about
                this tool and assist them to make use of
                it.

            

    

    

    
      	 	
              e.

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

            

    

    

    
      	 	
              3.

            	
              Child
                Health Check-Up Program (CHCUP)

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide a health screening evaluation that shall
                consist
                of: comprehensive health and developmental history (including assessment
                of past medical history, developmental history and behavioral health
                status); comprehensive unclothed physical examination; developmental
                assessment; nutritional assessment; appropriate immunizations according
                to
                the appropriate Recommended Childhood Immunization Schedule for the
                United
                States; laboratory testing (including blood lead testing); health
                education (including anticipatory guidance); dental screening (including
                a
                direct referral to a dentist for Enrollees beginning at three (3)
                years of
                age or earlier as indicated); vision screening, including objective
                testing as required; hearing screening, including objective testing
                as
                required; diagnosis and treatment; and referral and follow-up as
                appropriate.

            

    

    

    
      	 	
              b.

            	
              For
                Children/Adolescents who the Health Plan identifies through blood
                lead
                screenings as having abnormal levels of lead, the Health Plan shall
                provide Case Management follow-up services as required in Chapter
                Two of
                the Child Health Check-Up Services Coverage and Limitations Handbook.
                Screening for lead poisoning is a required component of this Contract.
                The
                Health Plan shall require all Providers to screen all Enrolled
                Children/Adolescents for lead poisoning at twelve (12) and twenty-four
                (24) months of age. In addition, Children/Adolescents between the
                ages of
                twenty-four (24) months and seventy-two (72) months of age must receive
                a
                screening blood lead test if there is no record of a previous test.
                The
                Health Plan shall provide additional diagnostic and treatment services
                determined to be Medically Necessary to a Child/Adolescent diagnosed
                with
                an elevated blood lead level. The Health Plan shall recommend, but
                shall
                not require, the use of paper filter tests as part of the lead screening
                requirement.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall inform Enrollees of all testing/screenings due
                in
                accordance with the periodicity schedule specified in the Medicaid
                Child
                Health Check-Up Services Coverage and Limitations Handbook. The Health
                Plan shall contact Enrollees to encourage them to obtain health assessment
                and preventative care.

            

    

    

    
      	 	
              d.
                

            	
              The
                Health Plan shall authorize Enrollee referrals to appropriate Providers
                within four (4) weeks of these examinations for further assessment
                and
                treatment of conditions found during the examination. The Health
                Plan
                shall ensure that the referral appointment is scheduled for a date
                within
                six (6) months of the initial examination, or within the time periods
                set
                forth in Section VII.D., as
                applicable.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall offer scheduling assistance and Transportation
                to
                Enrollees in order to assist them to keep, and travel to, medical
                appointments.

            

    

    

    
      	 	
              f.

            	
              The
                CHCUP program includes the maintenance of a coordinated system to
                follow
                the Enrollee through the entire range of screening and treatment,
                as well
                as supplying CHCUP training to medical care
                Providers.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall achieve a CHCUP screening rate of at least sixty
                percent
                (60%) for those Enrollees who are continuously enrolled for at least
                eight
                (8) months during the Federal Fiscal Year (October 1 - September
                30) in
                accordance with Section 409.912, F.S. This screening compliance rate
                shall
                be based on the CHCUP screening data reported by the Health Plan
                and due
                to the Agency by January 15 following the end of each Federal Fiscal
                Year
                as specified in Section XII, Reporting, of this Contract. The data
                shall
                be monitored by the Agency for accuracy and, if the Health Plan does
                not
                achieve the sixty percent (60%) screening rate for the Federal Fiscal
                Year
                reported, the Health Plan shall file a corrective action plan (CAP)
                with
                the Agency no later than February 15, following the fiscal year reported.
                Any data reported by the Health Plan that is found to be inaccurate
                shall
                be disallowed by the Agency and the Agency shall consider such findings
                as
                being in violation of the Contract and may sanction the Health Plan
                accordingly.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan shall adopt annual screening and participation goals
                to
                achieve at least an eighty percent (80%) CHCUP screening and participation
                rate. For each Federal Fiscal Year that the Health Plan does not
                meet the
                eighty percent (80%) screening and participation rate, it must file
                a CAP
                with the Agency no later than February 15 following the Federal Fiscal
                Year being reported.

            

    

    

    
      	 	
              4.

            	
              Co-Payments

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall not require a co-payment or cost sharing for services
                listed in Section V.A., Covered Services, Section V.B., Optional
                Services,
                if provided, or Section V.C., Expanded Services, nor may the Health
                Plan
                charge Enrollees for missed
                appointments.

            

    

    

    
      	 	
              5.

            	
              Dental
                Services (Optional)

            

    

    

    
      	 	
              a.

            	
              Dental
                services are defined in the Medicaid Dental Services Coverage and
                Limitations Handbook. Children’s Medicaid dental services include
                diagnostic services, preventive treatment, restorative treatment,
                endodontic treatment, periodontal treatment, restorative treatment,
                surgical procedures and/or extractions, orthodontic treatment and
                complete
                and partial dentures for beneficiaries under age 21. Complete and
                partial
                denture relines and repairs are also included, as well as adjunctive
                and
                emergency services. Adult services include adult
                full and partial denture services and
                Medically Necessary emergency dental procedures to alleviate pain
                or
                infection. Emergency dental care shall be limited to emergency oral
                examinations, necessary radiographs, extractions, and incision and
                drainage of abscess.

            

    

    

    6. Diabetes
      Supplies and Education

     

    

    
      	 	
              a.

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

            

    

    

    7. Emergency
      Services 

    

    
      	 	
              a.

            	
              The
                Health Plan shall advise all Enrollees of the provisions governing
                Emergency Services and Care. The Health Plan shall not deny claims
                for
                Emergency Services and Care received at a Hospital due to lack of
                parental
                consent. In addition, the Health Plan shall not deny payment for
                treatment
                obtained when a representative of the Health Plan instructs the Enrollee
                to seek Emergency Services and Care
                in
                accordance with section 743.64,
                F.S.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall not:

            

    

    

    
      	 	
              (1)

            	
              Require
                Prior Authorization for an Enrollee to receive pre-Hospital transport
                or
                treatment or for Emergency Services and
                Care;

            

    

    

    
      	 	
              (2)

            	
              Specify
                or imply that Emergency Services and Care are covered by the Health
                Plan
                only if secured within a certain period of
                time;

            

    

    

    
      	 	
              (3)

            	
              Use
                terms such as "life threatening" or "bona fide" to qualify the kind
                of
                emergency that is covered; or

            

    

    

    
      	 	
              (4)

            	
              Deny
                payment based on a failure by the Enrollee or the Hospital to notify
                the
                Health Plan before, or within a certain period of time after, Emergency
                Services and Care were given.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall provide pre-Hospital and Hospital-based trauma
                services
                and Emergency Services and Care to Enrollees. See
                Sections 395.1041, 395.4045 and 401.45,
                F.S.

            

    

    

    
      	 	
              d.

            	
              When
                an Enrollee presents himself/herself at a Hospital seeking Emergency
                Services and Care, the determination that an Emergency Medical Condition
                exists shall be made, for the purposes of treatment, by a physician
                of the
                Hospital or, to the extent permitted by applicable law, by other
                appropriate personnel under the supervision of a Hospital
                physician.
                See Sections 409.9128 and 409.901,
                F.S.

            

    

    

    
      	 	
              (1)

            	
              The
                physician, or the appropriate personnel, shall indicate on
                the Enrollee's chart the results of all screenings, examinations
                and
                evaluations.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall compensate the provider for all screenings, evaluations
                and examinations that are reasonably calculated to assist the provider
                in
                arriving at the determination as to whether the Enrollee's condition
                is an
                Emergency Medical Condition.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall pay for all Emergency Services and Care in accordance
                with this Contract.

            

    

    

    
      	 	
              (4)

            	
              If
                the provider determines that an Emergency Medical Condition does
                not
                exist, the Health Plan is not required to pay for services rendered
                subsequent to the provider's
                determination.

            

    

    

    
      	 	
              e.

            	
              If
                the provider determines that an Emergency Medical Condition exists,
                and
                the Enrollee notifies the Hospital or the Hospital emergency personnel
                otherwise have knowledge that the patient is an Enrollee of the Health
                Plan, the Hospital must make a reasonable attempt to notify the Enrollee's
                PCP, if known, or the Health Plan, if the Health Plan has previously
                requested in writing that said notification be made directly to the
                Health
                Plan, of the existence of the Emergency Medical
                Condition.

            

    

    

    
      	 	
              f.

            	
              If
                the Hospital, or any of its affiliated providers, do not know the
                Enrollee's PCP, or have been unable to contact the PCP, the Hospital
                must:

            

    

    

    
      	 	
              (1)

            	
              Notify
                the Health Plan as soon as possible before discharging the Enrollee
                from
                the emergency care area; or

            

    

    

    
      	 	
              (2)

            	
              Notify
                the Health Plan within twenty-four (24) hours or on the next Business
                Day
                after admission of the Enrollee as an inpatient to the
                Hospital.

            

    

    

    
      	 	
              g.

            	
              If
                the Hospital is unable to notify the Health Plan, the Hospital must
                document
                its attempts to notify the Health Plan, or the circumstances that
                precluded the Hospital's attempts to notify the Health Plan. The
                Health
                Plan shall not deny payment for Emergency Services and Care based
                on a
                Hospital's failure to comply with the notification requirements of
                this
                Section.

            

    

    

    
      	 	
              h.

            	
              If
                the Enrollee's PCP responds to the Hospital's notification, and the
                Hospital physician and the PCP discuss the appropriate care and treatment
                of the Enrollee, the Health Plan may have a member of the Hospital
                staff
                with whom it has a Participating Provider contract participate in
                the
                treatment of the Enrollee within the scope of the physician's Hospital
                staff privileges.

            

    

    

    
      	 	
              i.

            	
              The
                Health Plan may transfer the Enrollee, in accordance with State and
                federal law, to a Participating Hospital that has the service capability
                to treat the Enrollee's Emergency Medical Condition. The attending
                emergency physician, or the provider actually treating the Enrollee,
                is
                responsible for determining when the Enrollee is sufficiently stabilized
                for transfer discharge, and that determination is binding on the
                entities
                identified in 42 CFR 438.114(b) as responsible for coverage and
                payment.

            

    

    

    
      	 	
              j.

            	
              Notwithstanding
                any other State law, a Hospital may request and collect any insurance
                or
                financial information necessary to determine if the patient is an
                Enrollee
                of the Health Plan, in accordance with federal law, from an Enrollee,
                so
                long as Emergency Services and Care are not delayed in the
                process.

            

    

    

    
      	 	
              k.

            	
              In
                accordance with 42 CFR 438.414 and 42 CFR 422.113(c), the Health
                Plan
                shall cover Post-Stabilization Care Services without authorization,
                regardless of whether the Enrollee obtains a service within or outside
                the
                Health Plan's network for the following
                situations:

            

    

    

    
      	 	
              (1)

            	
              Post-Stabilization
                Care Services that were pre-approved by the Health
                Plan;

            

    

    

    
      	 	
              (2)

            	
              Post-Stabilization
                Care Services that were not pre-approved by the Health Plan because
                the
                Health Plan did not respond to the treating provider's request for
                pre-approval within one (1) hour after the treating provider sent
                the
                request; 

            

    

    

    
      	 	
              (3)

            	
              The
                treating Provider could not contact the Health Plan for pre-approval;
                and

            

    

    

    
      	 	
              (4)

            	
              Those
                Post-Stabilization Care Services that a treating physician viewed
                as
                Medically Necessary after stabilizing an Emergency Medical Condition.
                These are non-emergency services; the Health Plan can choose not
                to cover
                if provided by a non-participating provider, except in those circumstances
                detailed in k. (1), (2), and (3) above. 

            

    

    

    
      	 	
              l.

            	
              The
                Health Plan shall not deny claims for the provision of Emergency
                Services
                and Care submitted by a nonparticipating provider solely based on
                the
                period between the date of service and the date of clean claim submission,
                unless that period exceeds 365
                days.

            

    

    

    
      	 	
              m.

            	
              Reimbursement
                for services provided to an Enrollee under this Section by a
                non-participating provider shall be the lesser
                of:

            

    

    

    
      	 	
              (1)

            	
              The
                non-participating provider's
                charges;

            

    

    

    
      	 	
              (2)

            	
              The
                usual and customary provider charges for similar services in the
                community
                where the services were provided;

            

    

    

    
      	 	
              (3)

            	
              The
                amount mutually agreed to by the Health Plan and the non-participating
                provider within sixty (60) Calendar Days after the non-participating
                provider submits a claim; or

            

    

    

    
      	 	
              (4)

            	
              The
                Medicaid rate.

            

    

    

    
      	 	
              n.

            	
              Notwithstanding
                the requirements set forth in this Section, the Health Plan shall
                make
                payment on all claims for Emergency Services and Care by nonparticipating
                providers pursuant to the requirements set forth in Section 641.3155,
                F.S.

            

    

    

    
      	 	
              8.

            	
              Emergency
                Services - Behavioral Health
                Services

            

    

    

    
      	 	
              a.

            	
              In
                cases in which the Enrollee has no identification, or is unable to
                verbally identify himself/herself when presenting for Behavioral
                Health
                Services, the out-of-area, non-participating provider shall notify
                the
                Health Plan within twenty-four (24) hours of learning the Enrollee's
                identity. The out-of-area, non-participating provider shall deliver
                to the
                Health Plan the Medical Records that document that the identity of
                the
                Enrollee could not be ascertained at the time the Enrollee presented
                for
                Emergency Behavioral Health Services due to the Enrollee's
                condition.

            

    

    

    
      	 	
              b.

            	
              If
                the out-of-area, non-participating provider fails to provide the
                Health
                Plan with an accounting of the Enrollee's presence and status within
                twenty-four (24) hours after the Enrollee presents for treatment
                and
                provides identification, the Health Plan shall only approve claims
                for the
                time period required for treatment of the Enrollee's Emergency Behavioral
                Health Services, as documented by the Enrollee's Medical
                Record.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall review and approve or disapprove all out-of-plan
                Emergency Behavioral Health Service claims within the time frames
                specified for emergency claims payment in Section V.E.7., Emergency
                Services.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall submit to the Agency for review and final determination
                all denied Appeals from Behavioral Health Care Providers and out-of-plan,
                non-participating behavioral health care providers for denied Emergency
                Behavioral Health Service claims. The provider, whether a participating
                provider or not, must submit the denied Appeal to the Agency within
                ten
                (10) days after receiving notice of the Health Plan's final Appeal
                determination. 

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan must evaluate and authorize or deny services for Enrollees
                presenting at non-participating receiving facilities (that are not
                Crisis
                Stabilization Units), within the Health Plan's service area, for
                involuntary examination within three (3) hours of being notified
                by phone
                by the receiving facility.

            

    

    

    
      	 	
              f.

            	
              The
                receiving facility must notify the Health Plan within four (4) hours
                of
                the Enrollee presenting. If the Receiving Facility fails to notify
                the
                Health Plan of the Enrollee's presence and status within four (4)
                hours,
                the Health Plan shall pay only for the first four (4) hours of the
                Enrollee's treatment, subject to Medical
                Necessity.

            

    

    

    
      	 	
              g.

            	
              If
                the receiving facility is a non-participating receiving facility
                and
                documents in the Medical Record that it is unable, after a good faith
                effort, to identify the Enrollee and, therefore, fails to notify
                the
                Health Plan of the Enrollee's presence, the Health Plan shall pay
                for
                medical stabilization lasting no more than three (3) days from the
                date
                the Enrollee presented at the receiving facility, as documented by
                the
                Enrollee's Medical Record and subject to Medical Necessity, unless
                there
                is irrefutable evidence in the Medical Record that a longer period
                was
                required to treat the Enrollee.

            

    

    

    
      	 	
              9.

            	
              Family
                Planning Services

            

    

    

    
      	 	
              a.

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

            

    

    

    (1) The
      Health Plan shall furnish services on a voluntary and confidential
      basis. 

    

    
      	 	
              (2)

            	
              The
                Health Plan shall allow Enrollees freedom of choice of family planning
                methods covered under the Medicaid program, including Medicaid covered
                implants, where there are no medical
                contra-indications.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall render the services to Enrollees under the age
                of
                eighteen (18) provided the Enrollee is married, a parent, pregnant,
                has
                written consent by a parent or legal guardian, or in the opinion
                of a
                physician, the Enrollee may suffer health hazards if the services
                are not
                provided. See Section
                390.01114, F.S.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan shall allow each Enrollee to obtain family planning services
                from any Provider and require no prior authorization for such services.
                If
                the Enrollee receives services from a non-network Medicaid provider,
                then
                the Plan must reimburse at the Medicaid reimbursement rate, unless
                another
                payment rate is negotiated.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan shall make available and encourage all pregnant women
                and
                mothers with infants to receive postpartum visits for the purpose
                of
                voluntary family planning, including discussion of all appropriate
                methods
                of contraception, counseling and services for family planning to
                all women
                and their partners. The Health Plan shall direct Providers to maintain
                documentation in the Enrollee's Medical Records to reflect this provision.
                See Section
                409.912, F.S.

            

    

    

    
      	 	
              (6)

            	
              The
                provisions of this subsection shall not be interpreted so as to prevent
                a
                health care provider or other person from refusing to furnish any
                contraceptive or family planning service, supplies or information
                for
                medical or religious reasons. A health care provider or other person
                shall
                not be held liable for such
                refusal.

            

    

    

    
      	 	
              10.

            	
              Hospital
                Services — Inpatient

            

    

    

    
      	 	
              a.

            	
              Inpatient
                Services are Medically Necessary services ordinarily furnished by
                a State
                licensed acute care Hospital for the medical care and treatment of
                inpatients provided under the direction of a physician or dentist
                in a
                Hospital maintained primarily for the care and treatment of patients
                with
                disorders other than mental diseases. Inpatient psychiatric Hospital
                services are Medically Necessary Behavioral Health Care Services
                and may
                be provided in a general Hospital psychiatric unit or in a specialty
                Hospital.

            

    

    

    
      	 	
              (1)

            	
              Inpatient
                services include, but are not limited to, rehabilitation Hospital
                care
                (which are counted as inpatient Hospital days), medical supplies,
                diagnostic and therapeutic services, use of facilities, drugs and
                biologicals, room and board, nursing care and all supplies and equipment
                necessary to provide adequate care. See
                the Medicaid Hospital Services Coverage & Limitations
                Handbook.  

            

    

    

    
      	 	
              (2)

            	
              Inpatient
                services also include inpatient care for any diagnosis including
                psychiatric and mental health (Baker Act and non-Baker Act), tuberculosis
                and renal failure when provided by general acute care Hospitals in
                both
                emergent and non-emergent conditions.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan may provide services in a nursing home as downward
                substitution for Inpatient Services. In such cases, said inpatient
                care
                shall not be counted as inpatient hospital days.
                

            

    

    

    
      	 	
              (4)

            	
              The
                health screening examination shall consist of:

            

    

    

    
      	 	
              (a)

            	
              Comprehensive
                health and developmental history, including an assessment of past
                medical
                history, developmental history and behavioral health status;
                

            

    

    

    
      	 	
              (b)

            	
              Comprehensive
                unclothed physical examination; 

            

    

    

    
      	 	
              (c)

            	
              Developmental
                assessment; 

            

    

    

    
      	 	
              (d)

            	
              Nutritional
                assessment; 

            

    

    

    
      	 	
              (e)

            	
              Appropriate
                immunizations according to the appropriate Recommended Childhood
                Immunization Schedule for the United States;

            

    

    

    
      	 	
              (f)

            	
              Laboratory
                testing, including blood lead screenings, where required (for
                Children/Adolescents whom the Health Plan identifies through blood
                lead
                screenings as having abnormal levels of lead, the Health Plan shall
                provide case management follow-up services as required in Chapter
                2 of the
                Child Health Check-Up Services Coverage and Limitations
                Handbook);

            

    

    

    
      	 	
              (g)

            	
              Health
                education (including anticipatory guidance);

            

    

    

    
      	 	
              (h)

            	
              Dental
                screening (including a direct referral to a dentist, or to a Prepaid
                Dental Health Plan (PDHP), where applicable, for Children/Adolescents
                beginning at 3 years of age or earlier as indicated);
                

            

    

    

    
      	 	
              (i)

            	
              Vision
                screening, including objective testing, when required;
                

            

    

    

    
      	 	
              (j)

            	
              Hearing
                screening, including objective testing, when required;
                

            

    

    

    
      	 	
              (k)

            	
              Diagnosis,
                treatment, referral and follow-up, as
                appropriate.

            

    

     

    
      	 	
              (5)

            	
              The
                Health Plan shall cover physical therapy services when Medically
                Necessary
                and when provided during an Enrollee's inpatient
                stay.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan shall provide up to twenty-eight (28) inpatient hospital
                days
                in an inpatient Hospital substance abuse treatment program for pregnant
                substance abusers who meet ISD Criteria with Florida Medicaid
                modifications, as specified in InterQual Level of Care 2003-Acute
                Criteria-Pediatric and/or InterQual Level of Care 2003-Acute
                Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”), 2003 Edition
                or the most current edition, for use in screening cases admitted
                to
                rehabilitative Hospitals and CON approved rehabilitative units in
                acute
                care Hospitals with admission dates of January 1, 2003 and after.
                In
                addition, the Health Plan shall provide inpatient Hospital treatment
                for
                severe withdrawal cases exhibiting medical complications which meet
                the
                severity of illness criteria under the alcohol/substance abuse
                system-specific set which generally requires treatment on a medical
                unit
                where complex medical equipment is available. Withdrawal cases (not
                meeting the severity of illness criteria under the alcohol/substance
                abuse
                criteria) and substance abuse rehabilitation (other than for pregnant
                women), including court ordered services, are not covered in the
                inpatient
                Hospital setting.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall adhere to the provisions of the Newborns and Mothers
                Health Protection Act (NMHPA) of 1996 regarding postpartum coverage
                for
                mothers and their newborns. Therefore, the Health Plan shall provide
                for
                no less than a forty-eight (48) hour Hospital length of stay following
                a
                normal vaginal delivery, and at least a ninety-six (96) hour Hospital
                length of stay following a Cesarean section. In connection with coverage
                for maternity care, the Hospital length of stay is required to be
                decided
                by the attending physician in consultation with the
                mother.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan shall provide up to forty-five (45) days of inpatient
                coverage
                per Enrollee from July 1 or the initial date of Enrollment, whichever
                comes later, through June 30 of each
                year.

            

    

    

    
      	 	
              (9)

            	
              The
                Health Plan shall prohibit the following
                practices:

            

    

    

    
      	 	
              (a)

            	
              Denying
                the mother or newborn child eligibility, or continued eligibility,
                to
                enroll or renew coverage under the terms of the Health Plan, solely
                for
                the purpose of avoiding the NMHPA
                requirements;

            

    

    

    
      	 	
              (b)

            	
              Providing
                monetary payments or rebates to mothers to encourage them to accept
                less
                than the minimum protections available under
                NMHPA;

            

    

    

    
      	 	
              (c)

            	
              Penalizing
                or otherwise reducing or limiting the reimbursement of an attending
                physician because the physician provided care in a manner consistent
                with
                NMHPA;

            

    

    

    
      	 	
              (d)

            	
              Providing
                incentives (monetary or otherwise) to an attending physician to induce
                the
                physician to provide care in a manner inconsistent with NMHPA;
                

            

    

    

    
      	 	
              (e)

            	
              Restricting
                for any portion of the forty-eight (48) hour, or ninety-six (96)
                hour,
                period prescribed by NMHPA in a manner that is less favorable than
                the
                Benefits provided for any preceding portion of the Hospital stay;
                and

            

    

    

    
      	 	
              (f)

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

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan’s inpatient Hospital services also includes the
                following:

            

    

    

    
      	 	
              (1)

            	
              Medically
                Necessary and appropriate transplants, including:
                

            

    

    

    (a) Bone
      marrow, all ages;

    

    (b) Cornea,
      all ages; and 

    

    (c) Kidney,
      all ages. 

    

    
      	 	
              (2)

            	
              For
                other transplants not covered by Medicaid, the evaluations, pre-transplant
                care and post-transplant follow-up care are covered by Medicaid and,
                therefore, must be covered by the Health Plan even though the transplant
                procedure is not covered. Transplant service components are also
                covered
                under outpatient services, physician services and prescribed drug
                services
                per the applicable Medicaid Services Coverage and Limitations
                handbooks.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan is not responsible for the cost of transplant evaluations,
                pre-transplant care and post-transplant follow-up care, when an adult
                Enrollee (age 21 and over) is listed with the United Network for
                Organ
                Sharing (UNOS) as a level 1A, 1B, or 2 candidate for heart transplant.
                The
                Health Plan must disenroll said Enrollees at the conclusion of the
                transplant evaluation and cannot re-enroll the Enrollee until at
                least one
                (1) year post transplant.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan is not responsible for the cost of a completed adult
                heart
                transplant evaluation regardless of whether or not the Enrollee was
                determined a candidate for a transplant. The Health Plan is responsible,
                however, for the cost of adult heart transplant evaluations that
                are not
                completed for any reason.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan is not responsible for the cost of pre-transplant care
                and
                post transplant follow-up care when an Enrollee has been listed as
                a
                candidate for a pediatric heart, lung or heart/lung transplant (ages
                20
                and under) or a liver transplant (all ages). If, at the conclusion
                of the
                transplant evaluation, the Enrollee is listed with UNOS as a level
                1A, 1B
                or 2 for heart, lung or heart/lung or, Model End Stage Renal Disease
                (MELD) score of 11-25, for a liver transplant, the Health Plan must
                disenroll the Enrollee. The Enrollee will have the option to re-enroll
                at
                one (1) year post transplant. The Health Plan is responsible for
                the cost
                of the above-referenced transplant
                evaluations.

            

    

    

    
      	 	
              11.

            	
              Hospital
                Services — Outpatient

            

    

    

    
      	 	
              a.

            	
              Outpatient
                Hospital services consist of preventive, diagnostic, therapeutic
                or
                palliative care under the direction of a physician or dentist at
                a
                licensed acute care Hospital. Outpatient Hospital services include
                Medically Necessary emergency room services, dressings, splints,
                oxygen
                and physician ordered services and supplies for the clinical treatment
                of
                a specific diagnosis or treatment.

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide outpatient Hospital services and Emergency
                Services and Care as Medically Necessary and appropriate and without
                any
                specified dollar limitations.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall have a procedure for the authorization of dental
                care
                and associated ancillary medical services provided in an outpatient
                Hospital setting if that care meets the following
                requirements:

            

    

    

    
      	 	
              (1)

            	
              Is
                provided under the direction of a dentist at a licensed Hospital;
                and

            

    

    

    
      	 	
              (2)

            	
              Is
                Medically Necessary; or

            

    

    

    
      	 	
              (3)

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

            

    

    

    
      	 	
              12.

            	
              Hospital
                Services — Ancillary
                Services

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide Medically Necessary ancillary medical services
                at the Hospital without limitation. Ancillary Hospital services include,
                but are not limited to, radiology, pathology, neurology, neonatology,
                and
                anesthesiology. When the Health Plan or the Health Plan's authorized
                physician authorizes these services (either inpatient or outpatient),
                the
                Health Plan must reimburse the provider of the service at the Medicaid
                line item rate, unless the Health Plan and the Hospital have negotiated
                another reimbursement rate. Also, the Health Plan must reimburse
                non-network physicians for emergency ancillary services provided
                in a
                Hospital setting.

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan provides dental services as an optional service,
                the
                Health Plan shall have a procedure for the authorization of Medically
                Necessary dental care and associated ancillary services provided
                in
                licensed ambulatory surgical center settings if that care is provided
                under the direction of a dentist as described in the State
                plan.

            

    

    

    
      	 	
              13.

            	
              Hysterectomies,
                Sterilizations and Abortions

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

            	
              If
                the pregnancy is a result of an act of rape or incest;
                or

            

    

    

    
      	 	
              (2)

            	
              The
                physician certifies that the woman is in danger of death unless an
                abortion is performed.

            

    

    

    
      	 	
              14.

            	
              Immunizations

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall: 

            

    

    

    
      	 	
              1.

            	
              Provide
                immunizations in accordance with the Recommended Childhood Immunization
                Schedule for the United States, or when Medically Necessary for the
                Enrollee's health;

            

    

    

    
      	 	
              2.

            	
              Provide
                for the simultaneous administration of all vaccines for which an
                Enrollee
                under the age of twenty (20) is eligible at the time of each visit;
                

            

    

    

    
      	 	
              3.

            	
              Follow
                only true contraindications established by the Advisory Committee
                on
                Immunization Practices ("ACIP"),
                unless:

            

    

    

    
      	 	
              (a)

            	
              In
                making a medical judgment in accordance with accepted medical practices,
                such compliance is deemed medically inappropriate;
                or

            

    

    

    
      	 	
              (b)

            	
              The
                particular requirement is not in compliance with Florida law, including
                Florida law relating to religious or other
                exemptions;

            

    

    

    
      	 	
              4.

            	
              Participate,
                or direct its Providers to participate, in the Vaccines For Children
                Program ("VFC"). See
                Section 1905(r)(1) of the Social Security Act. The VFC is administered
                by
                the Department of Health, Bureau of Immunizations, and provides vaccines
                at no charge to physicians and eliminates the need to refer children
                to
                CHDs for immunizations.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall provide coverage and reimbursement to the Participating
                Provider for immunizations covered by Medicaid, but not provided
                through
                VFC;

            

    

    

    
      	 	
              6.
                

            	
              Ensure
                that Providers have a sufficient supply of vaccines if the Health
                Plan is
                the VFC enrollee. The Health Plan shall direct those Providers that
                are
                directly enrolled in the VFC program to maintain adequate vaccine
                supplies;

            

    

    

    
      	 	
              7.

            	
              Pay
                no more than the Medicaid program vaccine administration fee of ten
                dollars ($10.00) per administration, unless another rate is negotiated
                with the Participating Provider.

            

    

    

    
      	 	
              8.

            	
              Pay
                the immunization administration fee at no less than the Medicaid
                rate when
                an Enrollee receives immunizations from a non-participating provider,
                so
                long as:

            

    

    

    
      	 	
              (a)

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

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan is unable to document to the non-participating provider
                that
                the Enrollee has already received the immunization;
                and

            

    

    

    
      	 	
              (c)

            	
              The
                non-participating provider submits a claim for the administration
                of
                immunization services and provides Medical Records documenting the
                immunization to the Health Plan.

            

    

    
      	 	 	 

    

    
      	 	
              15.

            	
              Pregnancy
                Related Requirements

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall ensure that the Provider uses the DOH prenatal
                risk form
                (DH Form 3134), which can be obtained from the local CHD.
                

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall ensure that the Provider retains a copy of the
                completed
                screening instrument in the Enrollee's Medical Record and provides
                a copy
                to the Enrollee.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan shall ensure that the Provider submits the completed
                DH Form
                3134 to the CHD in the county in which the prenatal screen was completed
                within ten (10) Business Days of
                completion.

            

    

    

    
      	 	
              (d)

            	
              The
                Health Plan shall collaborate with the Healthy Start care coordinator
                within the Enrollee's county of residence to assure risk appropriate
                care
                is delivered.

            

    

    

    
      	 	
              (2)

            	
              Florida's
                Healthy Start Infant (Postnatal) Risk Screening Instrument - The
                Health
                Plan shall ensure that the Provider completes the Florida Healthy
                Start
                Infant (Postnatal) Risk Screening Instrument (DH Form 3135) with
                the
                Certificate of Live Birth and transmits the documents to the CHD
                in the
                county in which the infant was born within ten (10) Business Days
                of
                completion. The Health Plan shall ensure that the Provider retains
                a copy
                of the completed DH Form 3135 in the Enrollee's Medical Record and
                provides a copy to the Enrollee.

            

    

    

    
      	 	
              (3)

            	
              Pregnant
                Enrollees or infants who do not score high enough to be eligible
                for
                Healthy Start care coordination may be referred for services, regardless
                of their score on the Healthy Start risk screen, in the following
                ways:
                

            

    

    

    
      	 	
              (a)

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

            

    

     

    
      	 	
              (b)

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

            

    

    

    
      	 	
              (4)

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

            

    

    

    (a) The
      Health Plan shall provide:

    

    
      	 	
              (i)

            	
              A
                completed Florida WIC program Medical Referral Form with the current
                height or length and weight (taken within sixty (60) Calendar Days
                of the
                WIC appointment);

            

    

    

    
      	 	
              (ii)

            	
              Hemoglobin
                or hematocrit; and

            

    

    

    
      	 	
              (iii)

            	
              Any
                identified medical/nutritional
                problems.

            

    

    

    
      	 	
              (b)

            	
              For
                subsequent WIC certifications, the Health Plan shall ensure that
                Providers
                coordinate with the local WIC office to provide the above referral
                data
                from the most recent CHCUP.

            

    

    

    
      	 	
              (c)

            	
              Each
                time the Health Plan completes a WIC Referral Form, the Health Plan
                shall
                ensure that the Provider gives a copy of the WIC Referral Form to
                the
                Enrollee and retains a copy in the Enrollee's Medical
                Record.

            

    

    

    
      	 	
              (5)

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

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall ensure that its Providers, in accordance with Florida
                law, offer all pregnant women counseling and HIV testing at the initial
                prenatal care visit and again at twenty-eight (28) to thirty-two
                (32)
                weeks.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall ensure that its Providers attempt to obtain a signed
                objection if a pregnant woman declines an HIV test. See Section 384.31,
                F.S. and 64D-3.019, F.A.C.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan shall ensure that all pregnant women who are infected
                with HIV
                are counseled about and offered the latest antiretroviral regimen
                recommended by the U.S. Department of Health & Human Services (U.S.
                Department of Health & Human Services, Public Health Service Task
                Force Report entitled Recommendations for the Use of Antiretroviral
                Drugs
                in Pregnant HIV-1 Infected Women for Maternal Health and Interventions
                to
                Reduce Perinatal HIV-1 Transmission in the United States. To receive
                a
                copy of the guidelines, contact the DOH, Bureau of HIV/AIDS at (850)
                245-4334, or go to http://aidsinfo.nih.gov/guidelines/).

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan shall ensure that its Providers screen all pregnant Enrollees
                receiving prenatal care for the Hepatitis B surface antigen (HBsAg)
                during
                the first (1st)
                prenatal visit.

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall ensure that the Providers perform a second
                (2nd)
                HBsAg test between twenty-eight (28) and thirty-two (32) weeks of
                pregnancy for all pregnant Enrollees who tested negative at the first
                (1st)
                prenatal visit and are considered high-risk for Hepatitis B infection.
                This test shall be performed at the same time that other routine
                prenatal
                screening is ordered.

            

    

    

    
      	 	
              (b)

            	
              All
                HBsAg-positive women shall be reported to the local CHD and to Healthy
                Start, regardless of their Healthy Start screening
                score.

            

    

    

    
      	 	
              (7)

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

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall ensure that its Providers test infants born to
                HBsAg-positive Enrollees for HBsAg and Hepatitis B surface antibodies
                (anti-HBs) six (6) months after the completion of the vaccine series
                to
                monitor the success or failure of the
                therapy.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall ensure that Providers report to the local CHD a
                positive
                HBsAg result in any child aged twenty-four (24) months or less within
                twenty-four (24) hours of receipt of the positive test
                results.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan shall ensure that infants born to Enrollees who are
                HBsAg-positive are referred to Healthy Start regardless of their
                Healthy
                Start screening score.

            

    

    

    
      	 	
              (8)

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

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall report the following information - name, date of
                birth,
                race, ethnicity, address, infants, contacts, laboratory test performed,
                date the sample was collected, the due date or EDC, whether or not
                the
                Enrollee received prenatal care, and immunization dates for infants
                and
                contacts.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall use the Perinatal Hepatitis B Case and Contact
                Report (DH Form 1876) for reporting purposes.

            

    

    

    
      	 	
              (9)

            	
              The
                Health Plan shall ensure that the PCP maintains all documentation
                of
                Healthy Start screenings, assessments, findings and referrals in
                the
                Enrollees’ Medical Records. The Health Plan shall ensure quick access to
                Enrollees’ Medical Records in the Provider
                Contract.

            

    

    

    
      	 	
              (10)

            	
              The
                Health Plan shall provide the most appropriate and highest level
                of
                quality care for pregnant Enrollees, including, but not limited to,
                the
                following:

            

    

    

    
      	 	
              (a)

            	
              Prenatal
                Care - The Health Plan shall:

            

    

    

    
      	 	
              (i)

            	
              Require
                a pregnancy test and a nursing assessment with referrals to a physician,
                PA or ARNP for comprehensive
                evaluation;

            

    

    

    
      	 	
              (ii)

            	
              Require
                Case Management through the gestational period according to the needs
                of
                the Enrollee; 

            

    

    

    
      	 	
              (iii)

            	
              Require
                any necessary referrals and
                follow-up;

            

    

    

    
      	 	
              (iv)

            	
              Schedule
                return prenatal visits at least every four (4) weeks until the
                thirty-second (32nd) week, every two (2) weeks until the thirty-sixth
                (36th) week, and every week thereafter until delivery, unless the
                Enrollee’s condition requires more frequent visits; 

            

    

    

    
      	 	
              (v)

            	
              Contact
                those Enrollees who fail to keep their prenatal appointments as soon
                as
                possible, and arrange for their continued prenatal
                care;

            

    

    

    
      	 	
              (vi)

            	
              Assist
                Enrollees in making delivery arrangements, if necessary;
                and

            

    

    

    
      	 	
              (vii)

            	
              Ensure
                that all Providers screen all pregnant Enrollees for tobacco use
                and make
                certain that the Providers make available to the pregnant Enrollees
                smoking cessation counseling and appropriate treatment as
                needed.

            

    

    

    
      	 	
              (b)

            	
              Nutritional
                Assessment/Counseling - The Health Plan shall ensure that its Providers
                supply nutritional assessment and counseling to all pregnant Enrollees.
                The Health Plan shall:

            

    

    

    
      	 	
              (i)

            	
              Ensure
                the provision of safe and adequate nutrition for infants by promoting
                breast-feeding and the use of breast milk
                substitutes;

            

    

    

    
      	 	
              (ii)

            	
              Offer
                a mid-level nutrition assessment;

            

    

    

    
      	 	
              (iii)

            	
              Provide
                individualized diet counseling and a nutrition care plan by a public
                health nutritionist, a nurse or physician following the nutrition
                assessment; and

            

    

    

    
      	 	
              (iv)

            	
              Documentation
                of the nutrition care plan in the Medical Record by the person providing
                counseling.

            

    

    

    
      	 	
              (c)

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

            

    

    

    
      	 	
              (i)

            	
              The
                Health Plan shall ensure that all Providers document preterm delivery
                risk
                assessments in the Enrollee’s Medical Record by the twenty-eighth (28th)
                week.

            

    

    

    
      	 	
              (ii)

            	
              If
                the Provider determines that the Enrollee’s pregnancy is high risk, the
                Health Plan shall ensure that the Provider’s obstetrical care during labor
                and delivery includes preparation by all attendants for symptomatic
                evaluation and that the Enrollee progresses through the final stages
                of
                labor and immediate postpartum
                care.

            

    

    

    
      	 	
              (d)

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

            

    

    

    
      	 	
              (i)

            	
              Instilling
                of prophylactic eye medications into each eye of the
                Newborn;

            

    

    

    
      	 	
              (ii)

            	
              When
                the mother is Rh negative, the securing of a cord blood sample for
                type Rh
                determination and direct Coombs
                test;

            

    

    

    
      	 	
              (iii)

            	
              Weighing
                and measuring of the Newborn;

            

    

    

    
      	 	
              (iv)

            	
              Inspecting
                the Newborn for abnormalities and/or
                complications;

            

    

    

    
      	 	
              (v)

            	
              Administering
                of one half milligram of vitamin K;

            

    

    

    
      	 	
              (vi)

            	
              APGAR
                scoring;

            

    

    

    
      	 	
              (vii)

            	
              Any
                other necessary and immediate need for referral in consultation from
                a
                specialty physician, such as the Healthy Start (postnatal) infant
                screen; and

            

    

    

    
      	 	
              (viii)

            	
              Any
                necessary Newborn and infant hearing screenings
                (to be conducted by a licensed audiologist pursuant to Chapter 468,
                F.S.,
                a physician licensed under Chapters 458 or 459, F.S., or an individual
                who
                has completed documented training specifically for newborn hearing
                screenings and who is directly or indirectly supervised by a licensed
                physician or a licensed audiologist).

            

    

    

    
      	 	
              (e)

            	
              Postpartum
                Care - The Health Plan shall:

            

    

    

    
      	 	
              (i)

            	
              Provide
                a postpartum examination for the Enrollee within six (6) weeks after
                delivery;

            

    

    

    
      	 	
              (ii)

            	
              Ensure
                that its Providers supply voluntary family planning, including a
                discussion of all methods of contraception, as
                appropriate;

            

    

    

    
      	 	
              (iii)

            	
              Ensure
                that eligible Newborns are enrolled with the Health Plan and that
                continuing care of the Newborn be provided through the CHCUP program
                component.

            

    

    

    
      	 	
              16.

            	
              Prescribed
                Drug Services

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall make available those drugs and dosage forms listed
                in
                the PDL.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall not arbitrarily deny or reduce the amount, duration
                or
                scope of prescriptions solely based on the Enrollee’s diagnosis, type of
                illness or condition. The Health Plan may place appropriate limits
                on
                prescriptions based on criteria such as Medical Necessity, or for
                the
                purpose of utilization control, provided the Health Plan reasonably
                expects said limits to achieve the purpose of the Prescribed Drug
                Services
                set forth in the Medicaid State Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall make available those drugs not on the PDL, when
                requested and approved, if the drugs on the PDL have been used in
                a step
                therapy sequence or when other documentation is
                provided.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan shall submit an updated PDL to the Agency annually, by
                October
                1 of each Contract Year, and provide thirty (30) days written notice
                of
                any changes to the Bureau of Managed Health Care and Pharmacy
                Services.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall provide to Enrollees, who desire to quit smoking,
                one
                (1) course of nicotine replacement therapy, of twelve (12) weeks
                duration,
                or the manufacturer’s recommended duration, per year. The Health Plan may
                use either nicotine transdermal patches or nicotine
                gum.

            

    

    

    
      	 	
              c.

            	
              If
                the Health Plan has authorization requirements for prescribed drug
                services, the Health Plan shall comply with all aspects of the Settlement
                Agreement to Hernandez,
                et. al. v. Medows
                (case number 02-20964 Civ-Gold/Simonton) (HSA). An HSA situation
                arises
                when an Enrollee attempts to fill a prescription at a participating
                pharmacy location and is unable to receive his/her prescription as
                a
                result of:

            

    

    

    
      	 	
              (1)

            	
              An
                unreasonable delay in filling the
                prescription;

            

    

    

    
      	 	
              (2)

            	
              A
                denial of the prescription;

            

    

    

    
      	 	
              (3)

            	
              The
                reduction of a prescribed good or service;
                and/or

            

    

     

    
      	 	
              (4)

            	
              The
                termination of a prescription.

            

    

    

      

      
        	 	
                d.

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

              

      

       

    

    
      	 	
              (1)

            	
              The
                Health Plan shall maintain a log of all correspondences and communications
                from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log”
                shall contain, at a minimum, the Enrollee’s name, address and telephone
                number and any other contact information, the reason for the participating
                pharmacy location’s denial (an unreasonable delay in filling a
                prescription, a denial of a prescription and/or the termination of
                a
                prescription), the pharmacy’s name (and store number, if applicable), the
                date of the call, a detailed explanation of the final resolution,
                and the
                name of prescribed good or service.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan’s Enrollees are third party beneficiaries for this Section of
                the Contract.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall conduct HSA surveys on an annual basis, of no less
                than
                five percent (5%) of all participating pharmacy locations to ensure
                compliance with the HSA.

            

    

    

    
      	(a)  	
              The
                Health Plan may survey less than five percent (5%), with written
                approval
                from the Agency, if the Health Plan can show that the number of
                participating pharmacies it surveys is a statistically significant
                sample
                that adequately represents the pharmacies that have contracted with
                the
                Health Plan to provide pharmacy
                services.

            

    

    

    
      	(b)  	
              The
                Health Plan shall not include in the HSA Survey any participating
                pharmacy
                location that the Health Plan found to be in complete compliance
                with the
                HSA requirements within the last twelve (12)
                months.

            

    

    

    
      	(c)  	
              The
                Health Plan shall require all participating pharmacy locations that
                fail
                any aspect of the HSA survey to undergo mandatory training within
                six (6)
                months and then be re-evaluated within one (1) month of the Health
                Plan’s
                HSA training to ensure that the participating pharmacy location is
                in
                compliance with the HSA.

            

    

    

    
      	(d)  	
              The
                Health Plan shall ensure that it complies with all aspects and surveying
                requirements set forth in Policy Transmittal 06-01, Hernandez Settlement
                Requirements, an electronic copy of which can be found
                at:

            

    

    

    http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_prov.shtml

    

    
      	 	
              (4)

            	
              The
                Health Plan shall offer to train all new and existing participating
                pharmacy locations regarding the HSA
                requirements.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan may delegate any or all functions to one (1) or more
                Pharmacy
                Benefits Administrators (PBA). Before entering into a Subcontract,
                the
                Health Plan shall:

            

    

    

    
      	(a)  	
              Provide
                a copy of the model Subcontract between the Health Plan and the PBA
                to the
                Bureau of Managed Health Care; 

            

    

    

    
      	(b)  	
              Receive
                written approval from the Bureau of Managed Health Care for the use
                of
                said model Subcontract; and 

            

    

    

    
      	(c)  	
              Work
                with the Fiscal Agent to integrate the
                systems.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall reimburse all pharmacies for the cost of a brand
                name
                drug if: 

            

    

    

    
      	 	
              (1)

            	
              Writes
                in his/her own handwriting on the valid prescription that the “Brand Name
                is Medically Necessary” (pursuant to Section 465.025, F.S.); and
                

            

    

    

    
      	 	
              (2)

            	
              Submits
                a completed “Multisource Drug and Miscellaneous Prior Authorization” form
                to the Health Plan indicating that the Enrollee has had an adverse
                reaction to a generic drug or has had, in the prescriber’s medical
                opinion, better results when taking the brand-name
                drug.

            

    

    

    
      	 	
              f.

            	
              Effective
                September 1, 2006, hemophilia-related drugs identified by the Agency
                for
                distribution through the Hemophilia Disease Management Pilot Program
                will
                be reimbursed on a Fee-for-Service basis. Upon implementation of
                the
                Hemophilia Disease Management Pilot Program, the Health Plan shall
                coordinate the care of its’ Enrollees with Agency-approved organizations
                and shall not be responsible for the distribution of Hemophilia-related
                drugs.

            

    

    

    
      	 	
              g.

            	
              Health
                Plans shall submit pharmacy encounter data in a format supplied by
                the
                Agency on an ongoing quarterly payment schedule, as specified in
                Section
                XII of this Contract. For example, data for all claims paid during
                04/01/06 and 06/30/06 is due to the Agency by
                07/31/06.

            

    

    

    
      	 	
              17.

            	
              Quality
                Enhancements 

            

    

    

    
      	 	
              a.

            	
              In
                addition to the covered services specified in this Section, the Health
                Plan shall offer Quality Enhancements ("QEs") to Enrollees as specified
                below.

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall offer QEs in community settings that are accessible
                to
                Enrollees.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall inform Enrollees and Providers of the QEs, and
                how to
                access services related to QEs, through the Enrollee and Provider
                Handbooks.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall develop and maintain written policies and procedures
                to
                implement QEs.

            

    

    
      

      
        	 	
                4.

              	
                 The
                  Health Plan may cosponsor the annual training of Providers, provided
                  that
                  the training meets the Provider training requirements for the programs
                  listed below. The Plan is encouraged to actively collaborate with
                  community agencies and organizations, including CHD's, local Early
                  Intervention Programs, Healthy Start Coalitions and local school
                  districts
                  in offering these
                  services.

              

      

    

    

    
      	 	
              5.

            	
              If
                the Health Plan involves the Enrollee in an existing community program
                for
                purposes of meeting the QE requirement, the Health Plan shall document
                referrals to the community program, shall follow-up on the Enrollee's
                receipt of services from the community program and record the Enrollee's
                involvement in the Enrollee’s Medical
                Record.

            

    

    

    
      	 	
              6.

            	
              QE
                programs shall include, but not be limited to, the
                following:

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (a)

            	
              Children's
                Programs shall promote increased utilization of prevention and early
                intervention services for at-risk Enrollees with Children/Adolescents
                in
                the target population. The Health Plan shall approve claims for services
                recommended by the Early Intervention Program when they are Covered
                Services and Medically Necessary.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall offer annual training to Providers that promote
                proper
                nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention
                and
                early intervention services.

            

    

    

    
      	 	
              (2)

            	
              Domestic
                Violence - The Health Plan shall ensure that PCPs screen Enrollees
                for
                signs of domestic violence and shall offer referral services to applicable
                domestic violence prevention community agencies.
                

            

    

    

    
      	 	
              (3)

            	
              Pregnancy
                Prevention - The Health Plan shall conduct regularly scheduled Pregnancy
                Prevention programs, or shall make a good faith effort to involve
                Enrollees in existing community Pregnancy Prevention programs, such
                as the
                Abstinence Education Program. The programs shall be targeted towards
                teen
                Enrollees, but shall be open to all Enrollees, regardless of age,
                gender,
                pregnancy status or parental consent.

            

    

    

    
      	 	
              (4)

            	
              Prenatal/Postpartum
                Pregnancy Programs - The Health Plan shall provide regular home visits,
                conducted by a home health nurse or aide, and counseling and educational
                materials to pregnant and postpartum Enrollees who are not in compliance
                with the Health Plan's prenatal and postpartum programs. The Health
                Plan
                shall coordinate its efforts with the local Healthy Start Care Coordinator
                to prevent duplication of services.

            

    

    

    
      	 	
              (5)

            	
              Smoking
                Cessation - The Health Plan shall conduct regularly scheduled Smoking
                Cessation programs as an option for all Enrollees, or the Health
                Plan
                shall make a good faith effort to involve Enrollees in existing community
                or Smoking Cessation programs. The Health Plan shall provide Smoking
                Cessation counseling to Enrollees. The Health Plan shall provide
                Participating PCPs with the Quick Reference Guide to assist in identifying
                tobacco users and supporting and delivering effective Smoking Cessation
                interventions (The Quick Reference Guide is a distilled version of
                the
                Public Health Service sponsored Clinical Practice Guideline, Treating
                Tobacco Use & Dependence. The Plan can obtain copies of the Quick
                Reference guide by contacting the DHHS, Agency for Health Care Research
                & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O.
                Box 8547, Silver Spring, MD 20907).

            

    

    

    
      	 	
              (6)

            	
              Substance
                Abuse - The Health Plan shall offer Substance Abuse screening training
                to
                its Providers on an annual basis. 

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan shall have all PCPs screen Enrollees for signs of Substance
                Abuse as part of prevention evaluation at the following
                times:

            

    

    

    
      	 	
              (i)

            	
              Initial
                contact with a new Enrollee;

            

    

    

    
      	 	
              (ii)

            	
              Routine
                physical examinations;

            

    

    

    
      	 	
              (iii)

            	
              Initial
                prenatal contact;

            

    

    

    
      	 	
              (iv)

            	
              When
                the Enrollee evidences serious over-utilization of medical, surgical,
                trauma or emergency services; and

            

    

    

    
      	 	
              (v)

            	
              When
                documentation of emergency room visits suggests the
                need.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall offer targeted Enrollees either community or Health
                Plan
                sponsored Substance Abuse programs.

            

    

    

    
      	 	
              18.

            	
              Protective
                Custody 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide a physical screening within seventy-two
                (72)
                hours, or immediately if required, for all enrolled Children/Adolescents
                taken into protective custody, emergency shelter or the foster care
                program by DCF. See
                Rule 65C-12.002, F.A.C.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall provide these required examinations, or, if unable
                to do
                so within the required time frames, must approve the out-of-network
                claim
                and forward it to the Agency and/or its Agent.

            

    

    

    
      	 	
              c.

            	
              For
                all CHCUP screenings for Children/Adolescents whose Enrollment and
                Medicaid eligibility are undetermined at the time of entry into the
                care
                and custody of DCF, and who are later determined to be Enrollees
                at the
                time the examinations took place, the Health Plan shall approve the
                claims
                and forward them to the Agency and/or the Fiscal Agent.
                

            

    

    

    
      	 	
              19.

            	
              Therapy
                Services 

            

    

    

    
      	 	
              a.

            	
              Medicaid
                therapy services are physical, speech-language (including augmentative
                and
                alternative communication systems), occupational and respiratory
                therapies. The Health Plan shall cover therapy services consistent
                with
                handbook requirements. Medicaid pays only for therapy services that
                are
                Medically Necessary for the provision of therapy evaluations and
                individual therapy treatment. Therapy services are limited to
                Children/Adolescents under the age of twenty-one (21). Adults are
                covered
                for physical and respiratory therapy services under the outpatient
                Hospital services program. The Agency shall reimburse schools
                participating in the certified school match program for school-based
                therapy services rendered to Enrollees. The provision of school-based
                therapy services to an Enrollee does not replace, substitute or fulfill
                a
                service prescription or doctors' orders for therapy services external
                to
                the Health Plan. The Health Plan
                shall:

            

    

     

    
      	 	
              (1)

            	
              Refer
                Enrollees to appropriate Providers for further assessment and treatment
                of
                conditions;

            

    

    

    
      	 	
              (2)

            	
              Offer
                Enrollees scheduling assistance in making treatment appointments
                and
                obtaining transportation; and

            

    

    

    
      	 	
              (3)

            	
              Provide
                for care management in order to follow the Enrollee’s progress from
                screening through his/her course of
                treatment.

            

    

    

    
      	 	
              20.

            	
              Transportation
                Services

            

    

    

    
      	 	
              a.

            	
              Transportation
                services are an Optional Service (as described in Section V.B., Optional
                Services, above). Transportation services include the arrangement
                and
                provision of an appropriate mode of Transportation for Enrollees
                to
                receive medical care services. The
                Health Plan shall comply with the limitations and exclusions in the
                Medicaid Transportation Coverage, Limitations & Reimbursement Handbook
                (the “Transportation Handbook”), including Emergency Transportation
                Services. In any instance where compliance conflicts with the terms
                of
                this Contract, the Contract terms shall take precedence. In
                no instance may the limitations or exclusions imposed by the Health
                Plan
                be more stringent than those specified in the Transportation Handbook.
                

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall have the option to provide
                Transportation services directly through the Health Plan’s network of
                Transportation Providers, or through a Provider contract relationship,
                which may include the CTD.

            

    

    

    
      	 	
              c.

            	
              Regardless
                of whether the Health Plan chooses to coordinate with a Transportation
                Provider or provide Transportation services directly, the Health
                Plan
                shall be responsible for monitoring the provision of services. The
                Health
                Plan:

            

    

    

    
      	 	
              (1)

            	
              Shall
                assure that Transportation providers are appropriately licensed and
                insured in accordance with the provisions of the Transportation
                Handbook;

            

    

    

    
      	 	
              (2)

            	
              Must
                provide Transportation Services for all Enrollees seeking necessary
                Medicaid services;

            

    

    

    
      	 	
              (3)

            	
              Is
                not obligated to follow the requirements of the Commission for the
                Transportation Disadvantaged or the Transportation Coordinating Boards
                as
                set forth in Chapter 427, F.S., unless the Health Plan has chosen
                to
                coordinate services with the CTD;

            

    

    

    
      	 	
              (4)

            	
              Shall
                be responsible for the cost of transporting an Enrollee from a
                nonparticipating facility or Hospital to a participating facility
                or
                Hospital if the reason for transport is solely for the Health Plan's
                convenience; and

            

    

    

    
      	 	
              (5)

            	
              Shall
                approve claims for Transportation Providers in accordance with the
                requirements set forth in this
                Contract.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan may delegate the provision of Transportation Services
                to a
                third party.

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide a copy of the model Participating Transportation
                Subcontract to the Bureau of Managed Health
                Care.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan may subcontract with more than one (1) Transportation
                Provider.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall maintain oversight of any third party providing
                services
                on the Health Plan's behalf.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall provide the following non-emergency Transportation,
                at a
                minimum, as part of its line of Transportation services (as defined
                in the
                Transportation Handbook):

            

    

    

    
      	 	
              (1)

            	
              Ambulatory
                Transportation;

            

    

    

    
      	 	
              (2)

            	
              Long
                haul ambulatory Transportation;

            

    

    

    
      	 	
              (3)

            	
              Wheelchair
                Transportation;

            

    

    

    
      	 	
              (4)

            	
              Stretcher
                Transportation;

            

    

    

    
      	 	
              (5)

            	
              Multiload
                Transportation;

            

    

    

    
      	 	
              (6)

            	
              Mass
                transit Transportation;

            

    

    

    
      	 	
              (7)

            	
              Over-the-road
                bus;

            

    

    

    
      	 	
              (8)

            	
              Over-the-road
                train;

            

    

    

    (9) Private
      volunteer Transportation; 

    

    
      	 	
              (10)

            	
              Escort
                services (including medical escort);
                and

            

    

    

    
      	 	
              (11)

            	
              Commercial
                air carrier Transportation.

            

    

    

    
      	 	
              f.

            	
              Before
                providing Transportation services, the Health Plan shall provide
                to the
                Bureau of Managed Health Care a copy of its policies and procedures
                relating to the following:

            

    

    

    
      	 	
              (1)

            	
              How
                the Health Plan will determine eligibility for each
                Enrollee;

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's course of action as to how it will determine what type
                of
                Transportation to provide to a particular
                Enrollee;

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan's procedure for providing Prior Authorization to Enrollees
                requesting Transportation services;

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan's comprehensive employee training program to investigate
                potential Fraud;

            

    

    

    
      	 	
              (5)

            	
              How
                the Health Plan will review Transportation Providers who demonstrate
                a
                pattern or practice of:

            

    

    

    
      	 	
              (a)

            	
              Falsified
                encounter or service reports; 

            

    

    

    
      	 	
              (b)

            	
              Overstated
                reports or up-coded levels of service;
                and/or

            

    

    

    
      	 	
              (c)

            	
              Fraud
                or Abuse, as defined in section 409.913,
                F.S.

            

    

    

    
      	 	
              (6)

            	
              How
                the Health Plan will review Transportation Providers
                that:

            

    

    

    
      	 	
              (a)

            	
              Alter,
                falsify or destroy records prior to the end of the five (5) year
                records
                retention requirement;

            

    

    

    
      	 	
              (b)

            	
              Make
                false statements about credentials;

            

    

    

    
      	 	
              (c)

            	
              Misrepresent
                medical information to justify
                referrals;

            

    

    

    
      	 	
              (d)

            	
              Fail
                to provide scheduled Transportation for Enrollees;
                

            

    

    

    
      	 	
              (e)

            	
              Charge
                Enrollees for Covered Services;
                and/or

            

    

    

    
      	 	
              (f)

            	
              Have
                committed, or been suspected of committing, Fraud or Abuse, as defined
                in
                Section 409.913, F.S.

            

    

    

    
      	 	
              (7)

            	
              How
                the Health Plan will provide Transportation Services outside of the
                Health
                Plan's service area. The Health Plan shall state clearly the guidelines
                it
                will use in order to control costs when providing Transportation
                Services
                outside of the Health Plan's service
                area.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall report immediately, in writing to the Agency Contract
                Manager, the Bureau of Medicaid Program Integrity (MPI), and Medicaid
                Fraud Control Unit (MFCU), any aspect of Transportation Service delivery,
                by any Transportation services provider, or any adverse or untoward
                incident (See
                section 641.55, F.S.).
                The Health Plan shall also report, immediately upon identification,
                in
                writing to the Agency Contract Manager, the MPI and the MFCU, all
                instances of suspected Enrollee or Transportation Services Provider
                fraud
                or abuse (as
                defined in Section 409.913, F.S.)

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              h.

            	
              Insurance,
                Safety Requirements and Standards (including,
                but not limited to, 41-2, F.A.C.)

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure compliance with the minimum liability insurance
                requirement of $100,000 per person and $200,000 per incident for
                all
                Transportation services purchased or provided for the Transportation
                disadvantaged through the Health Plan. See Section 768.28(5), F.S.
                The
                Health Plan shall indemnify and hold harmless the local, State, and
                federal governments and their entities and the Agency from any liabilities
                arising out of or due to an accident or negligence on the part of
                the
                Health Plan and/or all Transportation Providers under contract to
                the
                Health Plan. The Health Plan may act as a Transportation Provider,
                in
                which case it must follow all requirements set forth below for
                Transportation Providers.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan, and all Transportation Providers, shall ensure that
                all
                operations and services are in compliance with all federal and State
                safety requirements, including, but not limited to, Section 341.061(2)(a),
                F.S., and Chapter 14-90, F.A.C.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan, and all Transportation Providers, shall ensure continuing
                compliance with all applicable State or federal laws relating to
                drug
                testing, including, but not limited to, to Section 112.0455, F.S.,
                Rule
                14-17.012, Chapters 59A-24 and 60L-19, F.A.C., 41 USC 701, 49 CFR,
                Parts
                29 and 382, and 46 CFR, Parts 4, 5, 14, and
                16.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan and all Transportation Providers shall adhere to the
                following
                standards, including, but not limited
                to:

            

    

    

    
      	 	
              (a)

            	
              Drug
                and alcohol testing for safety sensitive job positions relating to
                the
                provision of Transportation services regarding pre-employment,
                randomization, post-accident, and reasonable suspicion as required
                by the
                Federal Highway Administration and the Federal Transit
                Administration;

            

    

    

    
      	 	
              (b)

            	
              Use
                of child safety restraint devices, where the use of such devices
                would not
                interfere with the safety of a child (for example, a child in a
                wheelchair);

            

    

    

    
      	 	
              (c)
                

            	
              Enrollee
                property that can be carried by the passenger and/or driver, and
                can be
                stowed safely on the vehicle, shall be transported with the passenger
                at
                no additional charge. The driver shall provide Transportation of
                the
                following items, as applicable, within the capabilities of the vehicle:
                

            

    

    

    
      	 	
              (i)

            	
              Wheelchairs;

            

    

    

    
      	 	
              (ii)

            	
              Child
                seats;

            

    

    

    
      	 	
              (iii)

            	
              Stretchers;

            

    

    

    
      	 	
              (iv)

            	
              Secured
                oxygen;

            

    

    

    
      	 	
              (v)

            	
              Personal
                assistive devices; and/or

            

    

    

    
      	 	
              (vi)

            	
              Intravenous
                devices.

            

    

    

    
      	 	
              (d)

            	
              Vehicle
                transfer points shall provide shelter, security, and safety of
                Enrollees;

            

    

    

    
      	 	
              (e)

            	
              Maintain
                inside all vehicles copies of the Health Plan’s toll-free phone number for
                Enrollee complaints;

            

    

    

    
      	 	
              (f)

            	
              The
                interior of all vehicles shall be free from dirt, grime, oil, trash,
                torn
                upholstery, damaged or broken seats, protruding metal or other objects
                or
                materials which could soil items placed in the vehicle or provide
                discomfort for Enrollees;

            

    

    

    
      	 	
              (g)

            	
              Maintain
                a passenger/trip database for each Enrollee transported by the Health
                Plan/Transportation Provider;

            

    

    

    
      	 	
              (h)

            	
              Ensure
                adequate seating for paratransit services for each Enrollee and escort,
                child, or personal care attendant, and shall ensure that the vehicle
                does
                not transport more passengers than the registered passenger seating
                capacity in a vehicle at any time; 

            

    

    

    
      	 	
              (i)

            	
              Ensure
                adequate seating space for transit services for each Enrollee and
                escort,
                child, or personal care attendant, and shall ensure that transit
                vehicles
                provide adequate seating or standing space to each rider, and shall
                ensure
                that the vehicle does not transport more passengers than the registered
                passenger seating or standing capacity in a vehicle at any
                time;

            

    

    

    
      	 	
              (j)

            	
              Drivers
                for paratransit services shall identify themselves by name and company
                in
                a manner that is conducive to communications with the specific passenger,
                upon pickup of each Enrollee, group of Enrollees, or representative,
                guardian, or associate of the Enrollee, except in situations where
                the
                driver regularly transports the Enrollee on a recurring
                basis;

            

    

    

    
      	 	
              (k)
                

            	
              Each
                driver must have photo identification that is viewable by the passenger.
                Name patches, inscriptions or badges that affix to driver clothing
                are
                acceptable. For transit services, the driver photo identification
                shall be
                in a conspicuous location in the
                vehicle;

            

    

    

    
      	 	
              (l)

            	
              The
                paratransit driver shall provide the Enrollee with boarding assistance,
                if
                necessary or requested, to the seating portion of the vehicle. The
                boarding assistance shall include, but not be limited to, opening
                the
                vehicle door, fastening the seat belt or utilization of wheel chair
                securement devices, storage of mobility assistive devices and closing
                the
                vehicle door. In the door-through-door paratransit service category,
                the
                driver shall open and close doors to buildings, except in situations
                in
                which assistance in opening and/or closing building doors would not
                be
                safe for passengers remaining in the vehicle. The driver shall provide
                assisted access in a dignified manner. Drivers may not assist wheelchair
                passengers up or down more than one (1) step, unless it can be performed
                safely as determined by the Enrollee, guardian, and
                driver;

            

    

    

    
      	 	
              (m)

            	
              Smoking,
                eating and drinking are prohibited in any vehicle, except in cases
                in
                which, as a Medical Necessity, the Enrollee requires fluids or sustenance
                during transport;

            

    

    

    
      	 	
              (n)

            	
              Ensure
                that all vehicles are equipped with two-way communications, in good
                working order and audible to the driver at all times, by which to
                communicate with the Transportation services hub or base of
                operations;

            

    

    

    
      	 	
              (o)

            	
              Ensure
                that all vehicles have working air conditioners and heaters. The
                Health
                Plan shall ensure that all vehicles that do not have a working air
                conditioner or heater are removed from the vehicle pool and scheduled
                for
                repair or replacement;

            

    

    

    
      	 	
              (p)

            	
              Develop
                and implement a first aid policy and cardiopulmonary resuscitation
                policy;

            

    

    

    
      	 	
              (q)

            	
              Ensure
                that all drivers providing Transportation services undergo a background
                screening;

            

    

    

    
      	 	
              (r)

            	
              Establish
                Enrollee pick-up windows and communicate these windows to Transportation
                Providers and Enrollees;

            

    

    

    
      	 	
              (s)
                

            	
              Establish
                a minimum 24-hour advance notification policy to obtain Transportation
                Services. The Health Plan shall communicate said policy to Transportation
                Providers and Enrollees;

            

    

    

    
      	 	
              (t)

            	
              Establish
                a performance measure to evaluate the safety of the Transportation
                services provided by Transportation
                Providers;

            

    

    

    
      	 	
              (u)

            	
              Establish
                a performance measure to evaluate the reliability of the vehicles
                utilized
                by Transportation Providers;

            

    

    

    
      	 	
              (v)

            	
              Establish
                a performance measure to evaluate the quality of service provided
                by a
                Transportation Provider;

            

    

    

    
      	 	
              (w)

            	
              The
                Health Plan shall submit these performance measures to the Agency
                for
                written approval by the end of the first month of this contract
                term;

            

    

    

    
      	 	
              (x)

            	
              The
                Health Plan shall report the results of these evaluations to the
                Agency as
                described in Section XII, Reporting Requirements;
                and

            

    

    

    
      	 	
              (y)

            	
              Ensure
                that all drivers speak English.

            

    

    

    
      	 	
              i.

            	
              Operational
                Standards - Each Health Plan shall implement, or ensure that each
                Transportation Provider has implemented, policies and procedures
                that, at
                a minimum, comply with the following (for
                reference, see 14-90, F.A.C.):

            

    

    

    
      	 	
              (1)

            	
              Address
                the following safety elements and
                requirements:

            

    

    

    
      	 	
              (a)

            	
              Safety
                policies and responsibilities;

            

    

    

    
      	 	
              (b)

            	
              Vehicle
                and equipment standards and procurement
                criteria;

            

    

    

    
      	 	
              (c)

            	
              Operational
                standards and procedures;

            

    

    

    
      	 	
              (d)

            	
              Vehicle
                driver and employee selection;

            

    

    

    
      	 	
              (e)

            	
              Driving
                requirements;

            

    

    

    
      	 	
              (f)

            	
              Vehicle
                driver and employee training;

            

    

    

    
      	 	
              (g)

            	
              Vehicle
                maintenance;

            

    

    

    
      	 	
              (h)

            	
              Investigations
                of events described below;

            

    

    

    
      	 	
              (i)

            	
              Hazard
                identification and resolution;

            

    

    

    
      	 	
              (j)

            	
              Equipment
                for transporting wheelchairs;

            

    

    

    
      	 	
              (k)

            	
              Safety
                data acquisition and analysis;

            

    

    

    
      	 	
              (l)

            	
              Safety
                standards for private contract vehicle transit system(s) that provide(s)
                Transportation services for compensation as a result of a contractual
                agreement with the vehicle transit
                system.

            

    

    

    
      	 	
              (2)

            	
              Shall
                submit an annual safety certification to the Agency verifying the
                following:

            

    

    

    
      	 	
              (a)

            	
              Adoption
                of policies and procedures that, at a minimum, establish standard
                set
                forth in this Section; and

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan/Transportation Provider is in full compliance with the
                policies and procedures relating to Transportation services, and
                that it
                has performed annual safety inspections on all vehicles operated
                by the
                Health Plan/Transportation Provider, by persons meeting the requirements
                set forth below.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall suspend immediately a Transportation Provider if,
                in the
                sole discretion of the Health Plan, and at any time, continued use
                of that
                Transportation Provider, is unsafe for passenger service or poses
                a
                potential danger to public safety.

            

    

    

    
      	 	
              (4)

            	
              Address
                the following security
                requirements:

            

    

    

    
      	 	
              (a)

            	
              Security
                policies, goals, and objectives;

            

    

    

    
      	 	
              (b)

            	
              Organization,
                roles, and responsibilities;

            

    

    

    
      	 	
              (c)

            	
              Emergency
                management processes and procedures for mitigation, preparedness,
                response, and recovery;

            

    

    

    
      	 	
              (d)

            	
              Procedures
                for investigation of any event involving a vehicle, or taking place
                on
                vehicle transit system controlled property, resulting in a fatality,
                injury, or property damage as discussed
                below;

            

    

    

    
      	 	
              (e)

            	
              Procedures
                for the establishment of interfaces with emergency response
                organizations;

            

    

    

    
      	 	
              (f)

            	
              Employee
                security and threat awareness training
                programs;

            

    

    

    
      	 	
              (g)

            	
              Conduct
                and participate in emergency preparedness drills and exercises;
                and

            

    

    

    
      	 	
              (h)

            	
              Security
                requirements for Transportation Providers that provide Transportation
                services for compensation as a result of a contractual agreement
                with the
                Health Plan/Transportation
                Provider.

            

    

    

    
      	 	
              (5)

            	
              Shall
                establish criteria and procedures for selection, qualification, and
                training of all drivers. The criteria shall include, at a minimum,
                the
                following:

            

    

    

    
      	 	
              (a)

            	
              Driver
                qualifications and background checks with minimum hiring
                standards;

            

    

    

    
      	 	
              (b)

            	
              Driving
                and criminal background checks for all new
                drivers;

            

    

    

    
      	 	
              (c)

            	
              Verification
                and documentation of valid driver licenses for all employees who
                drive
                vehicles;

            

    

    

    
      	 	
              (d)

            	
              Training
                and testing to demonstrate and ensure adequate skills and capabilities
                to
                safely operate each type of vehicle or vehicle combination before
                driving
                unsupervised;

            

    

    

    
      	 	
              (e)

            	
              At
                a minimum, drivers shall be given explicit instructional and procedural
                training and testing in the following
                areas:

            

    

    

    
      	 	
              (i)

            	
              The
                Health Plan’s/Transportation Provider’s safety and operational policies
                and procedures;

            

    

    

    
      	 	
              (ii)

            	
              Operational
                vehicle and equipment inspections;

            

    

    

    
      	 	
              (iii)

            	
              Vehicle
                equipment familiarization;

            

    

    

    
      	 	
              (iv)

            	
              Basic
                operations and maneuvering;

            

    

    

    
      	 	
              (v)

            	
              Boarding
                and alighting passengers;

            

    

    

    
      	 	
              (vi)

            	
              Operation
                of wheelchair lift and other special equipment and driving
                conditions;

            

    

    

    
      	 	
              (vii)

            	
              Defensive
                driving;

            

    

    

    
      	 	
              (viii)

            	
              Passenger
                assistance and securement;

            

    

    

    
      	 	
              (ix)

            	
              Handling
                of emergencies and security threats;
                and

            

    

    

    
      	 	
              (x)

            	
              Security
                and threat awareness.

            

    

    

    
      	 	
              (f)

            	
              Shall
                provide written operational and safety procedures to all vehicle
                drivers
                before the drivers are allowed to drive unsupervised. These procedures
                and
                instructions shall address, at a minimum, the
                following:

            

    

    

    
      	 	
              (i)

            	
              Communication
                and handling of unsafe conditions, security threats, and
                emergencies;

            

    

    

    
      	 	
              (ii)

            	
              Familiarization
                and operation of safety and emergency equipment, wheelchair lift
                equipment, and restraining devices;
                and

            

    

    

    
      	 	
              (iii)

            	
              Application
                and compliance with applicable federal and State rules and regulations.
                The provisions in Sections V.E.20.i.(5)(e) and (f), above, shall
                not apply
                to personnel licensed and authorized by the Plan/Transportation Provider
                to drive, move, or road test a vehicle in order to perform repairs
                or
                maintenance services where it has been determined that such temporary
                operation does not create an unsafe operating condition or create
                a hazard
                to public safety.

            

    

    

    
      	 	
              (g)

            	
              Shall
                maintain the following records for at least five (5)
                years:

            

    

    

    
      	 	
              (i)

            	
              Records
                of vehicle driver background checks and
                qualifications;

            

    

    

    
      	 	
              (ii)

            	
              Detailed
                descriptions of training administered and completed by each vehicle
                driver; 

            

    

    

    
      	 	
              (iii)

            	
              A
                record of each vehicle driver’s duty status, which shall include total
                days worked, on-duty hours, driving hours and time of reporting on-
                and
                off-duty each day; and

            

    

    

    
      	 	
              (iv)

            	
              Any
                documents required to be prepared by this
                Contract.

            

    

    

    
      	 	
              (h)

            	
              Shall
                establish a drug-free workplace policy statement, in accordance with
                49
                CFR Part 29 and a substance abuse management and testing
                program, in
                accordance with 49 CFR Parts 40 and 655; and

            

    

    

    
      	 	
              (i)

            	
              Shall
                require that drivers write and submit a daily vehicle inspection
                report,
                pursuant to Rule 14-90.006, F.A.C. 

            

    

    

    
      	 	
              (6)

            	
              Shall
                establish a maintenance policy and procedures for preventative and
                routine
                maintenance for all vehicles. The maintenance policy and procedures
                shall
                ensure, at a minimum, that:

            

    

    

    
      	 	
              (a)

            	
              All
                vehicles, all parts and accessories on such vehicles, and any additional
                parts and accessories which may affect the safety of vehicle operation,
                including frame and frame assemblies, suspension systems, axles and
                attaching parts, wheels and rims, and steering systems, are regularly
                and
                systematically inspected, maintained and lubricated in accordance
                with the
                standards developed and established according to the vehicle
                manufacturer’s recommendations and
                requirements;

            

    

    

    
      	 	
              (b)

            	
              That
                a recording and tracking system is established for the types of
                inspections, maintenance, and lubrication intervals, including the
                date or
                mileage when these services are due. Required maintenance inspections
                shall be more comprehensive than daily inspections performed by the
                driver;

            

    

    

    
      	 	
              (c)

            	
              That
                proper preventive maintenance is performed when on all vehicles;
                and

            

    

    

    
      	 	
              (d)

            	
              That
                the Health Plan/Transportation Provider maintains and provides written
                documentation of preventive maintenance, regular maintenance, inspections,
                lubrication, and repairs performed for each vehicle under their control.
                Such records shall be maintained by the Health Plan/Transportation
                Provider for at least five (5) years and include, at a minimum, the
                following information:

            

    

    

    
      	 	
              (i)

            	
              Identification
                of the vehicle, including make, model, and license number or other
                means
                of positive identification and
                ownership;

            

    

    

    
      	 	
              (ii)

            	
              Date,
                mileage, and type of inspection, maintenance, lubrication, or repair
                performed;

            

    

    

    
      	 	
              (iii)

            	
              Date,
                mileage, and description of each inspection, maintenance, and lubrication
                intervals performed;

            

    

    

    
      	 	
              (iv)

            	
              If
                not owned by the Health Plan/Transportation Provider, the name of
                any
                person or lessor furnishing any vehicle;
                and

            

    

    

    
      	 	
              (v)

            	
              The
                name and address of any entity or contractor performing an inspection,
                maintenance, lubrication, or
                repair.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan/Transportation Provider shall investigate, or cause to
                be
                investigated, any event involving a vehicle or taking place on Health
                Plan/Transportation Provider controlled property resulting in a fatality,
                injury, or property damage as
                follows:

            

    

    

    
      	 	
              (a)

            	
              A
                fatality, where an individual is confirmed dead, within three (3)
                days of
                a Transportation services related event, excluding suicides and deaths
                from illnesses. The Health Plan must file detailed report of the
                incident
                with the Agency within ten (10) days of the event (see Section 641.55(6),
                F.S.);

            

    

    

    
      	 	
              (b)

            	
              Injuries
                requiring immediate medical attention away from the scene for two
                (2) or
                more individuals;

            

    

    

    
      	 	
              (c)

            	
              Property
                damage to Health Plan/Transportation Provider vehicles, other Health
                Plan/Transportation Provider property or facilities, or any other
                property, except the Health Plan/Transportation Provider shall have
                the
                discretion to investigate events resulting in property damage totaling
                less than $1,000; 

            

    

    

    
      	 	
              (d)

            	
              Evacuation
                of a vehicle due where there is imminent danger to passengers on
                the
                vehicle, excluding evacuations due to vehicle operation
                issues;

            

    

    

    
      	 	
              (e)

            	
              Each
                investigation shall be documented in a final report that includes
                a
                description of investigation activities, identified causal factors
                and a
                corrective action plan;

            

    

    

    
      	 	
              (i)

            	
              Each
                corrective action plan shall identify the action to be taken by the
                Health
                Plan/Transportation Provider and the schedule for its implementation;
                and

            

    

    

    
      	 	
              (ii)

            	
              The
                Health Plan/Transportation Provider must monitor and track the
                implementation of each corrective action
                plan.

            

    

    

    
      	 	
              (f)

            	
              The
                Health Plan/Transportation Provider shall maintain all investigation
                reports, corrective action plans, and related supporting documentation
                for
                a minimum of five (5) years from the date of completion of the
                investigation.

            

    

    

    
      	 	
              j.

            	
              Medical
                Examinations for Drivers - The Health Plan/Transportation Provider
                shall
                establish medical examination requirements for all applicants for
                driver
                positions and for existing drivers. The medical examination requirements
                shall include a pre-employment examination for applicants, an examination
                at least once every two (2) years for existing drivers, and a return
                to
                duty examination for any driver prior to returning to duty after
                having
                been off duty for thirty (30) or more days due to an illness, medical
                condition, or injury.

            

    

    

    
      	 	
              (1)

            	
              Medical
                examinations may be performed and recorded according to qualification
                standards adopted by the Health Plan/Transportation Provider, provided
                the
                medical examination qualification standards adopted by the Health
                Plan/Transportation Provider meet or exceed those provided in Department
                Form Number 725-030-11, Medical Examination Report for Bus Transit
                System
                Driver, Rev. 07/05, hereby incorporated by reference. Copies of Form
                Number 725-030-11 are available from the Florida Department of
                Transportation, Public Transit Office, 605 Suwannee Street, Mail
                Station
                26, Tallahassee, Florida 32399-0450 or on-line at
                www.dot.state.fl.us/transit.

            

    

    

    
      	 	
              (2)

            	
              Medical
                examinations shall be performed by a Doctor of Medicine or Osteopathy,
                a
                Physician Assistant (PA) or ARNP licensed or certified by the State
                of
                Florida. The examination shall be conducted in person, and not via
                the
                Internet. If medical examinations are performed by a PA or ARNP,
                they must
                be performed under the supervision or review of a Doctor of Medicine
                or
                Osteopathy.

            

    

    

    
      	 	
              (a)

            	
              An
                ophthalmologist or optometrist licensed by the State of Florida may
                perform as much of the examination as pertains to visual acuity,
                field of
                vision and color recognition.

            

    

    

    
      	 	
              (b)

            	
              Upon
                completion of the examination, the examining medical professional
                shall
                complete, sign, and date the medical examination
                report.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall have on file proof of medical
                examination, i.e., a completed and signed medical examination report
                for
                each driver, dated within the past twenty-four (24) months. Medical
                examination reports of employee drivers shall be maintained by the
                Health
                Plan/Transportation Provider for a minimum of five (5) years from
                the date
                of the examination.

            

    

    

    
      	 	
              k.

            	
              Operational
                and Driving Requirements

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall not permit a driver to
                drive a
                vehicle when such driver’s license has been suspended, canceled or
                revoked. The Health Plan/Transportation Provider shall require a
                driver
                who receives a notice that his or her license to operate a motor
                vehicle
                has been suspended, canceled, or revoked notify his or her employer
                of the
                contents of the notice immediately, and no later than the end of
                the
                business day following the day he or she received the
                notice.

            

    

    

    
      	 	
              (2)

            	
              At
                all times, the Health Plan/Transportation Provider shall operate
                vehicles
                in compliance with applicable traffic regulations, ordinances and
                laws of
                the jurisdiction in which they are being
                operated.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall not permit or require a
                driver
                to drive more than twelve (12) hours in any one twenty-four (24)
                hour
                period, or drive after having been on duty for sixteen (16) hours
                in any
                one twenty-four (24) hour period. The Health Plan/Transportation
                Provider
                shall not permit a driver to drive until the driver fulfills the
                requirement of a minimum eight (8) consecutive hours off-duty. A
                driver’s
                work period shall begin from the time he or she first reports for
                duty to
                his or her employer. A driver is permitted to exceed his or her regulated
                hours in order to reach a regularly established relief or dispatch
                point,
                provided the additional driving time does not exceed one (1)
                hour.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan/Transportation Provider shall not permit or require a
                driver
                to be on duty more than seventy-two (72) hours in any period of seven
                (7)
                consecutive days; however, twenty-four (24) consecutive hours off-duty
                shall constitute the end of any such period of seven (7) consecutive
                days.
                The Health Plan/Transportation Provider shall ensure that a driver
                who has
                reached the maximum 72 hours of on-duty time during the seven (7)
                consecutive days has a minimum of twenty-four (24) consecutive hours
                off-duty before returning to on-duty
                status.

            

    

    

    
      	 	
              (5)

            	
              A
                driver is permitted to drive for more than the regulated hours for
                safety
                and protection of the public due to conditions such as adverse weather,
                disaster, security threat, a road or traffic condition, medical emergency
                or an accident.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan/Transportation Provider shall not permit or require any
                driver
                to drive when his or her ability is impaired, or likely to be impaired,
                by
                fatigue, illness, or other causes, as to make it unsafe for the driver
                to
                begin or continue driving.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan/Transportation Provider shall require pre-operational
                or daily
                inspection of all vehicles and reporting of all defects and deficiencies
                likely to affect safe operation or cause mechanical
                malfunctions.

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan/Transportation Provider shall maintain a log detailing
                a daily
                inspection or test of the following parts and devices to ascertain
                that
                they are in safe condition and in good working
                order:

            

    

    

    
      	 	
              (i)

            	
              Service
                brakes;

            

    

    

    
      	 	
              (ii)

            	
              Parking
                brakes;

            

    

    

    
      	 	
              (iii)

            	
              Tires
                and wheels;

            

    

    

    
      	 	
              (iv)

            	
              Steering;

            

    

    

    
      	 	
              (v)

            	
              Horn;

            

    

    

    
      	 	
              (vi)

            	
              Lighting
                devices;

            

    

    

    
      	 	
              (vii)

            	
              Windshield
                wipers;

            

    

    

    
      	 	
              (viii)

            	
              Rear
                vision mirrors;

            

    

    

    
      	 	
              (ix)

            	
              Passenger
                doors and seats;

            

    

    

    
      	 	
              (x)

            	
              Exhaust
                system;

            

    

    

    
      	 	
              (xi)

            	
              Equipment
                for transporting wheelchairs; and

            

    

    

    
      	 	
              (xii)

            	
              Safety,
                security, and emergency equipment.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan/Transportation Provider shall review daily inspection
                reports
                and document corrective actions taken as a result of any deficiencies
                identified by any inspections.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan/Transportation Provider shall retain records of all
                inspections and any corrective action documentation for five (5)
                years.

            

    

    

    
      	 	
              (8)

            	
              The
                driver shall not operate a vehicle with passenger doors in the open
                position when passengers are aboard. The driver shall not open the
                vehicle’s doors until the vehicle comes to a complete stop. The Health
                Plan/Transportation Provider shall not operate a vehicle with inoperable
                passenger doors with passengers aboard, except to move the vehicle
                to a
                safe location.

            

    

    

    
      	 	
              (9)

            	
              During
                darkness, interior lighting and lighting in stepwells on vehicles
                shall be
                sufficient for passengers to enter and exit
                safely.

            

    

    

    
      	 	
              (10)

            	
              Passenger(s)
                shall not be permitted in the stepwell(s) of any vehicle while the
                vehicle
                is in motion, or to occupy an area forward of the standee
                line.

            

    

    

    
      	 	
              (11)

            	
              Passenger(s)
                shall not be permitted to stand on or in vehicles not designed and
                constructed for that purpose.

            

    

    

    
      	 	
              (12)

            	
              The
                Health Plan/Transportation Provider shall not refuel vehicles in
                a closed
                building. The Health Plan/Transportation Provider shall minimize
                the
                number of times a vehicle shall refuel when passengers are
                onboard.

            

    

    

    
      	 	
              (13)

            	
              The
                Health Plan/Transportation Provider shall require the driver to be
                properly secured to the driver’s seat with a restraining belt at all times
                while the vehicle is in motion.

            

    

    

    
      	 	
              (14)

            	
              The
                driver shall not leave vehicles unattended with passenger(s) aboard
                for
                longer than five (5) minutes. The Health Plan/Transportation Provider
                shall ensure that the driver sets the parking or holding brake any
                time
                the vehicle is left unattended.

            

    

    

    
      	 	
              (15)

            	
              The
                Health Plan/Transportation Provider shall not leave vehicles unattended
                in
                an unsafe condition with passenger(s) aboard at any
                time.

            

    

    

    
      	 	
              l.

            	
              Vehicle
                Equipment Standards and Procurement
                Criteria

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall ensure that vehicles procured
                and operated meet the following requirements, at a
                minimum:

            

    

    

    
      	 	
              (a)

            	
              The
                capability and strength to carry the maximum allowed load and not
                exceed
                the manufacturer’s gross vehicle weight rating (GVWR), gross axle
                weighting, or tire rating;

            

    

    

    
      	 	
              (b)

            	
              Structural
                integrity that mitigates or minimizes the adverse effects of collisions;
                and

            

    

    

    
      	 	
              (c)

            	
              Federal
                Motor Vehicle Safety Standards (FMVSS), 49 C.F.R. Part 571, Sections
                102,
                103, 104, 105, 108, 207, 209, 210, 217, 220, 221, 225, 302, 403,
                and 404,
                October 1, 2004, are hereby incorporated by reference.
                

            

    

    

    
      	 	
              (2)

            	
              Proof
                of strength and structural integrity tests on new vehicles procured
                shall
                be submitted by manufacturers or the Health Plan/Transportation Providers
                to the Department of Transportation (See 14-90,
                F.A.C.).

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall ensure that every vehicle
                operated in the State in connection with this Contract shall be equipped
                as follows:

            

    

    

    
      	 	
              (a)

            	
              Mirrors
                - There must be at least two (2) exterior rear vision mirrors, one
                (1) at
                each side. The mirrors shall be firmly attached to the outside of
                the
                vehicle and so located as to reflect to the driver a view to the
                rear
                along both sides of the vehicle. 

            

    

    

    
      	 	
              (i)

            	
              Each
                exterior rear vision mirror, on Type I buses shall have a minimum
                reflective surface of fifty (50) square inches and the right (curbside)
                mirror shall be located on the bus so that the lowest part of the
                mirror
                and its mounting is a minimum eighty (80) inches above the ground.
                All
                Type I buses shall be equipped with an inside rear vision mirror
                capable
                of giving the driver a clear view of seated or standing passengers.
                Buses
                having a passenger exit door that is located inconveniently for the
                driver’s visual control shall be equipped with additional interior
                mirror(s), enabling the driver to view the passenger exit door. The
                exterior right (curbside) rear vision mirror and its mounting on
                Type I
                buses may be located lower than 80 inches from the ground, provided
                such
                buses are used exclusively for paratransit services. See Section
                341.031,
                F.S. 

            

    

    

    
      	 	
              (ii)

            	
              In
                lieu of interior mirrors, trailer buses and articulated buses may
                be
                equipped with closed circuit video systems or adult monitors in voice
                control with the driver.

            

    

    

    
      	 	
              (b)

            	
              Wiring
                and Battery - Electrical wiring shall be maintained so as not to
                come in
                contact with moving parts, or heated surfaces, or be subject to chafing
                or
                abrasion which may cause insulation to become worn.
                

            

    

    

    
      	 	
              (i)

            	
              Every
                Type I bus manufactured on or after February 7, 1988, shall be equipped
                with a storage battery(ies) electrical power main disconnect switch.
                The
                disconnect switch shall be practicably located in an accessible location
                adjacent to or near to the battery(ies) and be legibly and permanently
                marked for identification. 

            

    

    

    
      	 	
              (ii)

            	
              Every
                storage battery on each public-sector bus shall be mounted with proper
                retainment devices in a compartment which provides adequate ventilation
                and drainage.

            

    

    

    
      	 	
              (c)

            	
              Brake
                Interlock Systems - All Type I buses having a rear exit door shall
                be
                equipped with a rear exit door/brake interlock that automatically
                applies
                the brake(s) upon driver activation of the rear exit door to the
                open
                position. Interlock brake application shall remain activated until
                deactivation by the driver and the rear exit door returns to the
                closed
                position. The rear exit door interlock on such buses shall be equipped
                with an identified override switch enabling emergency release of
                the
                interlock function, which shall not be located within reach of the
                seated
                driver. Air pressure application to the brake(s) during interlock
                operation, on buses equipped with rear exit door/brake interlock,
                shall be
                regulated at the original equipment manufacturer’s
                specifications.

            

    

    

    
      	 	
              (4)

            	
              Standee
                Line and Warning - Every vehicle designed and constructed to allow
                standees shall be plainly marked with a line of contrasting color
                at least
                two (2) inches wide or be equipped with some other means to indicate
                that
                any passenger is prohibited from occupying a space forward of a
                perpendicular plane drawn through the rear of the driver’s seat and
                perpendicular to the longitudinal axis of the vehicle. A sign shall
                be
                posted at or near the front of the vehicle stating that it is a violation
                for a vehicle to be operated with passengers occupying an area forward
                of
                the line.

            

    

    

    
      	 	
              (5)

            	
              Handrails
                and Stanchions - Every vehicle designed and constructed to allow
                standees
                shall be equipped with overhead grab rails for standee passengers.
                Overhead grab rails shall be continuous, except for a gap at the
                rear exit
                door, and terminate into vertical stanchions or turn up into a ceiling
                fastener. 

            

    

    

    
      	 	
              (a)

            	
              Every
                Type I and Type II bus designed for carrying more than sixteen (16)
                passengers shall be equipped with grab handles, stanchions, or bars
                at
                least ten (10) inches long and installed to permit safe on-board
                circulation, seating and standing assistance, and boarding and unloading
                by elderly and handicapped persons. Type I buses shall be equipped
                with a
                safety bar and panel directly behind each entry and exit
                stepwell.

            

    

    

    
      	 	
              (6)

            	
              Flooring,
                Steps, and Thresholds - Flooring, steps, and thresholds on all vehicles
                shall have slip resistant surfaces without protruding or sharp edges,
                lips, or overhangs, to prevent tripping hazards. All step edges and
                thresholds shall have a band of color(s) running the full width of
                the
                step or edge which contrasts with the step tread and riser, either
                light-on-dark or dark-on-light.

            

    

    

    
      	 	
              (7)

            	
              Doors
                - Power activated doors on all vehicles shall be equipped with a
                manual
                device designed to release door closing
                pressure.

            

    

    

    
      	 	
              (8)

            	
              Emergency
                Exits - All vehicles shall have an emergency exit door, or in lieu
                thereof, shall be provided with emergency escape push-out windows.
                Each
                emergency escape window shall be in a form of a parallelogram with
                dimensions of not less than 18" by 24", and each shall contain an
                area of
                not less than 432 square inches. There shall be a sufficient number
                of
                such push-out or kick-out windows in each vehicle to provide a total
                escape area equivalent to 67 square inches per seat, including the
                driver’s seat.

            

    

    

    
      	 	
              (a)

            	
              No
                less than forty percent (40%) of the total escape area shall be on
                one (1)
                side of the vehicle. Emergency escape kick-out or push-out windows
                and
                emergency exit doors shall be conspicuously marked by a sign or light
                and
                shall always be kept in good working order so that they may be readily
                opened in an emergency. 

            

    

    

    
      	 	
              (b)

            	
              All
                such windows and doors shall not be obstructed by bars or other such
                means
                located either inside or outside so as to hinder escape. Vehicles
                equipped
                with an auxiliary door for emergency exit shall be equipped with
                an
                audible alarm and light indicating to the driver when a door is ajar
                or
                opened while the engine is running.

            

    

    

    
      	 	
              (c)

            	
              Supplemental
                security locks operable by a key are prohibited on emergency exit
                doors
                unless these security locks are equipped and connected with an ignition
                interlock system or an audio visual alarm located in the driver’s
                compartment. Any supplemental security lock system used on emergency
                exits
                shall be kept unlocked whenever a vehicle is in
                operation.

            

    

    

    
      	 	
              (9)

            	
              Tires
                and Wheels - Tires shall be properly inflated in accordance with
                manufacturer’s recommendations.

            

    

    

    
      	 	
              (a)

            	
              No
                vehicle shall be operated with a tread groove pattern
                depth:

            

    

    

    
      	 	
              (i)

            	
              Less
                than 4/32 (1/8) of an inch, measured at any point on a major tread
                groove
                for tires on the steering axle of all vehicles. The measurements
                shall not
                be made where tie bars, humps, or fillets are
                located.

            

    

    

    
      	 	
              (ii)

            	
              Less
                than 2/32 (1/16) of an inch, measured at any point on a major tread
                groove
                for all other tires of all vehicles. The measurements shall not be
                made
                where tie bars, humps, or fillets are
                located.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan/Transportation Provider shall not operate any vehicle
                with
                recapped, regrooved or retreaded tires on the steering
                axle.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan/Transportation Provider shall ensure that all wheels
                are
                visibly free from cracks and distortion and shall not have missing,
                cracked, or broken mounting lugs.

            

    

    

    
      	 	
              (10)

            	
              Suspension
                - The suspension system of all vehicles, including springs, air bags,
                and
                all other suspension parts as applicable, shall be free from cracks,
                leaks, or any other defect which would or may cause its impairment
                or
                failure to function properly.

            

    

    

    
      	 	
              (11)

            	
              Steering
                and Front Axle - The steering system of all vehicles shall have no
                indication of leaks which would or may cause its impairment to function
                properly, and shall be free from cracks and excessive wear of components
                that would or may cause excessive free play or loose motion in the
                steering system or above normal effort in steering
                control.

            

    

    

    
      	 	
              (12)

            	
              Seat
                Belts - Every vehicle shall be equipped with an adjustable driver’s
                restraining belt in compliance with the requirements of FMVSS 209,
“Seat
                Belt Assemblies” (see 49 CFR 571.209) and FMVSS 210, “Seat Belt Assembly
                Anchorages” (49 CFR 571.210). 

            

    

    

    
      	 	
              (13)

            	
              Safety
                Equipment - Every vehicle shall be equipped with one (1) fully charged
                dry
                chemical or carbon dioxide fire extinguisher, having at least a 1A:BC
                rating and bearing the label of Underwriter’s Laboratory,
                Inc.

            

    

    

    
      	 	
              (a)

            	
              Each
                fire extinguisher shall be securely mounted on the vehicle in a
                conspicuous place or a clearly marked compartment and be readily
                accessible.

            

    

    

    
      	 	
              (b)

            	
              Each
                fire extinguisher shall be maintained in efficient operating condition
                and
                equipped with some means of determining if it is fully
                charged.

            

    

    

    
      	 	
              (c)

            	
              Every
                Type I bus shall be equipped with portable red reflector warning
                devices
                (see Section 316.300, F.S.).

            

    

    

    
      	 	
              (14)

            	
              Vehicles
                used for the purpose of transporting individuals with disabilities
                shall
                meet the requirements set forth in 49 CFR Part 38, hereby incorporated
                by
                reference, and the following:

            

    

    

    
      	 	
              (a)

            	
              Installation
                of a wheelchair lift or ramp shall not cause the manufacturer’s GVWR,
                gross axle weight rating, or tire rating to be
                exceeded.

            

    

    

    
      	 	
              (b)

            	
              Except
                in locations within 3 1/2 inches of the vehicle floor, all readily
                accessible exposed edges or other hazardous protrusions of parts
                of
                wheelchair lift assemblies or ramps that are located in the passenger
                compartment shall be padded with energy absorbing material to mitigate
                injury in normal use and in case of a collision. This requirement
                shall
                also apply to parts of the vehicle associated with the operation
                of the
                lift or ramp.

            

    

    

    
      	 	
              (c)

            	
              The
                controls for operating the lift shall be at a location where the
                driver or
                lift attendant has a full view, unobstructed by passengers, of the
                lift
                platform, its entrance and exit, and the wheelchair passenger, either
                directly or with partial assistance of mirrors. Lifts located entirely
                to
                the rear of the driver’s seat shall not be operable from the driver’s
                seat, but shall have an override control at the driver’s position that can
                be activated to prevent the lift from being operated by the other
                controls
                (except for emergency manual operation upon power
                failure).

            

    

    

    
      	 	
              (d)

            	
              The
                installation of the wheelchair lift or ramp and its controls and
                the
                method of attachment in the vehicle body or chassis shall not diminish
                the
                structural integrity of the vehicle nor cause a hazardous imbalance
                of the
                vehicle. No part of the assembly, when installed and stowed, shall
                extend
                laterally beyond the normal side contour of the vehicle or vertically
                beyond the lowest part of the rim of the wheel closest to the
                lift.

            

    

    

    
      	 	
              (e)

            	
              Each
                wheelchair lift or ramp assembly shall be legibly and permanently
                marked
                by the manufacturer or installer with the following minimum
                information:

            

    

    

    
      	 	
              (i)

            	
              The
                manufacturer’s name and address;

            

    

    

    
      	 	
              (ii)

            	
              The
                month and year of manufacture; and

            

    

    

    
      	 	
              (iii)

            	
              A
                certificate that the wheelchair lift or ramp securement devices,
                and their
                installation, conform to State of Florida requirements applicable
                to
                accessible vehicles.

            

    

    

    
      	 	
              (15)

            	
              Wheelchair
                lifts, ramps, securement devices, and restraints shall be inspected
                and
                maintained as specified above. Instructions for normal and emergency
                operation of the lift or ramp shall be carried or displayed in every
                vehicle.

            

    

    

    
      	 	
              m.

            	
              Vehicle
                Safety Inspections

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall require that all vehicles
                be
                inspected in accordance with the vehicle inspection procedures set
                forth
                above.

            

    

    

    
      	 	
              (2)

            	
              It
                is the Health Plan’s/Transportation Provider’s responsibility to ensure
                that each individual performing a vehicle safety inspection is qualified
                as follows:

            

    

    

    
      	 	
              (a)

            	
              Understands
                the requirements set forth in 14-90, F.A.C., and can identify defective
                components;

            

    

    

    
      	 	
              (b)

            	
              Is
                knowledgeable of, and has mastered the methods, procedures, tools,
                and
                equipment used when performing an inspection;
                and

            

    

    

    
      	 	
              (c)

            	
              Has
                at least one (1) year of training and/or experience as a mechanic
                or
                inspector in a vehicle maintenance program and has sufficient general
                knowledge of vehicles owned and operated by the Health Plan/Transportation
                Provider to recognize deficiencies or mechanical
                defects.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall ensure that each vehicle
                receiving a safety inspection is checked for compliance with the
                safety
                devices and equipment requirements as referenced or specified above.
                Specific operable equipment and devices include the
                following:

            

    

    

    
      	 	
              (a)

            	
              Horn;

            

    

    

    
      	 	
              (b)

            	
              Windshield
                wipers;

            

    

    

    
      	 	
              (c)

            	
              Mirrors;

            

    

    

    
      	 	
              (d)

            	
              Wiring
                and battery(ies);

            

    

    

    
      	 	
              (e)

            	
              Service
                and parking brakes;

            

    

    

    
      	 	
              (f)

            	
              Warning
                devices;

            

    

    

    
      	 	
              (g)

            	
              Directional
                signals;

            

    

    

    
      	 	
              (h)

            	
              Hazard
                warning signals;

            

    

    

    
      	 	
              (i)

            	
              Lighting
                systems and signaling devices;

            

    

    

    
      	 	
              (j)

            	
              Handrails
                and stanchions;

            

    

    

    
      	 	
              (k)

            	
              Standee
                line and warning;

            

    

    

    
      	 	
              (l)

            	
              Doors
                and interlock devices;

            

    

    

    
      	 	
              (m)

            	
              Stepwells
                and flooring;

            

    

    

    
      	 	
              (n)

            	
              Emergency
                exits;

            

    

    

    
      	 	
              (o)

            	
              Tires
                and wheels;

            

    

    

    
      	 	
              (p)

            	
              Suspension
                system;

            

    

    

    
      	 	
              (q)

            	
              Steering
                system;

            

    

    

    
      	 	
              (r)

            	
              Exhaust
                system;

            

    

    

    
      	 	
              (s)

            	
              Seat
                belts; 

            

    

    

    
      	 	
              (t)

            	
              Safety
                equipment; and

            

    

    

    
      	 	
              (u)

            	
              Equipment
                for transporting wheelchairs.

            

    

    

    
      	 	
              (4)

            	
              A
                safety inspection report shall be prepared by the individual(s) performing
                the inspection which shall include the
                following:

            

    

    

    
      	 	
              (a)

            	
              Identification
                of the individual(s) performing the
                inspection;

            

    

    

    
      	 	
              (b)

            	
              Identification
                of the Health Plan/Transportation Provider operating the
                vehicle;

            

    

    

    
      	 	
              (c)

            	
              The
                date of the inspection;

            

    

    

    
      	 	
              (d)

            	
              Identification
                of the vehicle inspected;

            

    

    

    
      	 	
              (e)

            	
              Identification
                of the equipment and devices inspected including the identification
                of
                equipment and devices found deficient or defective;
                and

            

    

    

    
      	 	
              (f)

            	
              Identification
                of corrective action(s) for deficient or defective items and date(s)
                of
                completion of corrective action(s).

            

    

    

    
      	 	
              (5)

            	
              Records
                of annual safety inspections and documentation of any required corrective
                actions shall be retained for compliance review a minimum of five
                (5)
                years by the Health Plan/Transportation
                Provider.

            

    

    

    
      	 	
              n.

            	
              Certification
                - Each Health Plan/Transportation Provider shall submit an annual
                safety
                and security certification in accordance with 14-90.10, F.A.C., and
                shall
                submit to any and all safety and security inspections and reviews
                in
                accordance with 14-90.12, F.A.C.

            

    

    

    
      	 	
              o.

            	
              The
                Health Plan shall report the following by August 15th of each
                year:

            

    

    

    
      	 	
              (1)

            	
              The
                estimated number of one-way passenger trips to be provided in the
                following categories, as defined in the Transportation
                Handbook:

            

    

    

    
      	 	
              (a)

            	
              Ambulatory
                Transportation;

            

    

    

    
      	 	
              (b)

            	
              Long
                haul ambulatory Transportation;

            

    

    

    
      	 	
              (c)

            	
              Wheelchair
                Transportation;

            

    

    

    
      	 	
              (d)

            	
              Stretcher
                Transportation;

            

    

    

    
      	 	
              (e)

            	
              Ambulatory
                multiload Transportation;

            

    

    

    
      	 	
              (f)

            	
              Wheelchair
                multiload Transportation;

            

    

    

    
      	 	
              (g)

            	
              Mass
                transit pending Transportation;

            

    

    

    
      	 	
              (h)

            	
              Mass
                transit Transportation;

            

    

    

    
      	 	
              (i)

            	
              Mass
                transit Transportation (Enrollee has pass);
                and

            

    

    

    
      	 	
              (j)

            	
              Mass
                transit Transportation (sent pass to
                Enrollee).

            

    

    

    
      	 	
              (2)

            	
              The
                actual amount of funds expended and the total number of trips provided
                during the previous fiscal year;
                and

            

    

    

    
      	 	
              (3)

            	
              The
                operating financial statistics for the previous fiscal
                year.

            

    

    

    
      	 	
              p

            	
              The
                Health Plan shall provide the total number of vehicles in each category,
                other than public Transportation, that will serve each county as
                well as a
                provider directory for all Transportation
                Services.

            

    

    

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    Section
      VI

     

    Behavioral
      Health
      Care

     

    

     

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall provide Medically Necessary Behavioral Health Services
                for all Enrollees pursuant to this Contract. The Health Plan shall
                provide
                a full range of Behavioral Health Services authorized under the State
                Plan
                and specified by this Contract. 

            

    

    

    
      	 	
              a.

            	
              Nothing
                in this contract shall be construed as preventing the plan from
                substituting additional services supported by nationally recognized 
                evidence based clinical guidelines for those provided in the Handbooks
                described above, or from using different or alternative services,
                based on
                nationally recognized evidence based practices, methods, or approaches
                to
                assist individual enrollees, provided that the net effect of this
                substitution and these alternatives is that the overall benefits
                available
                to the enrollee are at least equivalent to those described in the
                applicable Handbooks.  Provision of substitution or alternate
                services shall not supplant or relieve the plan from providing covered
                services if needed.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall provide the following services as described in
                the
                Mental Health Targeted Case Management Coverage & Limitations
                Handbook, and the Community Behavioral Health Services Coverage &
                Limitations Handbook (the Handbooks). The Health Plan shall not alter
                the
                amount, duration and scope of such services from that specified in
                the
                Handbooks. The Health Plan shall not establish service limitations
                that
                are lower than, or inconsistent with the Handbooks.
                

            

    

    

    
      	 	
              a.

            	
              Inpatient
                Hospital services for psychiatric conditions (ICD-9-CM codes 290
                through
                290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through
                312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                315.9);

            

    

    

    
      	 	
              b.

            	
              Outpatient
                Hospital services for psychiatric conditions (ICD-9-CM codes 290
                through
                290.43, 293 through 298.9, 300 through 301.9, 302.7, 306.51 through
                312.4
                and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                315.9);

            

    

    

    
      	 	
              c.

            	
              Psychiatric
                physician services (for psychiatric specialty codes 42, 43, 44 and
                ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through
                301.9,
                302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31,
                315.5, 315.8, and 315.9);

            

    

    

    
      	 	
              d.

            	
              Community
                mental health services (ICD-9-CM codes 290 through 290.43, 293.0
                through
                298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and 312.81
                through
                314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these procedure
                codes H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN;
                H0031TS;
                H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO; H2010HE;
                H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
                H2019HO;
                H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
                T1023HE;
                or T1023HF.

            

    

    

    
      	 	
              e.

            	
              Mental
                Health Targeted Case Management (Children: T1017HA; Adults: T1017);
                and

            

    

    

    
      	 	
              f.

            	
              Mental
                Health Intensive Targeted Case Management (Adults:
                T1017HK).

            

    

    

    
      	 	
              3.

            	
              Non-Covered
                Services

            

    

    

    
      	 	
              a.

            	
              The
                following services are not covered by the Health Plan. Should the
                Health
                Plan determine the need for, or be advised of the need for, these
                or other
                services not customarily covered by the Health Plan, the Health Plan
                shall
                refer the Enrollee to the appropriate
                provider:

            

    

    

    (1) Specialized
      Therapeutic Foster Care;

     

    (2) Therapeutic
      Group Care Services;

    

    (3) Behavioral
      Health Overlay Services;

    

    
      	 	
              (4)

            	
              Community
                Substance Abuse Services, except as required by this Contract;
                

            

    

    

    (5) Residential
      Care;

    

    (6) Sub-acute
      Inpatient Psychiatric Program (SIPP) Services; 

    

    (7) Clubhouse
      Services;

    

    (8) Comprehensive
      Behavioral Assessment; and

    

    (9) Florida
      Assertive Community Treatment Services (FACT). 

    
      	 	 	 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall not be responsible for the provision of Behavioral
                Health Services to Enrollees assigned to a FACT team by the DCF Substance
                Abuse and Mental Health Program (SAMH) Office. The Health Plan shall
                disenroll these Enrollees from the Health Plan so that the Enrollees
                can
                receive all Behavioral Health Services through the funding mechanism
                developed by DCF/SAMH and AHCA. 

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall provide Outpatient Medical Services in accordance
                with
                Section V, Covered Services, of this Contract.

            

    

    

    
      	 	
              5.

            	
              If
                an Enrollee makes a request for Behavioral Health Services to the
                Health
                Plan, the Health Plan shall provide the Enrollee with the name (or
                names)
                of qualified Behavioral Health Care Providers, and if requested,
                assist
                the Enrollee with making an appointment with the Provider that is
                within
                the required access times indicated in Section VII.D., Appointment
                Waiting
                Times and Geographic Access Standards, and Section VII.E., Behavioral
                Health Services.

            

    

    

    
      	 	
              6.

            	
              Services
                available under the Health Plan shall represent a comprehensive range
                of
                appropriate services for both Children/Adolescents and adults who
                experience impairments ranging from mild to severe and persistent.
                This
                Section outlines the Agency’s expectations and requirements related to
                each of the categories of service. 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan may provide Expanded Services under the Contract as a
                substitution of care or downward substitution.

            

    

    

    
      	 	
              b.

            	
              When
                the Health Plan intends to provide a service as a downward substitution,
                the provider must use clinical rationale for determining the benefit
                of
                the service for the Enrollee.

            

    

    

    
      	 	
              7.

            	
              The
                Health Plan must provide Covered
                Services to Enrollees as required by each Enrollee without regard
                to the
                frequency or cost of services relative to the amount paid pursuant
                to the
                Contract.

            

    

    

    
      	
              B.

            	
              Service
                Requirements

            

    

    

    
      	 	
              1.

            	
              Inpatient
                Hospital Services

            

    

    

    
      	 	
              a.

            	
              Inpatient
                Hospital services are Medically Necessary Behavioral Health Services
                provided in a Hospital setting (see Section V.7, Covered Services,
                Hospital Services - Inpatient. Inpatient hospital services may be
                provided
                in a general Hospital psychiatric unit or in a specialty Hospital.
                The
                inpatient care and treatment services that an Enrollee receives must
                be
                under the direction of a licensed physician with the appropriate
                Medicaid
                specialty requirements.

            

    

    

    
      	 	
              b.

            	
              A
                Hospital’s per diem (daily rate) for inpatient mental health hospital care
                and treatment covers all services and items furnished during a 24-hour
                period. The facilities, supplies, appliances, and equipment furnished
                by
                the Hospital during the inpatient stay are included in the per diem
                as
                well as the related nursing, social, and other services furnished
                by the
                Hospital during the inpatient stay.

            

    

    

    
      	 	
              c.
                

            	
              For
                all Child/Adolescent Enrollees, the Health Plan shall be responsible
                for
                the provision of up to 365 days of behavioral health-related Hospital
                inpatient care for each year.

            

    

    

    
      	 	
              d.

            	
              For
                all Enrollees, the Health Plan shall pay for inpatient mental
                health-related Hospital days determined Medically Necessary by the
                Health
                Plan’s medical director or designee, up to the maximum number of days
                required under the Contract.

            

    

    

    
      	 	
              e.

            	
              If
                an Enrollee is admitted to a Hospital for a non-psychiatric diagnosis
                and
                during the same hospitalization transfers to a psychiatric unit or
                receives treatment for a psychiatric diagnosis, the Health Plan is
                at risk
                for the Medically Necessary behavioral health treatment inpatient
                days up
                to the maximum number of days required under this
                Contract.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall be responsible to cover the cost of all Enrollees’
                Medically Necessary stays resulting from a mental health emergency,
                until
                such time as the Health Plan can safely transport the Enrollee to
                a
                designated facility.

            

    

    

    
      	 	
              g.

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

            

    

    

    
      	 	
              2.

            	
              Outpatient
                Hospital Services

            

    

    

    
      	 	
              a.

            	
              Outpatient
                Hospital services are Medically Necessary Behavioral Health Services
                provided in a Hospital setting. The outpatient care and treatment
                services
                that an Enrollee receives must be under the direction of a licensed
                physician with the appropriate specialty.

            

    

    

    
      	 	
              3.

            	
              Physician
                Services

            

    

    

    
      	 	
              a.

            	
              Physician
                services are those services rendered by a licensed physician who
                possesses
                the appropriate Medicaid specialty requirements when applicable.
                A
                psychiatrist must be certified as a psychiatrist by the American
                Board of
                Psychiatry and Neurology or the American Osteopathic Board of Neurology
                and Psychiatry, or have completed a psychiatry residency accredited
                by the
                Accreditation Council for Graduate Medical Education (ACGME) or the
                Royal
                College of Physicians and Surgeons of
                Canada.

            

    

    

    
      	 	
              b.

            	
              Physician
                services include specialty consultations for evaluations. A physician
                consultation shall include an examination and evaluation of the Enrollee
                with information from family member(s) or significant others as
                appropriate. The consultation shall include written documentation
                on an
                exchange of information with the attending Provider. The components
                of the
                evaluation and management procedure code and diagnosis code must
                be
                documented in the Enrollee's medical record. A Hospital visit to
                an
                Enrollee in an acute care Hospital for a behavioral health diagnosis
                must
                be documented with a behavioral health procedure code and behavioral
                health diagnosis code. All procedures with a minimum time requirement
                shall be documented in the Enrollee’s Medical Record to show the time
                spent providing the service to the Enrollee. The Health Plan must
                be
                responsive to requests for consultations made by the
                PCP.

            

    

    

    
      	 	
              c.

            	
              Physicians
                are required to coordinate Medically Necessary Behavioral Health
                Services
                with the PCP and other Providers involved with the care of the Enrollee.
                The Health Plan shall draft and implement a set of protocols that
                indicate
                when such coordination is required.

            

    

    

    
      	 	
              4.

            	
              Community
                Mental Health Services

            

    

    

    
      	 	
              a.

            	
              General
                Provisions

            

    

    

    
      	 	
              (1)

            	
              Community
                mental health services include Behavioral Health Services that are
                provided for the maximum reduction of the Enrollee’s behavioral health
                disability and restoration to the best possible functional level.
                Community mental health services are those services that can reasonably
                be
                expected to improve the Enrollee’s condition or prevent further regression
                so that the services will no longer be needed. The Health Plan shall
                provide community mental health services that are Medically Necessary
                and
                are rendered or recommended by a physician or psychiatrist and included
                in
                a treatment plan. Medically Necessary community mental health services
                must be provided to Enrollees of all ages from very young children
                through
                the geriatric population. Because the provision of community mental
                health
                services at an early stage may reduce the provision of expensive
                services
                later, the Health Plan is encouraged to expand the criteria for some
                community mental health services and base the criteria upon social
                necessity rather than strict Medical Necessity requirements. Community
                mental health services should be age appropriate and sensitive to
                the
                developmental level of the Enrollee. The term “community mental health
                services” is not intended to suggest that the following services must be
                provided by State funded “community mental health centers” or to preclude
                State funded “community mental health centers” from providing these
                services.

            

    

    

    
      	 	
              (2)

            	
              The
                services provided must meet the intent of the services covered in
                the
                Florida Medicaid Community Mental Health Services Coverage and Limitations
                Handbook. Although the Health Plan can provide flexible services,
                the
                service limits and medical necessity criteria cannot be more restrictive
                than those in Medicaid policy as stated in Medicaid handbooks and
                this
                Contract. Additionally, the Health Plan may have available additional
                services, but must have the core services available as outlined and
                discussed below.

            

    

    

    
      	 	
              (3)

            	
              The
                health plan shall establish “Medical Necessity” criteria, including
                admission criteria, continuing stay criteria, and discharge criteria
                for
                all mandatory and optional
                services.

            

    

    

    
      	 	
              (a)

            	
              Criteria
                must be specific to Enrollee ages and diagnoses and must account
                for
                orders for involuntary outpatient placement pursuant to 394.4655,
                F.S.
                These criteria must be submitted for review by the Agency and
                approval.

            

    

    

    
      	 	
              (4)

            	
              Treatment
                Plan Development and Modification:

            

    

    

    
      	 	
              (a)

            	
              Treatment
                planning includes working with the Enrollee, their natural support
                system,
                and all involved treating Providers to develop an individualized
                plan for
                addressing identified clinical needs. A Behavioral Health Care Provider
                must complete a face-to-face interview with the Enrollee during the
                development of the plan. The individualized treatment plan should
                accurately reflect the presenting problems of the Enrollee, identified
                strengths of the Enrollee, family, and other natural support systems,
                and
                outcome-oriented objectives for the Enrollee. The treatment plan
                shall
                also include an outcome-oriented schedule of Behavioral Health Services
                that will be provided to meet the Enrollee’s needs. Behavioral Health
                Services and service frequency shall be individualized and reflect
                the
                needs, goals, and abilities of each
                Enrollee.

            

    

    

    
      	 	
              (b)

            	
              The
                Individualized Treatment Plan
                shall:

            

    

    

    
      	 	
              (i)

            	
              Be
                recovery-oriented and promote
                resiliency;

            

    

    

    
      	 	
              (ii)

            	
              Be
                Enrollee-directed;

            

    

    

    
      	 	
              (iii)

            	
              Accurately
                reflect the presenting problems of the
                Enrollee;

            

    

    

    
      	 	
              (iv)

            	
              Be
                based on the strengths of the Enrollee, family, and other natural
                support
                systems;

            

    

    

    
      	 	
              (v)

            	
              Provide
                outcome-oriented objectives for the
                Enrollee;

            

    

    

    
      	 	
              (vi)

            	
              Include
                an outcome-oriented schedule of services that will be provided to
                meet the
                Enrollee’s needs; and

            

    

    

    
      	 	
              (vii)

            	
              Include
                the coordination of services not covered by the Health Plan such
                as
                school-based services, vocational rehabilitation, housing supports,
                Medicaid fee-for-service substance abuse treatment, and physical
                health
                care.

            

    

    

    
      	 	
              (c)
                

            	
              Individualized
                Treatment Plan reviews shall be conducted at six (6) month intervals
                to
                assure that the services being provided are effective and remain
                appropriate for addressing individual Enrollee needs. Additionally,
                a
                review is expected whenever clinically significant events occur.
                The
                provider is expected to use the Individualized Treatment Plan review
                process in the utilization management of Medically Necessary services.
                For
                further guidance see the most recent Community Behavioral Health
                Services
                and Coverage Handbook.

            

    

    

    
      	 	
              (d)

            	
              Treatment
                plan reviews shall be conducted at appropriate time intervals to
                assure
                that the services being provided are effective and remain appropriate
                for
                addressing individual needs. A review is expected whenever a clinically
                significant event occurs. The Health Plan is expected to use the
                treatment
                plan review process in the Utilization Management of Medically Necessary
                services.

            

    

    

    (e) Assessment
      Services:

    

    
      	 	
              (i)

            	
              Evaluation
                and testing services include psychological testing (standardized
                tests)
                and evaluations that assess the Enrollee’s functioning in all areas.
                Evaluations completed prior to provision of treatment must include
                a
                holistic view of factors that underlie or may have contributed to
                the
                Enrollee’s need for Behavioral Health Services. Evaluations that are
                completed for diagnostic purposes are included in this category.
                Diagnostic evaluations must be comprehensive and when completed must
                be
                used in the development of an individualized treatment plan. All
                evaluations must be appropriate to the age, developmental level and
                functioning of the Enrollee. All evaluations must include a clinical
                summary that integrates all the information gathered and identifies
                the
                Enrollee’s needs. The evaluation should prioritize the clinical needs,
                evaluate the effectiveness of any prior treatment, and include
                recommendations for interventions and mental health services to be
                provided. All new Enrollees who appear for treatment services should
                receive an evaluation unless there is sufficient collateral information
                that a new evaluation would not be
                necessary.

            

    

    

    
      	 	
              (ii)

            	
              Evaluation
                services, when determined Medically Necessary must include assessment
                of
                mutual status, functional capacity, strengths and service needs by
                trained
                mental health staff. Also included in this category is the administration
                of functional assessments that are required by the Agency, DCF or
                the
                Florida Mental Health Institute Independent
                Evaluation.

            

    

    

    
      	 	
              (iii)

            	
              Prior
                to receiving any community mental health services, children ages
                0-5 must
                have a current assessment (within one year) of presenting symptoms
                and
                behaviors; developmental and medical history; family psychosocial
                and
                medical history; assessment of family functioning; a clinical interview
                with the primary caretaker and an observation of the child’s interaction
                with the caretaker; and an observation of the child’s language, cognitive,
                sensory, motor, self-care, and social
                functioning.

            

    

    

    
      	 	
              (3)

            	
              Medical
                and Psychiatric Services:

            

    

    

    
      	 	
              (a)

            	
              These
                services include Medically Necessary interventions that require the
                skills
                and expertise of a psychiatrist, psychiatric ARNP, or
                physician.

            

    

    

    
      	 	
              (b)

            	
              Medical
                psychiatric interventions include the prescribing and management
                of
                medications, monitoring side effects associated with prescribed
                medications, individual or group medical psychotherapy, psychiatric
                evaluation (for diagnostic purposes and for initiating treatment),
                psychiatric review of treatment records for diagnostic purposes,
                and
                psychiatric consultation with an Enrollee’s family or significant others,
                PCPs, and other treatment providers. Clinic visits are also a required
                service. 

            

    

    

    
      	 	
              (c)

            	
              Interventions
                related to specimen collections, taking vital signs and administering
                injections are also a Covered
                Service.

            

    

    

    
      	 	
              (d)

            	
              Treatment
                services are distinguished from the physician services outlined above
                in
                that they are provided through a community mental health provider.
                Psychiatric or physician services must be available at sites where
                substantial amounts of community mental health services are
                provided.

            

    

    

    
      	 	
              (4)

            	
              Behavioral
                Health Therapy Services:

            

    

    

    
      	 	
              (a)

            	
              Therapy
                services include individual and family therapy, group therapy and
                behavioral health day services. These services may include psychotherapy
                or supportive counseling focused on assisting Enrollees with the
                problems
                or symptoms identified in an assessment. The focus should be on
                identifying and utilizing the strengths of the Enrollee, family,
                and other
                natural support systems. Therapy services should be geared to the
                individual needs of the Enrollee and should be sensitive to the age,
                developmental level, and functional level of the
                Enrollee.

            

    

    

    
      	 	
              (b)

            	
              Family
                and marital therapy are also included in this category. Examples
                of
                interventions include those that focus on resolution of a life crisis
                or
                an adjustment reaction to an external stressor or developmental challenge.
                

            

    

    

    
      	 	
              (c)

            	
              Behavioral
                day services are designed to enable Enrollees to function successfully
                in
                the community in the least restrictive environment and to restore
                or
                enhance ability for social and prevocational life management services.
                The
                primary functions of behavioral health day services are stabilization
                of
                the symptoms related to a behavioral health disorder to reduce or
                eliminate the need for more intensive levels of care, to provide
                transitional treatment after an acute episode, or to provide a level
                of
                therapeutic intensity not possible in a traditional outpatient
                setting.

            

    

    

    
      	 	
              (5)

            	
              Community
                Support and Rehabilitative
                services:

            

    

    

    
      	 	
              (a)

            	
              These
                services include: Psychosocial Rehabilitation Services and Clubhouse
                services. Clubhouse services are excluded from the Health Plan’s Covered
                Services. Psychosocial rehabilitation services may be provided in
                a
                facility, home, or community setting. These services assist Enrollees
                in
                functioning within the limits of a disability or disabilities resulting
                from a mental illness. Services focus on restoration of a previous
                level
                of functioning or improving the level of functioning. Services must
                be
                individualized and directly related to goals for improving functioning
                within a major life domain.

            

    

    

    
      	 	
              (b)
                

            	
              The
                coverage must include a range of social, educational, vocational,
                behavioral, and cognitive interventions to improve Enrollees’ potential
                for social relationships, occupational/educational achievement and
                living
                skills development. Skills training development is also included
                in this
                category and includes activities aimed toward restoration of Enrollees’
                skills/abilities that are essential for managing their illness, actively
                participating in treatment, and conducting the requirements of daily
                independent living. Providers must offer the services in a setting
                best
                suited for desired outcomes, i.e., home or community-based
                settings.

            

    

    

    
      	 	
              (c)
                

            	
              Psychosocial
                Rehabilitative Services may also be provided to assist Enrollees
                in
                finding or maintaining appropriate housing arrangements or to maintain
                employment. Interventions should focus on the restoration of
                skills/abilities that are adversely affected by the mental health
                illness
                and supports required to manage the Enrollee’s housing or employment
                needs. The provider must be knowledgeable about the local TANF initiative
                and is responsible for Medically Necessary mental health services
                that
                will assist the individual in finding and maintaining
                employment.

            

    

    

    
      	 	
              (6)

            	
              Therapeutic
                Behavioral On-Site Services for Children and Adolescents
                (TBOS):

            

    

    

    (a) Therapeutic
      Behavioral On-Site Services are community services and natural supports for
      Children/Adoloscents with serious emotional disturbances. Clinical services
      include the provision of a professional level therapeutic service that may
      include the teaching of problem solving skills, behavioral strategies,
      normalization activities and other treatment modalities that are determined
      to
      be Medically Necessary. These services should be designed to maximize strengths
      and reduce behavior problems or functional deficits stemming from the existence
      of a mental health disorder. Social services include interventions designed
      for
      the restoration, modification, and maintenance of social, personal adjustment
      and basic living skills.

    

    (b)
       TBOS
      services are intended to maintain the Child/Adolescent in the home and to
      prevent reliance upon a more intensive, restrictive, and costly mental health
      placement. They are also focused on helping the Child/Adolescent possess the
      physical, emotional, and intellectual skills to live, learn and work in their
      own communities. Coverage must include the provision of these
      services outside of the traditional office setting. The services must be
      provided where they are needed, in the home, school, childcare centers or other
      community sites.

    
      	 	
              (7)

            	
              Day
                Treatment Services:

            

    

    

    
      	 	
              (a)

            	
              Adult
                day treatment services include therapy, rehabilitation, social
                interactions, and other therapeutic services that are designed to
                redevelop, maintain, or restore skills that are necessary for Enrollees
                to
                function in the community. The Provider must have an array of available
                services designed to meet the individualized needs of the Enrollee,
                and
                which address the following primary
                functions:

            

    

    

    
      	 	
              (i)

            	
              Stabilize
                symptoms related to a behavioral health disorder to reduce or eliminate
                the need for more intensive levels of
                care;

            

    

    

    
      	 	
              (ii)

            	
              Provide
                a level of therapeutic intensity between traditional outpatient and
                an
                inpatient or partial Hospital
                setting;

            

    

    

    
      	 	
              (iii)

            	
              Provide
                a level of treatment that will assist Enrollees in transitioning
                from an
                acute care or institutional
                settings;

            

    

    

    
      	 	
              (iv)

            	
              Assist
                Enrollees in redeveloping the skills required to maintain a living
                environment, use community resources, and conduct activities of daily
                living; and

            

    

    

    
      	 	
              (v)

            	
              Assist
                Enrollees in redeveloping or restoring skills that are needed to
                increase
                an Enrollee’s ability to live independently in the
                community.

            

    

    

    
      	 	
              (b)

            	
              Children/Adolescent’s
                day treatment services include therapy, rehabilitation and social
                interactions, and other therapeutic services that are designed to
                redevelop, maintain, or restore skills that are necessary for
                Children/Adolescents to function in their community. For
                Children/Adolescents, the approach must take into consideration their
                developmental levels and delays in development due to emotional disorders.
                If the Child/Adolescent is school age, the services must be coordinated
                with the school system. All therapeutic day treatment interventions
                for
                Children/Adolescents must have a component that addresses caregiver
                participation and involvement. Services for all Children/Adolescents
                should be coordinated with home care to the greatest extent possible.
                Day
                treatment services must include an array of programs with the following
                functions:

            

    

    

    
      	 	
              (i)

            	
              Stabilize
                the symptoms related to a behavioral health disorder to reduce or
                eliminate the need for more intensive levels of
                care;

            

    

    

    
      	 	
              (ii)

            	
              Provide
                transitional treatment after an acute episode, admission to an inpatient
                program, or discharge from a residential treatment
                setting;

            

    

    

    
      	 	
              (iii)

            	
              Provide
                a therapeutic intensity not possible in a traditional outpatient
                setting;
                and

            

    

    

    
      	 	
              (iv)

            	
              Assist
                the Child/Adolescent in redeveloping the skills required to conduct
                activities of everyday living in the community that are age
                appropriate.

            

    

     

    
      	 	
              (c)

            	
              Staff
                providing adult or Children/Adolescent’s day treatment services must have
                appropriate training and experience. Behavioral Health Care Providers
                must
                be available to provide clinical services when
                necessary.

            

    

    

    
      	 	
              (8)

            	
              Additional
                Community Mental Health Services for
                Children/Adolescents:

            

    

    

    
      	 	
              (a)

            	
              All
                of the community mental health services discussed above must be made
                available to Children/Adolescents when Medically Necessary. The services
                described in this section are two (2) additional core services that
                must
                be available to Children/Adolescents when Medically Necessary. This
                coverage is mandatory for Children/Adolescents with a serious emotional
                disturbance. These services are intended to maintain the Child/Adolescent
                in the home and to prevent reliance upon a more intensive, restrictive,
                and costly behavioral health placement. They are also focused on
                helping
                the Child/Adolescent possess the physical, emotional, and intellectual
                skills to live, learn and work in their own communities. Coverage
                must
                include the provision of these services outside of the traditional
                office
                setting. The services must be provided where they are needed, in
                the home,
                school or other community sites.

            

    

    

    
      	 	
              (b)

            	
              Therapeutic
                behavioral on site services include the provision of a professional
                level
                therapeutic service that may include the teaching of problem solving
                skills, behavioral strategies, normalization activities and other
                treatment modalities that are determined to be Medically Necessary.
                These
                services should be designed to maximize strengths, reduce behavior
                problems or functional deficits stemming from the existence of a
                behavioral health disorder. These services shall not be
                office-based.

            

    

    

    
      	 	
              (9)

            	
              Services
                for Children Ages 0 through 5-Years

            

    

     

    
      	 	
              (a)

            	
              Services
                to these Enrollees include behavioral health day services and Therapeutic
                Behavioral On-Site Services for Children Ages 0 through 5
                years.

            

    

    

    
      	 	
              (b)

            	
              Prior
                to receiving these services, the Enrollees in this age group must
                meet the
                criteria as stated in the Medicaid Community Behavioral Health Service
                Coverage and Limitations Handbook.

            

    

    

    
      	 	
              (10)

            	
              Crisis
                Intervention Mental Health Services and Post-Stabilization Care Services
                

            

    

    

    
      	 	
              (a)
                

            	
              Crisis
                intervention services include intervention activities of less than
                24-hour
                duration (within a 24-hour period) designed to stabilize an Enrollee
                in a
                Psychiatric emergency.

            

    

    

    (b)
      Post-stabilization care services include any of the mandatory services that
      a
      treating physician views as Medically Necessary, that are provided after an
      Enrollee is stabilized from an emergency mental health condition in order to
      maintain the stabilized condition, or under the circumstances described in
      42
      CFR 438.114(e) to improve or resolve the Enrollee’s condition.

    

    
      	 	
              (11)

            	
              Substance
                Abuse Services 

            

    

    

    
      	 	
              (a)

            	
              Health
                Plan Enrollees will receive Medicaid funded substance abuse services
                through the fee-for-service system. The Health Plan shall develop
                methods
                of coordinating and integrating mental health and substance abuse
                services
                for Enrollees. The Health Plan shall be required to use the Florida
                Supplement to the American Society of Addictions Medicine Patient
                Placement Criteria for the coordination of mental health treatment
                with
                substance abuse providers as part of the integration effort (Second
                Edition ASAM PPC-2, July 1998) the coordination shall be reflected
                in
                their individualized Treatment Plan for Enrollees with co-occurring
                disorder. The protocol for integrating mental health services with
                substance abuse services shall be monitored through the Quality of
                Care
                monitoring activities completed by the Agency’s EQRO contractor and the
                Quality Improvement requirements in Section VIII.A., Quality
                Improvement.

            

    

    

    
      	 	
              5.

            	
              Behavioral
                Health Targeted Case
                Management

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must provide targeted Case Management services to
                Children/Adolescents with serious emotional disturbances and adults
                with a
                severe mental illness as defined below. The Health Plan shall meet
                the
                intent of the services as outlined below and in the Medicaid Mental
                Health
                Targeted Case Management Coverage and Limitations Handbook. The Health
                Plan shall set criteria and clinical guidelines for Case Management
                services. Service limits and criteria developed cannot be more restrictive
                than those in Medicaid policy and as stated
                below.

            

    

    

    
      	 	
              (1)

            	
              At
                a minimum, case management services are to incorporate the principles
                of a
                strengths-based approach. Strengths-based case management services
                are an
                alternative service modality for working with individuals and families.
                This method stresses building on the strengths of individuals that
                can be
                used to resolve current problems and issues, countering more traditional
                approaches that focus almost exclusively on individuals’ deficits or
                needs.

            

    

    

    
      	 	
              b.

            	
              Target
                Populations: 

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have Case Management services available to
                Children/Adolescents who have a serious emotional disturbance, defined
                as:
                a Child/Adolescent with a defined mental disorder; a level of functioning
                which requires two (2) or more coordinated Behavioral Health Services
                to
                be able to live in the community; and be at imminent risk of out
                of home
                behavioral health treatment
                placement.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall also have Case Management services available for
                adults
                who:

            

    

    

    
      	 	
              (a)

            	
              Have
                been denied admission to a long-term mental health institution or
                residential treatment facility or have been discharged from a long-term
                mental health institution or residential treatment
                facility;

            

    

    

    
      	 	
              (b)

            	
              Require
                numerous services from different providers and also require advocacy
                and
                coordination to implement or access
                services;

            

    

    

    
      	 	
              (c)

            	
              Would
                be unable to access or maintain consistent care within the service
                delivery system without case management services;
                and/or

            

    

    

    
      	 	
              (d)

            	
              Do
                not possess the strengths, skills, or support system to allow them
                to
                access or coordinate services; 

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan will not be required to seek approval from the Department
                of
                Children and Families, District Substance Abuse and Mental Health
                (SAMH)
                Office for individual eligibility or mental health targeted case
                management agency or individual provider certification. The staffing
                requirements for case management services are listed in Section
                VII.E.7.

            

    

    

    
      	 	
              (4)

            	
              Behavioral
                health targeted Case Management services shall be available to all
                Enrollees within the principles and guidelines described as
                follows:

            

    

    

    
      	 	
              (a)

            	
              Enrollees
                who require numerous services from different providers and also require
                advocacy and coordination to implement or access services are appropriate
                for Case Management services;

            

    

    

    
      	 	
              (b)

            	
              Enrollees
                who would be unable to access or maintain consistent care within
                the
                service delivery system without Case Management services are appropriate
                for the service;

            

    

    

    
      	 	
              (c)

            	
              Enrollees
                who do not possess the strengths, skills, or support system to allow
                them
                to access or coordinate services are appropriate for Case Management
                services;

            

    

    

    
      	 	
              (d)

            	
              Enrollees
                without the skills or knowledge necessary to access services may
                benefit
                from Case Management. Case Management provides support in gaining
                skills
                and knowledge needed to access services and enhances the Enrollee’s level
                of independence.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan will not be required to seek approval from the SAMH Program
                Office for client eligibility or behavioral health targeted Case
                Management agency or individual provider certification. The staffing
                requirements for Case Management services are found in Section VII.E.7,
                Provider Network, Behavioral Health Services, in this Contract.
                

            

    

    

    
      	 	
              d.

            	
              Required
                Services 

            

    

    

    
      	 	
              (1)

            	
              Behavioral
                health targeted Case Management services include working with the
                Enrollee
                and the Enrollee’s natural support system to develop and promote a needs
                assessment-based service plan. The service plan reflects the services
                or
                supports needed to meet the needs identified in an individualized
                assessment of the following areas: education or employment, physical
                health, mental health, substance abuse, social skills, independent
                living
                skills, and support system status. The approach used should identify
                and
                utilize the strengths, abilities, cultural characteristics, and informal
                supports of the Enrollee, family, and other natural support systems.
                Targeted case managers focus on overcoming barriers by collaborating
                and
                coordinating with Providers and the Enrollee to assist in the attainment
                of service plan goals. The targeted case manager takes the lead in
                both
                coordinating services/treatment and assessing the effectiveness of
                the
                services provided. A strengths-based approach to providing services
                is
                consistent with the values of individuality and uniqueness and promotes
                participant self-direction and choice. The planning process is vital
                to
                achieving desired outcomes for the Enrollee. The Enrollee must have
                a
                sense of ownership about his/her goals, and the goals must have true
                meaning and vitality for him/her.

            

    

    

    
      	 	
              (2)

            	
              When
                targeted case management recipients enrolled in the Health Plan are
                hospitalized in an acute care setting or held in a county jail or
                juvenile
                detention facility, the Health Plan shall maintain contact with the
                Enrollee and shall participate actively in the discharge planning
                processes.

            

    

    

    
      	 	
              (3)

            	
              Case
                managers are also responsible for coordination and collaboration
                with the
                parents or guardians of Children/Adolescents who receive mental health
                targeted Case Management services. The Health Plan shall make reasonable
                efforts to assure that case managers include the parents or guardians
                of
                Enrollees in the process of providing targeted Case Management services.
                Integration of the parent’s input and involvement with the case manager
                and other Providers shall be reflected in Medical Record documentation
                and
                monitored through the Health Plan’s quality of care monitoring activities.
                Involvement with the Child’s/Adolescent’s school and/or childcare center
                must also be a component of case management with
                Children/Adolescents.

            

    

    

    
      	 	
              e.

            	
              Additional
                Requirements for Targeted Case
                Management

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have a Case Management program, including clinical
                guidelines and protocol that addresses the issues
                below:

            

    

    

    
      	 	
              (a)

            	
              Caseloads
                shall be set to achieve the desired results. Size limitations must
                clearly
                state the ratio of Enrollees to each individual case manager. The
                limits
                shall be specified for Children/Adolescents and adults, with a description
                of the clinical rationale for determining each limitation. If the
                Health
                Plan permits “mixed” caseloads, i.e., Children/Adolescents and adults, a
                separate limitation is expected along with the rationale for the
                determination. Ratios must be no greater than the requirements set
                forth
                in the Medicaid Mental Health Targeted Case Management Coverage and
                Limitations Handbook.

            

    

    

    
      	 	
              (b)

            	
              A
                system shall be in place to manage caseloads when positions become
                vacant.

            

    

    

    
      	 	
              (c)

            	
              The
                modality of service provision, and the location that services will
                be
                provided, shall be described.

            

    

    

    
      	 	
              (d)

            	
              Case
                Management protocol and clinical practice guidelines, which outline
                the
                expected frequency, duration and intensity of the service, shall
                be
                available.

            

    

    

    
      	 	
              (e)

            	
              Clinical
                guidelines shall address issues related to recovery and self-care,
                including services that will assist Enrollees in gaining independence
                from
                the behavioral health and Case Management
                system.

            

    

    

    
      	 	
              (2)

            	
              The
                Case Management program shall have services available based on the
                individual needs of the Enrollees receiving the service. The service
                should reflect a flexible system that allows movement within a continuum
                of care that addresses the changing needs and abilities of
                Enrollees.

            

    

    

    
      	 	
              (a)

            	
              Case
                management staff must have expertise and training necessary to competently
                and promptly assist Enrollees in working with Social Security
                Administration or Disability Determination in maintaining benefits
                from
                SSI and SSDI. For Enrollees who wish to work, case management staff
                must
                have the expertise and training necessary to assist Enrollees to
                access
                Social Security Work Incentives including development of Plans for
                Achieving Self-Support (PASS).

            

    

    

    
      	 	
              (b)

            	
              At
                a minimum, case management services are to incorporate the principles
                of a
                strengths-based approach. Strengths-based case management services
                are a
                preferred service modality for work with individuals and families.
                This
                method stresses building on the strengths of individuals and families
                that
                can be used to resolve current problems and issues. This approach
                counters
                more traditional approaches that focus almost exclusively on individuals’
                deficits or needs. Service limits and criteria developed cannot be
                more
                restrictive than those in Medicaid
                policy.

            

    

    

    
      	 	
              6.

            	
              Intensive
                Case Management

            

    

    

    
      	 	
              a.

            	
              Intensive
                Case Management is intended to provide intensive team Case Management
                to
                highly recidivistic adults who have a severe and persistent mental
                illness. The service is intended to help Enrollees remain in the
                community
                and avoid institutional care. Clinical care criteria for this level
                of
                Case Management shall address the same elements required above, as
                well as
                expanded elements related to access and twenty-four (24) hour coverage
                as
                described below. Additionally, the intensive Case Management team
                composition shall be expanded to include members of the team selected
                specifically to assist with the special needs of this population.
                The
                Health Plan shall include the team composition and how it will assist
                with
                special needs in the description of how this service will be
                provided.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall provide this service for all Enrollees for whom
                the
                service is determined to be Medically Necessary, to include Enrollees
                who
                meet the following criteria:

            

    

    

    
      	 	
              (1)

            	
              Has
                resided in a state mental health treatment facility for at least
                six (6)
                months in the past 36 months;

            

    

    

    
      	 	
              (2)

            	
              Resides
                in the community and has had two (2) or more admissions to a state
                mental
                health treatment facility in the past 36
                months;

            

    

    

    
      	 	
              (3)

            	
              Resides
                in the community and has had three (3) or more admissions to a crisis
                stabilization unit, short-term residential facility, inpatient psychiatric
                unit, or any combination of these facilities within the past twelve
                (12)
                months; or

            

    

    

    
      	 	
              (4)

            	
              Resides
                in the community and, due to a mental illness, exhibits behavior
                or
                symptoms that could result in long-term hospitalization if frequent
                interventions for an extended period of time were not
                provided.

            

    

    

    
      	 	
              c.

            	
              Intensive
                Case Management provides services through the use of a team of case
                managers. The team can be expanded to include other specialists that
                are
                qualified to address identified needs of the Enrollees receiving
                intensive
                Case Management. This level of care for Case Management is the most
                intensive and serves Enrollees with the most severe and disabling
                mental
                conditions. Services are frequent and intense with a focus on assisting
                the Enrollee with attaining the skills and supports needed to gain
                independent living skills. Case Management services are provided
                primarily
                in the Enrollee’s residence and include community-based
                interventions.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall provide this service in the least restrictive setting
                with the goal of improving the Enrollee’s level of functioning, and
                providing ample opportunities for rehabilitation, recovery, and
                self-sufficiency. Intensive Case Management services shall be accessible
                twenty-four (24) hours per day, seven (7) days per week. The Health
                Plan
                shall demonstrate adequate capacity to provide this service for the
                targeted population within the guidelines
                outlined.

            

    

    

    
      	 	
              e.

            	
              Intensive
                Case Management teams shall provide the same coordination and Case
                Management services for Enrollees admitted to inpatient facilities,
                State
                mental Hospitals, and forensic or corrections facilities as those
                listed
                above for behavioral health targeted Case Management
                services.

            

    

    

    
      	 	
              7.

            	
              Community
                Treatment of Patients Discharged from State Mental
                Hospitals 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide Medically Necessary Behavioral Health Services
                to Enrollees who have been discharged from any State mental Hospital,
                including, but not limited to, follow-up services and care. All Enrollees
                who have previously received services at the State mental Hospital
                must
                receive follow up care.

            

    

    

    
      	 	
              b.

            	
              The
                plan of care shall be aimed at encouraging Enrollees to achieve a
                high
                quality of life while living in the community in the least restrictive
                environment that is medically appropriate and reducing the likelihood
                that
                the Enrollees will be readmitted to a State mental
                Hospital.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall follow the progress of all Enrollees enrolled in
                the
                Health Plan prior to admission to a State mental Hospital until the
                one
                hundred eightieth (180th) day after Disenrollment from the Health
                Plan.
                The Health Plan shall use behavioral health targeted case managers
                to
                follow the progress of Enrollees. The behavioral health targeted
                case
                manager must attend and participate in the discharge planning activities
                at the facility. Targeted case managers are responsible for working
                with
                the former Enrollee before discharge from the State facility to assure
                that Benefits are reinstated as soon as possible, and that the Enrollee
                receives community Behavioral Health Services within twenty-four
                (24)
                hours of his/her discharge from the State
                facility.

            

    

    

    
      	 	
              d.

            	
              If
                the Enrollee remains in the State facility more than one hundred
                eighty
                (180) days after Disenrollment, the Health Plan shall cooperate with
                DCF
                and the Enrollee to ensure that the Enrollee is assigned a DCF funded
                Case
                Management provider who will bear the responsibility of ongoing monthly
                follow-up care and discharge planning until such time that the Enrollee
                is
                again eligible for, and enrolled in, a Health
                Plan.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall develop a cooperative agreement with the behavioral
                health care facility to enable the Health Plan to anticipate those
                Medicaid Recipients who were Enrollees of the Health Plan prior to
                admission to the Facility, and will be soon discharged from the Facility.
                The cooperative agreement must address arrangements for Medicaid
                Recipients, whom the Facility is discharging, but who are not eligible
                for
                immediate re-enrollment.

            

    

    

    
      	 	
              8.

            	
              Community
                Services for Medicaid Recipients Involved with the Corrections
                System

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide Medically Necessary community-based services
                for
                Health Plan Enrollees who have corrections involvement as
                follows:

            

    

    

    
      	 	
              (1)

            	
              Establish
                a linkage to pre-booking sites for assessment, screening or diversion
                related to Behavioral Health
                Services;

            

    

    

    
      	 	
              (2)

            	
              Provide
                immediate access (within twenty-four (24) hours of release) for
                psychiatric services upon release from jail, prison, juvenile detention
                facility, or other corrections facility to assure that prescribed
                medications are available for all
                Enrollees.

            

    

    
      	 	 	 

    

    
      	 	
              (3)

            	
              Establish
                a linkage to post-booking sites for discharge planning and assuring
                that
                prior Health Plan Enrollees receive necessary services upon release
                from
                the facility. Health Plan Enrollees must be linked to services and
                receive
                routine care within seven (7) days from the date they are
                released.

            

    

    

    
      	 	
              (4)

            	
              Provide
                outreach to homeless and other populations of Health Plan Enrollees
                at
                risk of corrections involvement, as well as those Health Plan Enrollees
                currently involved in this system, to assure that services are accessible
                and provided when necessary. This activity should be oriented toward
                preventive measures to assess behavioral health needs and provide
                services
                that can potentially prevent the need for future inpatient services
                or
                possible deeper involvement in the forensic or corrections
                system.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan shall develop a cooperative agreement with corrections
                facilities to enable the Health Plan to anticipate Enrollees who
                were
                Health Plan Enrollees prior to incarceration who will be released
                from
                these institutions. The cooperative agreement must address arrangement
                for
                persons who are to be released, but for whom re-Enrollment may not
                take
                effect immediately. All Enrollees who were Health Plan Enrollees
                prior to
                incarceration and Medicaid Recipients who are likely to enroll in
                the
                Health Plan upon return to the community must receive a community
                Behavioral Health Service within twenty-four (24) hours of discharge
                from
                the corrections facility.

            

    

    

    
      	 	
              9.

            	
              Treatment
                and Coordination of Care for Enrollees with Medically Complex
                Conditions

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall ensure that there are appropriate treatment resources
                available to address the treatment of complex conditions that reflect
                both
                mental health and physical health involvement. The following conditions
                must be addressed:

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (2)

            	
              Eating
                disorders - ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
                307.52.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall provide medically necessary community mental health
                services to enrollees who exhibit the above diagnoses and shall develop
                a
                plan of care that includes all appropriate collateral providers necessary
                to address the complex medical issues involved. Clinical care criteria
                shall address modalities of treatment that are effective for each
                diagnosis. The Health Plan’s provider network must include appropriate
                treatment resources necessary for effective treatment of each diagnosis
                within the required access time
                periods.

            

    

    

    
      	 	
              10.

            	
              Monitoring
                of Enrollees admitted to Children's Residential Treatment (Level
                I -
                IV)

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall maintain contact with Children/Adolescents who
                are
                disenrolled from the Health Plan due to placement in a residential
                treatment facility (Statewide Inpatient Psychiatric Program (SIPP),
                Therapeutic Group Care Services (TGCS), or Behavioral Health Overlay
                Services (BHOS)). The Health Plan shall participate in discharge
                planning,
                assist the Enrollee and their caregiver to locate community-based
                services, and notify Medicaid when the enrollee is discharged from
                the
                facility. The Health Plan’s contract manager or designee shall re-enroll
                the Enrollee in the Health Plan upon notification of discharge into
                the
                community.

            

    

    

    
      	 	
              b.

            	
              Children
                placed in SIPP, TGCS, or BHOS facilities will be disenrolled from
                the
                Health Plan and then covered under Medicaid Fee-for-Service for mental
                health services. The Medicaid contract manager or designee will be
                responsible for the disenrollment process. The Department of Juvenile
                Justice, residential providers, and/or the assigned Mental Health
                Targeted
                Case Management providers will be responsible for notifying Medicaid
                of
                all admissions and discharges. A specific agreement regarding the
                disenrollment and re-enrollment process will be developed between
                the
                Agency, residential providers, and the
                departments.

            

    

    

    
      	 	
              c.
                

            	
              Upon
                notification of the Enrollee's discharge from the facility the Health
                Plan
                shall notify the Choice Counselor/Enrollment Broker for re-Enrollment
                into
                the Health Plan, if it is within six (6) months (180 days) from the
                disenrollment. 

            

    

    

    
      	 	
              11.

            	
              Coordination
                of Children’s Services 

            

    

    

    
      	 	
              a.

            	
              General
                Principles

            

    

    

    
      	 	
              (1)

            	
              The
                delivery and coordination of Children’s/Adolescent’s mental health
                services shall be provided for all Children/Adolescents who exhibit
                the
                symptoms and behaviors of an emotional disturbance. The delivery
                of
                services must address the needs of any Child/Adolescent served in
                an SED
                or EH school program. Developmentally appropriate early childhood
                mental
                health services must be available to children age birth to five (5)
                years
                old and their families.

            

    

    

    (2) The
      Health Plan shall deliver services for all Children/Adolescents within a
      strengths-based, culturally competent service design. The service design shall
      recognize and ensure that services are family-driven and include the
      participation of family, significant others, informal support systems, school
      personnel, and any State entities or other service providers involved in the
      Child’s/Adolescent’s life. 

    

    
      	 	
              (3)

            	
              For
                all Children/Adolescents receiving services from the Health Plan,
                the
                Provider shall work with the parents, guardians, or other responsible
                parties to monitor the results of services and determine whether
                progress
                is occurring. Active monitoring of the Child/Adolescent’s status shall
                occur to detect potential risk situations and emerging needs or
                problems.

            

    

    

    
      	 	
              (4)

            	
              When
                the court mandates a parental behavioral health assessment, and the
                parent
                is an Enrollee, the Provider must complete an assessment of the parent’s
                mental health status and the effects on the child. Time frames for
                completion of this service shall be determined by the mandates issued
                by
                the courts.

            

    

    

    
      	 	
              b.

            	
              Targeted
                Case Management

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide behavioral case management services to
                Children/Adolescents in the care or custody of the State who need
                behavioral health targeted Case Management services, as defined in
                the
                Health Plan’s approved clinical protocols. These children shall not be
                transferred to the new Medicaid Child Welfare Targeted Case Management
                program. The Health Plan shall develop a cooperative agreement with
                DCF or
                their provider of community based services, to address how to minimize
                duplication of case management services and to promote the establishment
                of one case manager for the Child/Adolescent and family whenever
                possible.

            

    

    

    
      	 	
              c.

            	
              Community
                Based Care Programs

            

    

    

    
      	 	
              (1)

            	
              If
                the community in which the Health Plan operates has a community-based
                care
                program contracted by DCF for the provision of children’s protective
                services, the Health Plan shall determine how to provide services
                to
                Enrollees served by the community-based care program. The Health
                Plan
                shall develop, during the implementation phase of the Contract, or
                upon
                notification that the department has contracted with a Health Plan,
                a
                cooperative agreement between the Health Plan and the community-based
                care
                program. Medicaid and DCF shall approve the agreement. The Health
                Plan
                shall be prepared to provide services in a collaborative manner in
                each
                county covered by the Health Plan.

            

    

    

    
      	 	
              12.

            	
              Evaluation
                and Treatment Services for Enrolled Children/Adolescents
                

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide all Medically Necessary evaluation and
                treatment
                services for Children/Adolescents referred to the Health Plan by
                DCF, DJJ
                and by schools (elementary, middle, and secondary
                schools).

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall provide Medically Necessary Children/Adolescent
                Behavioral Health Services in such a way as to minimize disruption
                of
                services available to high-risk populations served by
                DCF.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall promptly evaluate, provide psychological testing,
                and
                deliver Behavioral Health Services to Children/Adolescents (including
                delinquent and dependent Children/Adolescent) referred by DCF in
                accordance with Medical Necessity. As well, the Health Plan shall
                adhere
                to the minimum staffing, availability and access standards described
                in
                this Contract.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall provide court ordered evaluation and treatment
                required
                for Children/Adolescents who are Enrollees. See specifications in
                the
                Medicaid Community Behavioral Health Services Coverage & Limitations
                Handbook.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan must participate in all DCF or school staffings that
                may
                result in the provision of Behavioral Health Services to an Enrolled
                Child/Adolescent.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall refer Children/Adolescents to DCF when residential
                treatment is Medically Necessary. The Health Plan shall not be responsible
                for providing any residential treatment for Children/Adolescents.
                The SAMH
                or DJJ district office shall coordinate the placement of the Enrolled
                Child/Adolescent with the Health Plan.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan's Case Management of Children/Adolescents shall include
                those
                persons, schools, programs, networks and agencies that figure importantly
                in the Child's/Adolescent's life.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan shall make determinations about care based on a comprehensive
                evaluation, consultation with those persons, schools, programs, networks
                and agencies that figure importantly in the Child's/Adolescent's
                life, and
                appropriate protocols for admission and
                retention.

            

    

    

    
      	 	
              i.

            	
              The
                Health Plan shall monitor services for adequacy in conformity with
                the
                cooperative agreement between the Health Plan and the
                facility.

            

    

    

    
      	 	
              13.

            	
              Assessment
                and Treatment of Mental Health Residents Who Reside in Assisted Living
                Facilities (ALF) that hold a Limited Mental Health
                License

            

    

    

    
      	 	
              a.

            	
              The
                provider must develop and implement a plan to ensure compliance with
                Section 394.4574, F.S., related to services provided to residents
                of
                licensed assisted living facilities that hold a limited mental health
                license. A cooperative agreement, as defined in Section 400.402,
                F.S.,
                must be developed by the ALF if an Enrollee is a resident of an ALF.
                The
                provider must ensure that appropriate assessment services are provided
                to
                Enrollees and that Medically Necessary Behavioral Health Services
                are
                available to all Enrollees who reside in this type of
                setting.

            

    

    

    
      	 	
              b.

            	
              A
                Community Living Support Plan, as defined in Section I, Definitions
                and
                Acronyms, must be developed for each Enrollee who is a resident of
                an ALF,
                and it must be updated annually. The Health Plan case manager is
                responsible for ensuring that the community living support plan is
                implemented as written.

            

    

    

    

    

    
      	 	
              14.

            	
              Psychiatric
                Evaluations for Enrollees Applying for Nursing Home
                Admission

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan, upon request from the SAMH district office, shall promptly
                arrange for and authorize psychiatric evaluations for Enrollees applying
                for admission to a Nursing Facility, and who, on the basis of a screening
                conducted by CARES, are thought to need Behavioral Health Services,
                pursuant to OBRA, 1987. The examination shall be adequate to determine
                the
                need for "specialized treatment" under the Act. Any of the Mental
                Health
                Professionals listed in section 394.455, F.S., and make the observations
                as part of the evaluation, although a psychiatrist must sign all
                evaluations. The examination shall be adequate to determine the need
                for
                “specialized treatment” under the Act. Evaluations must be completed
                within five (5) Business Days from the receipt of the request from
                the DCF
                SAMH Program Office. The State has interpreted regulations to permit
                any
                of the “mental health professionals” listed in Section 394.455, F.S. to
                make observations preparatory to the evaluation, although a psychiatrist
                must sign such evaluations.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall not be responsible for annual resident reviews
                or for
                providing services as a result of a Preadmission Screening Assessment
                Annual Resident Review ("PASSAR")
                evaluation.

            

    

    

    
      	 	
              15.

            	
              Individuals
                with Special Health Care
                Needs

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall implement mechanisms for identifying, assessing
                and
                ensuring the existence of an Individualized Treatment Plan for Enrollees
                with Special Health Care Needs, as defined in Section I, Definitions
                and
                Acronyms. Mechanisms shall include evaluation of risk assessments,
                claims
                data, and CPT/ICD-9 codes. Additionally, the Health Plan shall implement
                a
                process for receiving and considering provider and Enrollee
                input.

            

    

    

    
      	 	
              b.

            	
              In
                accordance with this Contract and 42 CFR 438.208(c)(3), an Individualized
                Treatment Plan for an Enrollee determined to need a course of treatment
                or
                regular care monitoring must be:

            

    

    

    
      	 	
              (1)

            	
              Developed
                by the Enrollee's direct service mental health care professional
                with
                Enrollee participation and in consultation with any specialists caring
                for
                the Enrollee; 

            

    

    

    
      	 	
              (2)

            	
              Approved
                by the Health Plan in a timely manner if this approval is required;
                and

            

    

    

    
      	 	
              (3)

            	
              Developed
                in accordance with any applicable Agency quality assurance and utilization
                review standards.

            

    

    

    
      	 	
              c.

            	
              Pursuant
                to 42 CFR 438.208(c)(4), for Enrollees with Special Health Care Needs
                determined through an assessment by appropriate mental health care
                professionals (consistent with 42 CFR 438.208(c)(2))
                to need a course of treatment or regular care monitoring, the Health
                Plan
                must have a mechanism in place to allow Enrollees to directly access
                a
                mental health care specialist (for example, through a standing referral
                or
                an approved number of visits) as appropriate for the Enrollee's condition
                and identified needs.

            

    

    

    
      	 	
              16.

            	
              Crisis
                Support/Emergency Services

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall operate, as part of its Crisis Support/Emergency
                Services, a crisis emergency hotline available to all Enrollees
                twenty-four (24) hours a day, seven (7) days a
                week.

            

    

    

    
      	 	
              17.

            	
              Provision
                of Behavioral Health Services When Not Covered by the Health
                Plan

            

    

    

    
      	 	
              a.

            	
              If
                the Health Plan determines that an Enrollee is in need of Behavioral
                Health Services that are not covered under the Contract, the Health
                Plan
                shall refer the Enrollee to the appropriate provider. The Health
                Plan may
                request the assistance of the Agency’s local field office or the local DCF
                District ADM Office for referral to the appropriate service
                setting.

            

    

    

    
      	 	
              b.

            	
              Long
                term care institutional services in a nursing facility, an institution
                for
                persons with developmental disabilities, specialized therapeutic
                foster
                care, children's residential treatment services or State hospital
                services
                are not covered by the Health Plan. For Enrollees requiring those
                services, the Health Plan shall consult the Medicaid Field Office
                and/or
                the DCF District ADM Office to identify appropriate methods of assessment
                and referral.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan is responsible for transition and referral of the Enrollee
                to
                appropriate providers. The Health Plan shall request Disenrollment
                of all
                Enrollees receiving the services described in this
                Section.

            

    

    

    
      	 	
              18.

            	
              Behavioral
                Health Services Care Coordination and Management
                

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall be responsible for the coordination and management
                of
                Behavioral Health Services and continuity of care for all Enrollees.
                At a
                minimum, the Health Plan shall provide the following services to
                its
                Enrollees:

            

    

    

    
      	 	
              (1)

            	
              Minimize
                disruption to the Enrollee as a result of any change in Behavioral
                Health
                Care Providers or Behavioral Health Care Case Managers that occur
                as a
                result of this Contract. For new Enrollees who had been receiving
                Behavioral Health Services, the Health Plan shall continue to authorize
                all valid claims for services until the Health Plan has:
                

            

    

    

    
      	 	
              (a)

            	
              Reviewed
                the Enrollee's treatment plan;

            

    

    

    
      	 	
              (b)

            	
              Developed
                an appropriate written transition plan;
                and

            

    

    

    
      	 	
              (c)

            	
              Implemented
                the written transition plan.

            

    

    

    
      	 	
              (2)

            	
              If
                the previous Behavioral Health Care Provider is unable to allow the
                Health
                Plan access to the Enrollee's Medical Records because the Enrollee
                refuses
                to release his/her records, then the Health Plan shall
                provide:

            

    

    

    
      	 	
              (a)

            	
              Up
                to four (4) sessions of individual or group
                therapy;

            

    

    

    
      	 	
              (b)

            	
              One
                (1) psychiatric medical session;

            

    

    

    
      	 	
              (c)

            	
              Two
                (2) one-hour intensive therapeutic on-site sessions;
                or

            

    

    

    
      	 	
              (d)

            	
              Six
                (6) days of day treatment services.

            

    

    

    
      	 	
              (3)

            	
              Document
                all Emergency Behavioral Health Services received by an Enrollee,
                along
                with any follow-up services, in the Enrollee's behavioral health
                Medical
                Records. The Health Plan shall also assure the PCP receives the
                information about the Emergency Behavioral Health Services for filing
                in
                the PCP's Medical Record.

            

    

    

    
      	 	
              (4)

            	
              Document
                all referral services in the Enrollees’ behavioral health Medical
                Records.

            

    

    

    
      	 	
              (5)

            	
              Monitor
                Enrollees admitted to State mental health institutions by participating
                in
                discharge planning and community placement of Enrollees who are discharged
                within sixty (60) days of losing their Health Plan enrollment due
                to State
                institutionalization. The Agency shall sanction the Health Plan,
                as
                described in Section XIV, Sanctions, for any inappropriate
                over-utilization of State mental hospital services for its
                Enrollees.

            

    

    

    
      	 	
              (6)

            	
              Coordinate
                Hospital and institutional discharge planning for psychiatric admissions
                and substance abuse detoxification to ensure inclusion of appropriate
                post-discharge care. 

            

    

    

    
      	 	
              (a)

            	
              Enrollees
                admitted to an acute care facility (inpatient Hospital or CSU) shall
                receive appropriate services upon discharge from the acute care
                facility.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall have follow-up services available to Enrollees
                within
                twenty-four (24) hours of discharge from an acute care facility,
                provided
                the acute care facility notified the Health Plan that it had provided
                services to the Enrollee.

            

    

    

    
      	 	
              (c)

            	
              The
                Health Plan shall continue the medication prescribed by a State mental
                health facility to the Enrollee for at least ninety (90) days after
                the
                State mental health facility discharges the Enrollee, unless the
                Health
                Plan's prescribing psychiatrist, in consultation and agreement with
                the
                State mental health facility's prescribing physician, determines
                that the
                medications: 

            

    

    

    
      	 	
              (i)

            	
              Are
                not Medically Necessary; or

            

    

    

    
      	 	
              (ii)

            	
              Are
                potentially harmful to the
                Enrollee.

            

    

    

    
      	 	
              g.

            	
              Provide
                appropriate referral of the Enrollee for non-covered services to
                the
                appropriate service setting. The Health Plan shall request referral
                assistance, as needed, from the Medicaid Field Office. The Health
                Plan is
                encouraged to use the Florida Supplement to the American Society
                of
                Addictions Medicine Patient Placement Criteria for coordination and
                treatment of substance abuse related disorders with substance abuse
                providers. The Health Plan is encouraged to use the Florida Supplement
                to
                the American Society of Addictions Medicine Placement Criteria for
                coordination and treatment of substance-related disorders with substance
                abuse Providers. The Health Plan shall provide coordination of care
                with
                community-based substance abuse agencies as part of its policies
                and
                procedures developed for continuity of care for Enrollees who are
                diagnosed with mental illness and substance abuse or
                dependency.

            

    

    

    
      	 	
              h.

            	
              Provide
                court ordered mental health evaluations for Enrollees. The Health
                Plan
                shall also provide expert behavioral health testimony for
                Enrollees.

            

    

    

    
      	 	
              i.

            	
              Provide
                appropriate screening, assessment, and crisis intervention in support
                of
                Enrollees who are in the care and custody of the State. See Specifications
                listed in the Medicaid Community Mental Health Services Coverage
&
                Limitations Handbook.

            

    

    

    
      	 	
              j..

            	
              Upon
                request from an ALF, the Health Plan shall provide procedures for
                the ALF
                to follow should an emergent condition arise with an Enrollee that
                resides
                at the ALF (see Section 409.912,
                F.S.).

            

    

    

    
      	 	
              k.

            	
              The
                Health Plan shall participate in the SAMH planning process in each
                DCF
                district (see Section 394.75,
                F.S.).

            

    

    

    
      	 	
              l.

            	
              The
                Health Plan shall design and implement a Drug Utilization Review
                ("DUR")
                program. Once the Health Plan's pharmacy utilization indicates that
                an
                Enrollee is receiving an antipsychotic medication from a PCP or
                prescribing non-psychiatrist physician, the Health Plan shall request
                a
                consultation with the PCP or prescribing non-psychiatrist physician.
                Once
                the Health Plan's pharmacy utilization indicates that an Enrollee,
                who is
                being treated by a Behavioral Health Care Provider, receives medication
                for certain physical conditions (such as hypertension, diabetes,
                neurological disorders, cardiac problems, or any other serious medical
                condition) the Health Plan shall schedule a consultation with the
                PCP or
                prescribing physician to discuss coordination of care and concerns
                related
                to drug interactions. The Health Plan shall ensure coordination with
                the
                PCP or prescribing physician with regards to drug utilization and
                potential contraindications.

            

    

    

    
      	 	
              19.

            	
              Discharge
                Planning

            

    

    

    
      	 	
              a.

            	
              Discharge
                Planning is the evaluation of an Enrollee's medical care needs, including
                Behavioral Health Service needs, substance abuse service needs, or
                both,
                in order to arrange for appropriate care after discharge from one
                level of
                care to another level of care. The Health Plan
                shall:

            

    

    

    
      	 	
              (1)

            	
              Monitor
                all Enrollee discharge plans from behavioral health inpatient admissions
                to ensure that they incorporate the Enrollees’ needs for continuity in
                existing behavioral health therapeutic
                relationships.

            

    

    

    
      	 	
              (2)

            	
              Ensure
                that Enrollees' family members, guardians, outpatient individual
                practitioners and other identified supports are given the opportunity
                to
                participate in Enrollee treatment to the maximum extent practicable
                and
                appropriate, including behavioral health treatment team meetings
                and
                developing the discharge plan. For adult Enrollees, family members
                and
                other identified supports may be involved in the development of the
                Discharge Plan only if the Enrollee consents to their
                involvement.

            

    

    

    
      	 	
              (3)

            	
              Designate
                staff members who are responsible for identifying Enrollees who remain
                in
                the Hospital for non-clinical reasons (i.e., absence of appropriate
                treatment setting availability, high demand for appropriate treatment
                setting, high-risk Enrollees and Enrollees with multiple agency
                involvement).

            

    

    

    
      	 	
              (4)

            	
              Develop
                and implement a plan that monitors and ensures that clinically indicated
                Behavioral Health Services are offered and available to Enrollees
                within
                twenty-four (24) hours of discharge from an inpatient
                setting.

            

    

    

    
      	 	
              (5)

            	
              Ensure
                that a behavioral health program clinician provides medication management
                to Enrollees requiring medication monitoring within twenty-four (24)
                hours
                of discharge from a behavioral health program inpatient setting.
                The
                Health Plan shall ensure that the behavioral health program clinician
                is
                duly qualified and licensed to provide medication
                management.

            

    

    

    
      	 	
              (6)

            	
              Upon
                the admission of an Enrollee, the Health Plan shall make its best
                efforts
                to ensure the Enrollee’s smooth transition to the next service or to the
                community; and shall require that Behavioral Health Care
                Providers:

            

    

    

    
      	 	
              (a)

            	
              Assign
                a Behavioral Health Care Case Manager to oversee the care given to
                the
                Enrollee;

            

    

    

    
      	 	
              (b)

            	
              Develop
                an individualized discharge plan, in collaboration with the Enrollee
                where
                appropriate, for the next service or program or the Enrollee's discharge,
                anticipating the Enrollee's movement along a continuum of services;
                and

            

    

    

    
      	 	
              (c)

            	
              Make
                best efforts to ensure a smooth transition to the next service or
                community;

            

    

    

    
      	 	
              (d)

            	
              Document
                all significant efforts related to these activities, including the
                Enrollee's active participation in discharge
                planning.

            

    

    

    
      	 	
              20.

            	
              Transition
                Plan 

            

    

    

    
      	 	
              a.

            	
              A
                transition plan is a detailed description of the process of transferring
                Enrollees from non-participating providers to the Health Plan's Behavioral
                Health Care Provider network to ensure optimal continuity of care.
                The
                transition plan shall include, but not be limited to, a timeline
                for
                transferring Enrollees, description of provider medical record transfers,
                scheduling of appointments, and propose prescription drug protocols
                and
                claims approval for existing providers during the transition period.
                The
                Health Plan shall document its efforts relating to the transition
                plan in
                the Enrollee’s Medical Records.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall minimize the disruption of treatment by an Enrollee's
                current behavioral health care provider by arranging for Enrollee
                use of
                services outside of the Health Plan's network. For Enrollees who
                have
                received Behavioral Health Services for at least six (6) months from
                a
                behavioral health care provider, whether the provider is in the Health
                Plan’s network or not, the Health Plan shall continue to authorize all
                valid claims until the Health Plan reviews the Enrollee's treatment
                plan
                and implements an appropriate written transition
                plan.

            

    

    

    
      	 	
              c.

            	
              During
                the first three (3) months that the Enrollee receives Behavioral
                Health
                Services under this Contract, the Health Plan shall not deny requests
                for
                Behavioral Health Services outside the network under the following
                conditions:

            

    

    

    
      	 	
              (1)

            	
              The
                Enrollee is a patient at a community behavioral health center and
                the
                center has discussed the Enrollee's care with the Health
                Plan.

            

    

    

    
      	 	
              (2)

            	
              If,
                following contact with the Health Plan, there is no Behavioral Health
                Care
                Provider readily available and the Enrollee's condition would not
                permit a
                delay in treatment.

            

    

    

    
      	 	
              d.

            	
              If
                the previous treating provider is unable to allow the Health Plan
                access
                to the Enrollee's Medical Records because the Enrollee refuses to
                release
                the records, then the Health Plan shall approve the provider’s claims
                for:

            

    

    

    
      	 	
              (1)

            	
              Four
                (4) sessions of outpatient behavioral health counseling or
                therapy;

            

    

    

    
      	 	
              (2)

            	
              One
                (1) outpatient psychiatric physician session;

            

    

    

    
      	 	
              (3)

            	
              Two
                (2) one-hour intensive therapeutic on-site sessions;
                or

            

    

    

    
      	 	
              (4)

            	
              Six
                (6) days of day treatment services.

            

    

    

    
      	 	
              e.

            	
              Any
                disputes related to coverage of services necessary for the transition
                of
                Enrollees from their current behavioral health care provider to a
                Behavioral Health Care Provider shall follow the process set forth
                in
                Section IX, Grievance System.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall approve claims from providers for authorized out-of-plan
                non-emergency services, provided such claims are submitted within
                twelve
                (12) months of the date of service. The Health Plan must process
                such
                claims within the time period specified in Section 641.3155,
                F.S.

            

    

    

    
      	 	
              21.

            	
              Functional
                Assessments 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall ensure that all Behavioral Health Care Providers
                administer functional assessments using the Functional Assessment
                Rating
                Scales (FARS) for all Enrollees over the age of eighteen (18) and
                Child
                Functional Assessment Rating Scale (CFARS) for all Enrollees age
                eighteen
                (18) and under.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall ensure that all Behavioral Health Care Providers
                administer and maintain the FARS and CFARS, according to the FARS
                and
                CFARS manuals, to all Enrollees receiving Behavioral Health Services
                and
                upon termination of providing such services.

            

    

    

    
      	 	
              c.

            	
              The
                results of the FARS and CFARS assessments shall be maintained in
                each
                Enrollee's Medical Record, including a chart trending the results
                of the
                functional assessments.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall submit the FARS/CFARS reports as required in Section
                XII, Reporting Requirements.

            

    

    

    
      	 	
              22.

            	
              Outreach
                Program

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall have an outreach program designed to encourage
                Enrollees
                to seek Behavioral Health Services through the Health Plan when the
                Health
                Plan, or Providers, perceive a need for Behavioral Health Services.
                In
                addition, the outreach program, at a minimum, shall provide for the
                following:

            

    

    

    
      	 	
              (1)

            	
              Make
                available, by mail or at the request of an Enrollee/provider
                (participating or non-participating), outreach program documentation
                that
                is written at the fourth (4th)
                grade reading level and written in the primary language spoken by
                the
                Enrollee;

            

    

    

    
      	 	
              (2)

            	
              A
                program to identify and manage Enrollees who are
                homeless.

            

    

    

    
      	 	
              (3)

            	
              A
                program, including referral and other resources, designed to assist
                PCP's
                in the identification, management and treatment
                of:

            

    

    

    
      	 	
              (a)

            	
              Enrollees
                with severe and persistent mental illness;

            

    

    

    
      	 	
              (b)

            	
              Children/Adolescents
                with severe emotional disturbances;
                and

            

    

    

    
      	 	
              (c)

            	
              Enrollees
                with clinical depression.

            

    

    

    
      	 	
              23.

            	
              Behavioral
                Health Provider Contracts

            

    

     

    
      	 	
              a.

            	
              If
                the Health Plan subcontracts with a Managed Behavioral Health Organization
                (MBHO) for the provision of Behavioral Health Services, the MBHO
                must be
                accredited by at least one (1) of the recognized national accreditation
                organizations. 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall submit to the Agency the staff psychiatrist employment
                contract, if any, and the model Provider Contracts for each Behavioral
                Health Services specialist type or
                facility.

            

    

    

    
      	 	
              b.

            	
              All
                subcontracts and Provider Contracts must adhere to the requirements
                set
                forth in this Contract.

            

    

    

    
      	 	
              24.

            	
              Optional
                Services

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan is encouraged to provide additional services that will
                enhance
                the Health Plan’s Covered Services for Enrollees. To the degree possible,
                the Health Plan should use existing community resources. Below is
                a list
                of possible optional services that could be provided with the savings
                achieved or as downward substitutions. This list is not intended
                to be
                all-inclusive and the Health Plan is encouraged to use creativity
                in
                developing new and innovative services to expand the array of services
                and
                meet the needs of Enrollees.

            

    

    

    
      	 	
              (1)
                

            	
              Respite
                Care Services;

            

    

    

    
      	 	
              (2)
                

            	
              Prevention
                Services in the Community;

            

    

    

    
      	 	
              (3)
                

            	
              Supportive
                Living Services;

            

    

    

    
      	 	
              (4)
                

            	
              Supported
                Employment Services;

            

    

    

    
      	 	
              (5)
                

            	
              Foster
                Homes for Adults;

            

    

    

    
      	 	
              (6)
                

            	
              Parental
                Education Programs;

            

    

    

    
      	 	
              (7)
                

            	
              Drop-In
                Centers and other consumer operated programs (beyond the elements
                provided
                under the Opportunities for Recovery and Reintegration
                component);

            

    

    

    
      	 	
              (8)
                

            	
              Intensive
                Therapeutic On-Site Services for
                Adults;

            

    

    

    
      	 	
              (9)
                

            	
              Home
                and Community Based Rehabilitation Services for Adults;
                and

            

    

    

    
      	 	
              (10)
                

            	
              Any
                other new and innovative interventions or services designed to benefit
                Enrollees.

            

    

    

    
      	 	
              25.
                

            	
              Community
                Coordination and
                Collaboration

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must be or become a vital part of the community services
                and
                support system. It must actively participate with and support community
                programs and coalitions that promote school readiness, that assist
                persons
                to return to work and provide for prevention programs. The Health
                Plan
                must have linkages with numerous community programs that will assist
                Enrollees in obtaining housing, economic assistance and other
                supports.

            

    

    

    
      	
              C.

            	
              Behavioral
                Health Managed Care Local Advisory
                Group

            

    

    

    
      	 	
              1.

            	
              There
                will be a local advisory group for the Health Plan that convenes
                quarterly
                and reports to the Agency on advocacy and programmatic concerns.
                The local
                advisory group is responsible for providing technical and policy
                advice to
                the Agency regarding the Health Plan’s provision of services. The local
                advisory group does not have access to Enrollee Medical
                Records.

            

    

    

    
      	 	
              2.

            	
              The
                role of the local advisory group is to report to the Agency information
                related to practical and real events that occur related to the activities
                of Medicaid health plans. Concerns about services, program changes,
                quality of care, difficulties, advocacy issues, and reports about
                positive
                outcomes are presented by members of the local advisory group and
                are
                addressed by the Agency as part of the ongoing monitoring of the
                Health
                Plan. The Agency presents information about actions taken related
                to
                issues presented by the group. If the local advisory group determines
                that
                it is appropriate, the local advisory group members also vote to
                present
                their issues to the Agency in
                writing.

            

    

    

    
      	 	
              3.

            	
              The
                local advisory group may request information to be presented at each
                meeting that will keep the local advisory group up-to-date regarding
                the
                Contract and activities of each Health Plan. Minutes of the meetings
                are
                kept and distributed to all members and attendees. The voting membership
                of the local advisory group is updated periodically.  This
                is a public meeting and may be attended by anyone in the
                community.

            

    

    
      	 	 	 

    

    
      	 	
              4.

            	
              The
                local advisory group is coordinated by Agency area staff (who are
                not part
                of the voting membership) and consists of providers, consumer
                representatives, advocacy groups, and other relevant groups as identified
                by the Agency, which represent the counties within the Service Area.
                Such
                relevant groups include the Agency’s Medicaid Office, including Health
                Plan representatives; SAMH and Family Safety representatives;
                representatives from any community based care Providers contracted
                with
                DCF; the Florida Drop-In Center Association; the Human Rights Advocacy
                Committee; the Alliance for the Mentally Ill; the Florida Consumer
                Action
                Council; and the Substance Abuse and Mental Health Planning Council.
                In
                addition, the Health Plan provides representation to the local advisory
                group. The local advisory group elects a chairperson and vice-chairperson
                from the voting membership, who facilitates the meetings and prepares
                any
                written correspondence on behalf of the
                group.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan’s responsibility related to the local advisory group is as
                follows:

            

    

    

    
      	 	
              a.

            	
              Assure
                representation at all scheduled
                meetings;

            

    

    

    
      	 	
              b.

            	
              Provide
                information requested by local advisory group
                members;

            

    

    

    
      	 	
              c.

            	
              Follow
                up on identified issues of concern related to the provision of services
                or
                administration of the Health Plan;
                and

            

    

    

    
      	 	
              d.

            	
              Share
                pertinent information about Quality Improvement findings and outreach
                activities with the local advisory
                group.

            

    

    

    
      	
              D.

            	
              Community
                Behavioral Health Services Annual 80/20 Expenditure
                Report 

            

    

    

    
      	 	
              1.

            	
              By
                April 1 of each year, Health Plans shall provide a breakdown of
                expenditures related to the provision of community behavioral health
                services, using the spreadsheet template provided by the Agency (see
                Section XII, Reporting Requirements).  In accordance with Section
                409.912, F.S., eighty percent (80%) of the Capitation Rate paid to
                the
                Health Plan by the Agency shall be expended for the provision of
                community
                behavioral health services.  In the event the Health Plan expends
                less than eighty percent (80%) of the Capitation Rate, the Health
                Plan
                shall return the difference to the Agency no later than May 1 of
                each
                year.

            

    

    

    
      	 	
              a.  

            	
              For
                reporting purposes in accordance with this Section, ‘community behavioral
                health services’ are defined as those services that the Health Plan is
                required to provide as listed in the Community Mental Health Services
                Coverage and
                Limitations Handbook and the Mental Health Targeted Case Management
                Coverage and Limitations handbook. 

            

    

    

    
      	 	 	
              b.  
                

            	
              For
                reporting purposes in accordance with this Section ‘expended’ means the
                total amount, in dollars, paid directly or indirectly to community
                behavioral health services
                providers solely for the provision of community
                behavioral health services, not
                including administrative expenses or overhead of the plan.  If the
                report indicates that a portion of the capitation payment is to be
                returned to the Agency, the Health Plan shall submit a check for
                that
                amount with the Behavioral
                Health Services Annual 80/20 Expenditure Report that the Health Plan
                provides to the Agency.

            

    

    

    

    

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    Section
      VII

     

    Provider
      Network

     

    

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

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

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall provide the Agency with adequate assurances that
                the
                Health Plan has the capacity to provide Covered Services to all Enrollees
                up to the maximum enrollment level in each county, including assurances
                that the Health Plan: 

            

    

    

    
      	 	
              a.

            	
              Offers
                an appropriate range of services and accessible preventive and primary
                care services such that the Health Plan can meet the needs of the
                maximum
                enrollment level in each county,
                and

            

    

    

    
      	 	
              b.

            	
              Maintains
                a sufficient number, mix and geographic distribution of Providers,
                including Providers who are accepting new Medicaid patients as specified
                in Section 1932(b)(7) of the Social Security Act, as enacted by Section
                4704(a) of the Balanced Budget Act of
                1997.

            

    

    

    
      	 	
              3.

            	
              By
                November 30, 2006, the Health Maintenance Organizations and other
                licensed
                managed care organizations shall register all network providers with
                the
                Agency’s Fiscal Agent, in the manner, and format determined by the
                Agency.

            

    

    

    
      	 	
              4.

            	
              Each
                Provider shall maintain Hospital privileges if Hospital privileges
                are
                required for the delivery of Covered Services. The Health Plan may
                use
                admitting panels to comply with this
                requirement.

            

    

    

    
      	 	
              5.

            	
              When
                designing the Provider network, the Health Plan shall take the following
                into consideration as required by 42 CFR
                438.206:

            

    

    

    
      	 	
              a.

            	
              The
                anticipated number of Enrollees;

            

    

    

    
      	 	
              b.

            	
              The
                expected utilization of services, taking into consideration the
                characteristics and health care needs of specific Medicaid populations
                represented;

            

    

    

    
      	 	
              c.

            	
              The
                numbers and types (in terms of training, experience, and specialization)
                of providers required to furnish the Covered
                Services;

            

    

    

    
      	 	
              d.

            	
              The
                numbers of network providers who are not accepting new Enrollees;
                

            

    

    

    
      	 	
              e.

            	
              The
                geographic location of providers and Enrollees, considering distance,
                travel time, the means of transportation ordinarily used by Enrollees
                and
                whether the location provides physical access for Medicaid enrollees
                with
                disabilities; and

            

    

    

    
      	 	
              f.

            	
              There
                is to be no discrimination against particular providers that serve
                high-risk populations or specialize in conditions that require costly
                treatments.

            

    

    

    
      	 	
              6.

            	
              If
                the Health Plan is unable to provide Medically Necessary services
                to an
                Enrollee, the Health Plan must cover these services by using providers
                and
                services that are not providers in the Health Plan's network, in
                an
                adequate and timely manner, for as long as the Health Plan is unable
                to
                provide the Medically Necessary services within the Health Plan's
                network.

            

    

    

    
      	 	
              7.

            	
              The
                Health Plan shall allow each Enrollee to choose his or her Providers
                to
                the extent possible and
                appropriate.

            

    

    

    
      	 	
              8.

            	
              The
                Health Plan shall require each Provider to have a unique Florida
                Medicaid
                Provider number, in accordance with the requirement of Section X.C.jj.,
                of
                this Contract. By May 2007, the Health Plan shall require each Provider
                to
                have a National Provider Identifier (NPI) in accordance with section
                1173(b) of the Social Security Act, as enacted by section
                4707(a) of the Balanced Budget Act of
                1997.

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (2)

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

            

    

    

    
      	 	
              9.

            	
              The
                Health Plan shall provide the Agency with documentation of compliance
                with
                access requirements: 

            

    

    

    
      	 	
              a.

            	
              Upon
                the effective date of the Contract;
                and

            

    

    

    
      	 	
              b.

            	
              At
                any time there has been a significant change in the Health Plan's
                operations that would affect adequate capacity and services, including,
                but not limited to, the following:

            

    

    

    
      	 	
              (1)

            	
              Changes
                in Health Plan services or Service Area;
                and

            

    

    

    
      	 	
              (2)

            	
              Enrollment
                of a new population in the Health
                Plan.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan shall have procedures to inform Potential Enrollees and
                Enrollees of any changes to service delivery and/or the Provider
                network
                including the following:

            

    

    

    
      	 	
              a.

            	
              Inform
                Potential Enrollees and Enrollees of any restrictions to access to
                Providers, including Providers who are not taking new patients, upon
                request and, for Enrollees, at least on a six (6) month
                basis.

            

    

    

    
      	 	
              b.

            	
              An
                explanation to all Potential Enrollees that an enrolled family may
                choose
                to have all family members served by the same PCP or they may choose
                different PCPs based on each family member’s
                needs.

            

    

    

    
      	 	
              c.

            	
              Inform
                Potential Enrollees and Enrollees of objections to providing counseling
                and referral services based on moral or religious grounds within
                ninety
                (90) days after adopting the policy with respect to any
                service.

            

    

    

    
      	 	
              11.

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

            

    

    

    
      	
              B.

            	
              Primary
                Care Providers 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall enter into Provider Contracts with a sufficient
                number
                of PCPs to ensure adequate accessibility for Enrollees of all ages.
                The
                Health Plan shall select and approve its PCPs. The Health Plan shall
                ensure its PCP Provider Contracts provide for the following: 

            

    

    

    
      	 	
              a.

            	
              The
                PCP shall accept all associated Case Management
                responsibilities;

            

    

    

    
      	 	
              b.

            	
              The
                PCP shall provide, or arrange for coverage of services, consultation
                or
                approval for referrals twenty four (24) hours per day, seven (7)
                days per
                week by Medicaid enrolled providers who will accept Medicaid
                reimbursement. This coverage must consist of an answering service,
                call
                forwarding, provider call coverage or other customary means approved
                by
                the Agency. The chosen method of twenty four (24) hour coverage must
                connect the caller to someone who can render a clinical decision
                or reach
                the PCP for a clinical decision. The after hours coverage must be
                accessible using the medical office’s daytime telephone number. The PCP or
                covering medical professional must return the call within thirty
                (30)
                minutes of the initial contact; and

            

    

    

    c. The
      PCP
      shall arrange for coverage of primary care services during absences due to
      vacation, illness or other situations which require the PCP to
      be
      unable to provide services. Coverage must be provided by a Medicaid eligible
      PCP. 

    

    
      	 	
              2.
                

            	
              The
                Health Plan shall provide the
                following:

            

    

    

    
      	 	
              a.

            	
              At
                least one (1) FTE PCP per Service Area including, but not limited
                to, the
                following specialties:

            

    

    

    
      	 	
              (1)

            	
              Family
                Practice;

            

    

    

    
      	 	
              (2)

            	
              General
                Practice;

            

    

    

    
      	 	
              (3)

            	
              Obstetrics
                or Gynecology;

            

    

    

    
      	 	
              (4)

            	
              Pediatrics;
                and

            

    

    

    
      	 	
              (5)

            	
              Internal
                Medicine.

            

    

    

    
      	 	
              b.

            	
              At
                least one (1) FTE PCP per 1,500 Enrollees. The Health Plan may increase
                the ratio by 750 Enrollees for each FTE ARNP or FTE PA affiliated
                with a
                PCP.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall allow pregnant Enrollees to choose the Health Plan’s
                obstetricians as their PCPs to the extent that the obstetrician is
                willing
                to participate as a PCP.

            

    

    

    
      	 	
              3.

            	
              At
                least annually, the Health Plan shall review each PCP’s average wait times
                to ensure services are in compliance with Section VII.D., Appointment
                Waiting Times and Geographic Access
                Standards.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall assign a pediatrician or other appropriate PCP
                to all
                pregnant Enrollees for the care of their newborn babies no later
                than the
                beginning of the last trimester of gestation. If the Health Plan
                was not
                aware that the Enrollee was pregnant until she presented for delivery,
                the
                Health Plan shall assign a pediatrician or a PCP to the newborn baby
                within one (1) Business Day after birth. The Health Plan shall advise
                all
                Enrollees of the Enrollees’ responsibility to notify their Health Plan and
                their DCF public assistance specialists (case workers) of their
                pregnancies and the births of their
                babies.

            

    

    

    
      	
              C.

            	
              Minimum
                Standards

            

    

    

    
      	 	
              1.

            	
              Emergency
                Services and Emergency Services Facilities - The Health Plan shall
                ensure
                the availability of Emergency Services and Care twenty-four (24)
                hours a
                day, seven (7) days a week. 

            

    

    

    
      	 	
              2.

            	
              General
                Acute Care Hospital - The
                Health Plan shall provide at least one
                (1) fully accredited general acute care Hospital bed
                per 275 Enrollees.
                The Agency may waive this accreditation requirement, in
                writing, for
                Rural
                areas.

            

    

    

    
      	 	
              3.

            	
              Birth
                Delivery Facility - The Health Plan shall provide at least one (1)
                birth
                delivery facility, licensed under Chapter 383, F.S., or
                a Hospital with birth delivery facilities, licensed under Chapter
                383,
                F.S. The birth delivery facility may be part of a Hospital or a
                freestanding facility.

            

    

    

    
      	 	
              4.

            	
              Birthing
                Center - The Health Plan shall provide a birthing center, licensed
                under
                Chapter 383, F.S. that is accessible to low risk Enrollees.
                

            

    

    

    
      	 	
              5.

            	
              Regional
                Perinatal Intensive Care Centers (RPICC)
                -
                The Health Plan shall assure access for Enrollees in one (1) or more
                of
                Florida's Regional Perinatal Intensive Care Centers (RPICC), see
                Sections
                383.15 through 383.21, F.S., or a Hospital licensed by the Agency
                for
                Neonatal Intensive Care Unit (NICU) Level III
                beds.

            

    

    

    
      	 	
              6.

            	
              Neonatal
                Intensive Care Unit (NICU) - The Health Plan shall ensure that care
                for
                medically high risk perinatal Enrollees is provided in a facility
                with a
                NICU sufficient to meet the appropriate level of need for the
                Enrollee.

            

    

    

    
      	 	
              7.

            	
              Certified
                Nurse Midwife Services - The Health Plan shall ensure access to certified
                nurse midwife services or licensed midwife services for low risk
                Enrollees, licensed in accordance with Section 641.31, F.S.
                

            

    

    

    
      	 	
              8.

            	
              Pharmacy
                - If the Health Plan elects to use a more restrictive pharmacy network
                than the non-Medicaid Reform fee-for-service network, the Health
                Plan
                shall provide at least one (1) licensed pharmacy per 2,500 Enrollees.
                The
                Health Plan shall ensure that its contracted pharmacies comply with
                the
                Settlement Agreement to Hernandez
                et al. v. Medows
                (case number 02-20964 Civ-Gold/Simonton)
                (HSA).

            

    

    

    
      	 	
              9.

            	
              Access
                for Persons with Disabilities - The Health Plan shall ensure that
                all
                facilities have access for persons with disabilities.
                

            

    

    

    
      	 	
              10.

            	
              Health,
                Cleanliness and Safety - The Health Plan shall ensure adequate space,
                supplies, proper sanitation, and smoke-free facilities with proper
                fire
                and safety procedures in operation.

            

    

    

    
      	
              D.

            	
              Appointment
                Waiting Times and Geographic Access
                Standards

            

    

    

    
      	 	
              1.

            	
              The
                Health Plans must assure that PCP services and referrals to Participating
                Specialists are available on a timely basis, as
                follows:

            

    

    

    
      	 	
              a.

            	
              Urgent
                Care — within one (1) day,

            

    

    

    
      	 	
              b.

            	
              Routine
                Sick Patient Care — within one (1) week,
                and

            

    

    

    
      	 	
              c.

            	
              Well
                Care Visit — within one (1) month.

            

    

    

    
      	 	
              2.

            	
              All
                PCP's and Hospital services must be available within an average of
                thirty
                (30) minutes travel time from an Enrollee's residence. All Participating
                Specialists and Ancillary Providers must be within an average of
                sixty
                (60) minutes travel time from an Enrollee's residence. The Agency
                may
                waive this requirement, in writing, for Rural Areas and for areas
                where
                there are no PCPs or Hospitals within a thirty (30) minute average
                travel
                time.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall provide a designated emergency services facility
                within
                an average of thirty (30) minutes travel time from an Enrollee's
                residence, that provides care on a twenty-four (24) hours a day,
                seven (7)
                days a week basis. Each designated emergency service facility shall
                have
                one (1) or more physicians and one (1) or more nurses on duty in
                the
                facility at all times. The Agency may waive the travel time requirement,
                in writing, in Rural areas. 

            

    

    
      	 	 	 

    

    
      	 	
              4.

            	
              For
                Rural areas, if the Health Plan is unable to enter into an agreement
                with
                specialty or ancillary service providers within the required sixty
                (60)
                minute average travel time, the Agency may waive, in writing, the
                requirement.

            

    

    

    
      	 	
              5.

            	
              At
                least one (1) pediatrician or one (1) CHD, FQHC or RHC within an
                average
                of thirty (30) minutes travel time from an Enrollee's residence,
                provided
                that this requirement remains consistent with the other minimum time
                requirements of this Contract. In order to meet this requirement,
                the
                pediatrician(s), CHD, FQHC, and/or RHC must provide access to care
                on a
                twenty-four (24) hours a day, seven (7) days a week basis. The Agency
                may
                waive this requirement, in writing, for Rural areas and where there
                are no
                pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
                average
                travel time. 

            

    

    

    
      	
              E.

            	
              Behavioral
                Health Services

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall have at least one (1) certified adult psychiatrist
                and
                at least one (1) board certified child psychiatrist (or one (1) child
                psychiatrist who meets all education and training criteria for Board
                Certification) that is available within thirty (30) minutes average
                travel
                time for Urban areas and sixty (60) minutes average travel time for
                Rural
                areas of all Enrollees. 

            

    

    

    
      	 	
              2.

            	
              For
                Rural areas, if the Health Plan does not have a Provider with the
                necessary experience, the Agency may waive, in writing, the requirements
                in Section VII.E.1, above.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall ensure that outpatient staff includes at least
                one (1)
                FTE Direct Service Behavioral Health Provider per 1,500 Enrollees.
                The
                Agency expects the Health Plan’s staffing pattern for direct service
                Providers to reflect the ethnic and racial composition of the
                community.

            

    

    

    
      	 	
              4.

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

            

    

    

    
      	 	
              a.

            	
              Adoption;

            

    

    

    
      	 	
              b.

            	
              Child
                protection or foster care;

            

    

    

    
      	 	
              c.

            	
              Dual
                diagnosis (mental illness and substance
                abuse);

            

    

    

    
      	 	
              d.

            	
              Dual
                diagnosis (mental illness and developmental
                disability);

            

    

    

    
      	 	
              e.

            	
              Developmental
                disabilities;

            

    

    

    
      	 	
              f.

            	
              Behavior
                analysis;

            

    

    

    
      	 	
              g.

            	
              Behavior
                management and alternative therapies for
                children/Adolescents;

            

    

    

    
      	 	
              h.

            	
              Separation
                and loss;

            

    

    

    
      	 	
              i.

            	
              Victims
                and perpetrators of sexual abuse (Children/Adolescents and
                adults);

            

    

    

    
      	 	
              j.

            	
              Victims
                and perpetrators of violence and violent crimes (Children/Adolescents
                and
                adults);

            

    

    

    
      	 	
              k.

            	
              Court
                ordered mental health evaluations including assessment of parental
                mental
                health issues and parental competency as it relates to mental health;
                and

            

    

    

    
      	 	
              l.

            	
              Expert
                witness testimony.

            

    

    

    
      	 	
              5.

            	
              All
                Direct Service Behavioral Health Providers and mental health targeted
                case
                managers serving the Children/Adolescent population shall be certified
                by
                DCF to administer CFARS (or other rating scale required by DCF or
                the
                Agency).

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall not count Behavioral Health targeted case managers
                shall
                not be counted as direct service Behavioral Health
                Providers.

            

    

    

    
      	 	
              7.

            	
              For
                Case Management services, the Health Plan shall provide staff that
                meets
                the following minimum requirements:

            

    

    

    
      	 	
              a.
                

            	
              Have
                a baccalaureate degree from an accredited university, with major
                course
                work in the areas of psychology, social work, health education or
                a
                related human service field and, if working with Children/Adolescents,
                have a minimum of one-(1) year full-time experience, or equivalent
                experience, working with the target population. Prior experience
                is not
                required if working with the adult population;
                or

            

    

    

    
      	 	
              b.
                

            	
              Have
                a baccalaureate degree from an accredited university and if working
                with
                Children/Adolescents, have at least three (3) years full-time or
                equivalent experience, working with the target population. If working
                with
                adults, the case manager must have two (2) years of experience. (Note:
                case managers who were certified by the Department prior to July
                1, 1999,
                who do not meet the degree requirements, may provide Case Management
                services if they meet the other requirements;
                and

            

    

    

    
      	 	
              c.

            	
              Have
                completed a training program within six (6) months of employment.
                The
                training program must be prior approved in writing by the Agency.
                The
                training must include a review of the local resources and a thorough
                presentation of the applicable State and federal statutes and promote
                the
                knowledge, skills, and competency of all case managers through the
                presentation of key core elements relevant to the target population.
                The
                case manager must also be able to demonstrate an understanding of
                the
                Health Plan’s Case Management policies and
                procedures.

            

    

    

    
      	 	
              8.
                

            	
              Case
                Management supervision must be provided by a person who has a master’s
                degree in a human services field and three (3) years of professional
                full
                time experience serving this target population or a person with a
                bachelor’s degree and five (5) years of full time or equivalent Case
                Management experience. For supervising case managers who work only
                with
                adults, two (2) years of full time experience is required. The supervisors
                must have had the approved Health Plan training in Case Management
                or have
                documentation that they have prior equivalent
                training.

            

    

    

    
      	 	
              9.
                

            	
              The
                Health Plan shall have access to no less than one (1) fully accredited
                psychiatric community Hospital bed per 2,000 Enrollees, as appropriate,
                for both Children/Adolescents and adults. Specialty psychiatric Hospital
                beds may be used to count toward this requirement when psychiatric
                community Hospital beds are not available within a particular community.
                Additionally, the Health Plan shall have access to sufficient numbers
                of
                accredited Hospital beds on a medical/surgical unit to meet the need
                for
                medical detoxification treatment.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan’s facilities must be licensed, as required by law and rule,
                accessible to the handicapped, in compliance with federal Americans
                with
                Disabilities Act guidelines, and have adequate space, supplies, good
                sanitation, and fire, safety, and disaster preparedness and recovery
                procedures in operation.

            

    

    

    
      	 	
              11.

            	
              The
                Health Plan shall ensure that it has Providers that are qualified
                to serve
                Enrollees and experienced in serving severely emotionally disturbed
                Children/Adolescents and severely and persistent mentally ill adults.
                The
                Health Plan shall maintain documentation of its Providers’ experience in
                the Providers' credentialing file.

            

    

    

    
      	 	
              12.

            	
              The
                Health Plan shall adhere to the staffing ratio of at least one (1)
                FTE
                Behavioral Health Care Case Manager for twenty (20) Children/Adolescents
                and at least one (1) FTE Behavioral Health Care Case Manager per
                forty
                (40) adults. Direct Service Behavioral Health Care Providers shall
                not
                count as Behavioral Health Care Case
                Managers.

            

    

    

    
      	 	
              13.

            	
              Prior
                to commencement of Behavioral Health Services, the Health Plan shall
                enter
                into agreements for coordination of care and treatment of Enrollees,
                jointly or sequentially served, with county community mental health
                care
                center(s) that are not a part of the Health Plan's Provider network.
                The
                Health Plan shall enter into similar agreements with agencies funded
                pursuant to Chapter 394, F.S. The Agency shall approve all model
                agreements between the Health Plan and county community mental health
                center(s)/agencies before the Health Plan enters into the agreement.
                This
                requirement shall not apply if the Health Plan provides the Agency
                with
                documentation that shows the Health Plan has made a good faith effort
                to
                contract with county community mental health center(s)/agencies,
                but could
                not reach an agreement.

            

    

    

    
      	 	
              14.

            	
              The
                Health Plan shall request current behavioral health care provider
                information from all new Enrollees upon enrollment. The Health Plan
                shall
                solicit these behavioral health services providers to participate
                in the
                Health Plan's network. The Health Plan may request in writing that
                the
                Agency grant exemption to a Health Plan from soliciting a specific
                behavioral health services provider on a case-by-case
                basis.

            

    

    

    
      	 	
              15.

            	
              To
                the maximum extent possible, the Health Plan shall contract for the
                provision of Behavioral Health Services with the State's community
                mental
                health centers designated by the Agency and
                DCF.

            

    

    

    
      	
              F.

            	
              Specialists
                and Other Providers

            

    

    

    
      	 	
              1.

            	
              In
                addition to the above requirements, the Health Plan shall assure
                the
                availability of the following specialists, as appropriate for both
                adults
                and pediatric Enrollees, on at least a referral basis. The Health
                Plan
                shall use Participating Specialists with pediatric expertise for
                Children/Adolescents when the need for pediatric specialty care is
                significantly different from the need for adult specialty care (for
                example a pediatric cardiologist for Children/Adolescents with congenital
                heart defects).

            

    

    

    a. Allergist,

    

    b. Cardiologist,

    

    c. Endocrinologist,

    

    d. General
      Surgeon,

    

    e. Obstetrical/Gynecology
      (OB/GYN),

    

    f. Neurologist,

    

    g. Nephrologist,

    

    h. Orthopedist,

    

    i. Urologist,

    

    j. Dermatologist,

    

    k. Otolaryngologist,

    

    l. Pulmonologist,

    

    m. Chiropractic
      Physician,

    

    n. Podiatrist,

    

    o. Ophthalmologist,

    

    p. Optometrist,

    

    q. Neurosurgeon,

    

    r. Gastroenterologist,

    

    s. Oncologist,

    

    t. Radiologist,

    

    u. Pathologist,

    

    v. Anesthesiologist,

    

    w. Psychiatrist,

    

    x. Oral
      surgeon,

    

    y. Physical,
      respiratory, speech and occupational therapists, and

    

    z. Infectious
      disease specialist.

    

    
      	 	
              2.

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

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall make a good faith effort to execute memoranda of
                agreement with the local CHDs to provide services which may include,
                but
                are not limited to, family planning services, services for the treatment
                of sexually transmitted diseases, other public health related diseases,
                tuberculosis, immunizations, foster care emergency shelter medical
                screenings, and services related to Healthy Start prenatal and post-natal
                screenings. The Health Plan shall provide documentation of its good
                faith
                effort upon the Agency’s request.

            

    

    

    
      	 	
              4.

            	
              Notwithstanding
                Section VIII.B.2, Certain Public Providers, of this Contract, the
                Health
                Plan shall pay, without prior authorization, at the contracted rate
                or the
                Medicaid fee-for-service rate, all valid claims initiated by any
                CHD for
                office visits, prescribed drugs, laboratory services directly related
                to
                DCF emergency shelter medical screening, and tuberculosis. The Health
                Plan
                must reimburse the CHD when the CHD notifies the Health Plan and
                provides
                the Health Plan with copies of the appropriate Medical Records and
                provides the Enrollee's PCP with the results of any tests and associated
                office visits.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall make a good faith effort to execute a contract
                with a
                Federally Qualified Health Center (FQHC) and, if applicable, a Rural
                Health Clinic (RHC). The Health Plan shall reimburse FQHCs and RHCs
                at
                rates comparable to those rates paid for similar services in the
                FQHC's or
                RHC's community. The Health Plan shall report to the Agency, on a
                quarterly basis, the payment rates and the payment amounts made to
                FQHCs
                and RHCs for contractual services provided by these
                entities.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall permit female Enrollees to have direct access to
                a
                women's health specialist within the network for Covered Services
                necessary to provide women's routine and preventive health care services.
                This is in addition to an Enrollee's designated PCP, if that Provider
                is
                not a women's health specialist.

            

    

    

    
      	
              G.

            	
              Continuity
                of Care 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall allow Enrollees in active treatment to continue
                care
                with a terminated treating provider when such care is Medically Necessary,
                through completion of treatment of a condition for which the Enrollee
                was
                receiving care at the time of the termination, until the Enrollee
                selects
                another treating Provider, or during the next Open Enrollment period.
                None
                of the above may exceed six (6) months after the termination of the
                Provider's contract.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall allow pregnant Enrollees who have initiated a course
                of
                prenatal care, regardless of the trimester in which care was initiated,
                to
                continue care with a terminated treating provider until completion
                of
                postpartum care.

            

    

    

    
      	 	
              3.

            	
              Notwithstanding
                the provisions in this subsection, a terminated provider may refuse
                to
                continue to provide care to an Enrollee who is abusive or
                noncompliant.

            

    

    

    
      	 	
              4.

            	
              For
                continued care under this subsection, the Health Plan and the terminated
                provider shall continue to abide by the same terms and conditions
                as
                existed in the terminated contract.

            

    

    

    
      	 	
              5.

            	
              The
                requirements set forth in this subsection shall not apply to providers
                who
                have been terminated from the Health Plan for
                Cause.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall develop and maintain policies and procedures for
                the
                above requirements. 

            

    

    

    
      	
              H.

            	
              Network
                Changes 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall notify the Agency within seven (7) Business Days
                of any
                significant changes to the Health Plan network. A significant change
                is
                defined as:

            

    

    

    
      	 	
              a.

            	
              A
                decrease in the total number of PCPs by more than five percent
                (5%);

            

    

    

    
      	 	
              b.

            	
              A
                loss of all Participating Specialists in a specific specialty where
                another Participating Specialist in that specialty is not available
                within
                sixty (60) minutes;

            

    

    

    
      	 	
              c.

            	
              A
                loss of a Hospital in an area where another Health Plan Hospital
                of equal
                service ability is not available within thirty (30) minutes;
                or

            

    

    

    
      	 	
              d.

            	
              Other
                adverse changes to the composition of the network which impair or
                deny the
                Enrollee's adequate access to
                Providers.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall have procedures to address changes in the Health
                Plan
                network that negatively affect the ability of Enrollees to access
                services, including access to a culturally diverse Provider network.
                Significant changes in network composition that negatively impact
                Enrollee
                access to services may be grounds for Contract termination or Agency
                determined sanctions.

            

    

    

    
      	 	
              3.

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

            

    

    

    
      	 	
              a.

            	
              If
                an Enrollee is in a Prior Authorized ongoing course of treatment
                with any
                other Provider who becomes unavailable to continue to provide services,
                the Health Plan shall notify the Enrollee in writing within ten (10)
                Calendar Days from the date the Health Plan becomes aware of such
                unavailability.

            

    

    

    
      	 	
              b.

            	
              These
                requirements to provide notice prior to the effective dates of termination
                shall be waived in instances where a Provider becomes physically
                unable to
                care for Enrollees due to illness, a Provider dies, the Provider
                moves
                from the Service Area and fails to notify the Health Plan, or when
                a
                Provider fails credentialing. Under these circumstances, notice shall
                be
                issued immediately upon the Health Plan becoming aware of the
                circumstances.

            

    

    

    

    REMAINDER
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    Section
      VIII

     

    Quality
      Management

     

    

    
      	
              A.

            	
              Quality
                Improvement

            

    

    

    
      	1.  	
              General
                Requirements

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall have an ongoing Quality Improvement Program (QIP)
                that
                objectively and systematically monitors and evaluates the quality
                and
                appropriateness of care and services rendered, thereby promoting
                quality
                of care and quality patient outcomes in service performance to its
                Enrollees.

            

    

    

    
      	 	
              b.

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

            

    

    

    
      	 	
              c.

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

            

    

    

    
      	 	
              d.

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

            

    

    

    
      	 	
              e.

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

            

    

    

    
      	 	
              f.

            	
              Prior
                to implementation, the Agency and/or the EQRO shall review the Health
                Plan’s QIP.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan must submit its QIP to the Agency no later than the execution
                date of the Contract. The QIP must be approved, in writing, by the
                Agency
                no later than three (3) months following the execution of this Contract.
                

            

    

    

    
      	 	
              2.
                

            	
              Specific
                Required Components of the
                QIP

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall have a QIP Committee. The Health Plan’s Medical Director
                shall serve as either the Chairman or Co-Chairman of the QIP Committee.
                Appropriate Health Plan staff representing the various departments
                of the
                organization shall have membership on the Committee. The Committee
                shall
                meet on a regular periodic basis. Its responsibilities shall include
                the
                following:

            

    

    

    
      	 	
              (1)

            	
              Development
                and implementation of a written QI plan, which incorporates the strategic
                direction provided by the governing
                body.

            

    

    

    
      	 	
              (2)

            	
              The
                QI plan shall reflect a coordinated strategy to implement the QIP
                including planning, decision making, intervention, and assessment
                of
                results.

            

    

    

    
      	 	
              (3)

            	
              The
                QI plan shall include a description of the Health Plan staff assigned
                to
                the QIP; their specific training regarding Medicaid; how they are
                organized; and their
                responsibilities.

            

    

    

    
      	 	
              (4)

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

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan is encouraged to include an advocate representative on
                the QIP
                Committee.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan shall submit its written QI plan to the Agency for written
                approval within thirty (30) days of the execution of the
                Contract.

            

    

    

    
      	 	
              c.

            	
              Direct
                and review QI activities, including, but not limited
                to:

            

    

    

    
      	 	
              (1)

            	
              Assure
                that QIP activities take place throughout the Health
                Plan;

            

    

    

    
      	 	
              (2)

            	
              Review
                and suggest new and/or improved QI
                activities;

            

    

    

    
      	 	
              (3)

            	
              Direct
                task forces/committees to review areas of concern in the provision
                of
                health care services to Enrollees;

            

    

     

    
      	 	
              (4)

            	
              Designate
                evaluation and study design
                procedures;

            

    

    

    
      	 	
              (5)

            	
              Report
                findings to appropriate executive authority, staff, and departments
                within
                the Health Plan; and 

            

    

    

    
      	 	
              (6)

            	
              Direct
                and analyze periodic reviews of Enrollees' service utilization
                patterns.

            

    

    
      	 	 	 

    

    
      	 	
              d.

            	
              Maintain
                minutes of all Committee and Sub-Committee
                meetings.

            

    

    

    
      	 	
              3.

            	
              Health
                Plan QI Activities

            

    

    

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

    

    
      	 	
              a.

            	
              PIPs

            

    

    

    The
      Health Plan shall perform no less than six (6) Agency approved performance
      improvement projects.

    

    
      	 	
              (1)

            	
              Each
                PIP must include a statistically significant sample of
                Enrollees.

            

    

    

    
      	 	
              (2)

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

            

    

    

    
      	 	
              (3)

            	
              At
                least two (2) of the PIPs must relate to Behavioral Health
                Services.

            

    

    

    
      	 	
              (4)

            	
              All
                PIPs by the Health Plan must achieve, through ongoing measurements
                and
                intervention, significant improvement to the quality of care and
                service
                delivery, sustained over time, in both clinical care and non-clinical
                care
                areas that are expected to have a favorable effect on health outcomes
                and
                Enrollee satisfaction.

            

    

    

    
      	 	
              (5)

            	
              The
                PIPs must be completed in a reasonable time period so as to allow
                the
                Health Plan to evaluate the information drawn from them and to use
                the
                results of the analysis to improve quality of care and service delivery
                every year.

            

    

    

    
      	 	
              (6)

            	
              Within
                three (3) months of the execution of this Contract, the Health Plan
                shall
                submit, in writing, a description of each of the PIPs to the Agency
                for
                written approval. The detailed description shall include:
                

            

    

    

    
      	 	
              (a)

            	
              An
                overview explaining how and why the project was selected, as well
                as its
                relevance to the Health Plan’s Enrollees and
                Providers;

            

    

    

    (b) The
      study
      question;

    

    (c) The
      study
      population;

    

    
      	 	
              (d)

            	
              The
                quantifiable measures to be used, including a goal or
                benchmark;

            

    

    

    (e) Baseline
      methodology;

    

    (f) Data
      sources;

    

    (g) Data
      collection methodology;

    

    (h) Data
      collection cycle;

    

    (i) Data
      analysis cycle;

    

    (j) Results
      with quantifiable measures;

    

    (k) Analysis
      with time period and the measures covered;

    

    
      	 	
              (l)

            	
              Analysis
                and identification of opportunities for improvement;
                and

            

    

    

    (m) An
      explanation of all interventions to be taken.

    

    
      	 	
              b.

            	
              Behavioral
                Health QI Requirements

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan's QIP shall include a Behavioral Health component in
                order to
                monitor and assure that the Health Plan's Behavioral Health Services
                are
                sufficient in quantity, of acceptable quality and meet the needs
                of the
                Enrollees. 

            

    

    

    
      	 	
              (2)

            	
              Treatment
                plans must:

            

    

    

    (a) Identify
      reasonable and appropriate objectives;

    

    (b) Provide
      necessary services to meet the identified objectives; and

    

    
      	 	
              (c)

            	
              Include
                retrospective reviews that confirm that the care provided, and its
                outcomes, were consistent with the approved treatment plans and
                appropriate for the Enrollees'
                needs.

            

    

    

    
      	 	
              (3)

            	
              In
                determining if Behavioral Health Services are acceptable according
                to
                current treatment standards, the Health Plan
                shall:

            

    

    

    
      	 	
              (a)

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

            

    

    

    (b) Elements
      of these reviews shall include, but not be limited to: 

    

    
      	 	
              (i)

            	
              Management
                of specific diagnoses;

            

    

    

    
      	 	
              (ii)

            	
              Appropriateness
                and timeliness of care;

            

    

    

    
      	 	
              (iii)

            	
              Comprehensiveness
                of, and compliance with, the plan of
                care;

            

    

    

    
      	 	
              (iv)

            	
              Evidence
                of special screening for high risk Enrollees and/or conditions;
                and

            

    

    

    
      	 	
              (v)

            	
              Evidence
                of appropriate coordination of
                care.

            

    

    

    
      	 	
              (4)

            	
              In
                areas in which there is not an established local advisory group,
                the
                Health Plan is responsible for the development of local advisory
                group
                meetings within sixty (60) days of the effective date of the
                Contract.

            

    

    

    
      	 	
              (5)

            	
              In
                areas where there is more than one (1) Health Plan authorized to
                provide
                Behavioral Health Services, the Health Plans shall work together
                in
                establishing an area local advisory
                group.

            

    

    

    
      	 	
              (6)

            	
              Composition
                of local advisory groups shall follow the requirements set forth
                in
                Section VI.C., Behavioral Health Managed Care Local Advisory
                Group.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall send representation to the local advisory group’s
                meetings that convene quarterly and report to the Agency on the behavioral
                health advocacy and programmatic
                concerns.

            

    

    

    
      	 	
              (8)

            	
              Local
                advisory groups shall provide technical and policy advice to the
                Agency
                regarding Behavioral Health
                Services.

            

    

    

    c. Performance
      Measures (PMs) 

    

    
      	 	
              (1)

            	
              Quality
                and performance measures shall be evaluated at least once annually
                at
                dates to be determined by the Agency, or as otherwise specified by
                this
                Contract. The Health Plan will implement an enhanced quality improvement
                and performance measurement system to provide for the delivery of
                quality
                care with the primary goal of improving the health status of
                Enrollees.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan, in conjunction with the Agency, will participate in
                workgroups to plan further quality improvement strategies and learning
                to
                use best practice methods for enhancing quality of health
                care.

            

    

    

    
      	 	
              (3)

            	
              If
                CAHPS, the AHCA quality indicators, the annual medical record audit
                or the
                EQR indicate that the Health Plan's performance is not acceptable,
                then
                the Agency may restrict the Health Plan’s Enrollment activities,
                including, but not limited to, termination of Automatic
                Assignments.

            

    

    

    
      	 	
              (4)

            	
              For
                Health Plan performance that is not acceptable, the Agency shall
                require
                the Health Plan to submit a corrective action plan (CAP). Failure
                to
                provide a CAP within the time specified shall be cause for the Agency
                to
                immediately terminate all Enrollment activities and Automatic Assignments.
                When considering whether to impose a limitation on Enrollment activities
                or Automatic Assignments, the Agency may consider the Health Plan’s
                cumulative performance on all quality and performance
                measures.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan shall collect data on patient outcome PMs, as defined
                by the
                Health Plan Employee Data and Information Set (HEDIS) or otherwise
                defined
                by the Agency and report the results of the measures to the Agency
                annually. The Agency may add or remove reporting requirements with
                thirty
                (30) days advance notice. 

            

    

    

    (6) At
      a
      minimum, the following PMs shall be measured by the Health Plan:

    

    (a) Breast
      Cancer Screening;

    

    (b) Cervical
      Cancer Screening;

    

    (c) Colorectal
      Cancer Screening;

    

    (d) Well
      Child Visits in the First 15 Months of Life;

    

    (e) Well
      Child Visits in the Third, Fourth, Fifth and Sixth Years of Life;

    

    (f) Adolescent
      Well Care Visits;

    

    (g) Childhood
      Immunization Status; 

    

    (h) Adolescent
      Immunization Status;

    

    (i) Preventive
      and Total Dental Visits for Children/Adolescents Between Three Years and Eleven
      Years and for Children/Adolescents Between Twelve Years and Twenty Years of
      Age;

    

    (j) Average
      number of days spent in the community by all Enrollees receiving behavioral
      health intensive case management services;

    

    (k) Number
      of
      Enrollees admitted to a State Mental Hospital;

    

    (l) Amount
      of
      time between discharge from a State Mental Hospital and first date of service
      received from a Provider; and

    

    (m) Number
      of
      Enrollees who receive a psychiatric evaluation within the required time frames
      prior to admission to a nursing facility.

    

    
      	 	
              d.

            	
              Consumer
                Assessment of Health Plans Survey
                (CAHPS)

            

    

    

    
      	 	
              (1)

            	
              At
                the end of the first (1st) year under this Contract, the Agency shall
                conduct an annual Consumer Assessment of Health Plans Survey (CAHPS).
                The
                CAHPS survey shall be done on an annual basis thereafter. The Health
                Plan
                shall provide an action plan to address the results of the CAHPS
                Survey
                within two (2) months of receipt of the written request from the
                Agency.
                

            

    

    

    
      	 	
              e.

            	
              Medical
                Record Review

            

    

    

    
      	 	
              (1)

            	
              If
                the Health Plan is not accredited, or if the Health Plan is accredited
                by
                an entity, that does not review the Medical Records of the Health
                Plan's
                PCPs, then the Health Plan shall conduct reviews of Enrollees’ Medical
                Records to ensure that PCPs provide high quality health care that
                is
                documented according to established standards.

            

    

    

    
      	 	
              (2)

            	
              The
                standards, which must include all Medical Record documentation
                requirements addressed in this Contract, must be distributed to all
                Providers. 

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan must conduct these reviews at all PCP sites that serve
                fifty
                (50) or more Enrollees. 

            

    

    

    
      	 	
              (4)

            	
              Practice
                sites include both individual offices and large group facilities.
                

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan must review each practice site at least one (1) time
                during
                each two (2) year period. 

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan must review a reasonable number of records at each site
                to
                determine compliance. Five (5) to ten (10) records per site is a
                generally-accepted target, though additional reviews must be completed
                for
                large group practices or when additional data is necessary in specific
                instances. 

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall report the results of all Medical Record reviews
                to the
                Agency within thirty (30) Calendar Days of the
                review.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan must submit to the Agency for written approval and maintain
                a
                written strategy for conducting Medical Record reviews. The strategy
                must
                include, at a minimum, the following:

            

    

    

    
      	 	
              (a)

            	
              Designated
                staff to perform this duty; 

            

    

    

    
      	 	
              (b)

            	
              The
                method of case selection; 

            

    

    

    
      	 	
              (c)

            	
              The
                anticipated number of reviews by practice site;

            

    

    

    
      	 	
              (d)

            	
              The
                tool that the Health Plan will use to review each site;
                and

            

    

    

    
      	 	
              (e)

            	
              How
                the Health Plan will link the information compiled during the review to
                other Health Plan functions (e.g., QI, credentialing, Peer Review,
                etc.).

            

    

    

    
      	 	
              f.

            	
              Peer
                Review

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have a Peer Review process which:
                

            

    

    

    
      	 	
              (a)

            	
              Reviews
                a Provider's practice methods and patterns, morbidity/mortality rates,
                and
                all Grievances filed against the Provider relating to medical
                treatment.

            

    

    

    
      	 	
              (b)

            	
              Evaluates
                the appropriateness of care rendered by
                Providers.

            

    

    

    
      	 	
              (c)

            	
              Implements
                corrective action(s) when the Health Plan deems it necessary to do
                so.

            

    

    

    
      	 	
              (d)

            	
              Develops
                policy recommendations to maintain or enhance the Quality of care
                provided
                to Enrollees.

            

    

    

    
      	 	
              (e)

            	
              Conducts
                reviews which include the appropriateness of diagnosis and subsequent
                treatment, maintenance of a Provider's Medical Records, adherence
                to
                standards generally accepted by a Provider's peers and the process
                and
                outcome of a Provider's care.

            

    

    

    
      	 	
              (f)

            	
              Appoints
                a Peer Review Committee, as a Sub-Committee to the QIP Committee,
                to
                review provider performance when appropriate. The Medical Director
                or
                his/her designee shall chair the Peer Review Committee, and its membership
                shall be drawn from the Provider Network and include peers of the
                Provider
                being reviewed.

            

    

    

    
      	 	
              (g)

            	
              Receive
                and review all written and oral allegations of inappropriate or aberrant
                service by a Provider.

            

    

    

    
      	 	
              (h)

            	
              Educate
                Enrollees and Health Plan staff about the Peer Review process, so
                that
                Enrollees and the Health Plan staff can notify the Peer Review authority
                of situations or problems relating to
                Providers.

            

    

    

    
      	 	
              g.

            	
              Credentialing
                and Recredentialing 

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall be responsible for the credentialing and recredentialing
                of its Provider network. Hospital ancillary Providers are not required
                to
                be independently credentialed if those Providers only provide services
                to
                the Health Plan Enrollees through the
                Hospital.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall establish and verify credentialing and recredentialing
                criteria for all professional Providers that, at a minimum, meet
                the
                Agency's Medicaid participation standards. The Agency’s criteria
                includes:

            

    

    

    
      	 	
              (a)

            	
              A
                copy of each Provider's current medical license pursuant to Section
                641.495, F.S

            

    

    

    
      	 	
              (b)

            	
              No
                receipt of revocation or suspension of the Provider's State License
                by the
                Division of Medical Quality Assurance, Department of
                Health.

            

    

    

    
      	 	
              (c)

            	
              No
                ongoing investigation(s) by Medicaid Program Integrity, other governmental
                entities.

            

    

    

    
      	 	
              (d)

            	
              Conduct
                a background check with the Florida Department of Law Enforcement
                (FDLE)
                for all treating providers not currently enrolled in Medicaid’s
                Fee-for-Service program. 

            

    

    

    
      	 	
              (i)

            	
              If
                exempt from the criminal background screening requirements, a copy
                of the
                screen print of the Provider’s current Department of Health licensure
                status and exemption reason must be
                included.

            

    

    

    
      	 	
              (ii)

            	
              The
                Health Plan shall not contract with any Provider who has a record
                of
                illegal conduct; i.e., found guilty of, regardless of adjudication,
                or who
                entered a plea of nolo contendere or guilty to any of the offenses
                listed
                in Section 435.03, F.S.

            

    

    

    
      	 	
              (e)

            	
              Proof
                of the Provider's medical school graduation, completion of residency
                and
                other postgraduate training. Evidence of board certification shall
                suffice
                in lieu of proof of medical school graduation, residency and other
                postgraduate training.

            

    

    

    (f) Evidence
      of specialty board certification, if applicable.

    

    (g) Evidence
      of the Provider's professional liability claims history.

    

    
      	 	
              (h)

            	
              Any
                sanctions imposed on the Provider by Medicare or
                Medicaid.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan's credentialing and recredentialing files must document
                the
                education, experience, prior training and ongoing service training
                for
                each staff member or Provider rendering Behavioral Health
                Services.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan's credentialing and recredentialing policies and procedures
                shall be in writing and include the
                following:

            

    

    

    (a) Formal
      delegations and approvals of the credentialing process.

    

    (b) A
      designated credentialing committee.

    

    (c) Identification
      of Providers who fall under its scope of authority.

    

    
      	 	
              (d)

            	
              A
                process which provides for the verification of the credentialing
                and
                recredentialing criteria required under this
                Contract.

            

    

    

    
      	 	
              (e)

            	
              Approval
                of new Providers and imposition of sanctions, termination, suspension
                and
                restrictions on existing Providers.

            

    

    

    
      	 	
              (f)

            	
              Identification
                of quality deficiencies which result in the Health Plan's restriction,
                suspension, termination or sanctioning of a
                Provider.

            

    

    

    
      	 	
              (5)

            	
              The
                credentialing and recredentialing processes must also include verification
                of the following additional requirements for physicians and must
                ensure
                compliance with 42 CFR 438.214:

            

    

    

    
      	 	
              (a)

            	
              Good
                standing of privileges at the Hospital designated as the primary
                admitting
                facility by the PCP or if the PCP does not have admitting privileges,
                good
                standing of privileges at the Hospital by another Provider with whom
                the
                PCP has entered into an arrangement for Hospital
                coverage.

            

    

    

    
      	 	
              (b)

            	
              Valid
                Drug Enforcement Administration (DEA) certificates, where
                applicable.

            

    

    

    
      	 	
              (c)

            	
              Attestation
                that the total active patient load (all populations with Medicaid
                FFS, CMS
                Network, HMO, Health Plan, Medicare and commercial coverage) is no
                more
                than 3,000 patients per PCP. An active patient is one that is seen
                by the
                Provider a minimum of three (3) times per
                year.

            

    

    

    
      	 	
              (d)

            	
              A
                good standing report on a site visit survey. For each PCP and OB/GYN
                Provider, documentation in the Health Plan’s credentialing files regarding
                the site survey shall include the
                following:

            

    

    

    
      	 	
              (i)

            	
              Evidence
                that the Health Plan has evaluated the Provider's facilities using
                the
                Health Plan's organizational
                standards.

            

    

    

    
      	 	
              (ii)

            	
              Evidence
                that the Health Plan has evaluated the Provider's medical record
                keeping
                practices at each site to ensure conformity with the Health Plan's
                organizational standards.

            

    

    

    
      	 	
              (iii)

            	
              Evidence
                that the Health Plan has determined that the following documents
                are
                posted in the Provider's waiting room/reception area: the Agency’s
                statewide consumer call center telephone number, including hours
                of
                operation and a copy of the summary of Florida’s Patient’s Bill of Rights
                and Responsibilities, in accordance with Section 381.026, F.S.; the
                Provider has a complete copy of the Florida Patient’s Bill of Rights and
                Responsibilities, available upon request by an Enrollee, at each
                of the
                Provider's offices. 

            

    

    

    
      	 	
              (iv)

            	
              The
                Provider's waiting room/reception area has a consumer assistance
                notice
                prominently displayed in the reception area in accordance with Section
                641.511, F.S.

            

    

    

    
      	 	
              (e)

            	
              Attestation
                to the correctness/completeness of the Provider's
                application.

            

    

    

    
      	 	
              (f)

            	
              Statement
                regarding any history of loss or limitation of privileges or disciplinary
                activity as described in Section 456.039,
                F.S.

            

    

    

    
      	 	
              (g)

            	
              A
                statement from each Provider applicant regarding the
                following:

            

    

    

    
      	 	
              (i)

            	
              Any
                physical or mental health problems that may affect the Provider's
                ability
                to provide health care;

            

    

    

    (ii) Any
      history of chemical dependency/substance abuse;

    

    
      	 	
              (iii)

            	
              Any
                history of loss of license and/or felony convictions;
                and

            

    

    

    (iv) The
      Provider is eligible to become a Medicaid provider. 

    

    
      	 	
              (h)

            	
              Current
                curriculum vitae, which includes at least five (5) years of work
                history.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan shall recredential its Providers at least every three
                (3)
                years.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall develop and implement an appeal procedure for Providers
                against whom the Health Plan has imposed sanctions, restrictions,
                suspensions and/or terminations.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan shall submit a Provider Network for initial or expansion
                review to the Agency for approval only when the Health Plan has
                satisfactorily completed the minimum standards required in Section
                VII,
                Provider Network and the minimum credentialing steps required in
                Section
                VIII.A.3.h(2), and i.(5) and (6).

            

    

    

    
      	 	
              4.

            	
              Agency
                Oversight

            

    

    

    
      	 	
              a.

            	
              The
                Agency shall evaluate the Health Plan’s QIP and PMs at least one (1) time
                per year at dates to be determined by the Agency, or as otherwise
                specified by this Contract.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan, in conjunction with the Agency, shall participate in
                workgroups to design additional QI strategies and to learn to use
                the best
                practice methods for enhancing the quality of health care provided
                to
                Enrollees.

            

    

    

    
      	 	
              c.

            	
              If
                the PIPs, CAHPS, the PMs, the annual Medical Record audit or the
                EQRO
                indicate that the Health Plan's performance is not acceptable, then
                the
                Agency may restrict the Health Plan’s Enrollment activities including, but
                not limited to, termination of Mandatory
                Assignments.

            

    

    

    
      	 	
              d.

            	
              If
                the Agency determines that the Health Plan’s performance is not
                acceptable, the Agency shall require the Health Plan to submit a
                corrective action plan (CAP). If the Health Plan fails to provide
                a CAP
                within the time specified by the Agency, the Agency shall sanction
                the
                Health Plan, in accordance with the provisions of Section XIV, Sanctions,
                and may immediately terminate all Enrollment activities and Mandatory
                Assignments. When considering whether to impose a limitation on Enrollment
                activities or Mandatory Assignments, the Agency may take into account
                the
                Health Plan’s cumulative performance on all QI
                activities.

            

    

    

    
      	 	
              e.

            	
              Annual
                Medical Record Audit

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall furnish specific data requested by the Agency in
                order
                to conduct the Medical Record
                audit.

            

    

    

    
      	 	
              (2)

            	
              If
                the Medical Record audit indicates that quality of care is not acceptable,
                pursuant to contractual requirements, the Agency shall sanction the
                Health
                Plan, in accordance with the provisions of Section XIV, Sanctions,
                and may
                immediately terminate all Enrollment activities and Mandatory Assignments,
                until the Health Plan attains an acceptable level of quality of care
                as
                determined by the Agency.

            

    

    

    
      	 	
              f.

            	
              Independent
                Medical Record Review by an EQRO

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide all information requested by the EQRO and/or
                the
                Agency, including, but not limited to quality outcomes concerning
                timeliness of, and Enrollee access to, Covered
                Services.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall cooperate with the EQRO during the Medical Record
                review, which will be done at least one (1) time per year.
                

            

    

    

    
      	 	
              (3)

            	
              If
                the EQRO indicates that the Quality of care is not within acceptable
                limits set forth in this Contract, the Agency shall sanction the
                Health
                Plan, in accordance with the provisions of Section XIV, Sanctions
                and may
                immediately terminate all Enrollment activities and Mandatory Assignments
                until the Health Plan attains a satisfactory level of Quality of
                care as
                determined by the EQRO.

            

    

    

    
      	
              B.

            	
              Utilization
                Management (UM)

            

    

    

    
      	 	
              1.

            	
              General
                Requirements

            

    

    

    The
      UM
      program shall be consistent with 42 CFR 456 and include, but not be limited
      to:

    

    
      	 	
              a.

            	
              Procedures
                for identifying patterns of over-utilization and under-utilization
                by
                Enrollees and for addressing potential problems identified as a result
                of
                these analyses.

            

    

    

    
      	 	
              b.

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

            

    

    

    
      	 	
              c.

            	
              A
                procedure for Enrollees to obtain a second medical opinion and that
                the
                Health Plan shall be responsible for authorizing claims for such
                services
                in accordance with Section 641.51,
                F.S.

            

    

    

    
      	 	
              d.

            	
              Service
                Authorization protocols for Prior Authorization and denial of services;
                the process used to evaluate prior and con-current authorization;
                mechanisms to ensure consistent application of review criteria for
                authorization decisions; consultation with the requesting Provider
                when
                appropriate, Hospital discharge planning, physician profiling; and
                a
                retrospective review of both inpatient and ambulatory claims, meeting
                the
                predefined criteria below. The Health Plan shall be responsible for
                ensuring the consistent application of review criteria for authorization
                decisions and consulting with the requesting Provider when
                appropriate.

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan must have written approval from the Agency for its Service
                Authorization protocols and for any changes to the original protocols.
                

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's Service Authorization systems shall provide the
                authorization number and effective dates for authorization to Providers
                and non-participating providers.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan's Service Authorization systems shall provide written
                confirmation of all denials of authorization to providers (See 42
                CFR
                438.210(c)).

            

    

    

    
      	 	
              (a)

            	
              The
                Health Plan may request to be notified, but shall not deny claims
                payment
                based solely on lack of notification, for the
                following:

            

    

    

    
      	 	
              (i)

            	
              Inpatient
                emergency admissions (within ten (10)
                days);

            

    

    

    
      	 	
              (ii)

            	
              Obstetrical
                care (at first visit);

            

    

    

    
      	 	
              (iii)

            	
              Obstetrical
                admissions exceeding forty-eight (48) hours for vaginal delivery
                and
                ninety-six (96) hours for caesarean section;
                and

            

    

    

    
      	 	
              (iv)

            	
              Transplants.

            

    

    

    
      	 	
              (b)

            	
              The
                Health Plan shall ensure that all decisions to deny a Service
                Authorization request, or limit a service in amount, duration, or
                scope
                that is less than requested, are made by Health Care Professionals
                who
                have the appropriate clinical expertise in treating the Enrollee’s
                condition or disease (see 42 CFR
                438.210(b)(3)).

            

    

    

    
      	 	
              (4)

            	
              Only
                a licensed psychiatrist may authorize a denial for an initial or
                concurrent authorization of any request for Behavioral Health Services.
                The psychiatrist's review shall be part of the UM process and not
                part of
                the clinical review, which may be requested by a Provider or the
                Enrollee,
                after the issuance of a denial.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan shall provide post authorization to CHDs for the provision
                of
                emergency shelter medical screenings provided for clients of
                DCF.

            

    

    

    
      	 	
              (6)

            	
              Health
                Plans with automated authorization systems may not require paper
                authorization as a condition of receiving
                treatment.

            

    

    

    
      	 	
              2.

            	
              Certain
                Public Providers 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall authorize all claims, from a CHD, a migrant health
                center funded under Section 329 of the Public Health Services Act
                or a
                community health center funded under Section 330 of the Public Health
                Services Act, without Prior Authorization for the
                following:

            

    

    

    
      	 	
              (1)

            	
              The
                diagnosis and treatment of sexually transmitted diseases and other
                communicable diseases, such as tuberculosis and human immunodeficiency
                syndrome;

            

    

    

    
      	 	
              (2)

            	
              The
                provision of immunizations;

            

    

    

    
      	 	
              (3)

            	
              Family
                planning services and related
                pharmaceuticals;

            

    

    

    
      	 	
              (4)

            	
              School
                health services listed in (1), (2) and (3) above, and for services
                rendered on an urgent basis by such providers;
                and,

            

    

    

    
      	 	
              (5)

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

            

    

    

    
      	 	
              b.

            	
              The
                providers specified in Section VIII.B.2.a., above, shall attempt
                to
                contact the Health Plan before providing health care services to
                Enrollees. Such providers shall provide the Health Plan with the
                results
                of the office visit, including test
                results.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall not deny claims for services delivered by the providers
                specified in Section VIII.B.2.a., above solely based on the period
                between
                the date of service and the date of clean claim submission, unless
                that
                period exceeds 365 Calendar Days, and shall be reimbursed by the
                Health
                Plan at the rate negotiated between the Health Plan and the public
                provider or the Medicaid Fee-for-Service
                rate.

            

    

    

    
      	 	
              3.

            	
              Notice
                of Action

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall notify the Enrollee, in writing, using language
                at, or
                below the fourth (4th) grade reading level, of any Action taken by
                the
                Health Plan to deny a Service Authorization request, or limit a service
                in
                an amount, duration, or scope that is less than
                requested.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan must provide notice to the Enrollee as set forth below
                (see 42
                CFR 438.404(a) and (c) and 42 CFR 438.210(b) and (c)):
                

            

    

    

    
      	 	
              (1)

            	
              The
                Action the Health Plan has taken or intends to
                take;

            

    

    

    
      	 	
              (2)

            	
              The
                reasons for the Action, customized for the circumstances of the
                Enrollee;

            

    

    

    
      	 	
              (3)

            	
              The
                Enrollee’s or the Provider's (with written permission of the Enrollee)
                right to file an Appeal;

            

    

    

    
      	 	
              (4)

            	
              The
                procedures for filing an Appeal;

            

    

    

    
      	 	
              (5)

            	
              The
                circumstances under which expedited resolution is available and how
                to
                request it; and

            

    

    

    
      	 	
              (6)

            	
              The
                Enrollee’s 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.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan must provide the notice of Action within the following
                time
                frames:

            

    

    

    
      	 	
              (1)

            	
              At
                least ten (10) Calendar Days before the date of the Action or fifteen
                (15)
                Calendar Days if the notice is sent by Surface Mail (five [5] Calendar
                Days if the Health Plan suspects Fraud on the part of the Enrollee).
                See
                42 CFR 431.211, 42 CFR 431.213 and 42 CFR 431.214.
                

            

    

    

    
      	 	
              (2)

            	
              For
                denial of the claim, at the time of any Action affecting the
                claim.

            

    

    

    
      	 	
              (3)

            	
              For
                standard Service Authorization decisions that deny or limit services,
                as
                quickly as the Enrollee’s health condition requires, but no later than
                fourteen (14) Calendar Days following receipt of the request for
                service
                (see 42 CFR 438.201(d)(1)).

            

    

    

    
      	 	
              (4)

            	
              If
                the Health Plan extends the time frame for notification, it
                must:

            

    

    

    
      	 	
              (a)

            	
              Give
                the Enrollee written notice of the reason for the extension and inform
                the
                Enrollee of the right to file a Grievance if the Enrollee disagrees
                with
                the Health Plan’s decision to extend the time frame;
                and

            

    

    

    
      	 	
              (b)

            	
              Carry
                out its determination as quickly as the Enrollee's health condition
                requires, but in no case later than the date upon which the fourteen
                (14)
                Calendar Day extension period expires (see 42 CFR
                438.210(d)(1)).

            

    

    

    
      	 	
              (5)

            	
              If
                the Health Plan fails to reach a decision within the time frames
                described
                above, the failure on the part of the Health Plan shall be considered
                a
                denial and is an Action adverse to the Enrollee (See 42 CFR 438.210(d)).
                

            

    

    

    
      	 	
              (6)

            	
              For
                expedited Service Authorization decisions, within three (3) Business
                Days
                (with the possibility of a fourteen (14) Calendar Day extension).
                See 42
                CFR 438.210(d)(2).

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall provide timely approval or denial of authorization
                of
                out-of-network use through the assignment of a Prior Authorization
                number,
                which refers to and documents the approval. The Health Plan shall
                provide
                written follow-up documentation of the approval or the denial to
                the
                out-of-network provider within five (5) Business Days from the request
                for
                approval.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan shall determine when exceptional referrals to out-of-network
                specially qualified providers are needed to address the unique medical
                needs of an Enrollee (e.g., when an Enrollee’s medical condition requires
                testing by a geneticist). The Health Plan shall develop and maintain
                policies and procedures for such
                referrals.

            

    

    

    
      	 	
              4.

            	
              Care
                Management

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              (1)

            	
              Appropriate
                referral and scheduling assistance of Enrollees needing specialty
                health
                care/Transportation Services, including those identified through
                Child
                Health Check-Up Program (CHCUP)
                Screenings;

            

    

    

    
      	 	
              (2)

            	
              Determination
                of the need for Non-Covered Services and referral of the Enrollee
                for
                assessment and referral to the appropriate service setting (to include
                referral to WIC and Healthy Start) utilizing assistance as needed
                by the
                area Medicaid office;

            

    

    

    
      	 	
              (3)

            	
              Case
                Management follow-up services for Children/Adolescents, who the Health
                Plan identifies through blood Screenings as having abnormal levels
                of
                lead;

            

    

    

    
      	 	
              (4)

            	
              Coordinated
                Hospital/institutional discharge planning that includes post-discharge
                care, including skilled, short-term, skilled nursing facility care,
                as
                appropriate; and

            

    

    

    
      	 	
              (5)

            	
              A
                mechanism for direct access to specialists for Enrollees identified
                as
                having special health care needs, as is appropriate for their condition
                and identified needs.

            

    

    

    
      	 	
              (6)

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

            

    

    

    
      	 	
              (7)

            	
              Documentation
                of referral services in Enrollees’ Medical Records, including results.
                

            

    

    

    
      	 	
              (8)

            	
              Monitoring
                of Enrollees with ongoing medical conditions and coordination of
                services
                for high utilizers such that the following functions are addressed
                as
                appropriate: acting as a liaison between the Enrollee and Providers,
                ensuring the Enrollee is receiving routine medical care, ensuring
                that the
                Enrollee has adequate support at home, assisting Enrollees who are
                unable
                to access necessary care due to their medical or emotional conditions
                or
                who do not have adequate community resources to comply with their
                care,
                and assisting the Enrollee in developing community resources to manage
                the
                Enrollee’s medical condition. 

            

    

    

    
      	 	
              (9)

            	
              Documentation
                of emergency care encounters in Enrollees’ Medical Records with
                appropriate medically indicated follow-up.

            

    

    

    
      	 	
              (10)

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

            

    

    

    
      	 	
              (11)

            	
              Share
                with other MCOs, PIHPs, and PAHPs serving the Enrollee the results
                of its
                identification and assessment of any Enrollee with special health
                care
                needs so that those activities need not be
                duplicated.

            

    

    

    
      	 	
              (12)

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

            

    

    

    
      	 	
              5.

            	
              New
                Enrollee Procedures

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall not delay Service Authorization if written documentation
                is not available in a timely
                manner.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall contact each new Enrollee at least two (2) times,
                if
                necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment
                to schedule the Enrollee's initial appointment with his/her PCP for
                the
                purpose of obtaining a health risk assessment and/or CHCUP Screening.
                For
                this subsection, "contact" is defined as mailing a notice to, or
                telephoning, an Enrollee at the most recent address or telephone
                number
                available.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall urge Enrollees to see their PCPs within 180 Calendar
                Days of Enrollment.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall contact each new Enrollee within thirty (30) Calendar
                Days of Enrollment to request that the Enrollee authorize the release
                of
                his or her Medical Records (including those related to Behavioral
                Health
                Services) to the Health Plan, or the Health Plan's health services
                Subcontractor, from those providers who treated the Enrollee prior
                to the
                Enrollee's Enrollment with the Health Plan. Also, the Health Plan
                shall
                request or assist the Enrollee's new PCP by requesting the Enrollee's
                Medical Records from the Enrollee’s previous
                providers.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall use the Enrollee's health risk assessments and/or
                released Medical Records to identify Enrollees who have not received
                CHCUP
                Screenings in accordance with the Agency approved periodicity
                schedule.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall contact, up to two (2) times if necessary, any
                Enrollee
                more than two (2) months behind in the Agency approved periodicity
                Screening schedule to urge those Enrollees, or their legal
                representatives, to make an appointment with the Enrollees' PCPs
                for a
                Screening visit.

            

    

    

    
      	 	
              g.

            	
              Within
                thirty (30) Calendar Days of Enrollment, the Health Plan shall notify
                Enrollees of, and ensure the availability of, a Screening for all
                Enrollees known to be pregnant or who advise the Health Plan that
                they may
                be pregnant. The Health Plan shall refer Enrollees who are, or may
                be,
                pregnant to the appropriate Provider stating that the Enrollee can
                obtain
                appropriate prenatal care.

            

    

    

    
      	 	
              h.

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

            

    

    

    
      	 	
              (1)

            	
              Enrollees
                who voluntarily enrolled; and

            

    

    

    
      	 	
              (2)

            	
              Those
                Enrollees who were automatically reenrolled after regaining Medicaid
                eligibility.

            

    

    

    
      	 	
              i.

            	
              For
                Mandatory Assignment Enrollees, the Health Plan shall honor any written
                documentation of Prior Authorization of ongoing services for a period
                of
                one (1) month after the effective date of Enrollment or until the
                Mandatory Assignment Enrollee's PCP reviews the Enrollee's treatment
                plan,
                whichever comes first.

            

    

    

    
      	 	
              j.

            	
              For
                all Enrollees, written documentation of Prior Authorization of ongoing
                services includes the following, provided that the services were
                prearranged prior to Enrollment with the Health
                Plan:

            

    

    

    
      	 	
              (1)

            	
              Prior
                existing orders;

            

    

    

    
      	 	
              (2)

            	
              Provider
                appointments, e.g. dental appointments, surgeries, etc.;
                and

            

    

    

    
      	 	
              (3)

            	
              Prescriptions
                (including prescriptions at non-participating
                pharmacies).

            

    

    

    
      	 	
              k.

            	
              The
                Health Plan shall not delay Service Authorization if written documentation
                is not available in a timely manner. The Health Plan is not required
                to
                approve claims for which it has received no written documentation.
                

            

    

    

    
      	 	
              l.

            	
              The
                Health Plan shall not deny claims submitted by an out-of-network
                provider
                solely based on the period between the date of service and the date
                of
                clean claim submission, unless that period exceeds 365
                days.

            

    

    

    m. The
      Enrollee's guardian, next of kin or legally authorized responsible person is
      permitted to act on the Enrollee's behalf in matters relating to the Enrollee's
      Enrollment, plan of care, and/or provision of services, if the
      Enrollee: 

    

    
      	 	
              (1)

            	
              Was
                adjudicated incompetent in accordance with the law;
                

            

    

    

    
      	 	
              (2)

            	
              Is
                found by his or her Provider to be medically incapable of understanding
                his or her rights; or

            

    

    

    
      	 	
              (3)

            	
              Exhibits
                a significant communication
                barrier.

            

    

    

    
      	 	
              n.

            	
              The
                Health Plan shall take immediate action to address any identified
                urgent
                medical needs. "Urgent medical needs" means any sudden or unforeseen
                situation which requires immediate action to prevent hospitalization
                or
                nursing home placement. Examples include hospitalization of spouse
                or
                caregiver or increased impairment of an Enrollee living alone who
                suddenly
                cannot manage basic needs without immediate help, hospitalization
                or
                nursing home placement. 

            

    

    

    
      	 	
              6.

            	
              Incentive
                Programs 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan may offer incentives for Enrollees to receive preventive
                care
                services. The Health Plan shall receive written approval from the
                Agency
                before offering any incentives. The Health Plan shall make all incentives
                available to all Enrollees. The Health Plan shall not use incentives
                to
                direct individuals to select a particular Provider.
                

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan may inform Enrollees, once they are enrolled, about the
                specific incentives available.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall not include the provision of gambling, alcohol,
                tobacco
                or drugs in any of the Health Plan's
                incentives.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan's incentives shall have some health or child development
                related function (e.g., clothing, food, books, safety devices, infant
                care
                items, magazine subscriptions to publications which devote at least
                ten
                percent (10%) of their copy to health related subjects, membership
                in
                clubs advocating educational advancement and healthy lifestyles,
                etc.).
                Incentive dollar values shall be in proportion to the importance
                of the
                health service to be utilized (e.g., a T-shirt for attending one
                (1)
                prenatal class, but a car seat for completion of a series of
                classes).

            

    

    

    
      	 	
              e.

            	
              Incentives
                shall be limited to a dollar value of ten dollars ($10.00), except
                in the
                case of incentives for the completion of a series of services, health
                education classes or other educational activities, in which case
                the
                incentive shall be limited to a dollar value of fifty dollars ($50.00).
                The Agency will allow a special exception to the dollar value relating
                to
                infant car seats, strollers, and cloth baby carriers or
                slings.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall not include in the dollar limits on incentives
                any money
                spent on the transportation of Enrollees to services or child care
                provided during the provision of
                services.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan may offer an Agency approved program for pregnant women
                in
                order to encourage the commencement of prenatal care visits in the
                first
                (1st)
                trimester of pregnancy. The Health Plan’s prenatal and postpartum care
                Incentive Program must be aimed at promoting early intervention and
                prenatal care to decrease infant mortality and low birth weight and
                to
                enhance healthy birth outcomes. The prenatal and postpartum incentives
                may
                include the provision of maternity and health related items and
                education.

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan's request for approval of all incentives shall contain
                a
                detailed description of the incentive and its
                mission.

            

    

    

    
      	 	
              7.

            	
              Practice
                Guidelines

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall adopt practice guidelines that meet the following
                requirements:

            

    

    

    
      	 	
              (1)

            	
              Are
                based on valid and reliable clinical evidence or a consensus of Health
                Care Professionals in a particular
                field;

            

    

    

    
      	 	
              (2)

            	
              Consider
                the needs of the Enrollees;

            

    

    

    
      	 	
              (3)

            	
              Are
                adopted in consultation with Providers;
                and

            

    

    

    
      	 	
              (4)

            	
              Are
                reviewed and updated periodically, as appropriate (See 42 CFR
                438.236(b)).

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall disseminate any revised practice guidelines to
                all
                affected Providers and, upon request, to Enrollees and Potential
                Enrollees.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall ensure consistency with regard to all decisions
                relating
                to UM, Enrollee education, Covered Services and other areas to which
                the
                practice guidelines apply.

            

    

    

    9.
       Changes
      to Utilization Management Components 

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide no less than thirty (30) Calendar Days
                written
                notice before making any changes to the administration and/or management
                procedures and/or authorization, denial or review procedures, including
                any delegations, as described in this
                section.

            

    

    

    
      	 	
              10.
                

            	
              Out-of-Plan
                Use of Non-Emergency
                Services

            

    

    

    
      	 	
              a.

            	
              Unless
                otherwise specified in this Contract, where an Enrollee utilizes
                services
                available under the Health Plan other than Emergency Services from
                a
                non-participating provider, the Health Plan shall not be liable for
                the
                cost of such utilization unless the Health Plan referred the Enrollee
                to
                the non-participating provider or authorized such out-of-network
                utilization. The Health Plan shall provide timely approval or denial
                of
                authorization of out-of-network use through the assignment of a prior
                authorization number, which refers to and documents the approval.
                The
                Health Plan may not require paper authorization as a condition of
                receiving treatment if the Health Plan has an automated authorization
                system. Written follow up documentation of the approval must be provided
                to the out-of-network provider within one (1) Business Day from the
                request for approval. The Enrollee shall be liable for the cost of
                such
                unauthorized use of Covered Services from non-participating
                providers.

            

    

    

    
      	 	
              b.

            	
              In
                accordance with Section 409.912, F.S., the Health Plan shall reimburse
                any
                hospital or physician that is outside the Health Plan’s authorized Service
                Area for Health Plan authorized services provided by the hospital
                or
                physician to Enrollees at a rate negotiated with the hospital or
                physician
                for the provision of services or according to the lesser of the
                following:

            

    

    

    
      	 	
              (1)

            	
              The
                usual and customary charge made to the general public by the hospital
                or
                physician; or

            

    

    

    
      	 	
              (2)

            	
              The
                Florida Medicaid reimbursement rate established for the hospital
                or
                physician.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall reimburse all out-of-network providers pursuant
                to
                Section 641.3155, F.S.

            

    

    

     

    REMAINDER
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    Section
      IX

    Grievance
      System

    

     

    
      	
              A.

            	
              General
                Requirements

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan shall have a Grievance System in place that includes
                a
                Grievance process, an Appeal process and access to the Medicaid Fair
                Hearing system. The Health Plan’s Grievance System shall comply with the
                requirements set forth in Section 641.511, F.S., if applicable and
                with
                all applicable federal and State laws and regulations, including
                42 CFR
                431.200 and 42 CFR 438, Subpart F, “Grievance
                System.”

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan must develop and maintain written policies and procedures
                relating to the Grievance System and must provide its Grievance Procedures
                to the Agency for approval. Before implementation, the Agency must
                give
                the Health Plan written approval of the Health Plan’s Grievance System
                policies and procedures.

            

    

    

    
      	 	
              3.

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

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan's Grievance System must include an additional grievance
                resolution process, as set forth in Section 408.7056, F.S., and referred
                to in this Contract as the Subscriber Assistance Program
                (SAP).

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan must give Enrollees reasonable assistance in completing
                forms
                and other procedural steps, including, but not limited to, providing
                interpreter services and toll-free numbers with TTY/TDD and interpreter
                capability.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan must acknowledge, in writing, receipt of Appeal, unless
                the
                Enrollee or provider requests an expedited
                resolution.

            

    

    

    
      	 	
              7.

            	
              The
                Health Plan shall ensure that none of the decision makers on a Grievance
                or Appeal were involved in any of the previous levels of review or
                decision-making and that all decision makers are health care professionals
                with clinical expertise in treating the Enrollee's condition or disease
                when deciding any of the following:

            

    

    

    a. An
      Appeal
      of a denial that is based on lack of Medical Necessity;

    

    
      	 	
              b.

            	
              A
                Grievance regarding the denial of an expedited resolution of an Appeal;
                and

            

    

    

    c. A
      Grievance or Appeal that involves clinical issues.

    

    
      	 	
              8.

            	
              The
                Health Plan shall allow the Enrollee, and/or the Enrollee's
                representative, an opportunity to examine the Enrollee's case file
                before
                and during the Appeal process, including all medical records and
                any other
                documents and records.

            

    

    

    
      	 	
              9.

            	
              The
                Health Plan shall consider the Enrollee, the Enrollee's representative
                or
                the representative of a deceased Enrollee's estate as parties to
                the
                Grievance/Appeal.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan shall include information (including all related policies,
                procedures and time frames) regarding Grievances, Appeals and Medicaid
                Fair Hearings in the Health Plan's Provider Manual. The Health Plan
                shall
                provide a copy of the Provider Manual to all Providers/Subcontractors
                at
                the time the Plan enters into agreements with said
                Providers/Subcontractors. 

            

    

     

    
      	 	
              11.

            	
              The
                Enrollee Handbook and the Provider Manual must clearly specify all
                necessary procedural steps for filing Grievances, Appeals and Medicaid
                Fair Hearings, as set forth in Section IV.A.2. and 4., above,
                including:

            

    

    

    
      	 	
              a.

            	
              Enrollee
                rights to file Grievances and Appeals and all requirements and time
                frames
                for filing Grievances and Appeals.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan's Grievances and Appeals Coordinator’s address, toll-free
                telephone number and office hours.

            

    

    

    
      	 	
              c.

            	
              The
                availability of assistance to Enrollees in filing Grievances, Appeals
                and
                Medicaid Fair Hearings.

            

    

    

    
      	 	
              d.

            	
              Enrollee
                rights to a Medicaid Fair Hearing and the method for obtaining a
                Medicaid
                Fair Hearing, including the address for pursuing a Medicaid Fair
                Hearing:

            

    

    

    Office
      of
      Public Assistance Appeals Hearings

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      FL 32399-0700

    

    
      	 	
              e.

            	
              The
                rules that govern representation at the Medicaid Fair
                Hearing.

            

    

    

    
      	 	
              f.

            	
              A
                statement explaining the Enrollee's right to request a continuation
                of
                benefits during an Appeal and/or Medicaid Fair Hearing and a statement
                that if the Health Plan's Action is upheld in any Medicaid Fair Hearing,
                the Health Plan may hold the Enrollee liable for the cost of any
                continued
                Benefits.

            

    

    

    
      	 	
              g.

            	
              A
                detailed explanation of the proper procedure for an Enrollee to request
                a
                continuation of benefits during an Appeal and/or Medicaid Fair
                Hearing.

            

    

    

    
      	 	
              h.

            	
              An
                explanation regarding the Enrollee's rights to appeal to the Agency
                and
                the SAP after exhausting the Health Plan's Appeal/Grievance process,
                with
                the following exception: pursuant to Sections 408.7056 and 641.511,
                F.S.,
                the SAP will not consider a Grievance or Appeal taken to a Medicaid
                Fair
                Hearing.

            

    

    

    
      	 	
              i.

            	
              The
                information set forth in the Enrollee Handbook and the Provider Manual
                must explain that an Enrollee must request a review by the SAP within
                one
                (1) year of receipt of the final decision letter from the Health
                Plan,
                must explain how to initiate a review by the SAP and must include
                the
                SAP's address and telephone number:

            

    

    

    Agency
      for Health Care Administration

    Subscriber
      Assistance Program

    Building
      1, MS #26

    2727
      Mahan Drive, Tallahassee, Florida 32308

    (850)
      921-5458

    (888)
      419-3456 (toll-free)

    

    
      	 	
              12.

            	
              The
                Health Plan shall maintain a record/log of all Grievances, Appeals
                and
                Medicaid Fair Hearings in accordance with the terms of this Contract
                and
                to fulfill the reporting requirements as set forth in Section XII,
                Reporting Requirements. 

            

    

    

    
      	
              B.

            	
              The
                Grievance Process

            

    

    

    
      	 	
              1.

            	
              The
                Grievance process is the Health Plan's procedure for addressing Enrollee
                Grievances, which are expressions of dissatisfaction about any matter
                other than Action.

            

    

    

    
      	 	
              2.

            	
              An
                Enrollee may file a Grievance, or a provider (whether a participating
                Provider or a nonparticipating provider), acting on behalf of the
                Enrollee
                and with the Enrollee's written consent, may file a Grievance.
                

            

    

    

    
      	 	
              3.

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

            

    

    

    
      	 	
              4.

            	
              General
                Health Plan Duties

            

    

    

    a. The
      Health Plan must: 

    

    
      	 	
              (1)

            	
              Resolve
                each Grievance within State-established time frames not to exceed
                ninety
                (90) Calendar Days from the day the Health Plan received the initial
                Grievance request, be it oral or in
                writing;

            

    

    

    
      	 	
              (2)

            	
              Notify
                the Enrollee, in writing, within ninety (90) Calendar Days of the
                resolution of the Grievance. The notice of disposition shall include
                the
                results and date of the resolution of the Grievance, and for decisions
                not
                wholly in the Enrollee's favor, the notice of disposition shall
                include:

            

    

    

    
      	 	
              (a)

            	
              Notice
                of the right to request a Medicaid Fair Hearing if
                applicable;

            

    

    

    
      	 	
              (b)

            	
              Information
                necessary to allow the Enrollee/provider to request a Medicaid Fair
                Hearing, including the contact information necessary to pursue a
                Medicaid
                Fair Hearing (see Section IX.D.,
                below);

            

    

    

    
      	 	
              (3)

            	
              Provide
                the Agency with a copy of the written notice of disposition upon
                request;
                and

            

    

    

    
      	 	
              (4)

            	
              Ensure
                that no punitive action is taken against a provider who files a Grievance
                on behalf of an Enrollee, or supports an Enrollee's
                Grievance.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan may extend the Grievance resolution time frame by up
                to
                fourteen (14) Calendar Days if the Enrollee requests an extension,
                or the
                Health Plan documents
                that there is a need for additional information and that the delay
                is in
                the Enrollee's best interest.

            

    

    

    
      	 	
              (1)

            	
              If
                the extension is not requested by the Enrollee, the Health Plan must
                give
                the Enrollee written notice of the reason for the
                delay.

            

    

    

    c. 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, however the
                timeframe for resolution begins the date the plan receives the oral
                request.

            

    

    

    
      	
              C.

            	
              The
                Appeal Process 

            

    

    

    
      	 	
              1.

            	
              The
                Appeal process is the Health Plan's procedure for addressing Enrollee
                Appeals, which are requests for review of an
                Action.

            

    

    

    
      	 	
              2.

            	
              An
                Enrollee, or a provider (whether a participating Provider or a
                nonparticipating provider) acting on behalf of an Enrollee and with
                the
                Enrollee's written consent, may file an Appeal.

            

    

    

    
      	 	
              3.

            	
              The
                Appeal procedure must be the same for all
                Enrollees.

            

    

    

    
      	 	
              4.

            	
              General
                Health Plan Duties 

            

    

    

    a. The
      Health Plan shall:

    

    
      	 	
              (1)

            	
              Confirm
                in writing all oral inquiries seeking an Appeal, unless the Enrollee
                or
                provider requests an expedited
                resolution;

            

    

    

    
      	 	
              (2)

            	
              If
                the resolution is in favor of the Enrollee, provide the services
                as
                quickly as the Enrollee's health condition
                requires;

            

    

    

    
      	 	
              (3)

            	
              Provide
                the Enrollee or provider with a reasonable opportunity to present
                to
                evidence and allegations of fact or law, in person and/or in
                writing;

            

    

    

    
      	 	
              (4)

            	
              Allow
                the Enrollee, and/or the Enrollee's representative, an opportunity,
                before
                and during the Appeal process, to examine the Enrollee's case file,
                including all Medical Records and any other documents and
                records;

            

    

    

    
      	 	
              (5)

            	
              Consider
                the Enrollee, the Enrollee's representative or the representative
                of a
                deceased Enrollee's estate as parties to the
                Appeal;

            

    

    

    
      	 	
              (6)

            	
              Continue
                the Enrollee's Benefits if:

            

    

    

    
      	 	
              (a)

            	
              The
                Enrollee files the Appeal in a timely manner, meaning on or before
                the
                later of the following:

            

    

    

    
      	 	
              (i)

            	
              Within
                ten (10) Business Days of the date on the notice of Action (add five
                [5]
                Business Days if the notice is sent via Surface Mail);
                or

            

    

    

    
      	 	
              (ii)

            	
              The
                intended effective date of the Health Plan’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/or

            

    

    

    
      	 	
              (e)

            	
              The
                Enrollee requests extension of
                Benefits.

            

    

    

    
      	 	
              (7)

            	
              Provide
                written notice of the resolution of the Appeal, including the results
                and
                date of the resolution
                within two (2) business days after the resolution.
                For decisions not wholly in the Enrollee's favor, the notice of resolution
                shall include:

            

    

    

    
      	 	
              (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
                necessary for pursuing a Medicaid Fair Hearing, as set forth in Section
                IX.D., below;

            

    

    

    
      	 	
              (c)

            	
              Notice
                of the right to continue to receive Benefits pending a Medicaid Fair
                Hearing;

            

    

    

    
      	 	
              (d)

            	
              Information
                about how to request the continuation of
                Benefits;

            

    

    

    
      	 	
              (e)

            	
              Notice
                that if the Health Plan's Action is upheld in a Medicaid Fair Hearing,
                the
                Enrollee may be liable for the cost of any continued Benefits;
                and

            

    

    

    
      	 	
              (f)

            	
              Pursuant
                to Section 408.7056, F.S., the Health Plan must notify the
                Enrollee/provider that if the Appeal is not resolved to the satisfaction
                of the Enrollee/provider, the Enrollee/provider has one (1) year
                from the
                date of the occurrence that initiated the Appeal in which to request
                review of the Health Plan's decision concerning the Appeal by the
                SAP. The
                notice must explain how to initiate such a review and include the
                address
                and toll-free telephone numbers of the Agency and the SAP, as provided
                in
                Section IX.A.11(i), above.

            

    

    

    
      	 	
              (8)

            	
              Provide
                the Agency with a copy of the written notice of disposition upon
                request;
                and

            

    

    

    
      	 	
              (9)

            	
              Ensure
                that punitive action is not taken against a provider who files an
                Appeal
                on behalf of an Enrollee or supports an Enrollee's
                Appeal.

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan continues or reinstates the Enrollee’s Benefits while the
                Appeal is pending, the Health Plan must continue providing the Benefits
                until one (1) of the following
                occurs:

            

    

    

    (1) The
      Enrollee withdraws the Appeal;

    

    
      	 	
              (2)

            	
              Ten
                (10) Business Days pass from the date of the Health Plan's notice
                of
                resolution of the appeal if the resolution is adverse to the enrollee
                and
                if the Enrollee has not requested a Medicaid Fair Hearing with
                continuation of Benefits until a Medicaid Fair Hearing decision is
                reached. 

            

    

    

    (3) The
      Medicaid Fair Hearing panel's decision is adverse to the Enrollee; or

    

    
      	 	
              (4)

            	
              The
                authorization to provide services expires, or the Enrollee meets
                the
                authorized service limits. 

            

    

    

    
      	 	
              c.

            	
              If
                the final resolution of the Appeal is adverse to the Enrollee, the
                Health
                Plan may recover the costs of the services furnished from the Enrollee
                while the Appeal was pending, to the extent that the services were
                furnished solely because of the requirements of this
                Section.

            

    

    

    
      	 	
              d.

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

            

    

    

    
      	 	
              e.

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

            

    

    

    5. Filing
      Requirements

    

    
      	 	
              a.

            	
              The
                Enrollee/provider must file an Appeal within thirty (30) Calendar
                Days of
                receipt of the notice of the Health Plan's
                Action

            

    

    

    
      	 	
              b.

            	
              The
                Enrollee/provider may file an Appeal either orally or in writing.
                If the
                filing is oral, the Enrollee/provider must also file a written, signed
                Appeal within thirty (30) Calendar Days of the oral filing. The Health
                Plan shall notify the requesting party that it must file the written
                request within ten (10) Business Days after receipt of the oral request.
                For oral filings, time frames for resolution of the Appeal begin
                on the
                date the Health Plan receives the oral
                filing.

            

    

    

    
      	 	
              c.

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

            

    

    

    
      	 	
              d.

            	
              If
                the resolution is in favor of the Enrollee, the Health Plan shall
                provide
                the services as quickly as the Enrollee's health condition requires.
                

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan may extend the resolution time frames by up to fourteen
                (14)
                Calendar Days if the Enrollee requests an extension, or the Health
                Plan
                documents that there is a need for additional information and that
                the
                delay is in the Enrollee's best
                interest.

            

    

    

    
      	 	
              (1)

            	
              If
                the extension is not requested by the Enrollee, the Health Plan must
                give
                the Enrollee written notice of the reason for the
                delay.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan must provide written notice of the extension to the Enrollee
                within five (5) Business Days of determining the need for an
                extension.

            

    

    

    6. Expedited
      Process

    

    
      	 	
              a.

            	
              The
                Health Plan shall establish and maintain an expedited review process
                for
                Appeals when the Health Plan determines, the Enrollee requests or
                the
                provider indicates (in making the request on the Enrollee's behalf
                or
                supporting the Enrollee's request) that taking the time for a standard
                resolution could seriously jeopardize the Enrollee's life, health
                or
                ability to attain, maintain or regain maximum
                function.

            

    

    

    
      	 	
              b.

            	
              The
                Enrollee/provider may file an expedited Appeal either orally or in
                writing. No additional written follow-up on the part of the
                Enrollee/provider is required for an oral request for an expedited
                Appeal.

            

    

    

    c. The
      Health Plan 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 to the Enrollee, as quickly
                as
                the Enrollee's health condition requires, within State established
                time
                frames not to exceed seventy-two (72) hours after the Health Plan
                receives
                the Appeal request, whether the Appeal was made orally or in
                writing;

            

    

    

    
      	 	
              (3)

            	
              Provide
                written notice of the resolution in accordance with Section IX. C.7.
                of
                the expedited Appeal to the
                Enrollee;

            

    

    

    
      	 	
              (4)

            	
              Make
                reasonable efforts to provide oral notice of disposition to the Enrollee
                immediately after the Appeal panel renders a decision;
                and

            

    

    

    
      	 	
              (5)

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

            

    

    

    
      	 	
              d.

            	
              If
                the Health Plan denies a request for an expedited resolution of an
                Appeal,
                the Health Plan must:

            

    

    

    
      	 	
              (1)

            	
              Transfer
                the Appeal to the standard time frame of no longer than forty-five
                (45)
                Calendar Days from the day the Health Plan received the request for
                Appeal
                (with a possible fourteen [14] day
                extension);

            

    

    

    
      	 	
              (2)

            	
              Make
                all reasonable efforts to provide immediate oral notification of
                the
                Health Plan's denial for expedited resolution of the
                Appeal;

            

    

    

    
      	 	
              (3)

            	
              Provide
                written notice of the denial of the expedited Appeal within two (2)
                Calendar Days; and

            

    

    

    (4) Fulfill
      all requirements set forth in Section IX.C.1 - 5, above.

    

    
      	 	
              7.

            	
              Submission
                to the Subscriber Assistance Program
                (SAP)

            

    

    

    
      	 	
              (1)

            	
              Before
                filing with the SAP, the Enrollee/provider must complete the Health
                Plan’s
                Appeal process.

            

    

    

    
      	 	
              (2)

            	
              The
                Enrollee/provider must submit the Appeal to the SAP within one (1)
                year of
                the date of the occurrence that initiated the
                Appeal.

            

    

    

    
      	 	
              (3)

            	
              The
                SAP will not consider a Grievance or Appeal taken to a Medicaid Fair
                Hearing.

            

    

    

    
      	
              D.

            	
              Medicaid
                Fair Hearing System

            

    

    

    
      	 	
              1.

            	
              As
                set forth in Rule 65-2.042, FAC,
                the Health Plan's Grievance Procedure and Appeal and Grievance processes
                shall state that the Enrollee has the right to request a Medicaid
                Fair
                Hearing, in addition to, and at the same time as, pursuing resolution
                through the Health Plan's Grievance and Appeal
                processes.

            

    

    

    
      	 	
              a.

            	
              A
                provider must have an Enrollee's written consent before requesting
                a
                Medicaid Fair Hearing on behalf of an
                Enrollee.

            

    

    

    
      	 	
              b.

            	
              The
                parties to a Medicaid Fair Hearing include the Health Plan, as well
                as the
                Enrollee, his/her representative or the representative of a deceased
                Enrollee's estate.

            

    

    

    2. Filing
      Requirements

    

    
      	 	
              a.

            	
              The
                Enrollee/provider may request a Medicaid Fair Hearing within ninety
                (90)
                days of the date of the notice of the Health Plan's resolution of
                the
                Enrollee’s Grievance/Appeal by contacting DCF
                at:

            

    

    

    The
      Office of Appeal Hearings

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      Florida 32399-0700

    

    3. General
      Health Plan Duties

    

    a. The
      Health Plan must:

    

    
      	 	
              (1)

            	
              Continue
                the Enrollee's Benefits while the Medicaid Fair Hearing is pending
                if:

            

    

    

    
      	 	
              (a)

            	
              The
                Medicaid Fair Hearing is filed timely, meaning on or before the later
                of
                the following:

            

    

    

    
      	 	
              (i)

            	
              Within
                ten (10) Business Days of the date on the notice of Action (add five
                [5]
                Business Days if the notice is sent via Surface
                Mail);

            

    

    

    
      	 	
              (ii)

            	
              The
                intended effective date of the Health 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/or

    

    (e) The
      Enrollee requests extension of Benefits.

    

    
      	 	
              (2)

            	
              Ensure
                that punitive action is not taken against a provider who requests
                a
                Medicaid Fair Hearing on an Enrollee's behalf or supports an Enrollee's
                request for a Medicaid Fair
                Hearing.

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan continues or reinstates Enrollee Benefits while the
                Medicaid Fair Hearing is pending, the Health Plan must continue said
                Benefits until one (1) of the following
                occurs:

            

    

    

    
      	 	
              (1)

            	
              The
                Enrollee withdraws the request for a Medicaid Fair
                Hearing;

            

    

    

    
      	 	
              (2)

            	
              Ten
                (10) Business Days pass from the date of the Health Plan's notice
                of
                resolution of the appeal if the resolution is adverse to the enrollee
                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] Business Days if the Health Plan sends the notice of Action by
                Surface
                Mail);

            

    

    
      	 	 	 

    

    
      	 	
              (3)

            	
              The
                Medicaid Fair Hearing officer renders a decision that is adverse
                to the
                Enrollee; and/or

            

    

    

    
      	 	
              (4)

            	
              The
                Enrollee's authorization expires or the Enrollee reaches his/her
                authorized service limits.

            

    

    

    
      	 	
              4.

            	
              If
                the final resolution of the Medicaid Fair Hearing is adverse to the
                Enrollee, the Health Plan may recover the costs of the services furnished
                while the Medicaid Fair Hearing was pending, to the extent that the
                services were furnished solely because of the requirements of this
                Section. 

            

    

    

    
      	 	
              5.

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

            

    

    

    
      	 	
              6.

            	
              If
                the services were furnished while the Medicaid Fair Hearing was pending,
                and the Medicaid Fair Hearing resolution reverses the Plan's decision
                to
                deny, limit or delay services, the Health Plan must pay for disputed
                services in accordance with State policy and
                regulations.

            

    

    

    

     

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

     

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Section
      X

     

    Administration
      and Management

     

    

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan’s governing body shall set forth policy and has overall
                responsibility for the organization of the Health Plan. The Health
                Plan
                shall be responsible for the administration and management of all
                aspects
                of this Contract, including all Subcontracts, employees, agents and
                services performed by anyone acting for or on behalf of the Health
                Plan.
                The Health Plan shall have a centralized executive administration,
                which
                shall serve as the contact point for the Agency, except as otherwise
                specified in this Contract.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall be responsible for the administration and management
                of
                all aspects of this Contract, such as, but not limited to, the delivery
                of
                services, Provider network, Provider education, and claims resolution
                and
                assistance. 

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan 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 to deny, limit, or
                discontinue Medically Necessary services to any
                Enrollee.

            

    

    

    
      	
              B.

            	
              Staffing

            

    

    

    
      	 	
              1.

            	
              Minimum
                Staffing Requirements

            

    

    

    
      	 	
              a.

            	
              Contract
                Manager:
                The Health Plan shall designate a Contract Manager to work directly
                with
                the Agency. The Contract Manager shall be a full-time employee of
                the
                Health Plan with the authority to revise processes or procedures
                and
                assign additional resources as needed to maximize the efficiency
                and
                effectiveness of services required under the Contract. The Health
                Plan
                shall meet in person, or by telephone, at the request of Agency
                representatives, but at least monthly, to discuss the status of the
                Contract, Health Plan performance, benefits to the State, necessary
                revisions, reviews, reports and planning. Summary reports shall be
                developed and presented to the Agency, or its Agent, as
                specified.

            

    

    

    
      	 	
              b.

            	
              Full-Time
                Administrator:
                The Health Plan shall have a Full-Time Administrator specifically
                identified to administer the day-to-day business activities of this
                Contract. The Health Plan may designate the same person as the Contract
                Manager, the Full-time Administrator, or the Medical Director,
                The
                Health Plan may designate the same person as the Contract Manager,
                the
                Full-time Administrator, or the Medical Director, but such person
                cannot
                be designated to any other position in this section, including in
                other
                lines of business within the Health Plan, unless otherwise approved
                by the
                Agency.

            

    

    

    
      	 	
              c.

            	
              Medical
                and Professional Support Staff:
                The Health Plan shall have Medical and Professional Support Staff
                sufficient to conduct daily business in an orderly manner, including
                having Enrollee services staff directly available during business
                hours
                for Enrollee services consultation, as determined through management
                and
                medical reviews. The Health Plan shall maintain sufficient medical
                staff,
                available twenty-four (24) hours per day, seven (7) days per week,
                to
                handle Emergency Services and Care inquiries. The Health Plan shall
                maintain sufficient Medical and Professional Support Staff during
                non-business hours, unless the Health Plan's computer system automatically
                approves all Emergency Services and Care claims relating to Screening
                and
                treatment.

            

    

    

    
      	 	
              d.

            	
              Medical
                Director:
                The Health Plan shall have a full-time licensed physician to serve
                as
                Medical Director to oversee and be responsible for the proper provision
                of
                Covered Services to Enrollees, the Quality Management Program and
                the
                Grievance System. The Medical Director shall be licensed in accordance
                with Chapter 458 or 459, F.S. The Medical Director cannot be designated
                to
                serve in any other non-administrative position. The Medical Director
                cannot be designated to serve in any other non-administrative
                position.

            

    

    

    
      	 	
              e.

            	
              Medical
                Records Review Coordinator:
                A
                designated person, qualified by training and experience, to ensure
                compliance with the Medical Records requirements as described in
                this
                Contract. The Medical Records Review Coordinator shall maintain Medical
                Record standards and conduct Medical Record reviews according to
                the terms
                of this Contract. 

            

    

    

    
      	 	
              f.

            	
              Data
                Processing and Data Reporting Coordinator:
                The Health Plan shall have a person trained and experienced in data
                processing, data reporting, and claims resolution, as required, to
                ensure
                that computer system reports that that the Health Plan provides to
                the
                Agency and its Agents are accurate, and that computer systems operate
                in
                an accurate and timely manner.

            

    

    

    
      	 	
              g.

            	
              Marketing
                Oversight Coordinator:
                If
                the Health Plan engages in Marketing, the Health Plan shall have
                a
                designated person, qualified by training and experience, to assure
                the
                Health Plan adheres to the marketing requirements of this
                Contract.

            

    

    

    
      	 	
              h.

            	
              QI
                and UM Professional:
                The Health Plan shall have a designated person, qualified by training
                and
                experience in QI and UM and who holds the appropriate clinical
                certification and/or license.

            

    

    

    
      	 	
              i.

            	
              Grievance
                System Coordinator:
                The Health Plan shall have a designated person, qualified by training
                and
                experience, to process and resolve Appeals and Grievances and to
                be
                responsible for the Grievance
                System.

            

    

    

    
      	 	
              j.

            	
              Compliance
                Officer:
                The Health Plan shall have a designated person qualified by training
                and
                experience, to oversee a Fraud and Abuse program to prevent and detect
                potential Fraud and Abuse activities pursuant to State and federal
                rules
                and regulations.

            

    

    

    
      	 	
              k.

            	
              Case
                Management Staff:
                The Health Plan shall have sufficient Case Management Staff, qualified
                by
                training, experience and certification/licensure to conduct the Health
                Plan's Case Management functions.

            

    

    

    
      	 	
              l.

            	
              Claims/Encounter
                Manager:
                The Health Plan shall have a designated person qualified by training
                and
                experience to oversee claims and encounter submittal and processing
                and to
                ensure the accuracy, timeliness and completeness of processing payment
                and
                reporting.

            

    

    

    
      	 	
              2.

            	
              Behavioral
                Health Staff Requirements 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must name a staff member to maintain oversight responsibility
                for Behavioral Health Services and to act as a liaison to the Agency.
                

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan's Medical Director shall appoint a board certified, or
                board
                eligible, licensed psychiatrist (staff psychiatrist) to oversee the
                provision of Behavioral Health Services to Enrollees. The Health
                Plan may
                delegate this duty, by way of a written Subcontract, to a third
                party.

            

    

    

    
      	 	
              c.

            	
              The
                Agency shall review and approve the Health Plan's Behavioral Health
                Services staff and any Subcontracted Behavioral Health Care Providers
                in
                order to determine the Health Plan's compliance with all licensure
                requirements.

            

    

    

    
      	
              C.

            	
              Provider
                Contract Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all Agency procedures for Provider
                Contract
                review and approval submission. 

            

    

    

    
      	 	
              a.

            	
              All
                Provider Contracts must comply with 42 CFR 438.230.
                

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan is a capitated health plan, it shall ensure that
                all
                Providers are eligible for participation in the Medicaid program.
                If a
                Provider was involuntarily terminated from the Florida Medicaid program,
                other than for purposes of inactivity, that Provider is not considered
                an
                eligible Medicaid provider.

            

    

    

    
      	 	
              c.
                

            	
              The
                Health Plan shall not employ or contract with individuals on the
                State or
                federal exclusions list.

            

    

    

    
      	 	
              d.

            	
              No
                Provider Contract which the Health Plan enters into with respect
                to
                performance under Contract shall in any way relieve the Health Plan
                of any
                responsibility for the provision of services duties under this Contract.
                The Health Plan shall assure that all services and tasks related
                to the
                Provider Contract are performed in accordance with the terms of this
                Contract. The Health Plan shall identify in its Provider Contract
                any
                aspect of service that may be subcontracted by the
                Provider.

            

    

    

    
      	 	
              e.

            	
              All
                model Provider Contracts and amendments must be submitted by the
                Health
                Plan to the Agency for approval and the Health Plan must receive
                written
                approval by the Agency prior to
                use.

            

    

    

    
      	 	
              2.

            	
              All
                Provider Contracts and amendments executed by the Health Plan must
                be in
                writing, signed, and dated by the Health Plan and the Provider. All
                model
                and executed Provider Contracts and amendments shall meet the following
                requirements:

            

    

    

    
      	 	
              a.

            	
              Prohibit
                the Provider from seeking payment from the Enrollee for any Covered
                Services provided to the Enrollee within the terms of the
                Contract;

            

    

    

    
      	 	
              b.

            	
              Require
                the Provider to look solely to the Health Plan for compensation for
                services rendered, with the exception of nominal cost sharing, pursuant
                to
                the State Medicaid Plan and the Florida Coverages and Limitations
                Handbooks, 

            

    

    

    
      	 	
              c.

            	
              If
                there is a Health Plan physician incentive plan, include a statement
                that
                the Health Plan shall make no specific payment directly or indirectly
                under a physician incentive plan to a Provider as an inducement to
                reduce
                or limit Medically Necessary services to an Enrollee, and that all
                incentive plans shall not contain provisions which provide incentives,
                monetary or otherwise, for the withholding of Medically Necessary
                care;

            

    

    

    
      	 	
              d.

            	
              Specify
                that any contracts, agreements, or subcontracts entered into by the
                Provider for the purposes of carrying out any aspect of this Contract
                must
                include assurances that the individuals who are signing the contract,
                agreement or subcontract are so authorized and that it includes all
                the
                requirements of this Contract;

            

    

    

    
      	 	
              e.

            	
              Require
                the Provider to cooperate with the Health Plan's peer review, grievance,
                QIP and UM activities, and provide for monitoring and oversight,
                including
                monitoring of services rendered to Enrollees, by the Health Plan
                (or its
                Subcontractor) and for the Provider to provide assurance that all
                licensed
                Providers are Credentialed in accordance with the Health Plan’s and the
                Agency’s Credentialing requirements as found in Section VIII.A.3.h
                Credentialing and Recredentialing, of this Contract, if the Health
                Plan
                has delegated the Credentialing to a
                Subcontractor;

            

    

    

    
      	 	
              f.

            	
              Include
                provisions for the immediate transfer to another PCP or Health Plan
                if the
                Enrollee's health or safety is in
                jeopardy;

            

    

    

    
      	 	
              g.

            	
              Not
                prohibit a Provider from discussing treatment or non-treatment options
                with Enrollees that may not reflect the Health Plan's position or
                may not
                be covered by the Health Plan;

            

    

    

    
      	 	
              h.

            	
              Not
                prohibit a Provider from acting within the lawful scope of practice,
                from
                advising or advocating on behalf of an Enrollee for the Enrollee's
                health
                status, medical care, or treatment or non-treatment options, including
                any
                alternative treatments that might be
                self-administered;

            

    

    

    
      	 	
              i.

            	
              Not
                prohibit a Provider from advocating on behalf of the Enrollee in
                any
                Grievance System or UM process, or individual authorization process
                to
                obtain necessary health care
                services;

            

    

    

    
      	 	
              j.

            	
              Require
                Providers to meet appointment waiting time standards pursuant to
                this
                Contract;

            

    

    

    
      	 	
              k.

            	
              Provide
                for continuity of treatment in the event a Provider Contract terminates
                during the course of an Enrollee's treatment by that
                Provider;

            

    

    

    
      	 	
              l.

            	
              Prohibit
                discrimination with respect to participation, reimbursement, or
                indemnification of any Provider who is acting within the scope of
                his or
                her license or certification under applicable State law, solely on
                the
                basis of such license or certification. This provision should not
                be
                construed as a willing Provider law, as it does not prohibit the
                Health
                Plan from limiting provider participation to the extent necessary
                to meet
                the needs of the Enrollees. This provision does not interfere with
                measures established by the Health Plan that are designed to maintain
                quality and control costs;

            

    

    

    
      	 	
              m.

            	
              Prohibit
                discrimination against Providers serving high-risk populations or
                those
                that specialize in conditions requiring costly
                treatments;

            

    

    

    
      	 	
              n.

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

            

    

    

    
      	 	
              o.

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

            

    

    

    
      	 	
              p.

            	
              Specify
                that DHHS, the Agency, MPI and MFCU, shall have the right to inspect,
                evaluate, and audit all of the following related to this
                Contract:

            

    

    

    
      	 	
              (1)

            	
              Pertinent
                books, 

            

    

    

    
      	 	
              (2)

            	
              Financial
                records, 

            

    

    

    
      	 	
              (3)

            	
              Medical
                Records, and

            

    

    

    
      	 	
              (4)

            	
              Documents,
                papers, and records of any Provider involving financial
                transactions;

            

    

    

    
      	 	
              q.

            	
              Specify
                Covered Services and populations to be served under the Provider
                Contract;

            

    

    

    
      	 	
              r.

            	
              Require
                that Providers comply with the Health Plan's cultural competency
                plan;

            

    

    

    
      	 	
              s.

            	
              Require
                that any marketing materials related to this Contract that are distributed
                by the Provider be submitted to the Agency for written approval before
                use;

            

    

    

    
      	 	
              t.

            	
              Provide
                for submission of all reports and clinical information required by
                the
                Health Plan, including Child Health Check-Up reporting (if
                applicable);

            

    

    

    
      	 	
              u.

            	
              Require
                Providers of transitioning Enrollees to cooperate in all respects
                with
                providers of other Health Plans to assure maximum health outcomes
                for
                Enrollees;

            

    

    

    
      	 	
              v.

            	
              Require
                Providers to submit notice of withdrawal from the network at least
                ninety
                (90) Calendar Days prior to the effective date of such
                withdrawal;

            

    

    

    
      	 	
              w.

            	
              Require
                that all Providers agreeing to participate in the network as PCPs
                fully
                accept and agree to perform the Case Management responsibilities
                and
                duties associated with the PCP
                designation;

            

    

    

    
      	 	
              x.

            	
              Require
                all Providers to notify the Health Plan in the event of a lapse in
                general
                liability or medical malpractice insurance, or if assets fall below
                the
                amount necessary for licensure under Florida Statutes;
                

            

    

    

    
      	 	
              y.

            	
              Require
                Providers to offer hours of operation that are no less than the hours
                of
                operation offered to commercial HMO members or comparable Medicaid
                FFS
                Recipients if the Provider serves only Medicaid
                Recipients.

            

    

    

    
      	 	
              z.

            	
              Require
                safeguarding of information about Enrollees according to 42 CFR,
                Part
                438.224.

            

    

    

    
      	 	
              aa.

            	
              Require
                compliance with HIPAA privacy and security
                provisions.

            

    

    

    
      	 	
              bb.

            	
              Require
                an exculpatory clause, which survives Provider agreement termination,
                including breach of Provider Contract due to insolvency, that assures
                that
                Medicaid Recipients nor the Agency shall be held liable for any debts
                of
                the Provider. 

            

    

    

    
      	 	
              cc.

            	
              Contain
                a clause indemnifying, defending and holding the Agency and the Health
                Plan’s Enrollees harmless from and against all claims, damages, causes
                of
                action, costs or expense, including court costs and reasonable attorney
                fees to the extent proximately caused by any negligent act or other
                wrongful conduct arising from the Provider Contract:
                

            

    

    

    
      	 	
              (1)

            	
              This
                clause must survive the termination of the Provider Contract, including
                breach due to Insolvency, and 

            

    

    

    
      	 	
              (2)

            	
              The
                Agency may waive this requirement for itself, but not Health Plan
                Enrollees, for damages in excess of the statutory cap on damages
                for
                public entities if the Provider is a public health entity with statutory
                immunity (all such waivers must be approved in writing by the
                Agency);

            

    

    

    
      	 	
              dd.

            	
              Require
                that the Provider secure and maintain during the life of the Provider
                Contract worker's compensation insurance (complying with the Florida's
                Worker's Compensation Law) for all of its employees connected with
                the
                work under this Contract unless such employees are covered by the
                protection afforded by the Health
                Plan;

            

    

    

    
      	 	
              ee.

            	
              Make
                provisions for a waiver of those terms of the Provider Contract,
                which, as
                they pertain to Medicaid Recipients, are in conflict with the
                specifications of this Contract; 

            

    

    

    
      	ff.  	
              Contain
                no provision that in any way prohibits or restricts the Provider
                from
                entering into a commercial contract with any other health plan (see
                Section 641.315, F.S.);

            

    

    

    
      	gg.  	
              Contain
                no provision requiring the Provider to contract for more than one
                (1) HMO
                product or otherwise be excluded (see Section 641.315, F.S.);
                and

            

    

    

    
      	hh.  	
              Contain
                no provision that prohibits the Provider from providing inpatient
                services
                in a contracted Hospital to an Enrollee if such services are determined
                to
                be Medically Necessary and Covered Services under this
                Contract;

            

    

    

    
      	 	
              ii.

            	
              Require
                all Providers to apply for a National Provider Identification number
                (NPI)
                no later than May 1, 2007. Providers can obtain their NPIs through
                the
                National Plan and Provider Enumerator System located at: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
                Additionally, the Provider Contract shall require the Provider to
                submit
                all NPIs for its physicians and other health care providers to the
                Health
                Plan within fifteen (15) Business Days of receipt. The Health Plan
                shall
                report the Providers’ NPIs as part of its Provider Network Report, in a
                manner to be determined by the Agency, and in its Provider Directory,
                to
                the Agency or its Choice Counselor/Enrollment Broker, as set forth
                in
                Section XII, Reporting
                Requirements.

            

    

    

    (1) The
      Health Plan need not obtain an NPI from the following Providers:

    

    
      	 	
              (a)

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

            

    

    

    
      	 	
              (b)

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

            

    

    

    
      	 	
              jj.

            	
              Require
                Providers to cooperate fully in any investigation by the Agency,
                Medicaid
                Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU), or
                any
                subsequent legal action that may result from such an
                investigation.

            

    

    

    
      	
              D.

            	
              Provider
                Termination 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all State and federal laws regarding
                Provider termination. In its Provider contracts, the Health Plan
                shall:

            

    

    

    
      	 	
              a.

            	
              Specify
                that in addition to any other right to terminate the Provider contract,
                and not withstanding any other provision of this Contract, the Agency
                or
                the Health Plan may request immediate termination of a Provider contract
                if, as determined by the Agency, a Provider fails to abide by the
                terms
                and conditions of the Provider contract, or in the sole discretion
                of the
                Agency, the Provider fails to come into compliance with the Provider
                contract within fifteen (15) Calendar Days after receipt of notice
                from
                the Health Plan specifying such failure and requesting such Provider
                abide
                by the terms and conditions thereof;
                and

            

    

    

    
      	 	
              b.

            	
              Specify
                that any Provider whose participation is terminated pursuant to the
                Provider Contract for any reason shall utilize the applicable appeals
                procedures outlined in the Provider Contract. No additional or separate
                right of appeal to the Agency or the Health Plan is created as a
                result of
                the Health Plan's act of terminating, or decision to terminate any
                Provider under this Contract. Notwithstanding the termination of
                the
                Provider Contract with respect to any particular Provider, this Contract
                shall remain in full force and effect with respect to all other Providers;
                and

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall notify the Agency at least ninety (90) Calendar
                Days
                prior to the effective date of the suspension, termination, or withdrawal
                of a Provider from participation in the Health Plan network. If the
                termination was for "Cause" the Health Plan shall provide to the
                Agency
                the reasons for termination; and

            

    

    

    
      	 	
              3.

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

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall provide sixty (60) Calendar Days’ advance written notice
                to the Provider before canceling, without cause, the Contract with
                the
                Provider, except in a case in which a patient's health is subject
                to
                imminent danger or a physician's ability to practice medicine is
                effectively impaired by an action by the Board of Medicine or other
                governmental Agency, in which case notification shall be provided
                to the
                Agency immediately. A copy of the notice shall be submitted simultaneously
                to the Agency.

            

    

    

    
      	
              E.

            	
              Provider
                Services

            

    

    

    
      	 	
              1.

            	
              General
                Provisions

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall provide sufficient information to all Providers
                in order
                to operate in full compliance with this Contract and all applicable
                federal and State laws and regulations.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall monitor Provider knowledge and understanding of
                Provider
                requirements, and take corrective actions to ensure compliance with
                such
                requirements.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall submit to the Agency for written approval all materials
                and information to be distributed and/or made available to
                Providers.

            

    

    

    
      	 	
              2.

            	
              Provider
                Handbooks

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall develop and issue a Provider Handbook to all Providers
                at the time the Provider Contract is signed. The Health Plan may
                choose
                not to distribute the Provider Handbook via Surface Mail, provided
                it
                submits a written notification to all Providers that explains how
                to
                obtain the Provider Handbook from the Health Plan’s website. This
                notification shall also detail how the Provider can request a hard-copy
                from the Health Plan at no charge to the Provider. All Provider Handbooks
                and bulletins shall be in compliance with State and federal laws.
                The
                Provider Handbook shall serve as a source of information regarding
                Health
                Plan Covered Services, policies and procedures, statutes, regulations,
                telephone access and special requirements to ensure all Contract
                requirements are met. At a minimum, the Provider Handbook shall include
                the following information:

            

    

    

    
      	 	
              (1)

            	
              Description
                of the program;

            

    

    

    
      	 	
              (2)

            	
              Covered
                Services;

            

    

    

    
      	 	
              (3)

            	
              Emergency
                Service responsibilities;

            

    

    

    
      	 	
              (4)

            	
              Child
                Health Check-Up program services and
                standards;

            

    

    

    
      	 	
              (5)

            	
              Policies
                and procedures that cover the Provider complaint system. This information
                shall include, but not be limited to, specific instructions regarding
                how
                to contact the Health Plan’s Provider services to file a Provider
                complaint and which individual(s) has/have the authority to review
                a
                Provider complaint;

            

    

    

    
      	 	
              (6)

            	
              Information
                about the Grievance System, the timeframes and requirements, the
                availability of assistance in filing, the toll-free numbers and the
                Enrollee’s right to request continuation of Benefits while utilizing the
                Grievance System;

            

    

    

    
      	 	
              (7)

            	
              Medical
                Necessity standards and practice guidelines;

            

    

    

    
      	 	
              (8)

            	
              Practice
                protocols, including guidelines pertaining to the treatment of chronic
                and
                complex conditions;

            

    

    

    
      	 	
              (9)

            	
              PCP
                responsibilities;

            

    

    

    
      	 	
              (10)

            	
              Other
                Provider or Subcontractor
                responsibilities;

            

    

    

    
      	 	
              (11)

            	
              Prior
                Authorization and referral
                procedures;

            

    

    

    
      	 	
              (12)

            	
              Medical
                Records standards;

            

    

    

    
      	 	
              (13)

            	
              Claims
                submission protocols and standards, including instructions and all
                information necessary for a clean or complete
                claim;

            

    

    

    
      	 	
              (14)

            	
              Notice
                that Provider complaints regarding claims payment should be sent
                to the
                Health Plan;

            

    

     

    
      	 	
              (15)

            	
              The
                Health Plan’s cultural competency
                plan;

            

    

    

    
      	 	
              (16)

            	
              Enrollee
                rights and responsibilities (see 42 CFR 438.100); and
                

            

    

    

    
      	 	
              (17)

            	
              The
                Health Plan shall disseminate bulletins as needed to incorporate
                any
                needed changes to the Provider
                Handbook.

            

    

    

    
      	 	
              3.

            	
              Education
                and Training

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall offer training to all Providers and their staff
                regarding the requirements of this Contract and special needs of
                Enrollees. The Health Plan shall conduct initial training within
                thirty
                (30) Calendar Days of placing a newly contracted Provider, or Provider
                group, on active status. The Health Plan shall also conduct ongoing
                training, as deemed necessary by the Health Plan or the Agency, in
                order
                to ensure compliance with program standards and this
                Contract.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall submit the Provider training manual and training
                schedule to the Agency for written approval.

            

    

    

    
      	 	
              4.

            	
              Provider
                Relations

            

    

    

    The
      Health Plan shall establish and maintain a formal Provider relations function
      to
      timely and adequately respond to inquiries, questions and concerns from network
      Providers. The Health Plan shall implement policies addressing the compliance
      of
      Providers with the requirements of this Contract, institute a mechanism for
      Provider dispute resolution and execute a formal system of terminating Providers
      from the Health Plan’s network.

    

    
      	 	
              5.

            	
              Toll-free
                Provider Telephone Help
                Line

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall operate a toll-free telephone help line to respond
                to
                Provider questions, comments and inquiries.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall develop telephone help line policies and procedures
                that
                address staffing, personnel, hours of operation, access and response
                standards, monitoring of calls via recording or other means, and
                compliance with standards. 

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan shall submit these telephone help line policies and
                procedures, including performance standards, to the Agency for written
                approval. 

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan’s call center systems shall have the capability to track call
                management metrics identified in Section IV.A.7., Toll-free Enrollee
                Help
                Line.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall staff the telephone help line twenty-four (24)
                hours a
                day, seven (7) days a week to respond to Prior Authorization requests.
                The
                Health Plan shall staff the telephone help line so that the Health
                Plan
                can respond to Provider questions in all other areas, including the
                Provider complaint system, Provider responsibilities, etc., between
                the
                hours of 8:00 am and 7:00 pm EST or EDT as appropriate, Monday through
                Friday, excluding State holidays.

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall develop performance standards and monitor telephone
                help
                line performance by recording calls and employing other monitoring
                activities. All performance standards shall be submitted to the Agency
                for
                written approval. 

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall ensure that after regular business hours the Provider
                services line (not the Prior Authorization line) is answered by an
                automated system with the capability to provide callers with information
                about operating hours and instructions about how to verify Enrollment
                for
                an Enrollee with an Emergency or Urgent Medical Condition. The requirement
                that the Health Plan shall provide information to providers about
                how to
                verify Enrollment for an Enrollee with an Emergency or Urgent Medical
                Condition shall not be construed to mean that the provider must obtain
                verification before providing Emergency Services and
                Care.

            

    

    

    
      	 	
              6.

            	
              Provider
                Complaint System 

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall submit its Provider complaint system policies and
                procedures to the Agency for written
                approval.

            

    

     

    
      	 	
              c.

            	
              The
                Health Plan shall include its Provider complaint system policies
                and
                procedures in its Provider handbook as described
                above.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall also distribute the Provider complaint system policies
                and procedures to out of network providers upon written or oral request.
                The Health Plan may distribute a summary of these policies and procedures,
                if the summary includes information about how the provider may access
                the
                full policies and procedures on the Health Plan’s Web site. This summary
                shall also detail how the provider can request a hard-copy from the
                Health
                Plan at no charge to the provider.

            

    

    

    
      	 	
              e.

            	
              As
                a part of the Provider complaint system, the Health Plan
                shall:

            

    

    

    
      	 	
              (1)

            	
              Allow
                providers forty-five (45) Calendar Days to file a written
                complaint;

            

    

    

    
      	 	
              (2)

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

            

    

    

    
      	 	
              (3)

            	
              Identify
                a staff person specifically designated to receive and process provider
                complaints; 

            

    

    

    
      	 	
              (4)

            	
              Thoroughly
                investigate each provider complaint using applicable statutory,
                regulatory, Contractual and Provider contract provisions, collecting
                all
                pertinent facts from all parties and applying the Health Plan’s written
                policies and procedures; and

            

    

    

    
      	 	
              (5)

            	
              Ensure
                that Health Plan executives with the authority to require corrective
                action are involved in the provider complaint
                process.

            

    

    

    
      	 	
              f.

            	
              In
                the event the outcome of the review of the provider complaint is
                adverse
                to the provider, the Health Plan shall provide a written notice of
                adverse
                action to the provider.

            

    

    

    
      	 	
              g.

            	
              The
                Health Plan shall ensure that claims are processed and comply with
                the
                federal and State requirements set forth in 42 CFR 447.45 and 447.46
                and
                Chapter 641, F.S., whichever is more stringent.

            

    

    

    
      	
              F.

            	
              Medical
                Records Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall maintain Medical Records for each Enrollee in accordance
                with this Section. Medical Records shall include the quality, quantity,
                appropriateness, and timeliness of services performed under this
                Contract.

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must include/follow the Medical Record standards set
                forth
                below for each Enrollee's Medical Records, as
                appropriate:

            

    

    

    
      	 	
              (1)

            	
              The
                Enrollee’s identifying information, including name, Enrollee
                identification number, date of birth, sex and legal guardianship
                (if
                any);

            

    

    

    
      	 	
              (2)

            	
              Each
                record must be legible and maintained in
                detail;

            

    

    

    
      	 	
              (3)

            	
              A
                summary of significant surgical procedures, past and current diagnoses
                or
                problems, allergies, untoward reactions to drugs and current
                medications;

            

    

    

    
      	 	
              (4)

            	
              All
                entries must be dated and signed by the appropriate
                party;

            

    

    

    
      	 	
              (5)

            	
              All
                entries must indicate the chief complaint or purpose of the visit,
                the
                objective, diagnoses, medical findings or impression of the
                provider;

            

    

    

    
      	 	
              (6)

            	
              All
                entries must indicate studies ordered (e.g., laboratory, x-ray, EKG)
                and
                referral reports;

            

    

    

    
      	 	
              (7)

            	
              All
                entries must indicate therapies administered and
                prescribed;

            

    

    

    
      	 	
              (8)

            	
              All
                entries must include the name and profession of the provider rendering
                services (e.g., MD, DO, OD), including the signature or initials
                of the
                provider;

            

    

    

    
      	 	
              (9)

            	
              All
                entries must include the disposition, recommendations, instructions
                to the
                Enrollee, evidence of whether there was follow-up and outcome of
                services;

            

    

    

    
      	 	
              (10)

            	
              All
                records must contain an immunization
                history;

            

    

    

    
      	 	
              (11)

            	
              All
                records must contain information relating to the Enrollee’s use of tobacco
                products and alcohol/substance
                abuse;

            

    

    

    
      	 	
              (12)

            	
              All
                records must contain summaries of all Emergency Services and Care
                and
                Hospital discharges with appropriate medically indicated follow
                up;

            

    

    

    
      	 	
              (13)

            	
              Documentation
                of referral services in Enrollees' Medical
                Records;

            

    

    

    
      	 	
              (14)

            	
              All
                services provided by providers. Such services must include, but not
                necessarily be limited to, family planning services, preventive services
                and services for the treatment of sexually transmitted
                diseases;

            

    

    

    
      	 	
              (15)

            	
              All
                records must reflect the primary language spoken by the Enrollee
                and any
                translation needs of the Enrollee;

            

    

    

    
      	 	
              (16)

            	
              All
                records must identify Enrollees needing communication assistance
                in the
                delivery of health care services;
                and

            

    

    

    
      	 	
              (17)

            	
              All
                records must contain documentation that the Enrollee was provided
                with
                written information concerning the Enrollee’s rights regarding Advance
                Directives (written instructions for living will or power of attorney)
                and
                whether or not the Enrollee has executed an Advance Directive. Neither
                the
                Health Plan, nor any of its Providers shall, as a condition of treatment,
                require the Enrollee to execute or waive an Advance Directive. The
                Health
                Plan must maintain written policies and procedures for Advance
                Directives.

            

    

    

    
      	 	
              b.

            	
              Confidentiality
                of Medical Records

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have a policy to ensure the confidentiality of
                Medical
                Records in accordance with 42 CFR, Part 431, Subpart F. This policy
                shall
                also include confidentiality of a minor’s consultation, examination, and
                treatment for a sexually transmissible disease in accordance with
                section
                384.30(2), F.S.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall have a policy to ensure compliance with the Privacy
                and
                Security provisions of the Health Insurance Portability and Accountability
                Act (HIPAA).

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall maintain a behavioral health Medical Record for
                each
                Enrollee. Each Enrollee's behavioral health Medical Record shall
                include:

            

    

    

    
      	 	
              a.

            	
              Documentation
                sufficient to disclose the quality, quantity, appropriateness and
                timeliness of Behavioral Health Services
                performed;

            

    

    

    
      	 	
              b.

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

            

    

    

    
      	 	
              c.

            	
              For
                each service provided, clear identification as
                to:

            

    

    

    
      	 	
              (1)

            	
              The
                physician or other service provider;

            

    

    

    
      	 	
              (2)

            	
              Date
                of service;

            

    

    

    
      	 	
              (3)

            	
              The
                units of service provided; and

            

    

    

    
      	 	
              (4)

            	
              The
                type of service provided.

            

    

    

    
      	
              G.

            	
              Claims
                Payment

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall reimburse providers for the delivery of authorized
                services pursuant to Section 641.3155 F.S., including, but not limited
                to:

            

    

    

    
      	 	
              a.

            	
              Claims
                are considered received on the date the claims are received by the
                Health
                Plan at its designated claims receipt
                location.

            

    

    

    
      	 	
              b.

            	
              The
                provider must mail or electronically transfer (submit) the claim
                to the
                Health Plan within six (6) months
                of:

            

    

    

    
      	 	
              (1)

            	
              The
                date of service or discharge from an inpatient setting;
                or

            

    

    

    
      	 	
              (2)

            	
              The
                provider has been furnished with the correct name and address of
                the
                Enrollee’s Health Plan.

            

    

    

    
      	 	
              c.

            	
              When
                the Health Plan is the secondary payor, the provider must submit
                the claim
                to the Health Plan within ninety (90) days of the final determination
                of
                the primary payor.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall reimburse providers for Medicare deductibles and
                co-insurance payments for Medicare dually eligible members according
                to
                the lesser of the following:

            

    

    

    
      	 	
              a.

            	
              The
                rate negotiated with the provider;
                or

            

    

    

    
      	 	
              b.

            	
              The
                reimbursement amount as stipulated in Section 409.908
                F.S.

            

    

    

    
      	 	
              3.

            	
              In
                accordance with Section 409.912 F.S., the Health Plan shall reimburse
                any
                Hospital or physician that is outside the Health Plan’s authorized
                geographic service area for Health Plan authorized services provided
                by
                the Hospital or physician to
                Enrollees:

            

    

    

    
      	 	
              a.

            	
              At
                a rate negotiated with the Hospital or physician;
                or

            

    

    

    
      	 	
              b.

            	
              The
                lesser of the following:

            

    

    

    
      	 	
              (1)

            	
              The
                usual and customary charge made to the general public by the Hospital
                or
                physician; or

            

    

    

    
      	 	
              (2)

            	
              The
                Florida Medicaid reimbursement rate established for the Hospital
                or
                physician.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall have a process for handling and addressing the
                resolution of provider complaints concerning claims issues. The process
                shall be in compliance with Section 641 .3155
                F.S.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall have claims processing and payment performance
                metrics
                including those for quality, accuracy and timeliness and include
                a process
                for measurement and monitoring, and for the development and implementation
                of interventions for improvement. These metrics must be approved
                in
                writing by the Agency.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall ensure that claims are processed and payment systems
                comply with the federal and State requirements set forth in 42 CFR
                447.45,
                42 CFR 447.46, and Chapter 641, F.S., as
                applicable.

            

    

    

    
      	
              H.

            	
              Encounter
                Data 

            

    

    

    
      	 	
              1.

            	
              The
                Agency is developing a Medicaid Encounter Data System (MEDS) to collect
                all encounter data from health plans reimbursed on a capitated basis.
                Encounter data collection will be required from all Florida capitated
                health plans for all health care services rendered to its members.
                

            

    

    

    
      	 	
              2.

            	
              The
                information required to support encounter reporting and submission
                will be
                defined by the Agency in the MEDS Companion Guide and MEDS Operations
                Manual. Other information contained within the MEDS Companion Guide
                and
                MEDS Operations Manual will be Managed Care Organization testing
                requirements for SFY 06-07 and thereafter. The Companion Guide and
                Operations Manual will be distributed to Health Plans in a manner
                that
                makes them easily accessible. 

            

    

    

    
      	 	
              3.

            	
              Upon
                the request of the Agency, Health Plans shall be prepared to submit
                encounter data to the Agency or its designee. Health Plans shall
                have a
                comprehensive automated and integrated Encounter Data System that
                is
                capable of meeting the requirements listed
                below:

            

    

    

    
      	 	
              a.

            	
              All
                encounters shall be submitted in the standard HIPAA transaction formats,
                namely the ANSI X12N 837 Transaction formats (P - Professional, I
                -
                Institutional, and D - Dental), and the National Council for Prescription
                Drug Programs NCPDP format (for Pharmacy
                services).

            

    

    

    
      	 	
              b.

            	
              Health
                Plans shall collect and submit to the Agency or its designee, enrollee
                service level encounter data for all covered services. Health Plans
                will
                be held responsible for errors or noncompliance resulting from their
                own
                actions or the actions of an agent authorized to act on their
                behalf.

            

    

    

    
      	 	
              c.

            	
              Health
                Plans shall have the capability to convert all information that enters
                their claims systems via hard copy paper claims to encounter data
                to be
                submitted in the appropriate HIPAA compliant
                formats.

            

    

    

    d. Complete
      and accurate encounters shall be provided to the Agency. Health Plans will
      implement review procedures to validate encounter data submitted by providers.
      The historical encounter data submission shall be retained for a period not
      less
      than five years following generally accepted retention guidelines. 

    

    
      	 	
              e.

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

            

    

    

    
      	 	
              f.

            	
              Health
                Plans will designate sufficient IT and staffing resources to perform
                these
                encounter functions as determined by generally accepted best industry
                practices. 

            

    

    

    
      	
              I.

            	
              Fraud
                Prevention

            

    

    

    
      	1.  	
              The
                Health Plan shall establish functions and activities governing program
                integrity in order to reduce the incidence of Fraud and Abuse and
                shall
                comply with all State and federal program integrity requirements,
                including the applicable provisions of 42 CFR 438.608, 42 CFR 455(a)(2),
                Chapters 358, 414, 641 and 932, F.S. and Sections 409.912 (21) and
                (22),
                F.S. 

            

    

    

    
      	2.  	
              The
                Health Plan shall designate a compliance officer with sufficient
                experience in health care, who shall have the responsibility and
                authority
                for carrying out the provisions of the Fraud and Abuse policies and
                procedures. The Health Plan shall have adequate staffing and resources
                to
                investigate unusual incidents and develop and implement corrective
                action
                plans to assist the Health Plan in preventing and detecting potential
                Fraud and Abuse activities.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall have internal controls and policies and procedures
                in
                place that are designed to prevent, detect and report known or suspected
                Fraud and Abuse activities.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall submit its Fraud and Abuse policies and procedures
                to
                the Bureau of Managed Health Care (BMHC) for written approval before
                implementation. At a minimum, the Health Plan’s Fraud and Abuse policies
                and procedures shall:

            

    

    

    
      	 	
              a.

            	
              Ensure
                that all officers, directors, managers and employees know and understand
                the provisions of the Health Plan’s Fraud and Abuse policies and
                procedures;

            

    

    

    
      	 	
              b.

            	
              Include
                procedures designed to prevent and detect potential or suspected
                abuse and
                fraud in the administration and delivery of services under this Contract.
                Nothing in this Contract shall require that the Health Plan assure
                that
                non-participating providers are compliant with this Contract or State
                and/or federal law, but the Health Plan is responsible for reporting
                suspected abuse and fraud by non-participating providers when detected,
                in
                accordance with the Health Plan’s policies and procedures.
                

            

    

    

    
      	 	
              c.

            	
              Incorporate
                a description of the specific controls in place for prevention and
                detection of potential or suspected Fraud and Abuse, including, but
                not
                limited to:

            

    

    

    
      	 	
              (1)

            	
              Claims
                edits;

            

    

    

    
      	 	
              (2)

            	
              Post-processing
                review of claims;

            

    

    

    
      	 	
              (3)

            	
              Provider
                profiling and credentialing, including a review process for claims
                that
                shall include Providers and non-participating
                providers:

            

    

    

    
      	 	
              (a)

            	
              Who
                consistently demonstrate a pattern of submitting falsified encounter
                or
                service reports;

            

    

    

    
      	 	
              (b)

            	
              Who
                consistently demonstrate a pattern of overstated reports or up-coded
                levels of service;

            

    

    

    
      	 	
              (c)

            	
              Who
                alter, falsify or destroy clinical record
                documentation;

            

    

    

    
      	 	
              (d)

            	
              Who
                make false statements relating to
                credentials;

            

    

    

    
      	 	
              (e)

            	
              Who
                misrepresent medical information to justify Enrollee
                referrals;

            

    

    

    
      	 	
              (f)

            	
              Who
                fail to render Medically Necessary Covered Services that they are
                obligated to provide according to their Provider contracts;
                and

            

    

    

    
      	 	
              (g)

            	
              Who
                charge Enrollees for Covered
                Services.

            

    

    

    
      	 	
              (4)

            	
              Prior
                Authorization;

            

    

    

    
      	 	
              (5)

            	
              Utilization
                Management;

            

    

    

    
      	 	
              (6)

            	
              Relevant
                Subcontract and Provider contract provisions;
                and

            

    

    

    
      	 	
              (7)

            	
              Pertinent
                provisions from the Provider handbook and the Enrollee
                handbook.

            

    

    

    
      	 	
              d.

            	
              Contain
                provisions for the confidential reporting of Health Plan violations
                to the
                Health Plan’s analyst with the Bureau of Managed Health Care, MPI and
                MFCU;

            

    

    

    
      	 	
              e.

            	
              Include
                provisions for the investigation and follow-up of any
                reports;

            

    

    

    
      	 	
              f.

            	
              Ensure
                that the identities of individuals reporting acts of Fraud and Abuse
                are
                protected;

            

    

    

    
      	 	
              g.

            	
              Require
                all instances of provider or Enrollee Fraud and Abuse under State
                and/or
                federal law be reported to the Health Plan's analyst with the Bureau
                of
                Managed Health Care and MPI. The Health Plan shall not cease an
                investigation or resolve the suspicion, knowledge or action without
                first
                informing the Agency and MPI. Additionally, any final resolution
                must
                include a written statement that provides notice to the provider
                or
                enrollee that the resolution in no way binds the State of Florida
                nor
                precludes the State of Florida from taking further action for the
                circumstances that brought rise to the
                matter;

            

    

    

    
      	 	
              h.

            	
              The
                Health Plan and all Providers, upon request, and as required by State
                and/or federal law, shall:

            

    

    

    
      	 	
              (1)

            	
              Make
                available to the Agency, MPI and/or MFCU any and all administrative,
                financial and Medical Records relating to the delivery of items or
                services for which Medicaid monies are expended;
                and

            

    

    

    
      	(2)  	
              Allow
                access to the Agency, MPI and/or MFCU to any place of business and
                all
                Medical Records, as required by State and/or federal law. The Agency,
                MPI
                and MFCU shall have access during normal business hours, except under
                special circumstances when the Agency, MPI and MFCU shall have after
                hour
                admission. The Agency, MPI and/or MFCU shall determine the need for
                special circumstances.

            

    

    

    
      	 	
              i.

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

            

    

    

    
      	 	
              j.

            	
              Ensure
                that the Health Plan does not retaliate against any individual who
                reports
                violations of the Health Plan’s Fraud and Abuse policies and procedures or
                suspected Fraud and Abuse.

            

    

    

    
      	 	
              k.

            	
              The
                Health Plan shall provide for the use of the List of Excluded Individuals
                and Entities (LEIE), or its equivalent, to identify excluded parties
                during the process of an engaging the services of new Providers to
                ensure
                that the Providers are not in a nonpayment status or sanctioned from
                participation in federal health care programs. The Health Plan shall
                not
                engage the services of a provider if that provider is in nonpayment
                status
                or is excluded from participation in federal health care programs
                under
                Sections 1128 and 1128A of the Social Security Act. The Health Plan
                shall
                not employ or contract the services of excluded Providers and must
                terminate the Provider contract immediately between the Health Plan
                and a
                Provider that becomes an excluded
                provider.

            

    

    

    
      	 	
              5.

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

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall meet with the Agency periodically, at the Agency’s
                request, to discuss Fraud, Abuse, Neglect and Overpayment issues.
                For
                purpose of this Section, the Health Plan Compliance Officer shall
                be the
                point of contact for the Health Plan and the Agency’s Medicaid Fraud and
                Abuse Liaison shall be the point of contact for the
                Agency.

            

    

    

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    Section
      XI

     

    Information
      Management and Systems 

     

    

     

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

            	
              Systems
                Functions.
                The Health Plan shall have Information management processes and
                Information Systems that enable it to meet Agency and federal reporting
                requirements and other Contract requirements and that are in compliance
                with this Contract and all applicable State and federal laws, rules
                and
                regulations, including HIPAA.

            

    

    

    
      	 	
              2.

            	
              Systems
                Capacity.
                The Health Plan’s Systems shall possess capacity sufficient to handle the
                workload projected for the begin date of operations and will be scaleable
                and flexible so they can be adapted as needed, within negotiated
                timeframes, in response to changes in Contract requirements, increases
                in
                Enrollment estimates, etc. 

            

    

    

    
      	 	
              3.

            	
              E-Mail
                System.
                The Health Plan shall provide a continuously available electronic
                mail
                communication link (E-mail system) with the Agency. This system shall
                be:
                

            

    

    

    
      	 	
              a.

            	
              Available
                from the workstations of the designated Health Plan contacts;
                and

            

    

    

    
      	 	
              b.

            	
              Capable
                of attaching and sending documents created using software products
                other
                than Health Plan’s systems, including the Agency’s currently installed
                version of Microsoft Office and any subsequent upgrades as
                adopted.

            

    

    

    
      	 	
              4.

            	
              Participation
                in Information Systems Work Groups/Committees.
                The Health Plan shall meet as requested by the Agency, to coordinate
                activities and develop cohesive systems strategies across vendors
                and
                agencies. 

            

    

    

    
      	 	
              5.

            	
              Connectivity
                to the Agency/State Network and Systems.
                The Health Plan shall be responsible for establishing connectivity
                to the
                Agency’s/State’s wide area data communications network, and the relevant
                information systems attached to this network, in accordance with
                all
                applicable Agency and/or State policies, standards and guidelines.
                

            

    

    

    
      	
              B.

            	
              Data
                and Document Management
                Requirements

            

    

    

    
      	 	
              1.

            	
              Adherence
                to Data and Document Management Standards
                

            

    

    

    
      	a.  	
              The
                Health Plan’s Systems shall conform to the standard transaction code sets
                specified in Section XI.I. 

            

    

    

    
      	b.  	
              The
                Health Plan’s Systems shall conform to HIPAA standards for data and
                document management that are currently under development within one
                hundred twenty (120) Calendar Days of the standard’s effective date or, if
                earlier, the date stipulated by CMS or the
                Agency.

            

    

    

    
      	c.  	
              The
                Health Plan shall partner with the Agency in the management of standard
                transaction code sets specific to the Agency. Furthermore, the Health
                Plan
                shall partner with the Agency in the development and implementation
                planning of future standard code sets not specific to HIPAA or other
                federal efforts and shall conform to these standards as stipulated
                in the
                plan to implement the standards. 

            

    

    

    
      	 	
              2.

            	
              Data
                Model and Accessibility.
                Health Plan Systems shall be Structured Query Language (SQL) and/or
                Open
                Database Connectivity (ODBC) compliant. Alternatively, the Health’s Plan
                Systems shall employ a relational data model in the architecture
                of its
                databases in addition to a relational database management system
                (RDBMS)
                to operate and maintain them.

            

    

    

    
      	 	
              3.

            	
              Data
                and Document Relationships.
                The Health Plan shall house indexed images of documents used by Enrollees
                and providers to transact with the Health Plan in the appropriate
                database(s) and document management systems so as to maintain the
                logical
                relationships between certain documents and certain
                data.

            

    

     

    
      	 	
              4.

            	
              Information
                Retention.
                Information in the Health Plan’s Systems shall be maintained in electronic
                form for three (3) years in live Systems and, for audit and reporting
                purposes, for five (5) years in live and/or archival
                Systems.

            

    

    

    
      	 	
              5.

            	
              Information
                Ownership.
                All Information, whether data or documents, and reports that contain
                or
                make references to said Information, involving or arising out of
                this
                Contract is owned by the Agency. The Health Plan is expressly prohibited
                from sharing or publishing the Agency information and reports without
                the
                prior written consent of the Agency. In the event of a dispute regarding
                the sharing or publishing of information and reports, the Agency’s
                decision on this matter shall be final and not subject to change.
                

            

    

    

    
      	
              C.

            	
              System
                and Data Integration
                Requirements

            

    

    
      	 	
              1.

            	
              Adherence
                to Standards for Data Exchange

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan’s Systems shall be able to transmit, receive and process data
                in HIPAA-compliant formats that are in use as of the Contract execution
                date; these formats are detailed in Section
                XI.J.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan’s Systems shall be able to transmit, receive and process data
                in the Agency-specific formats and/or methods that are in use on
                the
                Contract execution date, as specified in Section
                XI.J.

            

    

    

    
      	 	
              c.

            	
              Health
                Plan Systems shall conform to future federal and/or Agency specific
                standards for data exchange within one hundred twenty (120) Calendar
                Days
                of the standard’s effective date or, if earlier, the date stipulated by
                CMS or the Agency. The Health Plan shall partner with the Agency
                in the
                management of current and future data exchange formats and methods
                and in
                the development and implementation planning of future data exchange
                methods not specific to HIPAA or other Federal effort. Furthermore,
                the
                Health Plan shall conform to these standards as stipulated in the
                plan to
                implement such standards.

            

    

    

    
      	 	
              2.

            	
              HIPAA
                Compliance Checker

            

    

    

    All
      HIPAA-conforming exchanges of data between the Agency and the Health Plan shall
      be subjected to the highest level of compliance as measured using an
      industry-standard HIPAA compliance checker application.

    

    

    
      	 	
              3.

            	
              Data
                and Report Validity and
                Completeness

            

    

    

    The
      Health Plan shall institute processes to ensure the validity and completeness
      of
      the data, including reports, it submits to the Agency. At its discretion, the
      Agency will conduct general data validity and completeness audits using
      industry-accepted statistical sampling methods. Data elements that will be
      audited include but are not limited to: Enrollee ID, date of service, assigned
      Medicaid Provider ID, category and sub category (if applicable) of service,
      diagnosis codes, procedure codes, revenue codes, date of claim processing,
      and
      (if and when applicable) date of claim payment. Control totals shall also be
      reviewed and verified.

    

    
      	 	
              4.

            	
              State/Agency
                Website/Portal Integration

            

    

    

    Where
      deemed that the Health Plan’s Web presence will be incorporated to any degree to
      the Agency’s or the State’s Web presence (also known as a portal), the Health
      Plan shall conform to any applicable Agency or State standard for Website
      structure, coding and presentation. 

    

    
      	 	
              5.

            	
              Connectivity
                to and Compatibility/Interoperability with Agency Systems and IT
                Infrastructure. 

            

    

    

    The
      Health Plan shall be responsible for establishing connectivity to the
      Agency’s/State’s wide area data communications network, and the relevant
      information systems attached to this network, in accordance with all applicable
      Agency and/or State policies, standards and guidelines.

    

    
      	 	
              6.

            	
              Functional
                Redundancy with FMMIS. 

            

    

    

    The
      Health Plan’s Systems shall be able to transmit and receive transaction data to
      and from FMMIS as required for the appropriate processing of claims and any
      other transaction that could be performed by either System. 

    

    
      	 	
              7.

            	
              Data
                Exchange in Support of the Agency’s Program Integrity and Compliance
                Functions. 

            

    

    

    The
      Health Plan’s System(s) shall be capable of generating files in the prescribed
      formats for upload into Agency Systems used specifically for program integrity
      and compliance purposes.

    

    
      	 	
              8.

            	
              Address
                Standardization. 

            

    

    

    The
      Health Plan’s System(s) shall possess mailing address standardization
      functionality in accordance with US Postal Service conventions.

    

    9. Eligibility
      and Enrollment Data Exchange Requirements

    

    
      	a.  	
              The
                Health Plan shall receive, process and update enrollment files sent
                daily
                by the Agency or its Agent.

            

    

    

    
      	b.  	
              The
                Health Plan shall update its eligibility/Enrollment databases within
                twenty-four (24) hours of receipt of said files.
                

            

    

    

    
      	c.  	
              The
                Health Plan shall transmit to the Agency or its Agent, in a periodicity
                schedule, format and data exchange method to be determined by the
                Agency,
                specific data it may garner from an Enrollee including third party
                liability data.

            

    

    

    
      	d.  	
              The
                Health Plan shall be capable of uniquely identifying a distinct Medicaid
                Recipient across multiple Systems within its Span of
                Control.

            

    

    

    
      	
              D.

            	
              Systems
                Availability, Performance and Problem Management
                Requirements

            

    

    
      	 	 	 

    

    1. Availability
      of Critical Systems Functions

    

    The
      Health Plan shall ensure that critical systems functions available to Enrollees
      and providers, functions that if unavailable would have an immediate detrimental
      impact on Enrollees and providers, are available twenty-four (24) hours a day,
      seven (7) days a week, except during periods of scheduled System Unavailability
      agreed upon by the Agency and the Health Plan. Unavailability caused by events
      outside of a Health Plan’s Span of Control is outside the scope of this
      requirement. The Health Plan shall make the Agency aware of the nature and
      availability of these functions prior to extending access to these functions
      to
      Enrollees and/or providers.

    

    2. Availability
      of Data Exchange Functions 

    

    The
      Health Plan shall ensure that the systems and processes within its Span of
      Control associated with its data exchanges with the Agency and/or its Agent(s)
      are available and operational according to specifications and the data exchange
      schedule. 

    

    3. Availability
      of Other Systems Functions 

    

    The
      Health Plan shall ensure that at a minimum all other System functions and
      Information are available to the applicable System users between the hours
      of
      7:00 a.m. and 7:00 p.m., EST or EDT as appropriate, Monday through Friday.
      

    

    4. Problem
      Notification

    

    
      	a.  	
              Upon
                discovery of any problem within its Span of Control that may jeopardize
                or
                is jeopardizing the availability and performance of all Systems functions
                and the availability of information in said Systems, including any
                problems impacting scheduled exchanges of data between the Health
                Plan and
                the Agency and/or its Agent(s), the Health Plan shall notify the
                applicable Agency staff via phone, fax and/or electronic mail within
                fifteen (15) minutes of such discovery. In its notification the Health
                Plan shall explain in detail the impact to critical path processes
                such as
                enrollment management and claims submission
                processes.

            

    

    

    
      	b.  	
              The
                Health Plan shall provide to appropriate Agency staff information
                on
                System Unavailability events, as well as status updates on problem
                resolution. At a minimum these up-dates shall be provided on an hourly
                basis and made available via electronic mail and/or telephone.
                

            

    

    

    5. Recovery
      from Unscheduled System Unavailability

    

    Unscheduled
      System unavailability caused by the failure of systems and telecommunications
      technologies within the Health Plan’s Span of Control will be resolved, and the
      restoration of services implemented, within forty-eight (48) hours of the
      official declaration of System Unavailability. 

     

    6. Exceptions
      to System Availability Requirement 

    

    The
      Health Plan shall not be responsible for the availability and performance of
      systems and IT infrastructure technologies outside of the Health Plan’s Span of
      Control. 

    

    7. Corrective
      Action Plan 

    

    Full
      written documentation, that includes a Corrective Action Plan, that describes
      how problems with critical Systems functions will be prevented from occurring
      again, shall be delivered within five (5) Business Days of the System
      Unavailability/problem’s occurrence.

    

    8. Business
      Continuity-Disaster Recovery (BC-DR) Plan 

    

    
      	 	
              a.

            	
              Regardless
                of the architecture of its Systems, the Health Plan shall develop,
                and be
                continually ready to invoke, a business continuity and disaster recovery
                (BC-DR) plan that is reviewed and prior-approved by the Agency.
                

            

    

    

    
      	 	
              b.

            	
              At
                a minimum the Health Plan’s BC-DR plan shall address the following
                scenarios: (1) the central computer installation and resident software
                are
                destroyed or damaged; (2) System interruption or failure resulting
                from
                network, operating hardware, software, or operational errors that
                compromise the integrity of transactions that are active in a live
                system
                at the time of the outage; (3) System interruption or failure resulting
                from network, operating hardware, software or operational errors
                that
                compromise the integrity of data maintained in a live or archival
                system;
                (4) System interruption or failure resulting from network, operating
                hardware, software or operational errors that do not compromise the
                integrity of transactions or data maintained in a live or archival
                system,
                but does prevent access to the System, i.e. causes unscheduled System
                Unavailability.

            

    

    
      	c.  	
              The
                Health Plan shall periodically, but no less than annually, perform
                comprehensive tests of its BC-DR plan through simulated disasters
                and
                lower level failures in order to demonstrate to the Agency that it
                can
                restore System functions per the standards outlined elsewhere in
                this
                Section of the Contract.

            

    

    

    
      	d.  	
              In
                the event that the Health Plan fails to demonstrate in the tests
                of its
                BC-DR plan that it can restore system functions per the standards
                outlined
                in this Contract, the Health Plan shall be required to submit to
                the
                Agency a Corrective Action Plan in accordance with Section XIV, Sanctions,
                that describes how the failure will be resolved. The Corrective Action
                Plan shall be delivered within ten (10) Business Days of the conclusion
                of
                the test.

            

    

    

    E. System
      Testing and Change Management Requirements 

    

    1. Notification
      and Discussion of Potential System Changes.
      

    

    The
      Health Plan shall notify the applicable Agency staff person of the following
      changes to Systems within its Span of Control within at least ninety (90)
      Calendar Days of the projected date of the change; if so directed by the Agency,
      the Health Plan shall discuss the proposed change with the applicable Agency
      staff: (1) software release updates of core transaction Systems: claims
      processing, eligibility and Enrollment processing, service authorization
      management, Provider enrollment and data management; (2) conversions of core
      transaction management Systems. 

    

    
      	 	
              2.

            	
              Response
                to Agency Reports of Systems Problems not Resulting in System
                Unavailability.
                

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall respond to Agency reports of System problems not
                resulting in System Unavailability according to the following timeframes:
                

            

    

    

    
      	 	
              (1)

            	
              Within
                seven (7) Calendar Days of receipt, the Health Plan shall respond
                in
                writing to notices of system problems.

            

    

    

    
      	 	
              (2)

            	
              Within
                twenty (20) Calendar Days, the correction will be made or a Requirements
                Analysis and Specifications document will be due.
                

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan will correct the deficiency by an effective date to be
                determined by the Agency. 

            

    

    

    3. Valid
      Window for Certain System Changes.
      

    

    Unless
      otherwise agreed to in advance by the Agency as part of the activities described
      in this Section, scheduled System Unavailability to perform System maintenance,
      repair and/or upgrade activities shall not take place during hours that could
      compromise or prevent critical business operations. 

    

    4. Testing

    

    
      	a.  	
              The
                Health Plan shall work with the Agency pertaining to any testing
                initiative as required by the Agency.

            

    

    

    
      	b.  	
              Upon
                the Agency’s written request, the Health Plan shall provide details of the
                test regions and environments of its core production Information
                Systems,
                including a live demonstration, to enable the Agency to corroborate
                the
                readiness of the Health Plan’s Information Systems.
                

            

    

    

    F. Information
      Systems Documentation Requirements 

    

    1. Types
      of Documentation

    

    The
      Health Plan shall develop, prepare, print, maintain, produce, and distribute
      distinct System Process and Procedure Manuals, User Manuals and Quick/Reference
      Guides, and any updates thereafter, for the Agency and other applicable Agency
      staff.

    

    2. Content
      of System Process and Procedure Manuals

    

    The
      Health Plan shall ensure that written System Process and Procedure Manuals
      document and describe all manual and automated system procedures for its
      information management processes and Information Systems. 

    

    
      	 	
              3.

            	
              Content
                of System User Manuals 

            

    

    

    The
      System User Manuals shall contain information about, and instructions for,
      using
      applicable System functions and accessing applicable system data. 

    

    
      	 	
              4.

            	
              Changes
                to Manuals

            

    

    

    
      	a.  	
              When
                a System change is subject to the Agency’s written approval, the Health
                Plan shall draft revisions to the appropriate manuals prior to Agency
                approval of the change. 

            

    

    

    
      	b.  	
              Updates
                to the electronic version of these manuals shall occur in real time;
                updates to the printed version of these manuals shall occur within
                ten
                (10) Business Days of the update taking
                effect.

            

    

    

    
      	 	
              5.

            	
              Availability
                of/Access to Documentation

            

    

    

    All
      of
      the aforementioned manuals and reference guides shall be available in printed
      form and/or on-line. If so prescribed, the manuals will be published in
      accordance with the appropriate Agency and/or State standard. 

    

    
      	
              G.

            	
              Reporting
                Requirements - Specific to Information Management and Systems Functions
                and Capabilities - and Technological Capabilities 

            

    

    

    
      	 	
              1.

            	
              Reporting
                Requirements. 

            

    

    

    If
      the
      Health Plan is extending access to “critical systems functions” to providers and
      Enrollees as described in Section XI.D.1., above, it shall submit a monthly
      Systems Availability and Performance Report to the Agency as described in
      Section XII, Reporting Requirements, otherwise this reporting requirement is
      not
      applicable.

    

    2. Reporting
      Capabilities.

    

    The
      Health Plan shall provide Systems-based capabilities, such as a data warehouse,
      that enables authorized Agency personnel, or the Agency’s Agent, on a secure and
      read-only basis, to build and generate reports for management use.

    

    
      	
              H.

            	
              Other
                Requirements

            

    

    

    
      	 	
              1.

            	
              Community
                Health Record/Electronic Medical Record and
                Related Efforts 

            

    

    

    
      	 	
              a.

            	
              At
                such times that the Agency requires, the Health Plan shall participate
                and
                cooperate with the Agency to implement, within a reasonable timeframe,
                a
                secure, Web-accessible, Community Health Records for
                Enrollees.

            

    

    

    
      	 	
              b.

            	
              The
                design of the vehicle(s) for accessing the Community Health Record,
                the
                health record format and design shall comply with all HIPAA and related
                regulations.

            

    

    

    
      	 	
              c.

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

            

    

    

    
      	
              I.

            	
              Compliance
                with Standard Coding
                Schemes

            

    

    

    1. Compliance
      with HIPAA-Based Code Sets. 

    

    
      	 	
              a.

            	
              A
                Health Plan System that is required to or otherwise contain the applicable
                data type shall conform to the following HIPAA-based standard code
                sets;
                the processes through which the data are generated should conform
                to the
                same standards as needed: 

            

    

    

    
      	 	
              (1)

            	
              Logical
                Observation Identifier Names and Codes
                (LOINC);

            

    

    

    
      	 	
              (2)

            	
              Health
                Care Financing Administration Common Procedural Coding System
                (HCPCS);

            

    

    

    
      	 	
              (3)

            	
              Home
                Infusion EDI Coalition (HEIC) Product
                Codes;

            

    

    

    
      	 	
              (4)

            	
              National
                Drug Code (NDC);

            

    

    

    
      	 	
              (5)

            	
              National
                Council for Prescription Drug Programs
                (NCPDP);

            

    

    

    
      	 	
              (6)

            	
              International
                Classification of Diseases (ICD-9);

            

    

    

    
      	 	
              (7)

            	
              Diagnosis
                Related Group (DRG);

            

    

    

    
      	 	
              (8)

            	
              Claim
                Adjustment Reason Codes; and

            

    

    

    
      	 	
              (9)

            	
              Remittance
                Remarks Codes.

            

    

    

    
      	 	
              2.

            	
              Compliance
                with Other Code Sets 

            

    

    

    
      	 	
              a.

            	
              A
                Health Plan System that is required to or otherwise contains the
                applicable data type shall conform to the following non-HIPAA-based
                standard code sets:

            

    

    

    
      	 	
              (1)

            	
              As
                described in all AHCA Medicaid Reimbursement Handbooks, for all "Covered
                Entities", as defined under HIPAA, and which submit transactions
                in paper
                format (non-electronic format).

            

    

    

    
      	 	
              (2)

            	
              As
                described in all AHCA Medicaid Reimbursement Handbooks for all
                "Non-covered Entities", as defined under
                HIPAA.

            

    

    

    
      	
              J.

            	
              Data
                Exchange and Formats and Methods Applicable to Health
                Plans

            

    

     

    
      	 	
              1.

            	
              HIPAA-Based
                Formatting Standards 

            

    

    

    
      	 	
              a.

            	
              Health
                Plan Systems shall conform to the following HIPAA-compliant standards
                for
                information exchange effective the first day of operations in the
                applicable service region:

            

    

    

    
      	 	
              (1)

            	
              Batch
                transaction types

            

    

    

    
      	 	
              (a)

            	
              ASC
                X12N 834 Enrollment and Audit
                Transaction

            

    

    

    
      	 	
              (b)

            	
              ASC
                X12N 835 Claims Payment Remittance Advice
                Transaction

            

    

    

    
      	 	
              (c)

            	
              ASC
                X12N 837I Institutional Claim/Encounter Transaction
                

            

    

    

    
      	 	
              (d)

            	
              ASC
                X12N 837P Professional Claim/Encounter
                Transaction

            

    

    

    
      	 	
              (e)

            	
              ASC
                X12N 837D Dental Claim/Encounter
                Transaction

            

    

    

    (f) NCPDP
      1.1 Pharmacy
      Claim/Encounter Transaction

    
      	 	 	
               

            

    

    
      	 	
              (2)

            	
              Online
                transaction types

            

    

    

    
      	 	
              (a)

            	
              ASC
                X12N 270/271 Eligibility/Benefit
                Inquiry/Response

            

    

    

    
      	 	
              (b)

            	
              ASC
                X12N 276 Claims Status Inquiry 

            

    

    

    
      	 	
              (c)

            	
              ASC
                X12N 277 Claims Status Response 

            

    

    

    
      	 	
              (d)

            	
              ASC
                X12N 278/279 Utilization Review Inquiry/Response
                

            

    

    

    
      	 	
              (e)

            	
              NCPDP
                5.1 Pharmacy Claim/Encounter
                Transaction

            

    

    

    
      	 	
              2.

            	
              Methods
                for Data Exchange

            

    

    

    The
      Health Plan and the Agency and/or its Agent shall made predominant use of Secure
      File Transfer Protocol (SFTP) and Electronic Data Interchange (EDI) in their
      exchanges of data.

     

    
      	 	
              3.

            	
              Agency-Based
                Formatting Standards and Methods 

            

    

    

    
      	 	
              a.

            	
              Health
                Plan Systems shall exchange the following data with the Agency and/or
                its
                Agent in a format to be jointly agreed upon by the Health Plan and
                the
                Agency: 

            

    

    

    
      	 	
              (1)

            	
              Provider
                network data;

            

    

    

    
      	 	
              (2)

            	
              Case
                Management fees; and

            

    

    

    
      	 	
              (3)

            	
              Administrative
                payments. 

            

    

    

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    Section
      XII

     

    Reporting
      Requirements

     

    

     

    
      	
              A.

            	
              Health
                Plan Reporting
                Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all Reporting Requirements set forth
                by the
                Agency in this Contract.

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan is responsible for assuring the accuracy, completeness,
                and
                timely submission of each report.

            

    

     

    
      	 	
              b.

            	
              The
                Health Plan’s chief executive officer (CEO), chief financial officer
                (CFO), or an individual who reports to the CEO or CFO and who has
                delegated authority to certify the Health Plan’s reports, must attest,
                based on his/her best knowledge, information, and belief, that all
                data
                submitted in conjunction with the reports and all documents requested
                by
                the Agency are accurate, truthful, and complete (see 42 CFR 438.606(a)
                and
                (b)). 

            

    

     

    
      	 	
              c.

            	
              The
                Health Plan must submit its certification at the same time it submits
                the
                certified data reports (see 42 CFR 438.606(c)).
                The
                certification page should be scanned and submitted it
                electronically.

            

    

    

    
      	 	
              d.

            	
              Before
                October 1 of each year, the Health Plan shall deliver to the Agency
                a
                certification by an Agency-approved independent auditor that the
                Performance Measure data reported for the previous calendar year
                are
                fairly and accurately presented.

            

    

    

    
      	 	
              e.

            	
              Deadlines
                for report submission referred to in this Contract specify the actual
                time
                of receipt at the Agency, not the date the file was postmarked or
                transmitted. 

            

    

    

    
      	 	
              f.

            	
              If
                a reporting due date falls on a weekend, the report shall be due
                to the
                Agency on the following Business Day.

            

    

    

    
      	 	
              g.

            	
              All
                reports filed on a quarterly basis shall be filed on a calendar year
                quarter.

            

    

    

    
      	 	
              2.

            	
              The
                Agency shall furnish the Health Plan with the appropriate reporting
                formats, templates,
                instructions, submission timetables, and technical assistance, as
                required.

            

    

    

    
      	 	
              3.

            	
              The
                Agency reserves the right to modify the Reporting Requirements, with
                a
                ninety (90) Calendar Day notice to allow the Health Plan to complete
                implementation, unless otherwise required by law.
                

            

    

    

    
      	 	
              4.

            	
              The
                Agency shall provide the Health Plan with written notification of
                any
                modifications to the Reporting Requirements.

            

    

    

    5. The
      Reporting Requirements specifications are outlined in detail below.

    

    
      	 	
              6.

            	
              If
                the Health Plan fails to submit the required reports accurately and
                within
                the timeframes specified below, the Agency shall fine or otherwise
                sanction the Health Plan in accordance with Section XIV,
                Sanctions.

            

    

    

    
      	7.  	
              The
                Health Plan must use the following naming convention for all submitted
                reports. Unless otherwise noted, each report will have an 8-digit
                file
                name, constructed as follows:

            

    

     

    
      

        
          	
                  Digit
                    1

                	
                  Report
                    Identifier

                	
                  Indicates
                    the report type. See Digit 1 Report Identifiers table
                    below.

                
	
                  Digits
                    2, 3, and 4

                	
                  Plan
                    Identifier

                	
                  Indicates
                    the specific Health Plan submitting the data by the use of three
                    (3)
                    unique alpha digits. Comports to the Health Plan identifier used
                    in
                    exchanging data with the Choice Counselor/Enrollment
                    Broker.

                
	
                  Digits
                    5 and 6

                	
                  Year

                	
                  Indicates
                    the year. For example, reports submitted in 2006 should indicate
                    06.

                
	
                  Digits
                    7 and 8

                	
                  Time
                    Period

                	
                  For
                    reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4.
                    For reports
                    submitted monthly, use the appropriate month, such as 01, 02,
                    03,
                    etc.

                

        

      

       

      

        
          	
                  Digit
                    1 Report Identifiers

                
	
                  R

                	
                  Marketing
                    Representative

                
	
                  I

                	
                  Information
                    Systems Availability

                
	
                  G

                	
                  Grievance
                    System Reporting

                
	
                  F

                	
                  Financial
                    Reporting

                
	
                  C

                	
                  Claims
                    Inventory

                
	
                  T

                	
                  Transportation

                
	
                  S

                	
                  Critical
                    Incident Summary

                
	
                  E

                	
                  Behavioral
                    Health Encounter Data

                
	
                  B

                	
                  Behavioral
                    Health Pharmacy Encounter Data

                
	
                  P

                	
                  Behavioral
                    Health Required Staff/Providers

                
	
                  O

                	
                  FARS/CFARS

                

        

      

    

     

    8. Unless
      otherwise specified, these files can be: 

    

    a. Mailed
      to
      the following address:

    

    Agency
      for Health Care Administration

    Bureau
      of
      Managed Health Care

    2727
      Mahan Drive, MS #26

    Tallahassee,
      FL 32308

    

    or

    

    
      	 	
              b.

            	
              Transmitted
                electronically to the Agency at the following
                address:

            

    

    

    MMCDATA@ahca.myflorida.com

    

    
      	 	
              c.

            	
              PHI
                information has to be submitted to the AHCA SFTP site.
                

            

    

    

    
      	 	
              9.

            	
              For
                financial reporting, the Health Plan shall complete the spreadsheets
                and
                mail the CD or DVD to the address indicated above or transmit it
                electronically to the Agency at the email address noted
                below:

            

    

    

    MMCFIN@ahca.myflorida.com

    

    
      	10.  	
              For
                Claims Inventory Summary reporting, the Health Plan shall complete
                the
                template and mail the CD or DVD to the address indicated above or
                transmit
                it electronically to the Agency at the e-mail address noted
                below:

            

    

    

    MMCCLMS@ahca.myflorida.com

    

    

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              Table
                1

            
	
              SUMMARY
                OF REPORTING REQUIREMENTS

            
	
              Health
                Plan Reports Required by AHCA

            
	
              Report

            	
              Specific
                Data Elements

            	
              Format

            	
              Frequency
                Requirements

            	
              Submit
                to:

            
	
              Suspected
                Fraud Reporting

            	
              See
                Section X.J.

            	
              Narrative

            	
              Immediately
                upon occurrence

            	
              Electronic
                mail to Bureau of Managed Health Care and MPI 

            
	
              Critical
                Incidents

            	
              See
                Section XII.F.

            	
              Code
                15 Report

            	
              Immediately
                upon occurrence

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

            
	
              Enrollment/Disenrollment

            	
              See
                Section XII.B.

            	
              Enrollee
                Level as needed

            	
              First
                Thursday of the Month

            	
              File
                Transfer Protocol (FTP) to the Agency or its Agent via a secure Internet
                site

            
	
              Provider
                Network Report

              (***REFPROVYYYYMMDD.dat)

            	
              See
                Section XII.D. Table 3

            	
              Fixed
                record length ASCII flat file (.dat)

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

            	
              FTP
                to Choice Counselor vendor

            
	
              Marketing
                Representative Report

              (R***YYMM.xls)

            	
              See
                Section XII.E. Table 4

            	
              Electronic
                template provided by the Agency

            	
              Monthly
                If
                applicable

            	
              Electronic
                mail to mmcdata@ahca.myflorida.com

            
	
              Information
                Systems Availability and Performance Report (I***YYMM.xls)

            	
              See
                Section XII.K. Table 5

            	
              Electronic
                template provided by the Agency

            	
              Monthly
                -
                If applicable

            	
              Electronic
                mail to mmcdata@ahca.myflorida.com 

            
	
              Minority
                Reporting

            	
              See
                Section XII.X.

            	
              Narrative

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

            	
              Electronic
                Mail to the Contract Manager or his/her designee

            
	
              Grievance
                System Reporting (G***YYQQ.txt)

            	
              See
                Section XII.C. Table 2

            	
              Fixed
                record length text file

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

            	
              Secure
                File Transfer Protocol (SFTP) or CD/DVD
                submission 

            

    

     

     

     

    
      	
              Behavioral
                Health Specific Reporting

            
	
               Report

            	
               Specific
                Data Elements

            	
               Format

            	
               Frequency
                Requirements

            	
               Submit
                to:

            
	
              Critical
                Incidents Individual

            	
              See
                section XII.S. Table 11-A

            	
              Electronic
                template provided by the Agency

            	
              Immediately
                upon occurrence

            	
              AHCA
                Contract Manager & designee

            
	
              Critical
                Incident Summary (S***YYMM.xls) 

            	
              See
                section XII.S. Table 11

            	
              Electronic
                template provided by the Agency

            	
              Quarterly
                -
                Due on the 15th of the month- Contains previous calendar month’s
                data

            	
              AHCA
                Contract Manager & designee via the AHCA Secure FTP
                site

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

            	
              See
                section XII.V. Table 14

            	
              Fixed
                record length text file

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

            	
              AHCA
                Contract Manager & designee via the AHCA Secure FTP
                site

            
	
              Behavioral
                Health Pharmacy Encounter Data

              (B***YYQ*.txt)

            	
              See
                section XII.W. Tables 16 and 16-A

            	
              Fixed
                record length text file

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

            	
              AHCA
                Contract Manager & designee via the AHCA Secure FTP
                site

            
	
              Required
                Staff/Providers (P***YYQQ.xls)

            	
              See
                section XII.T. Table 12

            	
              Electronic
                template provided by the Agency

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

            	
              AHCA
                Contract Manager & designee via the AHCA Secure FTP
                site

            
	
              Behavioral
                Health Services Grievance and Appeals

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

            	
              Fixed
                record length text file

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

            	
              CD/DVD
                to Contract Manager, or his/her designee, at
                HSD

            

    

     

     

    
      	
              Report

            	
              Specific
                Data Elements

            	
              Format

            	
              Frequency
                Requirements

            	
              Submit
                to:

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

            	
              See
                section XII.U. Table 13

            	
              Fixed
                record length text file

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

            	
              AHCA
                Contract Manager & designee via the AHCA Secure FTP
                site

            
	
              Enrollee
                Satisfaction Survey Summary

            	
              See
                section XII.P. Table 9

            	
              Hardcopy

            	
              Semi-annually
                -
                due 60 days after the end of the six months being reported. Also
                requires
                submission of copy of survey tool, the methodology used, and the
                results.

            	
              AHCA
                Contract Manager & designee 

            
	
              Stakeholders
                Satisfaction Survey Summary

            	
              See
                section XII.Q. Table 10

            	
              Hardcopy

            	
              Annually
                -
                due 60 days after the end of the six months being reported. Also
                requires
                submission of copy of survey tool, the methodology used, and the
                results.

            	
              AHCA
                Contract Manager & designee

            
	
              Behavioral
                Health: Annual 80/20 Expenditure Report

            	
              TBD

            	
              Electronic
                template provided by the Agency

            	
              Annually
                -
                due no later than April 1. Reporting is done for each calendar year.
                A new
                template is provided by AHCA for each reporting cycle

            	
              Electronic
                mail to mmcfin@ahca.myflorida.com
                or
                CD ROM submission 

            

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    
      	
              B.

            	
              Enrollment/Disenrollment
                Reports:

            

    

    

    1. Downloaded
      Enrollment/Disenrollment Reports

    

    
      	 	
              a.

            	
              The
                Agency or its Agent will report Enrollment/Disenrollment information
                to
                the Health Plan.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall review the Enrollment/Disenrollment reports for
                accuracy
                and will notify the Agency within three (3) Business Days of any
                discrepancies. Failure to notify the Agency of any discrepancies
                within
                three (3) Business Days shall lead
                to fines and other sanctions as detailed in Section XIV,
                Sanctions.

            

    

    

    
      	 	
              c.

            	
              The
                Enrollment/Disenrollment Reports will use HIPAA-compliant standard
                transactions. The Agency or its Agent will use the X12N 834 transaction
                for all Enrollee maintenance and reporting. The Health Plan must
                be
                capable of receiving and processing X12N 834 transactions.
                

            

    

    

    
      	 	
              d.

            	
              During
                the transition period from proprietary to standard formats, the Health
                Plan shall cooperatively participate with the Agency in the transition
                process. 

            

    

    

    2. Uploaded
      Disenrollment Reports

    

    Involuntary
      disenrollments that meet the criteria established by the Agency shall be
      submitted by the Health Plan using the X12N 834 transaction. This monthly file
      must meet the specifications outlined in the AHCA/ACS ANSI ASC X12N 834 Benefit
      Enrollment and Maintenance Florida Medicaid Companion Guide, and must be
      uploaded to the Medicaid fiscal agent’s secure Internet site. Upon 60-day
      notification from the Agency, the report format and submission requirements
      may
      change.

    

    
      	
              C.

            	
              Grievance
                System

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan shall submit the Grievance System report to the Agency
                via the
                Agency’s secure FTP server or
                CD/DVD.

            

    

    

    
      	 	
              2.

            	
              The
                report is due forty-five (45) Calendar Days following the end of
                the
                reported quarter. 

            

    

    

    
      	3.  	
              The
                Health
                Plan must
                submit the Grievance System report each quarter. If no new Grievances
                or
                Appeals have been filed with the Health
                Plan,
                or if the status of an unresolved Appeal has not changed to 'Resolved,'
                please submit one (1) record only. This record must contain the PLAN_ID
                field only, with the first 7-digits of the 9-digit Medicaid provider
                number. 

            

    

    

    
      	 	
              4.

            	
              The
                report shall contain information about Grievances and Appeals concerning
                both medical and behavioral health
                issues.

            

    

     

    

    

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    Table
      2

    Structure
      for Grievance/Appeal Reporting File

    

    

      
        	
                Field
                  Name

              	
                Length

              	
                Start
                  Column

              	
                End
                  Column

              	
                Description

              
	
                PLAN_ID

              	
                9

              	
                1

              	
                9

              	
                The
                  nine digit Medicaid provider number.

              
	
                RECIP_ID

              	
                9

              	
                10

              	
                18

              	
                The
                  Enrollee’s 9 digit Medicaid ID number

              
	
                LAST_NAME

              	
                20

              	
                19

              	
                38

              	
                The
                  Enrollee’s last name

              
	
                FIRST_NAME

              	
                10

              	
                39

              	
                48

              	
                The
                  Enrollee’s first name

              
	
                MID_INIT

              	
                1

              	
                49

              	
                49

              	
                The
                  Enrollee’s middle initial

              
	
                GRV_DATE

              	
                10

              	
                50

              	
                59

              	
                The
                  date of the grievance (MM/DD/CCYY)

              
	
                GRV_TYPE

              	
                2

              	
                60

              	
                61

              	
                1. Quality
                  of Care

                2. Access
                  to Care

                3. Emergency
                  Services

                4. Not
                  Medically Necessary

                5. Pre-Existing
                  Condition

                6. Excluded
                  Benefit

                7. Billing
                  Dispute

                8. Contract
                  Interpretation

              	
                9.
                  Enrollment/Disenrollment

                10.
                  Termination of Contract

                11.
                  Services after termination

                12.
                  Unauthorized out of plan svcs

                13.
                  Unauthorized in-plan svcs

                14.
                  Benefits available in plan

                15.
                  Experimental/ Investigational

                99.
                  Other

              
	
                APP_DATE

              	
                10

              	
                62

              	
                71

              	
                The
                  date of the appeal (MM/DD/CCYY)

              
	
                APP_ACTION

              	
                1

              	
                72

              	
                72

              	
                The
                  type of 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 time frames provided in Sec.
                  438.408(b).

                6. For
                  an Enrollee 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 Sec.
                  438.52(b)(2)(ii), to obtain services outside the
                  network.

              
	
                DISP_DATE

              	
                10

              	
                73

              	
                82

              	
                The
                  date of the Disposition (MM/DD/CCYY)

              
	
                DISP_TYPE

              	
                2

              	
                83

              	
                84

              	
                The
                  Disposition of the Appeal / Grievance:

              
	 	
                 

              	
                 

              	
                 

              	
                1. Referral
                  made to specialist

                2. PCP
                  Appointment made

                3. Bill
                  Paid

                4. Procedure
                  scheduled

                5. Reassigned
                  PCP

                6. Reassigned
                  Center

                7. Disenrolled
                  Self

                8. Disenrolled
                  by plan

              	
                9. In
                  HMO QA Review

                10. In
                  HMO Grievance System

                11. Referred
                  to Area Office

                12. Member
                  sent OLC form

                13. Lost
                  contact with member

                14. Hospitalized
                  / Institutionalized

                15. Confirmed
                  original decision

                16. Reinstated
                  in HMO

                99. Other

              
	
                DISP_STAT

              	
                1

              	
                85

              	
                85

              	
                R
                  =
                  Resolved

              	
                U
                  =
                  Unresolved

              
	 	 	
                 

              	
                 

              	
                Note:
                  Any grievance or appeal first reported as unresolved must be reported
                  again when resolved. Grievances and appeals that are resolved in
                  the
                  quarter prior to reporting should be reported for the first time
                  as
                  resolved.

              
	
                EXPED_REQ

              	
                1

              	
                86

              	
                86

              	
                Indicate
                  whether the appeal was an expedited request

                Y
                  =Yes N = No Note: This field is required for all reported
                  appeals.

              
	
                FILE_TYPE

              	
                2

              	
                87

              	
                88

              	
                Indicate
                  whether the report is related to Grievance or Appeal and a behavioral
                  health service respectively

                G
                  =
                  Grievance Report GB = Grievance Behavioral Report

                A
                  =
                  Appeal Report AB = Appeal Behavioral Report

              
	
                ORIGINATOR

              	
                1

              	
                89

              	
                89

              	
                1
                  =
                  An Enrollee

                2
                  =
                  A provider, acting on behalf of the Enrollee and with the Enrollee’s
                  written consent

              

      

    

    

    

    

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              D.

            	
              Provider
                Reporting

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit its provider directory as described in Section
                IV.A.5, Provider Directory, of this Contract, to the Agency or its
                Choice
                Counselor/Enrollment Broker at least on a monthly basis via FTP.
                The
                required file will be due the first Thursday of each
                month.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall ensure that the Provider Network Report as described
                in
                Table 3 of this Section is an electronic representation of the Health
                Plan’s complete network of Providers, not a listing of entities for whom
                the Health Plan has paid claims.

            

    

    

    
      	 	
              3.

            	
              The
                Provider Network Report shall be in an ASCII flat file and must be
                a
                complete refresh of the Health Plan’s Provider information. The file name
                will be XXX_PROVYYYYMMDD.dat
                (replacing X’s with the Health Plan’s three character approved
                abbreviation and the date the file is submitted).
                This file name may change in implementation. Plans will receive final
                instructions regarding file naming, Plan Code (see layout below),
                file
                transfers, file submission frequency and schedule and other issues
                prior
                to implementation.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan may choose to submit the Provider Network Report each
                Thursday
                of the month as needed. The files will be compiled during the following
                weekend and available for Agency and Choice Counselor/Enrollment
                Broker
                staff use on the following Monday (or workday if the Monday is a
                Holiday.)
                If a new file is not submitted, the last, good file will be used.
                This
                reporting schedule is subject to change upon notice from the
                Agency.

            

    

    

    

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

    

    

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    Table
      3

    File
      Layout for Provider Networks

    

      
        	
                Field
                  Name

              	
                Field
                  Length

              	
                Required
                  Field

              	
                Field
                  Format

              	
                Justification

              	
                Comments

              
	
                Plan
                  Code

              	
                9

              	
                X

              	
                alpha

              	
                Left
                  with leading zeros

              	
                This
                  is the 9 digit Medicaid Provider ID number specific to the county
                  of HMO/
                  operation.

              
	
                Provider
                  Type 

              	
                1

              	
                X

              	
                alpha

              	
                Left

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

                P
                  =
                  Primary Care Provider (PCP)

                I
                  =
                  Individual Practitioner other than a PCP

                B
                  =
                  Birthing Center

                T
                  =
                  Therapy

                G
                  =
                  Group Practice (includes FQHCs and RHCs)

                H
                  =
                  Hospital

                C
                  =
                  Crisis Stabilization Unit

                D
                  =
                  Dentist

                R
                  =
                  Pharmacy

                A
                  =
                  Ancillary Provider (DME providers, Home Health Care 

                Agencies,
                  etc.)

              
	
                Plan
                  Provider Number

              	
                15

              	
                X

              	
                alpha

              	
                Left
                  with leading zeros

              	
                Unique
                  number assigned to the provider by the plan.

              
	
                Group
                  Affiliation 

              	
                15

              	
                Required
                  for all groups and providers who are members of a group

              	
                alpha

              	
                Left
                  with leading zeros

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

              
	
                SSN
                  or FEIN 

              	
                9

              	
                X

              	
                alpha

              	
                Left
                  with leading zeros

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

              
	
                Provider
                  last name

              	
                30

              	
                X

              	
                alpha

              	
                Left

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

              
	
                Provider
                  first name

              	
                30

              	
                X

              	
                alpha

              	
                Left

              	
                The
                  first name of the provider, or the continuation of the name of
                  the group.
                  Please do not include provider middle name in this field. Middle
                  name
                  field has been added at the end of the file for this purpose. UPPER
                  CASE
                  ONLY PLEASE.

              
	
                Address
                  line 1

              	
                30

              	
                X

              	
                alpha

              	
                Left

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

              
	
                Address
                  line 2

              	
                30

              	 	
                alpha

              	
                Left

              	 
	
                City
                  

              	
                30

              	
                X

              	
                alpha

              	
                Left

                Left

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

              
	
                Zip
                  Code

              	
                9

              	
                X

              	
                numeric

              	
                Left
                  with trailing zeros

              	
                Physical
                  zip code location of the provider or practice. Accuracy is important,
                  since address information is one of the standard items used to
                  search for
                  providers that are located in close proximity to the member.
                  

              
	
                Phone
                  area code

              	
                3

              	 	
                numeric

              	
                Left

              	 
	
                Phone
                  number

              	
                7

              	 	
                numeric

              	
                Left

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

              
	
                Phone
                  extension

              	
                4

              	 	
                numeric

              	
                Left

              	 
	
                Sex

              	
                1

              	 	
                alpha

              	
                Left

              	
                The
                  gender of the provider. Valid values: M = male; F = Female; U =
                  Unknown

              
	
                PCP
                  Indicator 

              	
                1

              	
                X

              	
                alpha

              	
                Left

              	
                Used
                  to indicate if an individual provider is a primary care physician,
                  or for
                  the , a medical home. Valid values: P = Yes, the provider is a
                  PCP/medical
                  home; N = No, the provider is not a PCP/medical home. This field
                  should
                  not be used to note group providers as PCPs, since members must
                  be
                  assigned to specific providers, not group practices. 

              
	
                Provider
                  Limitation 

              	
                1

              	
                Required
                  if PCP Indicator = P 

              	
                alpha

              	
                Left

              	
                X
                  =
                  Accepting new patients

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

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

                P
                  =
                  Only accepting current patients

                C
                  =
                  Accepting children only

                A
                  =
                  Accepting adults only

                R
                  =
                  Refer member to HMO/ member services

                F
                  =
                  Only accepting female patients

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

              
	
                HMO//MediPass
                  Indicator 

              	
                1

              	
                X

              	
                alpha

              	
                Left

              	
                H
                  =
                  HMO/

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

              
	
                Evening
                  hours 

              	
                1

              	 	
                alpha

              	
                Left

              	
                Y
                  =
                  Yes; N = No

              
	
                Saturday
                  hours

              	
                1

              	 	
                alpha

              	
                Left

              	
                Y
                  =
                  Yes; N = No

              
	
                Age
                  restrictions

              	
                20

              	 	
                alpha

              	
                Left

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

              
	
                Primary
                  Specialty 

              	
                3

              	
                Required
                  if Provider Type = P or I

              	
                numeric

              	
                Left
                  with leading zeros

              	
                Insert
                  the 3 digit code that most closely describes

                001
                  Adolescent Medicine 002
                  Allergy

                003
                  Anesthesiology 004
                  Cardiovascular Medicine

                005
                  Dermatology 006
                  Diabetes

                007
                  Emergency Medicine 008
                  Endocrinology

                009
                  Family Practice 010
                  Gastroenterology

                011
                  General Practice 012
                  Preventative Medicine

                013
                  Geriatrics 014
                  Gynecology

                015
                  Hematology 016
                  Immunology

                017
                  Infectious Diseases 018
                  Internal Medicine

                019
                  Neonatal/Perinatal 020
                  Neoplastic Diseases

                021
                  Nephrology 022
                  Neurology

                023
                  Neurology/Children 024
                  Neuropathology

                025
                  Nutrition 026
                  Obstetrics

                027
                  OB-GYN 028
                  Occupational Medicine

                029
                  Oncology 030
                  Ophthalmology

                031
                  Otolaryngology 032
                  Pathology

                033
                  Pathology, Clinical 034
                  Pathology, Forensic

                035
                  Pediatrics 036
                  Pediatric Allergy

                037
                  Pediatric Cardiology 038
                  Pediatric Oncology &Hematology

                039
                  Pediatric Nephrology 040
                  Pharmacology

                041
                  Physical Medicine and Rehab 042
                  Psychiatry 

                043
                  Psychiatry, Child 044
                  Psychoanalysis

                045
                  Public Health 046
                  Pulmonary Diseases

                047
                  Radiology 048
                  Radiology, Diagnostic

                049
                  Radiology, Pediatric 050
                  Radiology, Therapeutic

                051
                  Rheumatology 052
                  Surgery, Abdominal

                053
                  Surgery, Cardiovascular 054
                  Surgery, Colon / Rectal

                055
                  Surgery, General 056
                  Surgery, Hand

                057
                  Surgery, Neurological 058
                  Surgery, Orthopedic

                059
                  Surgery, Pediatric 060
                  Surgery, Plastic

                061
                  Surgery, Thoracic 062
                  Surgery, Traumatic

                063
                  Surgery, Urological 064
                  Other Physician Specialty

                065
                  Maternal/Fetal 066
                  Assessment Practitioner

                067
                  Therapeutic Practitioner 068
                  Consumer Directed Care

                069
                  Medical
                  Oxygen Retailer  070
                  Adult Dentures Only

                071
                  General Dentistry 072
                  Oral Surgeon (Dentist)

                073
                  Pedodontist 074
                  Other Dentist

                075
                  Adult Primary Care Nurse Practitioner 076
                  Clinical Nurse Spec

                077
                  College Health Nurse Practitioner 078
                  Diabetic Nurse Practitioner

                079
                  Brain
                  & Spinal Injury Medicine  080
                  Family/Emergency Nurse Practitioner

                081
                  Family Planning Nurse Practitioner 082
                  Geriatric Nurse Practitioner

                083
                  Maternal/Child Family Planning Nurse Practitioner 084
                  Reg. Nurse Anesthetist

                085
                  Certified Registered Nurse Midwife 086
                  OB/GYN Nurse Practitioner

                087
                  Pediatric Neonatal  088
                  Orthodontist

                089
                  Assisted Living for the Elderly 090
                  Occupational Therapist

                091
                  Physical Therapist 092
                  Speech Therapist

                093
                  Respiratory Therapist 

                 

                100
                  Chiropractor

                101
                  Optometrist 102
                  Podiatrist

                103
                  Urologist 104
                  Hospitalist

                 

                BH1
                  Psychology, Adult BH2
                  Psychology, Child

                BH3
                  Mental Health Counselor BH4
                  Community Mental Health Center

                BH5
                  Clubhouse (TBD) 

              
	
                Specialty
                  2 

              	
                3

              	 	
                numeric

              	
                Left
                  with leading

              	
                Use
                  codes listed above.

              
	
                Specialty
                  3 

              	
                3

              	 	
                numeric

              	
                Left
                      with leading

              	
                Use
                  codes listed above.

              
	
                Language
                  1 

              	
                2

              	 	
                numeric

              	
                Left
                  with leading

              	
                01
                  = English

                02
                  = Spanish

                03
                  = Haitian Creole

                04
                  = Vietnamese

                05
                  = Cambodian

                06
                  = Russian

                07
                  = Laotian

                08
                  = Polish

                09
                  = French

                10
                  = Other

              
	
                Language
                  2 

              	
                2

              	 	
                numeric

              	 	
                Use
                  codes listed above.

              
	
                Language
                  3 

              	
                2

              	 	
                numeric

              	 	
                Use
                  codes listed above.

              
	
                Hospital
                  Affiliation 1 

              	
                9

              	 	
                numeric

              	
                Left
                  with leading zeros

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

              
	
                Hospital
                  Affiliation 2

              	
                9

              	 	
                numeric

              	
                Left
                  with leading zeros

              	
                as
                  above

              
	
                Hospital
                  Affiliation 3

              	
                9

              	 	
                numeric

              	
                Left
                  with leading zeros

              	
                as
                  above

              
	
                Hospital
                  Affiliation 4

              	
                9

              	 	
                numeric

              	
                Left
                  with leading zeros

              	
                as
                  above

              
	
                Hospital
                  Affiliation 5

              	
                9

              	 	
                numeric

              	
                Left
                  with leading zeros

              	
                as
                  above

              
	
                Wheel
                  Chair Access 

              	
                1

              	 	
                alpha

              	 	
                Indicates
                  if the provider’s office is wheelchair accessible. Use Y = Yes or N =
                  No.

              
	
                #
                  of HMO/ Members

              	
                4

              	
                X

              	
                numeric

              	
                Left
                  with leading zeros

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

              
	
                Active
                  Patient Load

              	
                4

              	
                X

              	
                numeric

              	
                Left
                  with leading zeros

              	
                Total
                  Active Patient Load, as defined in contract

              
	
                Professional
                  License Number

              	
                10

              	
                X

              	
                alpha/
                  numeric

              	 	
                Must
                  be included for all health care professionals. License number is
                  formatted
                  with up to 3 alpha characters followed by up to 7 numeric digits.
                  

              
	
                AHCA
                  Hospital ID1   

              	
                8

              	
                Required
                  if Provider Type = “H”

              	
                numeric

              	
                Left
                  with leading zeros

              	
                The
                  number assigned by the Agency to uniquely identify each specific
                  hospital
                  by physical location. Any out of state hospital for which an AHCA
                  ID is
                  not included should be designated with the pseudo-number
                  99999999.

              
	
                County
                  Health Department (CHD) Indicator

              	
                1

              	
                X

              	
                alpha

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

              
	
                Filler

              	
                47

              	
                X

              	 	 	 

      

    

    

    Trailer
      Record

    The
      trailer record is used to balance the number of records received with the number
      loaded on BESST. The data

    from
      the
      Trailer Record is not loaded on BESST.

    

    RECORD
      LENGTH: 76

    

    
      	
              Filed
                Name

            	
              Field
                Length
                

            	
              Field
                Format

            	
              Values

            
	
              Trailer
                Record Text

            	
              36

            	
              Alpha

            	
              ‘TRAILER
                RECORD DATA’

            
	
              Record
                Count

            	
              7

            	
              Numeric

            	
              Total
                number of records on file excluding
                the trailer record (right justified,
                zero filled)

            
	
              System
                Process date

            	
              8

            	
              Alpha

            	
              Mmddyyyy

            
	
              Filler

            	
              25

            	 	 

    

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

     

    
      1 The
        Agency provided the list of AHCA IDs for Hospitals to Health Plans on
        8-26-05. 

    

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Provider
      Error File Layout

    

    File
      Name

    
      	
              Provider
                Error File

            	
              XXX_PROV_ERRyyyymmdd.dat

            	
              The
                date is the day the file is made
                available.

            

    

    XXX
      = 3
      character plan identifier

    

    File
      Layout

    
      	
              Row
                #

            	
              Type

            	
              Description

            
	
              1

            	
              Text

            	
              Message
                identifying purpose of file

            
	
              2

            	
              Date

            	
              Date
                file was processed

            
	
              3

            	
              Title
                and count

            	
              Count
                of records skipped by load process

            
	
              4

            	
              Title
                and count

            	
              Count
                of records read by load process

            
	
              5

            	
              Title
                and count

            	
              Count
                of records rejected by load process

            
	
              6

            	
              Title
                and count

            	
              Count
                of records discarded by load process

            
	
              7

            	
              Count

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

            
	
              8

            	
              Blank

            	 
	
              9

            	
              Title

            	
              BAD:

            
	
              10

            	
              Blank

            	
              List
                of records skipped

            
	
              11

            	
              Title

            	
              DISCARDED

            
	
              12

            	
              Blank

            	
              List
                of records read and discarded

            
	
              13

            	
              Title

            	
              Trailer
                record

            
	
              14

            	
              Trailer
                record

            	
              Trailer
                record from provider file 

            

    

    

    Notes:
      

    

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

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

    

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

    

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

    

    File
      Example

    

    THE
      FOLLOWING ERRORS WERE FOUND IN YOUR PROVIDER FILE

    15-Feb-2006

    Total
      logical records skipped: 0

    Total
      logical records read: 5983

    Total
      logical records rejected: 0

    Total
      logical records discarded: 0

    5983
      Rows
      successfully loaded.

     

    BAD:

    

    DISCARDED:

    

    Trailer
      Record:

    TRAILER
      RECORD DATA 000598302132006 

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

     

    
      	
              E.

            	
              Marketing
                Representative Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall register each marketing representative with the
                Agency
                as outlined in Section IV, Enrollee Services and Marketing. The file
                will
                be submitted to the Agency prior to initial marketing activity to
                the
                following e-mail address: MMCDATA@ahca.myflorida.com. The Agency-supplied
                spreadsheet template must be used - Agent Registration Template.xls.
                Changes to the initial registration will be submitted immediately
                upon
                occurrence to the Agency at the following e-mail address: MMCDATA@ahca.myflorida.com.
                The Agency-supplied spreadsheet template must be used - Change in
                Agent
                Registration Template.xls. Do not change or alter the templates.
                These
                templates contain the following required data
                elements:

            

    

    

    Table
      4

    

    Required
      Information for Marketing Representative Report Template

    

    
      	
              Plan
                Information

            	
              Marketing
                Representative Information

            
	
              Plan
                Name

            	
              Last
                Name

            
	
              Address

            	
              First
                Name

            
	
              Contact
                Person

            	
              License
                Number issued by DFS

            
	
              Phone

            	
              DFS
                License Issue Date

            
	
              Fax

            	
              DFS
                License Termination Date

            
	
               

            	
              Address

            
	
               

            	
              City

            
	
               

            	
              State

            
	
               

            	
              Zip
                Code

            
	
               

            	
              Office
                Telephone

            
	
               

            	
              Cellular
                Telephone

            
	
               

            	
              Home
                Telephone

            
	
               

            	
              Last
                HMO Employer

            

    

    

    
      	 	
              2.

            	
              Agent
                Registration Template.xls Template is an Excel workbook consisting
                of
                three (3) worksheets:

            

    

    
      	§  	
              Instructions
                for the completion of the Template

            

    

    
      	§  	
              Jurat
                - health plan information

            

    

    
      	§  	
              Active
                Agents - marketing representative
                information

            

    

    

    
      	 	
              3.

            	
              Complete
                the Jurat worksheet by entering the correct information for (Plan
                Name),
                (Plan Address), (Contact Name), (Phone Number), (Fax Number) and
                the
                correct date for the month being
                reported.

            

    

    

    
      	4.  	
              Complete
                the Active Agents worksheet by entering the required information
                for all
                Marketing Representatives for the Health
                Plan.

            

    

    

    
      	5.  	
              Submit
                to the Agency. The file will be submitted to the Agency prior to
                initial
                marketing activity via electronic mail to mmcdata@ahca.myflorida.com.
                Name
                the file in the convention of R***YYMM.xls where *** is the 3-character
                plan identifier, YY is the year and MM is the month being
                reported.

            

    

    

    
      	6.  	
              The
                Agent Registration Template.xls Template is an Excel workbook consisting
                of three (3) worksheets:

            

    

    
      	§  	
              Instructions
                for the completion of the Template

            

    

    
      	§  	
              Jurat
                - health plan information

            

    

    
      	§  	
              New
                Activity - changes, additions and deletions to marketing representative
                information

            

    

    

    
      	7.  	
              Complete
                the Jurat worksheet by entering the correct information for (Plan
                Name),
                (Plan Address), (Contact Name), (Phone Number), (Fax Number) and
                the
                correct date for the month being
                reported.

            

    

    

    
      	8.  	
              Submit
                to the Agency immediately upon occurrence via electronic mail to
                mmcdata@ahca.myflorida.com. Name the file in the convention of
                R***YYMM.xls where *** is the 3-character plan identifier, YY is
                the year
                and MM is the month being reported.

            

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    
      	
              F.

            	
              Critical
                Incidents

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall report all serious Enrollee injuries occurring
                through
                health care services within 15 days of the Health Plan receiving
                information about the injury. The Health Plan will use the Florida
                Agency
                for Health Care Administration, Division of Health Quality Assurance’s
                Code 15 Report for Florida Ambulatory Surgical Centers, Hospitals
                and HMOs
                to document the incident. The Health Plan shall send the Code 15
                Report to
                the Health Plan’s analyst in the Bureau of Managed Health Care. The Health
                Plan can find the Code 15 Report
                at:

            

    

    

    www.ahca.myflorida/MCHQ/Health_Facility_Regulation/Risk/reporting

    

    
      	
              G.

            	
              Hernandez
                Settlement Agreement (HSA)
                Report

            

    

    

    
      	 	
              1.

            	
              If
                the Health Plan has authorization requirements for prescribed drug
                services, the Health Plan shall file reports biannually to the Bureau
                of
                Managed Health Care, to include the
                following:

            

    

    

    
      	 	
              a.

            	
              The
                results of the HSA survey with:

            

    

    

    
      	 	
              (1)

            	
              The
                total number of pharmacy locations
                surveyed;

            

    

    

    
      	 	
              (2)

            	
              The
                HSA areas surveyed;

            

    

    

    
      	 	
              (3)

            	
              Those
                HSA areas in which the pharmacy locations were delinquent;
                and

            

    

    

    
      	 	
              (4)

            	
              The
                process by which the Health Plan selected the pharmacy
                locations.

            

    

    

    
      	 	
              b.

            	
              A
                copy of the Health Plan’s completed Hernandez Ombudsman
                Log.

            

    

    

    
      	
              H.

            	
              Performance
                Measure Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report the performance measures described in Section
                VIII.A.3.c.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall calculate the performance measures based on the
                calendar
                year (January 1 through December 31), unless otherwise
                specified.

            

    

    

    
      	 	
              3.

            	
              The
                performance measure report is due by October 1 after the measurement
                year.

            

    

    

    
      	
              I.

            	
              Financial
                Reporting

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall complete the spreadsheet supplied by the
                Agency.

            

    

    

    
      	 	
              2.

            	
              Audited
                financial reports — The Health Plan shall submit to the Agency annual
                audited financial statements and four (4) quarterly unaudited financial
                statements.

            

    

    

    
      	 	
              a.

            	
              The
                audited financial statements are due no later than three (3) calendar
                months after the end of the Health Plan’s fiscal
                year.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall submit the quarterly unaudited financial statements
                no
                later than forty-five (45) days after each calendar quarter and shall
                use
                generally accepted accounting principles in preparing the unaudited
                quarterly financial statements, which shall include, but not be limited
                to, the following:

            

    

    

    (1) A
      Balance
      Sheet;

    

    (2) A
      Statement of Revenues and Expenses;

    

    (3) A
      Statement of Cash Flows; and 

    

    (4) Footnotes.

    

    
      	 	
              c.

            	
              The
                Health Plan shall submit the annual and quarterly financial statements
                using, an Agency-supplied template, by electronic transmission to
                the
                following e-mail address:

            

    

    

    MMCFIN@AHCA.MYFLORIDA.COM

    

    
      	 	
              d.

            	
              The
                Health Plan should mail in hard copy form (or submit to the above
                email
                address in a .PDF format) the audited financial statement along with
                a
                copy of the audited CPA report and CPA letter of opinion to:
                

            

    

    

    Agency
      for Health Care Administration

    Bureau
      of
      Managed Health Care

    Data
      Analysis Unit

    2727
      Mahan Drive, MS # 26

    Tallahassee,
      Florida 32308

    

    
      	 	
              e.

            	
              The
                Health Plan shall submit annual and quarterly financial statements
                that
                are specific to the operations of the Health Plan rather than to
                a parent
                or umbrella organization.

            

    

    

    
      	
              J.

            	
              Suspected
                Fraud Reporting

            

    

    
      	 	
              1.

            	
              Provider
                Fraud and Abuse 

            

    

    

    
      	 	
              a.

            	
              Upon
                detection of a potential or suspected fraudulent claim submitted
                by a
                provider, the Health Plan shall file a report with the Agency’s Bureau of
                Managed Health Care, MPI and MFCU.
                The report shall contain at a
                minimum:

            

    

    

    
      	 	
              (1)

            	
              The
                name of the provider;

            

    

    

    
      	 	
              (2)

            	
              The
                assigned Medicaid provider number and the tax identification
                number;

            

    

    

    
      	 	
              (3)

            	
              A
                description of the suspected fraudulent act;
                and

            

    

    

    2. Enrollee
      Fraud

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              b.

            	
              The
                report shall contain, at a minimum:

            

    

    

    (1) The
      name
      of the Enrollee,

    

    (2) The
      Enrollee’s Health Plan identification number,

    

    (3) The
      Enrollee’s Medicaid identification number,

    

    (4) A
      description of the suspected fraudulent act, and

    

    
      	 	
              3.

            	
              Failure
                to report instances of suspected Fraud and Abuse is a violation of
                law and
                subject to the penalties provided by
                law.

            

    

    

    
      	
              K.

            	
              Information
                Systems Availability and Performance
                Report

            

    

    

    
      	 	
              1.

            	
              The
                Information Systems Availability and Performance Report shall be
                submitted
                using the template provided by the Agency; the template’s layout is
                illustrated in Table 6, below.  This Report shall be submitted to the
                Agency by the Health Plan only if it extends access to “critical systems
                functions” to Providers and Enrollees as described in Section XI.D.1 of
                this Contract.  The Report shall only include “critical systems
                functions” as indicated per Section XI.D.1 of this Contract.  The
                Report shall provide total uptime, total downtime and total unscheduled
                downtime by system function for the report
                month.

            

    

    

    Table
      5

    

    Information
      Systems Availability and Performance Report

    

    
      	
              Sample
                Information Systems Availability and Performance Report Format and
                Content

            
	
              System

            	
               

            	
              Total
                Up Time

            	
              Total
                Down Time

            	
              Total
                UNSCHEDULED Down Time ("Outage Time")

            	
               

            
	
              Measurement
                Period

            	
              Up
                Time During Period

            	
              Up
                Time During Period

            	
              During
                Period

            	
              Notes/Comments

            
	
               

            	
              For
                All Measured Systems:

            	
              98.66%

            	
              1.34%

            	
               

            	
               

            
	
              system1

            	
              28
                days

            	
              02/01-02/28

            	
              94.79%

            	
              5.21%

            	
               

            	
               

            
	
              system2

            	
              28
                days

            	
              02/01-02/28

            	
              99.29%

            	
              0.71%

            	
               

            	
               

            
	
              system3

            	
              28
                days

            	
              02/01-02/28

            	
              99.42%

            	
              0.58%

            	
               

            	
               

            
	
              system4

            	
              28
                days

            	
              02/01-02/28

            	
              100.00%

            	
              0.00%

            	
               

            	
               

            
	
              system5

            	
              28
                days

            	
              02/01-02/28

            	
              96.76%

            	
              3.24%

            	
               

            	
               

            
	
              system6

            	
              28
                days

            	
              02/01-02/28

            	
              99.33%

            	
              0.67%

            	
               

            	
               

            
	
              system7

            	
              28
                days

            	
              02/01-02/28

            	
              99.39%

            	
              0.61%

            	
               

            	
               

            
	
              system8

            	
              28
                days

            	
              02/01-02/28

            	
              99.45%

            	
              0.55%

            	
               

            	
               

            
	
              system9

            	
              28
                days

            	
              02/01-02/28

            	
              98.76%

            	
              1.24%

            	
               

            	
               

            
	
              system10

            	
              28
                days

            	
              02/01-02/28

            	
              99.40%

            	
              0.60%

            	
               

            	
               

            
	
              Note:
                color scheme indicates systems which total down time that exceeded
                a
                threshold

            
	
              (e.g.
                exceeded 0.5% = light yellow; exceeded 3% = yellow; exceeded 5% =
                red).

            

    

    

    

    
      	
              L.

            	
              Claims
                Inventory Summary Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall file an Aging Claims Summary Report quarterly,
                noting
                paid, denied and unpaid claims by provider type. The Health Plan
                will
                submit this report using the CLAIMS
                AGING TEMPLATE.xls
                file supplied by the Agency and presented in Tables 6, 6-A, 6-B,
                6-C and
                6-D. This file is an Excel spreadsheet and may be submitted to the
                following email address:
                mmcclms@ahca.myflorida.com.

            

    

    

    Table
      6

    

    Total
      Claims Aging By Provider Type

    

    
      	
              00/00/00

            	 	
               

            	
              NOTE:
                List
                ALL claims including those contained in the beginning inventory on
                this
                page.

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    REMAINDER
      OF PAGE LEFT INTENTIONALLY BLANK

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      6-A

    

    Paid
      Claims Aging by Provider Type Report

    

    
      	
              00/00/00

            	 	
               

            	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    Table
      6-B

    

    Denied
      Claims Aging By Provider Type

    

    
      	
              00/00/00

            	 	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              HOSPITALS:

            	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    REMAINDER
      OF PAGE LEFT INTENTIONALLY BLANK

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      6-C

    

    Unpaid
      Claims Aging by Provider Type Report

    

    

    
      	
               

            	
              00/00/00

            	
               

            	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
              OTHER

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            

    

    

    Table
      6-D

    

    Claims
      Inventory by Provider Type

    

    

    
      	
              00/00/00

            	 	
              Inventory

            	
               

            	
               

            	
               

            
	
               

            	
              (Ending
                Inventory from Previous quarter) 

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Beginning
                

            	
              Claims

            	
               

            	
               

            	
              Ending
                

            
	
              PROVIDER

            	
              Inventory

            	
              Received

            	
              Claims
                Paid

            	
              Claims
                Denied

            	
              Inventory

            
	
              PRIMARY
                CARE

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
              SPECIALTY

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
              OTHER

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            

    

    

    REMAINDER
      OF PAGE LEFT INTENTIONALLY BLANK

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    
      	
              M.

            	
              Child
                Health Check-Up Reports

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit the Child Health Check Up, CMS 416. The
                Health
                Plan shall submit the report annually in the format set forth in
                Table 7,
                below. The reporting period is the federal fiscal year, October 1
                -
                September 30. The report is due on January 15, following the reporting
                period. The Health Plan shall submit to the Agency a certification
                by an
                Agency-approved independent auditor that the information and data
                contained in the Child Health Check-Up report is fairly and accurately
                presented before October 1 following each reporting period. This
                filing
                requires a copy of the audited reports and a copy of the auditors'
                letter
                of opinion.

            

    

    

    
      	 	
              2.

            	
              For
                each of the following line items, report total counts by the age
                groups
                indicated. In cases where calculations are necessary, perform separate
                calculations for the total column and each age group. Report age
                based
                upon the child's age as of September 30 of the federal fiscal
                year.

            

    

    

    Medicaid
      Provider ID Number:
      Enter
      the plan's seven digit Medicaid Provider ID number, i.e., 015----

    

    Plan
      Name:
      Enter
      the name of the Health Plan.

    

    Fiscal
      Year:
      Enter
      the federal fiscal year being reported. 

    

    Line
      1 - Total Individuals Eligible for Child Health Check-Up
      (CHCUP):  Enter
      the
      total unduplicated number of all Enrollees under the age of 21, distributed
      by
      age and by basis of Medicaid Eligibility category.
      Unduplicated
      means
      that an Enrollee is reported
      only once,
      although
      he or she may have had more than one period of Eligibility during the year.
      All
      Enrollees under age 21 are considered eligible for CHCUP services, regardless
      of
      whether they have been informed about the availability of CHCUP services or
      whether they accept CHCUP services at the time of informing. Do
      not count Enrollees in the MediKids populations.

    

    Line
      2a - State Periodicity Schedules
      -
      Given.

    

    Line
      2b - Number of Years in Age Group
      -
      Given.

    

    Line
      2c - Annualized State Periodicity Schedule
      -
      Given.

    

    Line
      3a - Total Months Eligibility
      - Enter
      the total months of Eligibility for the Enrollees in each age group in Line
      1
      during the reporting year.

    

    Line
      3b - Average Period of Eligibility
      -
      Pre-calculated by dividing the total months of Eligibility by Line 1, then
      by
      dividing that number by 12. This number represents the portion of the year
      that
      Enrollees remain Medicaid Eligible during the reporting year, regardless of
      whether Eligibility was maintained continuously.

    

    Line
      4 - Expected Number of Screenings per Eligible
      Multiply
      -
      Pre-calculated by multiplying Line 2c by Line 3b. This number reflects the
      expected number of initial or periodic screenings per Child/Adolescent per
      year
      based on the number required by the State-specific periodicity schedule and
      the
      average period of Eligibility.

    

    Line
      5 - Expected Number of Screenings
      -
      Pre-calculated by multiplying Line 4 by Line 1. This reflects the total number
      of initial or periodic screenings expected to be provided to the Enrollees
      in
      Line 1.

    

    Line
      6 - Total Screenings Received
      - Enter
      the total number of initial or periodic screens furnished to Enrollees. Use
      the
      CPT codes listed below or any Health Plan-specific CHCUP codes developed for
      these screens. Use of these proxy codes is for reporting purposes
      only.

    

    
      	 	
              3.

            	
              The
                Health Plan must continue to ensure that all five (5) age-appropriate
                elements of an CHCUP screen, as defined by law, are provided to CHCUP
                eligible Enrollees

            

    

    

    
      	 	
              4.

            	
              This
                number should not
                reflect sick visits or episodic visits provided to Children/Adolescents
                unless an initial or periodic screen was also performed during the
                visit.
                However, it may reflect a screen outside of the normal state periodicity
                schedule that the Plan uses as a "catch-up" CHCUP screening. The
                Agency
                defines a catch-up CHCUP screening as a complete
                screening that is provided to bring a child up-to-date with the State's
                screening periodicity schedule. The Health Plan shall use data reflecting
                date
                of service
                within the fiscal year for such screening services or other documentation
                of such services. The
                Health Plan shall not count MediKids Enrollees, who have had a
                check-up.
                The
                Health Plan shall use the following CPT-4 codes to document the receipt
                of
                an initial or periodic screen:

            

    

    

    Codes
      for Preventive Medicine Services

    

    99381
      New
      Patient Under One Year

    99382
      New
      Patient Ages 1 - 4 Years

    99383
      New
      Patient Ages 5 - 11 Years

    99384
      New
      Patient Ages 12 - 17 Years

    99385EP
      New
      Patient Ages 18 - 39 Years 

    99391
      Established Patient Under One Year

    99392
      Established Patient Ages 1 - 4 Years

    99393
      Established Patient Ages 5 - 11 Years

    99394
      Established Patient Ages 12 - 17 Years

    99395EP
      Established Patient Ages 18 - 39 Years

    99431
      Newborn
      Care - History and Examination

    99432
      Normal
      Newborn Care 

    99435
      Newborn
      Care (history and examination)

    

    Codes
      For Evaluation and Management Services
      (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
      V70.3-V70.9)

    

    99201-99205
      New
      Patient

    99211-99215
      Established
      Patient

    

    Line
      7 - Screening Ratio
      -
      Pre-calculated by dividing the actual number of initial and periodic screening
      services received (Line 6) by the expected number of initial and periodic
      screening services (Line 5). This ratio indicates the extent to which CHCUP
      eligible Enrollees receive the number of initial and periodic screening services
      required by the State's periodicity schedule, adjusted by the proportion of
      the
      year for which they are Medicaid Eligible. This
      ratio should not be over 100%. Any data submitted which exceeds 100% will be
      reflected as 100% on the final report.

    

    Line
      8 - Total Eligibles Who Should Receive at Least One (1) Initial or Periodic
      Screen-
      The
      number of Enrollees who should receive at least one (1) initial or periodic
      screen is dependent on the State's periodicity schedule. The State uses the
      following calculations to determine the number of Enrollees:

    

    
      	 	
              a.

            	
              If
                the number entered in Line 4 is greater than 1, the number 1 is used.
                If
                the number in Line 4 is less than or equal to 1, the number in Line
                4 is
                used. This eliminates situations where more than one visit is expected
                in
                any age group in a year.

            

    

    

    
      	 	
              b.

            	
              The
                number from calculation 1 is multiplied by the number in Line 1 and
                entered on Line 8.

            

    

    

    Line
      9 - Total Eligibles Receiving at Least One (1) Initial or Periodic
      Screen
      - Enter
      the unduplicated count of Enrollees who received at least one (1) documented
      initial or periodic screen during the year. Refer to codes in Line 6 and count
      Enrollees where the Health Plan have received a claim. The
      Health Plan shall not count MediKids Enrollees who have had a
      check-up.

    

    Line
      10 - Participant Ratio
      -
      Pre-Calculated by dividing Line 9 by Line 8. This ratio indicates the extent
      to
      which Enrollees are receiving any initial and periodic screening services during
      the year. NOTE:
      The
      Health Plan shall adopt annual participation goals to achieve at least an eighty
      percent (80%) CHCUP participation rate pursuant to Section 5360, Annual
      Participation Goals, of the State Medicaid Manual.

    

    Line
      11 - Total Eligibles Referred for Corrective
      Treatment
      - Enter
      the unduplicated
      number
      of Enrollees who, as a result of at least one (1) health problem identified
      during an initial or periodic screening service, including
      vision and hearing screenings,
      were
      scheduled for another appointment with the screening provider or referred to
      another provider for further needed diagnostic or treatment services. This
      element does not include correction of health problems during the course of
      a
      screening examination. This element is required. The Health Plan should include
      the new federally required referral codes in Line 11.

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

     

    
      	
              For
                reporting on the CMS-416 only count the referral codes "T" and
                "V". 
                

            
	
              U

            	
              Complete
                Normal

            
	
              Used
                when there are no referrals made.

            
	
              2

            	
              Abnormal,
                Treatment Initiated

            
	
              Used
                when a child is currently under treatment for referred diagnostic
                or
                corrective health problem.

            
	
              T

            	
              Abnormal,
                Recipient Referred

            
	
              Used
                for referrals to another provider for diagnostic or corrective treatments
                or scheduled for another appointment with check-up provider for diagnostic
                or corrective treatment

              for
                at least one (1) health problem identified during an initial check-up
                

            
	
              V

            	
              Patient
                Refused Referral

            
	
              Used
                when the patient refused a referral.

            

    

    

    
      	 	
              5.

            	
              For
                purposes of reporting information on dental services, unduplicated
                means that the Health Plan counts each child once for each
                line of data
                requested. Example: The Health Plan would count a child once on Line
                12a
                for receiving any dental service and count the child again for Line
                12b
                and/or 12c if the child received a preventive and/or treatment dental
                service. These numbers should reflect services received in managed
                care.
                Lines 12b and 12c do not
                equal total services reflected on Line
                12a.

            

    

    

    Line
      12a - Total Eligibles Receiving Any Dental
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving any
      dental
      services as defined by CDT Codes D0100 - D9999.

    

    Line
      12b - Total Eligibles Receiving Preventive Dental
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving a preventive dental service as defined by
      CDT
      Codes D1000 - D1999.

    

    Line
      12c - Total Eligibles Receiving Dental Treatment
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving treatment services as defined by CDT Codes
      D2000 - D9999.

    

    Line
      13 - Total Eligibles Enrolled in Managed Care
      - This
      number is for informational purposes only. This number represents all Enrollees
      eligible for CHCUP services, who were Enrolled at any time during the reporting
      year. The Health Plan should include these Enrollees in the total number of
      unduplicated eligibles on Line 1 and the Health Plan should include the number
      of initial or periodic screenings provided to these Enrollees in Lines 6 and
      8
      for purposes of determining the State's screening and participation rates.
      The
      Health Plan should include the number of Enrollees referred for corrective
      treatment and receiving dental services in Lines 11 and 12, respectively.
Do
      not count MediKids Enrollees.

    

    
      	 	
              6.

            	
              To
                report the number of screening blood lead tests the Health Plan shall
                do
                the following: Count the number of times CPT code 83655 ("lead")
                or any
                State-specific (local) codes used for a blood lead test reported
                with any
                ICD-9-CM except with diagnosis codes 984 (.0 - .9) ("Toxic Effects
                of Lead
                and Its Compounds"), E861.5 ("Accidental Poisoning by Petroleum Products,
                Other Solvents and Their Vapors NEC: Lead Paints"), and E866.0 (Accidental
                Poisoning by Other Unspecified Solid and Liquid Substances: Lead
                and Its
                Compounds and Fumes"). The Agency uses these specific ICD-9-CM diagnosis
                codes to identify people who are lead poisoned. The Health Plan should
                not
                count blood lead tests done on these individuals as a screening blood
                lead
                test. This
                is a federally mandated test for Enrollees ages 12 months, 24 months
                and
                between the ages of 36 - 72 months whom the Health Plan has not previously
                screened for lead
                poisoning.

            

    

    

    Line
      14 - Total Number of Screening Blood Lead Tests
      - Enter
      the total number of screening blood lead tests furnished to eligible Enrollees.
      Blood lead tests done on Enrollees who have been diagnosed or treated for lead
      poisoning should not be counted. Do not make entries in the shaded
      columns.

    

    Line
      15 - Total Number of POSITIVE Screening Blood Lead
      Tests
      - Enter
      the total number of positive blood lead tests.

    

    

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    Table
      7

    

    Child
      Health Check Up Report 

    

    

      
        	
                 

              	
                Enter
                  Data in Blue Colored Out-Lined Cells Only

              	
                CHILD
                  HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]

              
	 	
                Seven
                  Digit Medicaid Provider Number :

              	
                 

              	
                This
                  report is due to the Agency no later than January
                  15.

              
	 	
                Plan
                  Name :

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                Federal
                  Fiscal Year :

              	
                 

              	
                 

              	
                 

              	
                The
                  Audited Report is due October 1.

              
	
                 

              	
                Age
                  Groups

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                Less
                  than 1 Year

              	
                1-2
                  Years *

              	
                3-5
                  Years

              	
                6-9
                  Years

              	
                10-14
                  Years

              	
                15-18
                  Years

              	
                19-20
                  Years

              	
                Total
                  All Years

              
	
                1.

              	
                Total
                  Individuals Eligible for CHCUP (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                2a.

              	
                State
                  Periodicity Schedule

              	
                6

              	
                4

              	
                3

              	
                2

              	
                5

              	
                4

              	
                2

              	
                 

              
	
                2b.

              	
                Number
                  of Years in Age Group

              	
                1

              	
                2

              	
                3

              	
                4

              	
                5

              	
                4

              	
                2

              	
                 

              
	
                2c.

              	
                Annualized
                  State Periodicity Schedule

              	
                6.00

              	
                2.00

              	
                1.00

              	
                0.50

              	
                1.00

              	
                1.00

              	
                1.00

              	
                 

              
	
                3a.

              	
                Total
                  Months of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                3b.

              	
                Average
                  Period of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.

              	
                Expected
                  Number of screenings per Eligible

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                5.

              	
                Expected
                  Number of screenings

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.

              	
                Total
                  Screens Received

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                7.

              	
                Screening
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                8.

              	
                Total
                  Eligible who should receive at least one Initial or periodic
                  screening

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                9.

              	
                Total
                  Eligibles receiving at least one Initial or periodic screen
                  (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                10.

              	
                Participation
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                11.

              	
                Total
                  eligibles referred for corrective treatment (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12a.

              	
                Total
                  Eligibles receiving any dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12b.

              	
                Total
                  Eligibles receiving preventative dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12c.

              	
                Total
                  Eligibles receiving dental treatment services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                13.

              	
                Total
                  Eligibles Enrolled in Plan

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                14.

              	
                Total
                  number of Screening Blood Lead Tests

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                15

              	
                Total
                  number of POSITIVE Screening Blood Lead Tests

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              

      

     

    

    

    

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              7.

            	
              Florida
                Sixty Percent (60%) Ratio

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit the Child Health Check Up, CMS 416 Report
                annually and in the formats as presented in Table 7-A. The reporting
                period is the federal fiscal year. The report is due on January 1,
                following the reporting period. The Health Plan shall submit to the
                Agency
                a certification by an Agency-approved independent auditor that the
                information and data contained in the Child Health Check-Up 60% Ratio
                report is fairly and accurately reported before October 1 following
                each
                reporting period. This filing requires a copy of the audited reports
                and a
                copy of the auditors' letter of
                opinion.

            

    

    

    
      	 	
              2.

            	
              For
                each of the following line items, the Health Plan shall report total
                counts by the age groups indicated. In cases where calculations are
                necessary, the Agency has inserted formulas to pre-calculate the
                field.
                Report age based
                upon the child's age as of September 30 of the Federal fiscal
                year.

            

    

    

    Medicaid
      Provider ID Number:
      Enter
      the Health Plan's basic seven digit Medicaid Provider ID number, i.e.,
      015----

    

    Plan
      Name:
      Enter
      the name of the Health Plan.

    

    Fiscal
      Year:
      The
      federal fiscal year being reported.

    

    Line
      1 - Total Individuals Eligible for Child Health Check-Up
      (CHCUP):
      Enter
      the total unduplicated number of all Enrollees under the age of 21 Enrolled
      continuously
      for 8 months,
      distributed by age and by basis of Medicaid Eligibility.
      Unduplicated
      means
      that an Enrollee is reported
      only once
      although
      he or she may have had more than one period of Eligibility during the year.
      All
      Enrollees under age 21 (except MediKids Enrollees) are considered eligible
      for
      CHCUP services, regardless of whether they have been informed about the
      availability of CHCUP services or whether they accept CHCUP services at the
      time
      of informing. 

    

    Line
      2a - State Periodicity Schedules
      -
      Given.

    

    Line
      2b - Number of Years in Age Group
      -
      Given.

    

    Line
      2c - Annualized State Periodicity Schedule
      -
      Given.

    

    Line
      3a - Total Months Eligibility
      - Enter
      the total months of eligibility for the Enrollees in each age group in Line
      1
      during the reporting year.

    

    Line
      3b - Average Period Eligibility
      -
      Calculated by dividing the total months of eligibility by Line 1, then by
      dividing that number by 12. This number represents the portion of the year
      that
      Enrollees remain Medicaid Eligible during the reporting year, regardless of
      whether Eligibility was maintained continuously.

    

    Line
      4 - Expected Number of Screenings per Eligible
      Multiply
      -
      Calculated by multiplying Line 2c by Line 3b. This number reflects the expected
      number of initial or periodic screenings per Child/Adolescent per year based
      on
      the number required by the State-specific periodicity schedule and the average
      period of Eligibility.

    

    Line
      5 - Expected Number of Screenings
      -
      Calculated by multiplying Line 4 by Line 1. This reflects the total number
      of
      initial or periodic screenings expected to be provided to the Enrollees in
      Line
      1.

    

    Line
      6 - Total Screenings Received
      - Enter
      the total number of initial or periodic screens furnished to Enrollees. Use
      the
      CPT codes listed below or any Health Plan-specific CHCUP codes developed for
      these screens. Use
      of these proxy codes is for reporting purposes only.

    

    
      	 	
              3.

            	
              Health
                Plans must continue to ensure that all five (5) age-appropriate elements
                of an CHCUP screen, as defined by law, are provided to CHCUP eligible
                Enrollees.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall not include sick visits or episodic visits provided
                to
                Children/Adolescents in this number, unless an initial or periodic
                screen
                was also performed during the visit. However, it may reflect a screen
                outside of the normal State periodicity schedule that the Health
                Plan uses
                as a "catch-up" CHCUP screening. The Agency defines a catch-up CHCUP
                screening as a complete
                screening that is provided to bring a Child/Adolescent up-to-date
                with the
                State's screening periodicity schedule. Use data reflecting date
                of service
                within the fiscal year for such screening services or other documentation
                of such services. Do
                not count MediKids Enrollees, who have had a
                check-up. The
                Health Plan shall use the following CPT-4 codes to document the receipt
                of
                an initial or periodic screen:

            

    

    

    Codes
      for Preventive Medicine Services

    

    99381
      New
      Patient Under One Year

    99382
      New
      Patient Ages 1 - 4 Years

    99383
      New
      Patient Ages 5 - 11 Years

    99384
      New
      Patient Ages 12 - 17 Years

    99385EP
      New
      Patient Ages 18 - 39 Years

    99391
      Established Patient Under One Year

    99392
      Established Patient Ages 1 - 4 Years

    99393
      Established Patient Ages 5 - 11 Years

    99394
      Established Patient Ages 12 - 17 Years

    99395EP
      Established Patient Ages 18 - 39 Years

    99431
      Newborn
      Care - History and Examination

    99432
      Normal
      Newborn Care 

    99435
      Newborn
      Care (history and examination)

    

    Codes
      for Evaluation and Management
      (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
      V70.3-V70.9)

    

    99201-99205
      New
      Patient

    99211-99215
      Established
      Patient

    

    

    Line
      7 - Screening Ratio
      -
      Calculated by dividing the actual number of initial and periodic screening
      services received (Line 6) by the expected number of initial and periodic
      screening services (Line 5). This ratio indicates the extent to which CHCUP
      eligible Enrollees receive the number of initial and periodic screening services
      required by the State's periodicity schedule, adjusted by the proportion of
      the
      year for which they are Medicaid eligible. This
      ratio should not
      be over 100%. Any data submitted which exceeds 100% will be reflected as 100%
      on
      the final report. The goal ratio is sixty percent (60%) or higher under State
      requirements.

    

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      Table
        7-A

      Child
        Health Check Up Report

    

    

      
         

          COMPLETE
            THIS 60% TEMPLATE TO MEET THE 60% SCREENING RATIO PURSUANT TO SECTION
            409.912,
            FLORIDA STATUTES AND SECTIONS V.E.3 AND XIII, 2006-2009 MEDICAID HMO
            CONTRACT

           

          Enter
            Data in Blue Colored Out-Lined Cells ONLY - This report reflects only
            those
            eligibles that have at least 8 months of continuous enrollment -
State
            Required

          
            	
                     

                     

                  	
                    FL
                      60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP)
                      - 8 MONTHS
                      CONTINUOUS ENROLLMENT

                  

          

          
            	 	
                    Seven
                      Digit Medicaid Provider ID Number :

                  	
                     

                  	
                    The
                      unaudited report is due to the Agency no later than January
                      15.
                      The audited report is due October 1.

                  
	 	
                    Plan
                      Name :

                  	
                     

                  	
                    F.S.
                      409.912 & Section V.E.3., Medicaid HMO
                      Contract

                  
	
                     

                  	
                    Federal
                      Fiscal Year :

                  	
                    October
                      1, 2006 - September 30, 2007

                  	
                    REQUIRED
                      FILING

                  
	
                     

                  	
                    Age
                      Groups

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                    Less
                      than 1 Year

                  	
                    1-2
                      Years *

                  	
                    3-5
                      Years

                  	
                    6-9
                      Years

                  	
                    10-14
                      Years

                  	
                    15-18
                      Years

                  	
                    19-20
                      Years

                  	
                    Total
                      All Years

                  
	
                    1.

                  	
                    Total
                      Individuals Eligible for CHCUP with 8 months continuous enrollment
                      (Unduplicated)

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    2a.

                  	
                    State
                      Periodicity Schedule

                  	
                    6

                  	
                    4

                  	
                    3

                  	
                    2

                  	
                    5

                  	
                    4

                  	
                    2

                  	
                    26

                  
	
                    2b.

                  	
                    Number
                      of Years in Age Group

                  	
                    1

                  	
                    2

                  	
                    3

                  	
                    4

                  	
                    5

                  	
                    4

                  	
                    2

                  	
                    21

                  
	
                    2c.

                  	
                    Annualized
                      State Periodicity Schedule

                  	
                    6.00

                  	
                    2.00

                  	
                    1.00

                  	
                    0.50

                  	
                    1.00

                  	
                    1.00

                  	
                    1.00

                  	
                    1.24

                  
	
                    3a.

                  	
                    Total
                      Months of Eligibility

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    3b.

                  	
                    Average
                      Period of Eligibility

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.

                  	
                    Expected
                      Number of screenings per Eligible

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    5.

                  	Expected
                    Number of screenings	 	 	 	 	 	 	 	 
	
                     6.

                  	 Total
                    Screens Received	 	 	 	 	 	 	 	 
	 

                    7.

                  	 Screening
                    Ratio - F.S. 409.912 & Section V.E.3., Medicaid HMO
                    Contract	 	 	 	 	 	 	 	 

          

        

      

    

    

       

    

    

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    
      	
              N.

            	
              Pharmacy
                Encounter Data

            

    

    
      	 	
              1.

            	
              Health
                Plans shall submit pharmacy encounter data on an ongoing quarterly
                payment
                schedule. For example, all claims paid between 04/01/06 and 06/30/06
                is
                due to the Agency by 07/31/06. The Health Plan should submit the
                data
                using the following:

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must submit any claims paid during the payment period
                within
                thirty (30) days after the end of the
                quarter.

            

    

    

    b. The
      Health Plan should submit only the final adjudication of claims.

    

    
      	 	
              c.

            	
              The
                File Naming Convention is: [health plan abbreviation]_[current date]_[file
                type]_[Production]_[file#]_[total # of files].format. For example:
                ABC_07312006_Rx_Production_1_7.txt

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan must include and accompany the files with a field layout
                and
                the records must have carriage-returns and line-feeds for record/file
                separation.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan must submit all Medicaid pharmacy data via CD to the
                Bureau of
                Health Systems Development. The Health Plan shall ensure that it
                submits
                the data to the Agency timely, accurately and completely. The Health
                Plan
                must include a certification letter as to the accuracy and completeness
                of
                the information contained on the
                CD.

            

    

    

    
      	 	
              f.

            	
              At
                a minimum, the Health Plan must include the following data requirements
                -
                the Plan ID, Transaction Reference number (claim identifier), NDC
                code,
                Date of Service (CCYYMMDD), Medicaid ID as assigned by the State,
                and
                process/payment date (CCYYMMDD).

            

    

    

    
      	 	
              g.

            	
              The
                Agency anticipates changing the format to reflect the NCPDP and is
                in the
                process of developing the companion guide. The Health Plan shall
                conform
                to this change upon notification.

            

    

    

    
      	
              O.

            	
              Transportation
                Services

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report the Transportation Services encounter data
                on a
                quarterly basis as set forth below and in Tables 8 through
                8-I.

            

    

    

    a. A
      call
      log broken down by month that includes the following information:

    

    
      	 	
              (1)

            	
              Number
                of calls received;

            

    

    

    
      	 	
              (2)

            	
              Average
                time required to answer a call;

            

    

    

    
      	 	
              (3)

            	
              Number
                of abandoned calls;

            

    

    

    
      	 	
              (4)

            	
              Percentage
                of calls that are abandoned;

            

    

    

    
      	 	
              (5)

            	
              Average
                abandonment time; and

            

    

    

    
      	 	
              (6)

            	
              Average
                call time.

            

    

    

    
      	 	
              b.

            	
              A
                listing of the total number of reservations of Transportation Services
                by
                month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    (1) Ambulatory
      transportation;

    

    (2) Long
      haul
      ambulatory transportation;

    

    (3) Wheelchair
      transportation;

    

    (4) Stretcher
      transportation;

    

    (5) Ambulatory
      multiload transportation;

    

    (6) Wheelchair
      multiload transportation;

    

    (7) Mass
      transit pending transportation;

    

    (8) Mass
      transit transportation;

    

    (9) Mass
      transit transportation (Enrollee has pass); and

    

    (10) Mass
      transit transportation (sent pass to Enrollee).

    

    
      	 	
              c.

            	
              A
                listing of the total number of authorized uses of Transportation
                Services,
                by month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    
      	 	
              (1)

            	
              Ambulatory
                transportation;

            

    

    

    
      	 	
              (2)

            	
              Long
                haul ambulatory transportation;

            

    

    

    
      	 	
              (3)

            	
              Wheelchair
                transportation;

            

    

    

    
      	 	
              (4)

            	
              Stretcher
                transportation;

            

    

    

    
      	 	
              (5)

            	
              Ambulatory
                multiload transportation;

            

    

    

    
      	 	
              (6)

            	
              Wheelchair
                multiload transportation;

            

    

    

    
      	 	
              (7)

            	
              Mass
                transit pending transportation;

            

    

    

    
      	 	
              (8)

            	
              Mass
                transit transportation;

            

    

    

    
      	 	
              (9)

            	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    

    
      	 	
              (10)

            	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	 	
              d.

            	
              A
                listing of the total number of canceled trips, by month, level of
                service
                and percentage of level of service utilized, to include, but not
                be
                limited to, the following:

            

    

    

    
      	 	
              (1)

            	
              Ambulatory
                transportation;

            

    

    

    
      	 	
              (2)

            	
              Long
                haul ambulatory transportation;

            

    

    

    
      	 	
              (3)

            	
              Wheelchair
                transportation;

            

    

    

    
      	 	
              (4)

            	
              Stretcher
                transportation;

            

    

    

    
      	 	
              (5)

            	
              Ambulatory
                multiload transportation;

            

    

    

    
      	 	
              (6)

            	
              Wheelchair
                multiload transportation;

            

    

    

    
      	 	
              (7)

            	
              Mass
                transit pending transportation;

            

    

    

    
      	 	
              (8)

            	
              Mass
                transit transportation;

            

    

    

    
      	 	
              (9)

            	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    

    
      	 	
              (10)

            	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	 	
              e.

            	
              A
                listing of the total number of denied Transportation Services, by
                month,
                and a detailed description of why the Plan denied the Transportation
                Service request.

            

    

    

    
      	 	
              f.

            	
              A
                listing of the total number of authorized trips, by facility type,
                for
                each month and level of service.

            

    

    

    
      	 	
              g.

            	
              A
                listing of the total number of Transportation Service claims and
                payments,
                by facility type, for each month and level of
                service.

            

    

    

    
      	 	
              2.

            	
              Establish
                a performance measure to evaluate the safety of the Transportation
                Services provided by Participating Transportation Providers. The
                Health
                Plan shall report the results of the evaluation to the Agency on
                August
                15th of each year;

            

    

    

    
      	 	
              3.

            	
              Establish
                a performance measure to evaluate the reliability of the vehicles
                utilized
                by Participating Transportation Providers. The Health Plan shall
                report
                the results of the evaluation to the Agency on August 15th of each
                year;
                and

            

    

    

    
      	 	
              4.

            	
              Establish
                a performance measure to evaluate the quality of service provided
                by a
                Participating Transportation Provider. The Health Plan shall report
                the
                results of the evaluation to the Agency on August 15th of each
                year.

            

    

    

    
      	 	
              5.

            	
              Certification
                - Each Health Plan/Transportation Provider shall submit an annual
                safety
                and security certification in accordance with 14-90.10, F.A.C. and
                shall
                submit to any and all Safety and Security Inspections and Reviews
                in
                accordance with 14-90.12, F.A.C..

            

    

    

    
      	 	
              6.

            	
              The
                Plan shall report the following by August 15th
                of
                each year:

            

    

    

    
      	 	
              a.

            	
              The
                estimated number of one-way passenger trips the Health Plan expects
                to
                provide in the following
                categories:

            

    

    

    (1) Ambulatory
      transportation;

    

    (2) Long
      haul
      ambulatory transportation;

    

    (3) Wheelchair
      transportation;

    

    (4) Stretcher
      transportation;

    

    (5) Ambulatory
      multiload transportation;

    

    (6) Wheelchair
      multiload transportation;

    

    (7) Mass
      transit pending transportation;

    

    (8) Mass
      transit transportation;

    

    (9) Mass
      transit transportation (Enrollee has pass); and

    

    (10) Mass
      transit transportation (sent pass to Enrollee).

    

    
      	 	
              7.

            	
              The
                actual amount of funds expended and the total number of trips provided
                during the previous fiscal year;
                and

            

    

     

    
      	 	
              8.

            	
              The
                operating financial statistics for the previous fiscal
                year.

            

    

    

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    Table
      8

    

    Transportation
      Telephone Log Report

    

    
      	
              CY
                [yyyy]

            	
               

            	
              AVERAGE

            	
              NUMBER

            	
              ABANDON-

            	
              AVERAGE

            	
              AVERAGE

            
	
               

            	
              CALLS

            	
              SPEED
                TO

            	
              ABANDONED

            	
              MENT

            	
              ABANDONMENT

            	
              TALK

            
	
              MONTH

            	
              OFFERED

            	
              ANSWER

            	
              CALLS

            	
              PERCENT

            	
              TIME

            	
              TIME

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              Total

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            

    

    

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - “mm”
      refers to the month (e.g., “01” for January, etc.)

    
      -
“x:xx”
        refers to a measurement of time (e.g., “2:45” for two minutes and forty-five
        seconds or “0:59” for fifty-nine seconds

    

    - “#”
      refers to a number

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

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    Table
      8-A

    

    Non-Emergency
      Transportation Staffing Report

    

    

    
      	
              CY
                yyyy

            	
              Non-Emergency
                Transportation Operations Staffing

            	 
	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Total

            
	
              Administration

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Billing
                Verification

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Customer
                Service Representatives

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Driver
                Training & Field Investigations

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Fraud
                and Abuse

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Information
                Technology

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Ombudsman

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Quality
                Assurance 

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Regional
                Offices

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Social
                Services/Standing Order Dept.

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Transportation
                Coordinators

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Utilization
                Review

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Vehicle
                Inspectors

            	 	 	 	 	 	 	 	 	 	 	
               

            	 	 
	
              Public
                Transit Specialist

            	 	 	 	 	 	 	 	 	 	 	
               

            	 	 
	
              Total

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    

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    Table
      8-B

     

    
      	 	 	
              GROSS
                RESERVATIONS by Month by Level of Service

            	 
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr-05

            	
              May-05

            	
              Jun-05

            	
              Jul-05

            	
              Aug-05

            	
              Sep-05

            	
              Oct-05

            	
              Nov-05

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    Total
      Gross Transportations Reservations Report

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

    

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      8-C Net
      Authorized Transportation Report

     

    
      	 	 	
              NET
                AUTHORIZED TRIPS (Gross reservations less cancellations) for each
                Month by
                Level of Service

            	
               

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      8-D Canceled
      Trip Transportation Report

     

    
      	 	 	
              CANCELLED
                TRIPS for each Month by Level of Service. Please
                note that the numbers for a given month will likely increase over
                the
                ensuing month or two as additional cancellations are
                entered.

            	 
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	 	 
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Table
      8-E

    

    Transportation
      Complaint Report

    

    
      	 	 	
              COMPLAINTS
                for each Month by Complaint Type 

            
	
              CY
                yyyy

            	 	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              Region:

            	
              Complaint
                Type:

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]

            	
              Issue
                w/Health Plan

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Provider
                Late

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Issue
                with Driver

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Provider
                No Show

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Issue
                with tran. provider

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Rider
                No Show

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Injury*

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Broward
                County Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              %
                reservations complaint free

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	 
	
              Percent

            	
              Issue
                w/Health Plan

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Provider
                Late

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Issue
                with Driver

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Provider
                No Show

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Issue
                with tran. provider

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Rider
                No Show

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Injury

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100% 

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Table
      8-F

    

    Transportation
      Mileage Report

    

    
      	 	 	
              MILEAGE
                (based on Net Authorized Trips) for each MONTH and LEVEL of SERVICE:
                

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County[

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100% 

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	 	 	
              AVERAGE
                MILES PER TRIP (based on Net Authorized Trips)

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County]

            	
              Ambulatory

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Wheelchair

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Stretcher

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Ambulatory
                Multiload

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Wheelchair
                Multiload

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Mass
                Transit Has Pass

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Mass
                Transit Sent Pass

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	
              [County]
                Total

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            

    

    

    
      	
              -

            	
              “x.x”
                refers to a measurement of distance (e.g., “2.5” for two and a half miles
                or “0.9” for 9/10 of a mile)

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      8-G

    

    Denied
      Transportation Request Report

    

    
      	 	 	
              DENIED
                TRIP REQUESTS by Month and Region

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Total

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]

            	
              Abuses
                NET services

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Has
                access to vehicle

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Non-covered
                service

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Lacks
                3 days' notice

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Needs
                9-1-1

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ineligible
                for Medicaid

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ineligible
                for M'caid NET (e.g., QMB)

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Refuses
                closest facil.

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Requires
                Ambulance

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Refused
                public transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Relative
                can transport

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Resides
                outside LCI service areas

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Uncooperative/abusive

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dental
                Care 21 and Over

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Percent

            	
              Abuses
                NET services

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              for

            	
              Has
                access to vehicle

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Month

            	
              Non-covered
                service

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Lacks
                3 days' notice

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Needs
                9-1-1

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ineligible
                for Medicaid

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ineligible
                for M'caid NET (e.g., QMB)

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Refuses
                closest facil.

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Requires
                Ambulance

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Refused
                public transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Relative
                can transport

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Resides
                outside LCI service areas

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Uncooperative/abusive

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dental
                Care 21 and Over

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Table
      8-H

    

    Net
      Authorized Trip Transportation Report

    

    
      	 	 	
              NET
                AUTHORIZED TRIPS by Facility Type for each Month and Level of
                Service

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County]

            	
              Adult
                Daycare

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Assisted
                Living

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Clinic
                - Health

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Clinic
                - Specialty

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dental

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dialysis

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Doctors
                Office

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Facility

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Health
                Department

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Hospital

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Lab
                and x-ray

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mental
                Health

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mental
                Retardation

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Nursing
                Home

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Other

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Pharmacy

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Rehabilitation

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Residence

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              School

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Specialist

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Adult
                Daycare

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Assisted
                Living

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Clinic
                - Health

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Clinic
                - Specialty

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dental

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dialysis

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Doctors
                Office

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Facility

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Health
                Department

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Hospital

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Lab
                and x-ray

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mental
                Health

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mental
                Retardation

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Nursing
                Home

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Other

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Pharmacy

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Rehabilitation

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Residence

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              School

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Specialist

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      8-I

    

    Unduplicated
      Riders Transportation Report

    

    
      	
              [County]

            	
              UNDUPLICATED
                RIDERS for each Month by Level of Service

            
	
              CY
                - yyyy

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Mass
                Transit - Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Mass
                Transit - Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Mass
                Transit - Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Mass
                Transit - Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Percentage
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              P.

            	
              Enrollee
                Satisfaction Survey
                Summary

            

    

    

    
      	 	
              1.

            	
              In
                all
                Service Areas in which the Health Plan provides Behavioral Health
                Services,
                the Health Plan shall conduct a Behavioral Health Services Enrollee
                Satisfaction Survey in both English and
                Spanish.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall report the Enrollee Satisfaction Survey Summary
                to the
                Agency in accordance with the requirements set forth in Table 9,
                Enrollee
                Satisfaction Survey Summary, below.

            

    

    

    Table
      9

    

    Enrollee
      Satisfaction Survey Summary

    

    
      	
              Number
                of surveys distributed

            	 
	
              Number
                of surveys completed

            	 
	
              Method
                used 

            	 
	
              
                Number
                  of Responses for each item on the survey

              

               

            

    

    

    

      
        	
                Item
                  Numbers

              	
                Agree

              	
                Disagree

              	
                No
                  Response

              
	
                1

              	
                 

              	
                 

              	
                 

              
	
                2

              	
                 

              	
                 

              	
                 

              
	
                3

              	
                 

              	
                 

              	
                 

              
	
                4

              	
                 

              	
                 

              	
                 

              
	
                5

              	
                 

              	
                 

              	
                 

              
	
                6

              	
                 

              	
                 

              	
                 

              
	
                7

              	
                 

              	
                 

              	
                 

              
	
                8

              	
                 

              	
                 

              	
                 

              
	
                9

              	
                 

              	
                 

              	
                 

              
	
                10

              	 	 	 
	 	 	 	 
	
                Significant
                  findings or results that will be addressed: 

              
	 
	 
	 
	 
	 

      

    

    

    

    
      
        
           

        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    
      	
              Q.

            	
              Stakeholders’
                Satisfaction Survey
                Summary

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit to the Agency the results of a Stakeholders’
                Satisfaction Survey Summary in all Service Areas in which the Health
                Plan
                provides Behavioral Health Services.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall report the results from the survey in accordance
                with
                Table 10, Stakeholders’ Satisfaction Survey Summary,
                below.

            

    

    

    Table
      10

    

    Stakeholders
      Satisfaction Survey Summary

    

    
      	
              Types
                of Stakeholders Surveyed

            	
              DCF

              Counselors

            	
              Community
                Based Care Providers

            	
              Foster
                Parents

            	
              Consumer
                Advocacy Groups

            	
              Parents
                of SED Children

            	
              Out-of-Plan
                Providers (specify)

            	
              Others

            
	
               

              Number
                of Surveys Distributed

               

            	 	 	 	 	 	 	 
	
               

              Number
                of surveys completed in each type

               

            	 	 	 	 	 	 	 
	
               

              Method
                used for distribution

               

            	 	 	 	 	 	 	 

    

    

    

    
      	
              Summary
                of Responses:

               

            
	
              Significant
                findings or results that will be addressed:

               

            

    

    

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              R.

            	
              Behavioral
                Health Services Grievance and Appeals Reporting
                Requirements

            

    

    

    See
      Section XII.C. and Table 2, above, for reporting instructions.

    

    
      	
              S.

            	
              Critical
                Incident Reporting

            

    

    

    
      	 	
              a.

            	
              For
                Providers and providers under contract with DCF, the State’s operating
                procedures for incident reporting and client risk protection establishes
                departmental procedures and guidelines for reporting information
                related
                to the incidents specified in this Section. See CF Operating Procedure
                No.
                215-6, November 1, 1998.

            

    

    

    
      	 	
              b.

            	
              The
                critical incident reporting requirements set forth in this section
                do not
                replace the abuse, neglect and exploitation reporting system established
                by the State. Additionally, the Health Plan must report to the Agency
                in
                accordance with the format in Table 11, Critical Incidents Summary,
                and
                Table 11-A, Critical Incident Individual,
                below.

            

    

    

    
      	 	
              c.

            	
              The
                definitions of reportable critical incidents apply to the Health
                Plan,
                Providers (participating and non-participating) and any
                Subcontractors/delegates providing services to
                Enrollees.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall report the following events immediately to the
                Agency,
                in accordance with the format set forth in Table 11-A, Critical Incident
                Individual, below:

            

    

    

    (1) Death
      of
      an Enrollee due to one (1) of the following:

    

    (a) Suicide;

    

    (b) Homicide;

    

    (c) Abuse;

    

    (d) Neglect;
      or

    

    
      	 	
              (e)

            	
              An
                accident or other incident that occurs while the Enrollee is in a
                facility
                operated or contracted by the Health Plan or in an acute care
                facility.

            

    

    

    
      	 	
              (2)

            	
              Enrollee
                Injury or Illness - A medical condition that requires medical treatment
                by
                a licensed health care professional and which is sustained, or allegedly
                is sustained, due to an accident, act of abuse, neglect or other
                incident
                occurring while an Enrollee is in a Facility operated or contracted
                by the
                Health Plan or while the Enrollee is in an acute care
                facility.

            

    

    

    
      	 	
              (3)

            	
              Sexual
                Battery - An allegation of sexual battery, as determined by medical
                evidence or law enforcement involvement, by:

            

    

    

    (a) An
      Enrollee on another Enrollee;

    

    
      	 	
              (b)

            	
              An
                employee of the Health Plan, a provider or a Subcontractor, an Enrollee;
                and/or 

            

    

    

    
      	 	
              (c)

            	
              An
                Enrollee on an employee of the Health Plan, a provider or a
                Subcontractor.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall immediately report to the Agency, in accordance
                with the
                format in Table 11-A, Critical Incident Individual, below, if one
                (1) or
                more of the following events occur:

            

    

    

    (1) Medication
      errors in an acute care setting; and/or

    

    
      	 	
              (2)

            	
              Medication
                errors involving Children/Adolescents in the care or custody of DCF.
                

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall report quarterly to the Agency, in accordance with
                the
                format in Table 11 Critical Incidents Summary, below, a summary of
                all
                critical incidents.

            

    

    

    
      	 	
              g.

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

            

    

    

    Table
      11

    

    Critical
      Incidents Summary

    

    

      
        	
                Incident
                  Type

              	
                #
                  of Events

              
	
                Enrollee
                  Death - Suicide

              	 
	
                Enrollee
                  Death - Homicide

              	 
	
                Enrollee
                  Death - Abuse/Neglect

              	 
	
                Enrollee
                  Death - other

              	 
	
                Enrollee
                  Injury or Illness

              	 
	
                Sexual
                  Battery

              	 
	
                Medication
                  Errors - acute care

              	 
	
                Medication
                  Errors - children

              	 
	
                Enrollee
                  Suicide Attempt

              	 
	
                Altercations
                  requiring Medical Interventions

              	 
	
                Enrollee
                  Escape

              	 
	
                Enrollee
                  Elopement

              	 
	
                Other
                  reportable incidents

              	 
	
                 

                Total

              	 

      

    

    

    

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    Table
      11-A

    

    Critical
      Incident Individual

    

    
      	
               

              Enrollee
                Medicaid ID#:

            	 
	
               

              Date
                of Incident:

            	 
	
               

              Location
                of Incident:

            	 
	
               

              Critical
                Incident Type:

            	 
	
               

              Details
                of Incident: (Include
                enrollee’s age, gender, diagnosis, current medication, source of
                information, all reported details about the event, action taken by
                Health
                Plan or provider, and any other pertinent information)

            	 
	
               

              Follow
                up planned or required: (Include
                information related to any Health Plan or provider protocol that
                applies
                to event.)

            	 
	
               

              Assigned
                provider:

            	 
	
               

              Report
                submitted by:

            	 
	
               

              Date
                of submission:

            	 

    

    

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              T.

            	
              Required
                Staff/Providers

            

    

    

    The
      Health Plan shall submit contracted and subcontracted staffing information
      by
      position, name and FTE for all direct service positions on a quarterly basis
      in
      accordance with Table 12, Required Staff/Providers, below.

    

    REMAINDER
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    Table
      12

    Required
      Staff/Providers

    

    
      	
              Plan
                Name:

            	 	 	 	 	 	 	 	 
	
              Plan
                7-Digit Medicaid ID#:

            	 	 	 	 	 	 	 	 
	
              As
                of Date (3rd Month of the Qtr/Year):

            	 	 	 	 	 	 	 	 
	
              AHCA
                Area:

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Positions

            	
              Total

            	
              Non-Clinical
                Specialties

            	
              Therapeutic
                Specialty Areas With 2 Years Clinical
                Experience

            
	
              Bi-Lingual

            	
              Expert
                Witness

            	
              Court
                Ordered Evals

            	
              Adoption/
                Attachment Issues

            	
              Post
                Traumatic Stress Syndrome

            	
              Dual
                Diagnosis (Mental Disorder / Substance Abuse)

            	
              Gender
                / Sexual Issues

            	
              Geriatrics
                / Aging Issues

            	
              Separation,
                Grief & Loss

            	
              Eating
                Disorders

            	
              Adolescent/
                Children's Issues

            	
              Sexual/
                Physical Abuse-Child

            	
              Sexual/
                Physical Abuse-Adult

            	
              Domestic
                Violence-Child

            	
              Domestic
                Violence-Adult

            
	
              Adult
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Child
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Other
                Physicians

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychiatric
                ARNPs

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychologists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Master
                Level Clinicians (LCSW,
                LMFT, LMHC, MFCC)

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Bachelor
                Level

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              RN

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Unduplicated
                Totals

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              This
                report provides a snapshot of the required staff/providers on a day
                in the
                3rd month of the quarter: March, June, September, and
                December.

            	 	 	 
	 	
              The
                report is due within 45 days at the end of the quarter: May 15th,
                August
                15th, November 15th, and February 15th.

            	 	 	 	 	 

    

    

    
      	
              U.

            	
              FARS/CFARS

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit FARS and CFARS reports in accordance with
                Table
                13 below. In addition, the Health Plan shall submit summary trend
                data by
                individual recipient based on the data reported in Table 13 in a
                format to
                be specified by the Agency within the notice requirements indicated
                in
                Section XII.A.3., above. 

            

    

    

    

      
        	
                Table
                  13

                FARS/CFARS
                  Reporting

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

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

              
	
                Data
                  Element Name

              	
                Length

              	
                Start
                  Column

              	
                End
                  Column

              	
                Description

              
	
                Recipient
                  ID

              	
                9

              	
                1

              	
                9

              	
                9-Digit
                  Medicaid ID Number of plan member

              
	
                Recipient
                  DOB

              	
                10

              	
                10

              	
                19

              	
                Plan
                  member’s date of birth (MM/DD/CCYY)

              
	
                Provider
                  ID

              	
                9

              	
                20

              	
                28

              	
                9-Digit
                  Medicaid HMO ID Number

              
	
                Assessment
                  Type

              	
                1

              	
                29

              	
                29

              	
                Designate
                  the type of functional assessment that was done using “F: for FARS or “C”
                  for CFARS

              
	
                Initial
                  Date

              	
                10

              	
                30

              	
                39

              	
                Date
                  of initial assessment (MM/DD/CCYY)

              
	
                Initial
                  Score

              	
                2

              	
                40

              	
                41

              	
                Initial
                  overall assessment score

              
	
                6
                  Month Date

              	
                10

              	
                42

              	
                51

              	
                Date
                  of 6 month assessment, if applicable** (MM/DD/CCYY)

              
	
                6
                  Month Score

              	
                2

              	
                52

              	
                53

              	
                6
                  month overall assessment score, if applicable**

              
	
                Discharge
                  Date

              	
                10

              	
                54

              	
                63

              	
                Date
                  of Discharge (MM/DD/CCYY)

              
	
                Discharge
                  Score

              	
                2

              	
                64

              	
                65

              	
                Overall
                  assessment score at discharge

              
	 	 	 	 	 
	
                **
                  Note: Discharge date may occur prior to the 6 month
                  assessment.

              

      

    

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    
      	
              V.

            	
              Behavioral
                Health Encounter Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report Behavioral Health encounter data in the
                format
                given in Table 14, below. The Health Plan should use the following
                when
                completing the report.

            

    

    

    
      	 	
              a.

            	
              Diagnostic
                Criteria

            

    

    

    
      	 	
              (1)

            	
              All
                provider claims are restricted to claims for Enrollees with an ICD-9CM
                diagnosis code of 290 through 290.43; 293 through 298.9; 300 through
                301.9; 302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3,
                315.31,
                315.5, 315.8, and 315.9.

            

    

    

    
      	 	
              b.

            	
              Provider
                and Coding Criteria

            

    

    

    
      	 	
              (1)

            	
              General
                Hospital Services, Provider Type 01, Claim Input Indicator “I” - Use
                Revenue Codes 0114, 0124, 0134, 0144, 0154, or 0204 on the UB-92
                or
                837-I.

            

    

    

    
      	 	
              (2)

            	
              Hospital
                Outpatient Services - Provider Type 01, Claim Input Indicator “O” - Use
                Revenue Center Codes 0450, 0513, 0901, 0914, or 0918
                on the UB-92 or 837-I.

            

    

    

    
      	 	
              c.

            	
              Community
                Mental Health Services

            

    

    

    
      	 	
              (1)

            	
              Provider
                Type - 05, Community Alcohol, Drug and Mental Health, or Provider
                Type -
                07, Mental Health Practitioner - Both are Claim Input Indicator
                “J.”

            

    

    

    
      	 	
              (2)

            	
              Use
                Procedure code H0001; H000lHN; H0001H0; H0001TS; H0031; H0031 HO;
                H003lHN;
                H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP;
                H2010HO;
                H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM;
                M2019HN;
                H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE;
                T1015HF;
                Tl023HE; or T1023HF.

            

    

     

    d. Physician
      Services

    

    
      	 	
              (1)

            	
              Provider
                Type 25 (MD) or 26 (DO) with a specialty code of "42" Psychiatrist,
                "43”
                Child Psychiatrist, or "44" Psychoanalysis -All claims submitted
                by these
                specialists apply.

            

    

    

    
      	 	
              e.

            	
              Advanced
                Nurse Practitioner Provider Type 30 (ARNP) with a specialty code
                of “76” -
                Clinical Nurse Specialist - All claims submitted by these specialists
                apply.

            

    

    

    
      	 	
              f.

            	
              Case
                Management Agency - Provider Type 91

            

    

    

    
      	 	
              (1)

            	
              Procedure
                code T1017 (Targeted Case Management for Adults); T1017HA (Targeted
                Case
                Management for Children (birth through 17); and T1017HK (Intensive
                Team
                Targeted Case Management, Adults 18 an
                over).

            

    

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    Table
      14

    Behavioral
      Health Encounter Data

    

    

      
        	
                Field
                  Name

              	
                Field
                  Length

              	
                Comments

              
	
                Medicaid
                  ID

              	
                9

              	
                First
                  9 digits of the Enrollee ID number 

              
	
                Plan
                  ID

              	
                9

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

              
	
                Service
                  Type

              	
                1

              	
                I Hospital
                  Inpatient

                C CSU

                O Hospital
                  Outpatient

                P Physician
                  (MD or DO)

                A Advanced
                  Nurse Practitioner, ARNP

                H Comm.
                  Mental Health, Mental Health Practitioner

                T Targeted
                  Case Management

                L Locally
                  Defined or Optional Service

              
	
                First
                  Date of Service

              	
                8

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

              
	
                Revenue
                  Code

              	
                4

              	
                Use
                  only for Hospital Inpatient and Hospital Outpatient
                  Encounters

              
	
                Procedure
                  Code

              	
                5

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

              
	
                Procedure
                  Modifier 1

              	
                2

              	 
	
                Procedure
                  Modifier 2

              	
                2

              	 
	
                Units
                  of Service

              	
                3

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

              
	
                Diagnosis

              	
                6

              	
                Primary
                  Diagnosis Code

              
	
                Provider
                  Type

              	
                1

              	
                1 M.D.

                2 D.O.

                3 A.R.N.P.

                4 P.A.

                5 Community
                  Mental Health Center

                6 Licensed
                  Psychologist, LCSW, LMFT, LMHC

                7 Other

              
	
                Provider
                  ID Type

              	
                1

              	
                Type
                  of unique identifier for the direct service provider:

                A
                  =
                  AHCA ID 

                M
                  =
                  Medicaid Provider ID

                L
                  =
                  Professional License Number

              
	
                Provider
                  ID

              	
                9

              	
                Unique
                  identifier for the direct service provider

              
	
                Amount
                  Paid

              	
                10

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

              
	
                Run
                  Date

              	
                8

              	
                The
                  date the file was prepared. Use YYYYMMDD format

              
	
                Claim
                  Reference Number

              	
                25

              	
                The
                  Health Plan’s internal unique claim record
                  identifier

              

      

    

    

    

    
      	
              W.

            	
              Behavioral
                Health Pharmacy Encounter Data
                Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report Behavioral Health encounter data as set
                forth in
                the format given in Table 16, below. The Health Plan shall use the
                Behavioral Health Related Therapeutic Class Codes listed in Table
                16-A for
                the Behavioral Health Pharmacy Encounter Data
                report.

            

    

    

    

    Table
      16

    Behavioral
      Health Pharmacy Encounter Data (B***YYQ*.txt)

     

    
      	
              Data
                Element Name

            	
              Length

            	
              Data
                Type

            	
              Start
                Column

            	
              End
                Column

            	
              Description

            
	
              RECIP_ID

            	
              9

            	
              Character

            	
              1

            	
              9

            	
              Enrollee
                Medicaid Identification Number (first 9 digits; no check digit
                necessary)

            
	
              NDC

            	
              11

            	
              Character

            	
              10

            	
              20

            	
              National
                Drug Code Identification Number of the Dispensed
                Medication

            
	
              CLASS

            	
              3

            	
              Character

            	
              21

            	
              23

            	
              Therapeutic
                Class Code (see Behavioral Health Related Therapeutic Class Code
                Listing,
                below)

            
	
              QUANT

            	
              8

            	
              Numeric

            	
              24

            	
              31

            	
              Quantity
                of Drug Dispensed

            
	
              DOS

            	
              10

            	
              Character

            	
              32

            	
              41

            	
              Date
                of Service (mm/dd/ccyy Please include the “/”)

            
	
              HMO_ID

            	
              9

            	
              Character

            	
              42

            	
              50

            	
              9
                digit Medicaid Provider Number of the HMO

            
	
              RX_NUM

            	
              7

            	
              Character

            	
              51

            	
              57

            	
              Prescription
                Identification Number

            
	
              DEA

            	
              9

            	
              Character

            	
              58

            	
              66

            	
              9
                digit DEA Number of Prescriber

            
	
              LICENSE

            	
              10

            	
              Character

            	
              67

            	
              76

            	
              Professional
                License Number of Prescriber

            
	
              PHARM_ID

            	
              7

            	
              Character

            	
              77

            	
              83

            	
              Dispensing
                Pharmacy’s seven character National Association of Boards of Pharmacy
                Number (NABP) 

            

    

    

    

    

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    Table
      16-A

    BEHAVIORAL
      HEALTH RELATED THERAPEUTIC CLASS CODES

    

    
      	
              Class
                Code

            	
              Description

            
	
              J5B

            	
              ADRENERGICS,
                AROMATIC, NON-CATECHOLAMINE

            
	
              H7B

            	
              ALPHA-2
                RECEPTOR ANTAGONIST ANTIDEPRESSANTS

            
	
              C0D

            	
              ANTI-ALCOHOLIC
                PREPARATIONS

            
	
              H2F

            	
              ANTI-ANXIETY
                DRUGS

            
	
              H4B

            	
              ANTICONVULSANTS

            
	
              H2J

            	
              ANTIDEPRESSANTS
                O.U.

            
	
              Z2A

            	
              ANTIHISTAMINES

            
	
              H2M

            	
              ANTI-MANIA
                DRUGS

            
	
              H6B

            	
              ANTIPARKINSONISM
                DRUGS, ANTICHOLINERGIC

            
	
              H6A

            	
              ANTIPARKINSONISM
                DRUGS, OTHER

            
	
              L3P

            	
              ANTIPRURITICS,
                TOPICAL

            
	
              H7R

            	
              ANTIPSYCH,
                DOPAMINE ANTAG., DIPHENYLBUTYLPIPERIDINES

            
	
              H7X

            	
              ANTIPSYCHOTICS,
                ATYP, D2 PARTIAL AGONIST/5HT MIXED

            
	
              H7U

            	
              ANTIPSYCHOTICS,
                DOPAMINE & SEROTONIN ANTAGONISTS

            
	
              H7T

            	
              ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,&
                SEROTONIN ANTAG

            
	
              H7P

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONISTS, THIOXANTHENES

            
	
              H7O

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONISTS,BUTYROPHENONES

            
	
              H7S

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONST,DIHYDROINDOLONES

            
	
              H2L

            	
              ANTI-PSYCHOTICS,NON-PHENOTHIAZINES

            
	
              H2G

            	
              ANTI-PSYCHOTICS,PHENOTHIAZINES

            
	
              H2D

            	
              BARBITURATES

            
	
              U6W

            	
              BULK
                CHEMICALS

            
	
              H2A

            	
              CENTRAL
                NERVOUS SYSTEM STIMULANTS

            
	
              C6M

            	
              FOLIC
                ACID PREPARATIONS

            
	
              H2C

            	
              GENERAL
                ANESTHETICS,INJECTABLE

            
	
              H7J

            	
              MAOIS
                - NON-SELECTIVE & IRREVERSIBLE

            
	
              H2H

            	
              MONOAMINE
                OXIDASE(MAO) INHIBITORS

            
	
              H3T

            	
              NARCOTIC
                ANTAGONISTS

            
	
              H7D

            	
              NOREPINEPHRINE
                AND DOPAMINE REUPTAKE INHIB (NDRIS)

            
	
              S2B

            	
              NSAIDS,
                CYCLOOXYGENASE INHIBITOR - TYPE

            
	
              H2E

            	
              SEDATIVE-HYPNOTICS,NON-BARBITURATE

            
	
              H2S

            	
              SELECTIVE
                SEROTONIN REUPTAKE INHIBITOR (SSRIS)

            
	
              H7E

            	
              SEROTONIN-2
                ANTAGONIST/REUPTAKE INHIBITORS (SARIS)

            
	
              H7C

            	
              SEROTONIN-NOREPINEPHRINE
                REUPTAKE-INHIB (SNRIS)

            
	
              H7N

            	
              SMOKING
                DETERRENTS, OTHER

            
	
              H2X

            	
              TRICYCLIC
                ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS

            
	
              H2W

            	
              TRICYCLIC
                ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS

            
	
              H2U

            	
              TRICYCLIC
                ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB

            
	
              H2V

            	
              TX
                FOR ATTENTION
                DEFICIT-HYPERACT(ADHD)/NARCOLEPSY

            

    

    

    
      
        
        

        
        

      

      
        
        

        
          

        

      

      
        
        

        
          

        

      

    

    

    
      	
              X.

            	
              Minority
                Participation Report

            

    

    

    
      	 	
              1.

            	
              The
                Agency encourages the Health Plan to use Minority and Certified Minority
                businesses as Subcontractors when procuring commodities or services
                to
                meet the requirements of this
                Contract.

            

    

    

    
      	 	
              2.

            	
              The
                Agency requires information regarding the Vendor’s use of minority-owned
                businesses as Subcontractors under this Contract. The Agency will
                use this
                information for assessment and evaluation of the Agency’s Minority
                Business Utilization Plan. During the term of the Contract, the Health
                Plan shall provide this information monthly by the fifteenth
                (15th)
                day after the reporting month. A minority-owned business is defined
                as any
                business enterprise owned and operated by the following ethnic
                groups:

            

    

    

    
      	 	
              a.

            	
              African
                American (Certified Minority Code H or Non-Certified Minority Code
                N);

            

    

    

    
      	 	
              b.

            	
              Hispanic
                American (Certified Minority Code I or Non-Certified Minority
                O);

            

    

    

    
      	 	
              c.

            	
              Asian
                American (Certified Minority Code J or Non-Certified Minority Code
                P);

            

    

    

    
      	 	
              d.

            	
              Native
                American (Certified Minority Code K or Non-Certified Minority Code
                Q);
                or

            

    

    

    
      	 	
              e.

            	
              American
                Woman (Certified Minority Code M or Non-Certified Minority Code R).
                

            

    

    

    
      	 	
              3.

            	
              The
                Agency may waive this requirement, in writing, if the Health Plan
                demonstrates that it is either at least fifty-one percent (51%)
                minority-owned, at least fifty-one percent (51%) of its board of
                directors
                are a minority, at least fifty-one (51%) of its officers are a minority,
                or if the Health Plan is a not-for-profit corporation and
                at
                least fifty-one percent (51%) of the population it serves belong
                to a
                minority.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall provide the following information on company
                letterhead:

            

    

    

    a. Minority
      Subcontractor's company name and Minority Code (see above); 

    

    
      	 	
              b.

            	
              Subcontracted
                services related to this Contract;

            

    

    

    
      	 	
              c.

            	
              Dates
                of service (beginning and ending);

            

    

    

    
      	 	
              d.
                

            	
              Total
                dollar amount paid to Subcontractor for services related to this
                Contract;
                or

            

    

    

    
      	 	
              e.

            	
              A
                statement that the Health Plan did not use the services of any minority
                Subcontractors during this period.

            

    

    

     

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    Section
      XIII

     

    Method
      of Payment

     

    
      	
              A.

            	
              Fixed
                Price Unit Contract

            

    

    

    This
      is a
      fixed price unit cost contract. The Agency or its appointed Fiscal Agent shall
      make payment to the Health Plan on a monthly basis for the Health Plan’s
      satisfactory performance of its duties and responsibilities as set forth in
      this
      Contract. To accommodate payments, the Health Plan is a capitated health plan
      with the Fiscal Agent. Section XII, Reporting Requirements, details the
      enrollment reports, the monthly payment request processing and service
      utilization procedures.

    

    
      	
              B.

            	
              Child
                Health Check-Up Incentive
                Program

            

    

    

    Health
      Plans will be eligible to participate in the Child Health Check-Up (CHCUP)
      incentive program when the Health Plan has exceeded both the sixty percent
      (60%)
      State screening rate and the federal eighty percent (80%) participation and
      screening ratio goals as outlined in Section V, Covered Services, E.2. The
      Agency will determine which Health Plans will participate based upon the audited
      CHCUP reports submitted each October as set forth in Section XII.M.,
      above.

    

    
      	1.  	
              The
                amount of the incentive payment shall be calculated as follows: the
                ratio
                of a qualified Health Plan’s screenings to the total of all Health Plans’
                screenings will be multiplied by the total amount in the fund for
                the
                incentive payment. The ratios will be based on the Health Plans’ audited
                CHCUP reports. The total amount in the fund will be determined at
                the
                discretion of the Agency. In no event shall the total monies allotted
                to
                the incentive program be in excess of the incentive payment fund.
                

            

    

    

    
      	 	
              2.

            	
              Pursuant
                to 42 CFR 438.6, I(1)(iv) and (5)(iii), the payment to any one (1)
                Health
                Plan shall not be in excess of five percent (5%) of the capitation
                amount
                paid to all Health Plans for CHCUP services provided pursuant to
                this
                Contract.

            

    

    

    
      	
              C.

            	
              Capitation
                Rate

            

    

    

    The
      Agency shall pay the applicable Capitation Rate for each Enrollee whose name
      appears on the ONGOING REPORT (FLMR 8200-R004) and the REINSTATEMENT
      REPORT
      (FLMR
      8200-R009) for each month, except that the Agency shall not pay for, and shall
      recoup, any part of the total Enrollment that exceeds the maximum authorized
      Enrollment level(s) expressed in Attachment I. The total payment amount to
      the
      Health Plan shall depend upon the number of Enrollees in each eligibility
      category and each rate group, as provided for by this Contract, or as adjusted
      pursuant to the Contract when necessary. The Health Plan is obligated to provide
      services pursuant to the terms of this Contract for all Enrollees for whom
      the
      Health Plan has received capitation payment and for whom the Agency has assured
      the Health Plan that capitation payment is forthcoming.

    

    
      	 	
              1.

            	
              The
                Agency’s Capitation Rates are developed using historical rates paid by
                Medicaid fee-for-service for similar services in the same Service
                Area,
                adjusted for inflation, where applicable, in accordance with 42 CFR
                438.6(c).

            

    

    

    
      	 	
              2.

            	
              The
                Capitation Rates to be paid specific to the Health Plan shall be
                as
                indicated in Attachment I, which indicates the initial and maximum
                authorized Enrollment levels and Capitation Rates applicable to each
                authorized eligibility category.

            

    

    

    
      	 	
              3.

            	
              At
                such time as the Agency receives legislative direction to assess
                Health
                Plans for Enrollment and Disenrollment Services costs,
                the Agency shall apply assessments, in quarterly installments each
                Contract Year, against the Health Plan’s next capitation payment to pay
                for the Enrollment and Disenrollment Services Contractor as
                follows:

            

    

    

    
      	 	
              a.

            	
              July
                1, for costs estimated for the Agency’s Enrollment and Disenrollment
                Services Contractor system and contract for
                July and the following two (2)
                months.

            

    

    

    
      	 	
              b.

            	
              October
                1, for costs related to the third party Enrollment and Disenrollment
                Services contract for October and the
                following two (2) months.

            

    

    

    
      	 	
              c.

            	
              January
                1, for costs related to maintaining the third party Enrollment and
                Services contract for January and the
                following two (2) months.

            

    

    

    
      	 	
              d.

            	
              April
                1, for costs related to maintaining the third party Enrollment and
                Disenrollment Services contract for April and the following two (2)
                months.

            

    

    

    
      	 	
              4.

            	
              Unless
                otherwise specified in this Contract, the
                Health Plan shall accept the capitation payment received each month
                as
                payment in full by the Agency for all services provided to Enrollees
                covered under this Contract and the administrative costs incurred
                by the
                Health Plan in providing or arranging for such services. Any and
                all costs
                incurred by the Health Plan in excess of the capitation payment shall
                be
                borne in total by the Health Plan.

            

    

    

    
      	 	
              5.

            	
              The
                Agency shall pay a retroactive Capitation Rate for each Newborn enrolled
                in the Health Plan for up to the first (1st)
                three (3) months of life, provided the Newborn was enrolled through
                the
                Unborn Activation Process. 

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan shall use the Unborn Activation Process to enroll all
                babies
                born to pregnant Enrollees as specified in Section III.B.3, Newborn
                Enrollment.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan is responsible for payment of all Covered Services provided
                to
                Newborns enrolled through the Unborn Activation
                Process.

            

    

    

    
      	 	
              6.

            	
              Because
                the HomeSafeNet program covers the cost of Behavioral Health Services
                provided to members of the HomeSafeNet program, the Agency shall
                not pay
                the Health Plan the behavioral health component of the Capitation
                Rate for
                Enrollees that are part of the HomeSafeNet program, even if the Health
                Plan provides Behavioral Health Services in the county in which the
                Enrollee resides.

            

    

    

    
      	
              D.

            	
              Errors

            

    

    

    
      	 	
              1.

            	
              The
                Agency expects the Health Plan to prepare all reports and monthly
                payment
                requests for submission to the Agency. If after preparation and electronic
                submission, the Health Plan discovers an error, including, but not
                limited
                to, errors resulting in capitated payments above the Health Plan’s
                authorized levels, either by the Health Plan or the Agency, the Health
                Plan has thirty (30) Business Days from its discovery of the error,
                or
                thirty (30) Business Days after receipt of notice by the Agency,
                to
                correct the error and re-submit accurate reports and/or invoices.
                Failure
                to respond within the thirty (30) Business Day period shall result
                in a
                loss of any money due to the Health Plan for such errors and/or sanctions
                against the Health Plan pursuant to Section XIV of this
                Contract.

            

    

    

    
      	
              E.

            	
              Member
                Payment Liability
                Protection

            

    

    

    
      	 	
              1.

            	
              Pursuant
                to Section
                1932 (b)(6), Social Security Act (as enacted by section 4704 of the
                Balanced Budget Act of 1997), the
                Health Plan shall not hold members liable for the
                following:

            

    

    

    
      	 	
              a.

            	
              For
                debts of the Health Plan, in the event of the Health Plan’s
                insolvency;

            

    

    

    
      	 	
              b.

            	
              For
                payment of Covered Services provided by the Health Plan if the Health
                Plan
                has not received payment from the Agency for the Covered Services,
                or if
                the provider, under contract or other arrangement with the Health
                Plan,
                fails to receive payment from the Agency or the Health Plan;
                and/or

            

    

    

    
      	 	
              c.

            	
              For
                payments to a provider, including referral providers, that furnished
                Covered Services under a contract, or other arrangement with the
                Health
                Plan, that are in excess of the amount that normally would be paid
                by the
                Enrollee if the Covered Services had been received directly from
                the
                Health Plan.

            

    

    

    
      	
              F.

            	
              Co-payments

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall not require any co-payment or cost sharing for
                Covered
                Services, expanded services and/or optional services listed in Section
                V,
                Covered Services or Section VI, Behavioral Health Care, nor may the
                Health
                Plan charge Enrollees for missed
                appointments.

            

    

    

    
      	
              G.

            	
              Enrollment
                Levels

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan is assigned an authorized maximum Enrollment level for
                each
                operational county. The authorized maximum Enrollment level is in
                effect
                on September 1, 2006, or upon Contract execution, whichever is later.
                

            

    

    

    
      	 	
              2.

            	
              The
                Agency must approve in writing any increase in the Health Plan’s maximum
                Enrollment level for each operational county and subpopulation to
                be
                served, as applicable. Such approval shall not be unreasonably withheld,
                and shall be based on the Health Plan’s satisfactory performance of terms
                of the Contract and approval of the Health Plan’s administrative and
                service resources, as specified in this Contract, in support of each
                Enrollment level.

            

    

    

    
      	 	
              3.

            	
              Authorized
                Enrollment Levels in Attachment I indicate the Health Plan’s maximum
                authorized Enrollment levels for each Medicaid Reform county and
                each
                applicable authorized eligibility
                category.

            

    

    

    
      	 	
              4.

            	
              Attachment
                I sets forth the total Contract
                amount.

            

    

    

    
      	 	
              5.

            	
              Attachment
                I, Exhibit I sets forth the Health Plan’s authorized Service Areas and
                maximum enrollment levels.

            

    

    

    
      	 	
              6.

            	
              Attachment
                I, Exhibit II sets forth the Health Plan’s Capitation Rates for each
                County in which it is authorized to provide
                services.

            

    

    

    
      	 	
              7.

            	
              Attachment
                I, Exhibit III lists the Capitation Rates for the Health Plan’s authorized
                Service Areas.

            

    

    

    
      	
              H.

            	
              Transition
                to Medicaid Reform

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan understands that the State is commencing Medicaid Reform
                that
                shall start in Broward County and Duval County on September 1, 2006,
                with
                other counties added as authorized by the State. As a result, in
                all areas
                in which the State implements Medicaid Reform, the Health Plan’s
                Enrollment will transition from coverage under this Contract to the
                Medicaid Reform Contract in accordance with the Agency’s implementation
                schedule. By April 1, 2007, the Health Plan’s total maximum Enrollment in
                Broward County and Duval County, if any, will be zero (0).
                

            

    

    

    
      	 	
              2.

            	
              When
                the State authorizes expansion of Medicaid Reform into a new county
                in
                which the Health Plan is currently providing, or will provide, Medicaid
                services, the Health Plan acknowledges that it must request an amendment
                for an expansion of service under the Medicaid Reform Contract in
                order to
                continue to provide Benefits in the new Medicaid Reform county. Upon
                implementation of Medicaid Reform, the Health Plan shall
                not:

            

    

    

    
      	 	
              a.

            	
              Engage
                in Marketing activities with regard to the services and/or Benefits
                provided under this Contract;

            

    

    

    
      	 	
              b.

            	
              Receive
                voluntary or mandatory Enrollees for the Medicaid Reform county under
                this
                Contract; and must

            

    

    

    
      	
              I.

            	
              Cost
                Effectiveness

            

    

    

    
      	 	
              1.

            	
              The
                Agency shall ensure that the Health Plan is cost-effective (see Section
                409.912(44), F.S.). The Agency may not renew this Contract if it
                is not
                cost-effective.

            

    

    

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    Section
      XIV

     

    Sanctions

     

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all requirements and performance standards
                set forth in this Contract. In the event the Agency identifies a
                violation
                of this Contract, or other non-compliance with this Contract, the
                Health
                Plan shall submit a corrective action plan (CAP) within three (3)
                Calendar
                Days of the date of receiving notification of the violation or
                non-compliance from the Agency.

            

    

    

    
      	 	
              2.

            	
              Within
                five (5) Business Days of receiving the CAP the Agency will either
                approve
                or disapprove the CAP. If disapproved, the Health Plan shall resubmit,
                within ten (10) Business Days, a new CAP that addresses the concerns
                identified by the Agency. 

            

    

    

    
      	 	
              3.

            	
              Upon
                approval of the CAP, whether the initial CAP or the revised CAP,
                the
                Health Plan shall implement the CAP within the time frames specified
                by
                the Agency. 

            

    

    

    
      	 	
              4.

            	
              Except
                where specified below, the Agency shall impose a monetary sanction
                of $100
                per day on the Health Plan for each Calendar Day that the approved
                CAP is
                not implemented to the satisfaction of the
                Agency.

            

    

    

    
      	
              B.

            	
              Specific
                Sanctions

            

    

    

    
      	 	
              1.

            	
              As
                described in 42 CFR 438.700, the Agency may impose any of the following
                sanctions against a Health Plan if it determines that a Health Plan
                has
                violated any provision of this Contract, or any applicable
                statutes:

            

    

    

    
      	 	
              a.

            	
              Suspension
                of the Health Plan’s Voluntary Enrollments and participation in the
                Mandatory Assignment process for
                Enrollment

            

    

    

    
      	 	
              b.

            	
              Suspension
                or revocation of payments to the Health Plan for Enrollees during
                the
                sanction period; 

            

    

    

    
      	 	
              c.

            	
              For
                any nonwillful violation of the Contract, the Agency shall impose
                a fine,
                not to exceed $2,500 per Violation. In no event shall such fine exceed
                an
                aggregate amount of $10,000 for all nonwillful Violations arising
                out of
                the same action;

            

    

    

    
      	 	
              d.

            	
              With
                respect to any knowing and willful violation of the Contract the
                Agency
                shall impose a fine upon the Health Plan in an amount not to exceed
                $20,000 for each such violation. In no event shall such fine exceed
                an
                aggregate amount of $100,000 for all knowing and willful violations
                arising out of the same action;

            

    

    

    
      	 	
              e.

            	
              If
                the Health Plan fails to carry out substantive terms of the Contract
                or
                fails to meet all applicable requirements in 42 CFR 438.700, the
                Agency
                shall terminate the Contract. After the Agency notifies the Health
                Plan
                that it intends to terminate the Contract, the Agency shall give
                the
                Health Plan’s Enrollees written notice of the State’s intent to terminate
                the Contract and allow the Enrollees to disenroll immediately without
                Cause.

            

    

    

    
      	 	
              f.

            	
              The
                Agency may impose intermediate sanctions in accordance with 42 CFR
                438.702, including, but not limited
                to:

            

    

    

    
      	 	
              (1)

            	
              Civil
                monetary penalties in the amounts specified in this
                Contract.

            

    

    

    
      	 	
              (2)

            	
              Appointment
                of temporary management for the Health Plan. 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 on-site
                survey, Enrollee Grievances, financial audits, or any other means)
                that:

            

    

    

    
      	 	
              (i)

            	
              There
                is continued egregious behavior by the Health Plan, including but
                not
                limited to behavior that is described in 42 CFR
                438.700;

            

    

    

    
      	 	
              (ii)

            	
              There
                is substantial risk to Enrollees'
                health;

            

    

    

    
      	 	
              (iii)

            	
              The
                sanction is necessary to ensure the health of the Health Plan’s
                Enrollees;

            

    

    

    
      	 	
              (iv)

            	
              While
                improvements are made to remedy the Health Plan’s violation(s) under 42
                CFR 438.700; and/or

            

    

    

    
      	 	
              (v)

            	
              Until
                there is an orderly termination or reorganization of the Health
                Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                State must impose temporary management (regardless of any other sanction
                that may be imposed) if it finds that the Health Plan has repeatedly
                failed to meet substantive requirements in 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.

            

    

    

    
      	 	
              (4)

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

            

    

    

    
      	 	
              (5)

            	
              The
                State shall not terminate temporary management until it determines
                that
                the Health Plan can ensure that the sanctioned behavior will not
                recur.

            

    

    

    
      	 	
              g.

            	
              Granting
                Enrollees the right to terminate Enrollment without Cause and notifying
                affected Enrollees of their right to
                disenroll;

            

    

    

    
      	 	
              h.

            	
              Suspension
                or limitation of all new Enrollment, including Mandatory Enrollment,
                after
                the effective date of the sanction;

            

    

    

    
      	 	
              i.

            	
              Suspension
                of payment for Enrollees after the effective date of the sanction
                and
                until CMS or the Agency is satisfied that the reason for imposition
                of the
                sanction no longer exists and is not likely to recur;
                and/or

            

    

    

    
      	 	
              j.

            	
              Before
                imposing any intermediate sanctions, the State must give the Health
                Plan
                timely notice according to 42 CFR
                438.710.

            

    

    

    
      	 	
              7.

            	
              If
                the Health Plan’s CHCUP Screening compliance rate is below sixty percent
                (60%), it must submit to the Agency, and implement, an Agency accepted
                CAP. If the Health Plan does not meet the standard established in
                the CAP
                during the time period indicated in the plan, the Agency has the
                authority
                to impose sanctions in accordance with this
                Section;

            

    

    

    
      	 	
              8.

            	
              Unless
                the duration of a sanction is specified, a sanction shall remain
                in effect
                until the Agency is satisfied that the basis for imposing the sanction
                has
                been corrected and is not likely to recur;
                and/or

            

    

    

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    Section
      XV

     

    Financial
      Requirements

     

    

     

    
      	
              A.

            	
              Insolvency
                Protection 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall establish a restricted Insolvency protection account
                with a federally guaranteed financial institution licensed to do
                business
                in Florida (See Section 1903(m)(1) of the Social Security Act as
                amended
                by Section 4706 of the Balanced Budget Act of 1997, and Section 409.912,
                F.S.). The Health Plan shall deposit into that account five percent
                (5%)
                of the capitation payments made by the Agency each month until a
                maximum
                total of two percent (2%) of the total current Contract amount is
                reached.
                No interest may be withdrawn from this account until the maximum
                Contract
                amount is reached. This provision shall remain in effect as long
                as the
                Health Plan continues to contract with the Agency. The restricted
                Insolvency protection account may be drawn upon with the authorized
                signatures of two (2) persons designated by the Health Plan and two
                (2)
                representatives of the Agency. The signature card shall be resubmitted
                when a change in authorized personnel occurs. If the authorized persons
                remain the same, the Health Plan shall submit an attestation to this
                effect annually. The Health Plan may obtain a sample Multiple Signature
                Verification Agreement form from the Agency or its Agent. 
                All such agreements or other signature cards must be approved in
                advance
                by the Agency.

            

    

    

    
      	 	
              2.

            	
              In
                the event that a determination is made by the Agency that the Health
                Plan
                is insolvent, as defined in Section I Definitions, of this Contract,
                the
                Agency may draw upon the amount solely with the two (2) authorized
                signatures of representatives of the Agency and funds may be disbursed
                to
                meet financial obligations incurred by the Health Plan under this
                Contract. A statement of account balance shall be provided by the
                Health
                Plan within fifteen (15) Calendar Days of request of the
                Agency.

            

    

     

    
      	 	
              3.

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

            

    

    

    
      	 	
              4.

            	
              In
                the event the Contract is terminated or not renewed and the Health
                Plan is
                Insolvent, the Agency may draw upon the Insolvency protection account
                to
                pay any outstanding debts the Health Plan owes the Agency including,
                but
                not limited to, overpayments made to the Health Plan and fines imposed
                under the Contract or 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 Health Plan is unable to pay all of its outstanding debts to
                health
                care providers, the Agency and the Health Plan agree to the court
                appointment of an impartial receiver for the purpose of administering
                and
                distributing the funds contained in the Insolvency protection account.
                Should a receiver be appointed, he or she shall give outstanding
                debts
                owed to the Agency priority over other
                claims.

            

    

    

    
      	
              B.

            	
              Insolvency
                Protection Account Waiver

            

    

    Pursuant
      to Section 409.912, the Agency may waive the Insolvency protection account
      requirement, in writing, when evidence of adequate Insolvency insurance and
      reinsurance are on file with the Agency which shall protect Enrollees in the
      event the Health Plan is unable to meet its obligations. 

    

    
      	
              C.

            	
              Surplus
                Start Up Account 

            

    

    

    All
      new
      Health Plans, after initial Contract execution, but prior to initial Enrollee
      Enrollment, shall submit to the Agency, if a private entity, proof of working
      capital in the form of cash or liquid assets, excluding revenues from Medicaid
      premium payments, equal to at least the first three (3) months of operating
      expenses or $200,000, whichever is greater. This provision shall not apply
      to
      Health Plans that have been providing services to Enrollees for a period
      exceeding three (3) continuous months.

    

    
      	
              D.

            	
              Surplus
                Requirement 

            

    

    

    
      	 	
              1.

            	
              In
                accordance with Section 409.912, F.S., the Health Plan shall maintain
                at
                all times in the form of cash, investments that mature in less than
                180
                Calendar Days and allowable as admitted assets by the Department
                of
                Financial Services, and restricted funds of deposits controlled by
                the
                Agency (including the Health Plan’s Insolvency protection account) or the
                Department of Financial Services, a Surplus amount equal to one and
                one
                half (11⁄2) times the Health Plan’s monthly Medicaid prepaid revenues. In
                the event that the Health Plan’s Surplus falls below an amount equal to
                one and one half (11⁄2) times the Health Plan’s monthly Medicaid prepaid
                revenues, the Agency shall:

            

    

    

    
      	 	
              a.

            	
              Prohibit
                the Health Plan from engaging in Marketing and Request for Benefit
                Information activities;

            

    

    

    
      	 	
              b.

            	
              Shall
                cease to process new Enrollments until the required balance is achieved;
                and/or

            

    

    

    c. May
      terminate the Health Plan’s Contract.

    

    
      	
              E.

            	
              Interest

            

    

    

    
      	 	
              1.

            	
              Interest
                generated through investments made by the Health Plan under this
                Contract
                shall be the property of the Health Plan and shall be used at the
                Health
                Plan’s discretion.

            

    

    

    
      	
              F.

            	
              Inspection
                and Audit of Financial
                Records

            

    

    

    
      	 	
              1.

            	
              The
                State and DHHS may inspect and audit any financial records of the
                Health
                Plan or its Subcontractors. Pursuant to section 1903(m)(4)(A) of
                the
                Social Security Act and State Medicaid Manual 2087.6(A-B), non-federally
                qualified health plans 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.

            

    

    

    
      	
              G.

            	
              Physician
                Incentive Plans

            

    

    

    
      	 	
              1.

            	
              Physician
                incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h),
                42 CFR
                422.208 and 42 CFR 422.210. The Health Plan 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. Physician
                incentive plans must not contain provisions which provide incentives,
                monetary or otherwise, for the withholding of Medically Necessary
                care.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall disclose information on physician incentive plans
                listed
                in 42 CFR 417.479(h)(1) and 42 CFR 417.479(i) at the times indicated
                in 42
                CFR 417.479(d)-(g). All such arrangements must be submitted to the
                Agency
                for approval, in writing, prior to use. If any other type of withhold
                arrangement currently exists, it must be omitted from all Provider
                contracts.

            

    

    
      	
              H.

            	
              Third
                Party Resources 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan must specify whether it will assume full responsibility
                for
                third party collections in accordance with this
                Section.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall 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 Health Plan 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:

            

    

    

    
      	 	
              a.

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

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan determines 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 Health Plan may pay the Subcontractor
                or
                referral Provider only the amount, if any, by which the Subcontractor’s or
                referral Provider’s allowable claim exceeds the amount of the anticipated
                third party payment; or, the Health Plan may assume full responsibility
                for third party collections for services provided through the
                Subcontractor or referral Provider.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan may not withhold payment for services provided to an
                Enrollee
                if third party liability or the amount of liability cannot be determined,
                or if payment shall not be available within a reasonable time, beyond
                120
                Calendar Days from the date of
                receipt.

            

    

    

    
      	 	
              d.

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

            

    

    

    
      	 	
              e.

            	
              The
                Agency may, at its sole discretion, offer to provide third party
                recovery
                services to the Health Plan. If the Health Plan elects to authorize
                the
                Agency to recover on its behalf, the Health Plan shall be required
                to
                provide the necessary data for recovery in the format prescribed
                by the
                Agency. All recoveries, less the Agency’s cost to recover shall be income
                to the Health Plan. The Health Plan shall express the cost to recover
                as a
                percentage of recoveries and shall be fixed at the time the Health
                Plan
                elects to authorize the Agency to recover on its
                behalf.

            

    

    

    
      	 	
              f.

            	
              All
                funds recovered from third parties shall be treated as income for
                the
                Health Plan.

            

    

    

    
      	
              I.

            	
              Fidelity
                Bonds

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall secure and maintain during the life of this Contract
                a
                blanket fidelity bond from a company doing business in the State
                of
                Florida on all personnel in its employment. The bond shall be issued
                in
                the amount of at least $250,000 per occurrence. Said bond shall protect
                the Agency from any losses sustained through any fraudulent or dishonest
                act or acts committed by any employees of the Health Plan and
                Subcontractors, if any. Proof of coverage must be submitted to the
                Agency’s contract manager within sixty (60) Calendar Days after execution
                of the Contract and prior to the delivery of health care. To be acceptable
                to the Agency for fidelity bonds, a surety company shall comply with
                the
                provisions of Chapter 624, F.S. 

            

    

    

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    Section
      XVI

     

    Terms
      and Conditions

     

    

    
      	
              A.

            	
              Agency
                Contract Management

            

    

    

    
      	 	
              1.

            	
              The
                Division of Medicaid within the Agency shall be responsible for management
                of the Contract. The Division of Medicaid shall make all statewide
                policy
                decision-making or Contract interpretation. In addition, the Division
                of
                Medicaid shall be responsible for the interpretation of all federal
                and
                State laws, rules and regulations governing, or in any way affecting,
                this
                Contract. Management shall be conducted in good faith, with the best
                interest of the State and the Medicaid Recipients it serves being
                the
                prime consideration. The Agency shall provide final interpretation
                of
                general Medicaid policy. When interpretations are required, the Health
                Plan shall submit written requests to the Agency’s contract
                manager.

            

    

    

    
      	 	
              2.

            	
              The
                terms of this Contract do not limit or waive the ability, authority
                or
                obligation of the Office of Inspector General, the Bureau of Medicaid
                Program Integrity, its contractors, or other duly constituted government
                units (State or federal) to audit or investigate matters related
                to, or
                arising out of this Contract. 

            

    

    

    
      	 	
              3.

            	
              The
                Contract shall only be amended as
                follows:

            

    

    

    
      	 	
              a.

            	
              The
                parties cannot amend or alter the terms of this Contract without
                a written
                amendment.

            

    

    

    
      	 	
              b.

            	
              The
                Agency and the Health Plan understand that any such written amendment
                to
                amend or alter the terms of this Contract shall be executed by an
                officer
                of both parties, who is duly authorized to bind the Agency and the
                Health
                Plan.

            

    

    

    
      	 	
              c.

            	
              Only
                a person authorized by the Agency and a person authorized by the
                Health
                Plan may amend or alter the terms of this Contract.
                

            

    

     

    
      	
              B.

            	
              Applicable
                Laws and Regulations

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan agrees to comply with all applicable federal and State
                laws,
                rules and regulations including but not limited to: Title 42 CFR
                Chapter
                IV, Subchapter C; Title 45 CFR Part 74, General Grants Administration
                Requirements; Chapters 409 and 641, F.S.; all applicable standards,
                orders, or regulations issued pursuant to the Clean Air Act of 1970
                as
                amended (42 USC 1857, et seq.); Title VI of the Civil Rights Act
                of 1964
                (42 USC 2000d) in regard to persons served; Title IX of the education
                amendments of 1972 (regarding education programs and activities);
                42 CFR
                431, Subpart F; Section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b),
                F.A.C. in regard to the contractor safeguarding information about
                Enrollees; Title VII of the Civil Rights Act of 1964 (42 USC 2000e)
                in
                regard to employees or applicants for employment; Rule 59G-8.100,
                F.A.C.;
                Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC
                794
                (which prohibits discrimination on the basis of handicap in programs
                and
                activities receiving or benefiting from federal financial assistance);
                the
                Age Discrimination Act of 1975, as amended, 42 USC 6101 et. seq.
                (which
                prohibits discrimination on the basis of age in programs or activities
                receiving or benefiting from federal financial assistance); the Omnibus
                Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits
                discrimination on the basis of sex and religion in programs and activities
                receiving or benefiting from federal financial assistance; Medicare
                -
                Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget
                Reconciliation Acts; Americans with Disabilities Act (42 USC 12101,
                et
                seq.); the Newborns’ and Mothers’ Health Protection Act of 1996, the
                Balanced Budget Act of 1997, and the Health Insurance Portability
                and
                Accountability Act of 1996. The Health Plan is subject to any changes
                in
                federal and state law, rules, or
                regulations.

            

    

    

    
      	
              C.

            	
              Assignment

            

    

    

    
      	 	
              1.

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

            

    

    

    
      	 	
              a.

            	
              When
                a merger or acquisition of a health plan has been approved by the
                Department of Financial Services (see Section 628.4615, F.S.), the
                Agency
                shall approve the assignment or transfer of the appropriate Medicaid
                health plan contract upon the request of the surviving entity of
                the
                merger or acquisition if the health plan and the surviving entity
                have
                been in good standing with the Agency for the most recent twelve
                (12)
                month period, unless the Agency determines that the assignment or
                transfer
                would be detrimental to Medicaid Recipients or the Medicaid program
                (see
                Section 409.912, F.S.). The entity requesting the assignment or transfer
                shall notify the Agency of the request ninety (90) days prior to
                the
                anticipated effective date.

            

    

    

    
      	 	
              b.

            	
              To
                be in good standing, a Health Plan must not have failed accreditation
                or
                committed any material violation of the requirements of Section 641.52,
                F.S., and must meet the Medicaid contract
                requirements.

            

    

    

    
      	 	
              c.

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

            

    

    

    
      	
              D.

            	
              Attorney's
                Fees

            

    

    

    
      	 	
              1.

            	
              In
                the event of a dispute, each party to the Contract shall be responsible
                for its own attorneys’ fees, except as otherwise provided by
                law.

            

    

    

    
      	
              E.

            	
              Conflict
                of Interest

            

    

    
      	 	
              1.

            	
              This
                Contract is subject to the provisions of Chapter 112, F.S. The Health
                Plan
                shall 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
                Health Plan shall disclose the name of any State employee who owns,
                directly or indirectly, an interest of five percent (5%) or more
                in the
                offerer's firm or any of its branches. The Health Plan 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 Health Plan further covenants
                that in the performance of the Contract no person having any such
                known
                interest shall be employed. No official or employee of the Agency
                and no
                other public official of the State of Florida or the federal government
                who exercises any functions or responsibilities in the review or
                approval
                of the undertaking of carrying out the Contract shall, prior to completion
                of this Contract, voluntarily acquire any personal interest, direct
                or
                indirect, in this Contract or proposed
                Contract.

            

    

    

    
      	
              F.

            	
              Contract
                Variation

            

    

    
      	 	
              1.

            	
              If
                any provision of the Contract (including items incorporated by reference)
                is declared or found to be illegal, unenforceable, or void, then
                both the
                Agency and the Health Plan shall be relieved of all obligations arising
                under such provisions. If the remainder of the Contract is capable
                of
                performance, it shall not be affected by such declaration or finding
                and
                shall be fully performed. In addition, if the laws or regulations
                governing this Contract should be amended or judicially interpreted
                as to
                render the fulfillment of the Contract impossible or economically
                infeasible, both the Agency and the Health Plan shall be discharged
                from
                further obligations created under the terms of the Contract. However,
                such
                declaration or finding shall not affect any rights or obligations
                of
                either party to the extent that such rights or obligations arise
                from acts
                performed or events occurring prior to the effective date of such
                declaration or finding.

            

    

    

    
      	
              G.

            	
              Court
                of Jurisdiction or Venue

            

    

    
      	 	
              1.

            	
              For
                purposes of any legal action occurring as a result of, or under,
                this
                Contract, between the Health Plan and the Agency, the place of proper
                venue shall be Leon County.

            

    

    

    
      	
              H.

            	
              Damages
                for Failure to Meet Contract
                Requirements

            

    

     

    
      	 	
              1.

            	
              In
                addition to any remedies available through this Contract, in law
                or
                equity, the Health Plan shall reimburse the Agency for any federal
                disallowances or sanctions imposed on the Agency as a result of the
                Health
                Plan’s failure to abide by the terms of this
                Contract.

            

    

    

    
      	
              I.

            	
              Disputes  

            

    

    

    1. The
      Health Plan may request in writing an interpretation of the Contract from the
      contract manager. In the event the Health Plan disputes this interpretation,
      the
      Health Plan may request that the dispute be decided by the Division of Medicaid.
      The ability to dispute an interpretation does not apply to issues that are
      a
      matter of law or fact. Any disputes shall be decided by the Agency’s Division of
      Medicaid which shall reduce the decision to writing and serve a copy on the
      Health Plan. The written decision of the Agency’s Division of Medicaid shall be
      final and conclusive. The division will render its final decision based upon
      the
      written submission of the Health Plan and the Agency, unless, at the sole
      discretion of the Division director, the division allows an oral presentation
      by
      the Health Plan and the Agency. If such a presentation is allowed, the
      information presented will be considered in rendering the division’s decision.
      Should the Health Plan challenge an Agency decision through arbitration as
      provided below, the Agency action shall not be stayed except by order of an
      arbitrator. Thereafter, a Health Plan shall resolve any controversy or claim
      arising out of, or relating to, the Contract, or the breach thereof, by
      arbitration. Said arbitration shall be held in the City of Tallahassee, Florida,
      and administered by the American Arbitration Association in accordance with
      its
      applicable rules and the Florida Arbitration Code (chapter 682, F.S.). Judgment
      upon any award rendered by the arbitrator may be entered by the Circuit Court
      in
      and for the Second Judicial Circuit, Leon County, Florida. The chosen arbitrator
      must be a member of the Florida Bar actively engaged in the practice of law
      with
      expertise in the process of deciding disputes and interpreting contracts in
      the
      health care field. Any arbitration award shall be in writing and shall specify
      the factual and legal bases for the award. Either party may appeal a judgment
      entered pursuant to an arbitration award to the First District Court of Appeal.
      The parties shall bear their own costs and expenses relating to the preparation
      and presentation of a case in arbitration. The arbitrator shall award to the
      prevailing party all administrative fees and expenses of the arbitration,
      including the arbitrator’s fee. This Contract with numbered attachments
      represents the entire agreement between the Health Plan and the Agency with
      respect to the subject matter in it and supersedes all other contracts between
      the parties when it is duly signed and authorized by the Health Plan and the
      Agency. Correspondence and memoranda of understanding do not constitute part
      of
      this Contract. In the event of a conflict of language between the Contract
      and
      the attachments, the provisions of the Contract shall govern. However, the
      Agency reserves the right to clarify any contractual relationship in writing
      with the concurrence of the Health Plan and such clarification shall govern.
      Pending final determination of any dispute over an Agency decision, the Health
      Plan shall proceed diligently with the performance of the Contract and in
      accordance with the Agency’s Division of Medicaid direction.

    

    
      	
              J.

            	
              Force
                Majeure

            

    

    

    
      	 	
              1.

            	
              The
                Agency shall not be liable for any excess cost to the Health Plan
                if the
                Agency's failure to perform the Contract arises out of causes beyond
                the
                control and without the result of fault or negligence on the part
                of the
                Agency. In all cases, the failure to perform must be beyond the control
                without the fault or negligence of the Agency. The Health Plan shall
                not
                be liable for performance of the duties and responsibilities of the
                Contract when its ability to perform is prevented by causes beyond
                its
                control. These acts must occur without the fault or negligence of
                the
                Health Plan. These include destruction to the facilities due to
                hurricanes, fires, war, riots, and other similar acts. Annually by
                May 31,
                the Health Plan shall submit to the Agency for approval an emergency
                management plan specifying what actions the Health Plan shall conduct
                to
                ensure the ongoing provisions of health services in a disaster or
                man-made
                emergency.

            

    

    

    
      	
              K.

            	
              Legal
                Action Notification

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall give the Agency, by certified mail, immediate written
                notification (no later than thirty (30) Calendar Days after service
                of
                process) of any action or suit filed or of any claim made against
                the
                Health Plan by any Subcontractor, vendor, or other party which results
                in
                litigation related to this Contract for disputes or damages exceeding
                the
                amount of $50,000. In addition, the Health Plan shall immediately
                advise
                the Agency of the Insolvency of a Subcontractor or of the filing
                of a
                petition in bankruptcy by or against a principal
                Subcontractor.

            

    

    

    
      	
              L.

            	
              Licensing

            

    

     

    
      	 	
              1.

            	
              In
                accordance with Section 409.912, F.S., all entities that provide
                Medicaid
                prepaid health care services must be commercially licensed in accordance
                with the provisions of Part I and Part III of Chapter 641,
                F.S.

            

    

     

    
      	
              M.

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

            

    

    

    
      	 	
              1.

            	
              No
                person or Health Plan may use, in connection with any item constituting
                an
                advertisement, solicitation, circular, book, pamphlet or other
                communication, or a broadcast, telecast, or other production, alone
                or
                with other words, letters, symbols or emblems the words “Medicaid,” or
                “Agency for Health Care Administration,” except as required in the
                Agency’s Standard Contract, page two (2), unless prior written approval
                is
                obtained from the Agency. Specific written authorization from the
                Agency
                is required to reproduce, reprint, or distribute any Agency form,
                application, or publication for a fee. State and local governments
                are
                exempt from this prohibition. A disclaimer that accompanies the
                inappropriate use of program or Agency terms does not provide a defense.
                Each piece of mail or information constitutes a
                violation.

            

    

    

    
      	
              N.

            	
              Offer
                of Gratuities

            

    

    

    
      	 	
              1.

            	
              By
                signing this agreement, the Health Plan signifies that no member
                of, or a
                delegate of, Congress, nor any elected or appointed official or employee
                of the State of Florida, the General Accounting Office, Department
                of
                Health and Human Services, CMS, or any other federal agency has or
                shall
                benefit financially or materially from this procurement. The Agency
                may
                terminate this Contract may be terminated by the Agency if it is
                determined that gratuities of any kind were offered to, or received
                by,
                any officials or employees from the State, its agents, or
                employees.

            

    

     

    
      	
              O.

            	
              Subcontracts

            

    

    
      	 	
              1.

            	
              The
                Health Plan is responsible for all work performed under this Contract,
                but
                may, with the prior written approval of the Agency, enter into
                Subcontracts for the performance of work required under this Contract.
                All
                Subcontracts must comply with 42 CFR 438.230. All Subcontracts and
                amendments executed by the Health Plan shall meet the following
                requirements. 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. The Agency encourages
                use of minority business enterprise Subcontractors. See Section X.C.,
                Provider Contract Requirements, above of this Contract, for provisions
                and
                requirements specific to Provider
                contracts.

            

    

    

    
      	 	
              2.

            	
              No
                Subcontract that the Health Plan enter into with respect to performance
                under the Contract shall, in any way, relieve the Health Plan of
                any
                responsibility for the performance of duties under this Contract.
                The
                Health Plan shall assure that all tasks related to the Subcontract
                are
                performed in accordance with the terms of this Contract. The Health
                Plan
                shall identify in its Subcontracts any aspect of service that may
                be
                further subcontracted by the
                Subcontractor.

            

    

    

    
      	 	
              3.

            	
              All
                model and executed Subcontracts and amendments used by the Health
                Plan
                under this Contract must be in writing, signed, and dated by the
                Health
                Plan and the Subcontractor and meet the following
                requirements:

            

    

    

    
      	 	
              a.

            	
              Identification
                of conditions and method of payment:

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan agrees to make payment to all Subcontractors pursuant
                to all
                State and federal laws, rules and regulations, specifically, Section
                641.3155, F.S., 42 CFR 447.46, and 42 CFR 447.45(d)(2), (3), (d)(5)
                and
                (d)(6); 

            

    

    

    
      	 	
              (2)

            	
              Provide
                for prompt submission of information needed to make
                payment;

            

    

    

    
      	 	
              (3)

            	
              Make
                full disclosure of the method and amount of compensation or other
                consideration to be received from the Health Plan;
                

            

    

    

    
      	 	
              (4)

            	
              Require
                an adequate record system be maintained for recording services, charges,
                dates and all other commonly accepted information elements for services
                rendered to the Health Plan; and

            

    

    

    
      	 	
              (5)

            	
              Specify
                that the Health Plan shall assume responsibility for cost avoidance
                measures for third party collections in accordance with Section XV.,
                Financial Requirements.

            

    

    

    
      	 	
              b.

            	
              Provisions
                for monitoring and inspections:

            

    

    

    
      	 	
              (1)

            	
              Provide
                that the Agency and DHHS may evaluate through inspection or other
                means
                the quality, appropriateness and timeliness of services
                performed;

            

    

    

    
      	 	
              (2)

            	
              Provide
                for inspections of any records pertinent to the Contract by the Agency
                and
                DHHS;

            

    

    

    
      	 	
              (3)

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

            

    

    

    
      	 	
              (4)

            	
              Provide
                for monitoring and oversight by the Health Plan and the Subcontractor
                to
                provide assurance that all licensed medical professionals are Credentialed
                in accordance with the Health Plan’s and the Agency’s Credentialing
                requirements as found in Section VIII.A.3.h Credentialing and
                Recredentialing, above, if the Health Plan has delegated the Credentialing
                to a Subcontractor; and

            

    

    

    
      	 	
              (5)

            	
              Provide
                for monitoring of services rendered to Enrollees sponsored by the
                Provider.

            

    

    

    
      	 	
              c.

            	
              Specification
                of functions of the Subcontractor:

            

    

    

    
      	 	
              (1)

            	
              Identify
                the population covered by the
                Subcontract;

            

    

    

    
      	 	
              (2)

            	
              Provide
                for submission of all reports and clinical information required by
                the
                Health Plan, including Child Health Check-Up reporting (if applicable);
                and

            

    

    

    
      	 	
              (3)

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

            

    

    

    
      	 	
              d.

            	
              Protective
                clauses:

            

    

    

    
      	 	
              (1)

            	
              Require
                safeguarding of information about Enrollees according to 42 CFR,
                Part
                438.224;

            

    

    

    
      	 	
              (2)

            	
              Require
                compliance with HIPAA privacy and security
                provisions;

            

    

    

    
      	 	
              (3)

            	
              Require
                an exculpatory clause, which survives Subcontract termination, including
                breach of Subcontract due to insolvency, which assures that Medicaid
                Recipients or the Agency will not be held liable for any debts of
                the
                Subcontractor; and 

            

    

    

    
      	 	
              (4)

            	
              If
                there is a Health Plan physician incentive plan, include a statement
                that
                the Health Plan shall make no specific payment directly or indirectly
                under a physician incentive plan to a Subcontractor as an inducement
                to
                reduce or limit Medically Necessary services to an Enrollee, and
                affirmatively state that all incentive plans do not provide incentives,
                monetary or otherwise, for the withholding of Medically Necessary
                care.

            

    

    

    
      	 	
              4.

            	
              Contain
                a clause indemnifying, defending and holding the Agency and the Health
                Plan’s Enrollees harmless from and against all claims, damages, causes
                of
                action, costs or expenses, including court costs and reasonable attorney
                fees, to the extent proximately caused by any negligent act or other
                wrongful conduct arising from the Subcontract agreement. This clause
                must
                survive the termination of the Subcontract, including breach due
                to
                Insolvency. The Agency may waive this requirement for itself, but
                not
                Health Plan Enrollees, for damages in excess of the statutory cap
                on
                damages for public entities, if the Subcontractor is a public health
                entity with statutory immunity. All such waivers must be approved
                in
                writing by the Agency.

            

    

    

    
      	 	
              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 Health Plan. Such insurance
                shall comply with Florida's Worker's Compensation
                Law.

            

    

    

    
      	 	
              6.

            	
              Specify
                that if the Subcontractor delegates or Subcontracts any functions
                of the
                Health Plan, that the Subcontract or delegation includes all the
                requirements of this Contract.

            

    

    

    
      	 	
              7.

            	
              Make
                provisions for a waiver of those terms of the Subcontract, which,
                as they
                pertain to Medicaid Recipients, are in conflict with the specifications
                of
                this Contract.

            

    

    

    
      	 	
              8.

            	
              Provide
                for revoking delegation, or imposing other sanctions, if the
                Subcontractor’s performance is
                inadequate.

            

    

    

    
      	
              P.

            	
              Hospital
                Provider Contracts

            

    

    

    All
      Hospital Provider Contracts must meet the requirements outlined in Section
      X.C.,
      Provider Contract Requirements, above. In addition, Hospital Provider Contracts
      shall require that the Hospitals notify the Health Plan of births where the
      mother is a Health Plan Enrollee. The Hospital Provider Contract must also
      specify which entity (Health Plan or Hospital) is responsible for completing
      form DCF-ES 2039 and submitting it to the local DCF Economic Self-Sufficiency
      Services office. The Hospital Provider Contract must also indicate that the
      Health Plan’s name must be indicated as the referring Agency when the form
      DCF-ES 2039 is completed.

    

    
      	
              Q.

            	
              Termination
                Procedures

            

    

    

    
      	 	
              1.

            	
              In
                conjunction with Section III.B., Termination, on page eight (8) of
                the
                Standard Contract, all Provider Contracts and Subcontracts shall
                contain
                termination procedures. The Health Plan agrees to extend the thirty
                (30)
                Calendar Days notice found in Section III.B.1., Termination at Will,
                on
                page eight (8) of the Standard Contract to ninety (90) Calendar Days
                notice. The party initiating the termination shall render written
                notice
                of termination to the other party by certified mail, return receipt
                requested, or in person with proof of delivery, or by facsimile letter
                followed by certified mail, return receipt requested. The notice
                of
                termination shall specify the nature of termination, the extent to
                which
                performance of work under the Contract is terminated, and the date
                on
                which such termination shall become effective. In accordance with
                1932(e)(4), Social Security Act, the Agency shall provide the Health
                Plan
                with an opportunity for a hearing prior to termination for Cause.
                This
                does not preclude the Agency from terminating without
                Cause.

            

    

    

    
      	 	
              2.

            	
              Upon
                receipt of final notice of termination, on the date and to the extent
                specified in the notice of termination, the Health Plan
                shall:

            

    

    

    
      	 	
              a.

            	
              Stop
                work under the Contract, but not before the termination
                date.

            

    

    

    
      	 	
              b.

            	
              Cease
                enrollment of new Enrollees under the
                Contract.

            

    

    

    
      	 	
              c.

            	
              Terminate
                all Marketing activities and Subcontracts relating to
                Marketing.

            

    

    

    
      	 	
              d.

            	
              Assign
                to the State those Subcontracts as directed by the Agency's contracting
                officer including all the rights, title and interest of the Health
                Plan
                for performance of those
                Subcontracts.

            

    

    

    
      	 	
              e.

            	
              In
                the event the Agency has terminated this Contract in one or more
                Agency
                areas of the State, complete the performance of this Contract in
                all other
                areas in which the Health Plan’s Contract was not
                terminated.

            

    

    

    
      	 	
              f.

            	
              Take
                such action as may be necessary, or as the Agency's contracting officer
                may direct, for the protection of property related to the Contract
                that is
                in the possession of the Health Plan and in which the Agency has
                been
                granted or may acquire an interest.

            

    

    

    
      	 	
              g.

            	
              Not
                accept any payment after the Contract ends, unless the payment is
                for the
                time period covered under the Contract. Any payments due under the
                terms
                of this Contract may be withheld until the Agency receives from the
                Health
                Plan all written and properly executed documents as required by the
                written instructions of the Agency.

            

    

    

    
      	 	
              h.

            	
              At
                least sixty (60) Calendar Days prior to the termination effective
                date,
                provide written notification to all Enrollees of the following
                information: the date on which the Health Plan will no longer participate
                in the State’s Medicaid program and instructions on contacting the
                Agency’s Choice Counselor/Enrollment Broker help line to obtain
                information on the Enrollee’s enrollment options and to request a change
                in Health Plans.

            

    

    

    
      	
              R.

            	
              Waiver

            

    

    

    
      	 	
              1.

            	
              No
                covenant, condition, duty, obligation, or undertaking contained in
                or made
                a part of the Contract shall be waived except by written agreement
                of the
                parties, and forbearance or indulgence in any other form or manner
                by
                either party in any regard whatsoever shall not constitute a waiver
                of the
                covenant, condition, duty, obligation, or undertaking to be kept,
                performed, or discharged by the party to which the same may apply.
                Until
                complete performance or satisfaction of all such covenants, conditions,
                duties, obligations, or undertakings, the other party shall have
                the right
                to invoke any remedy available under law or equity not withstanding
                any
                such forbearance or indulgence.

            

    

    

    
      	
              S.

            	
              Withdrawing
                Services from a County

            

    

    

    
      	 	
              1.

            	
              If
                the Health Plan intends to withdraw services from a county, it shall
                provide written notice to all Enrollees in that county at least sixty
                (60)
                Calendar Days before the last day of service. The notice shall contain
                the
                same information as required for a notice of termination according
                to
                Section XVI.Q., Terms and Conditions, Termination Procedures, of
                this
                Contract. The Health Plan shall also provide written notice of the
                withdrawal to all Providers and Subcontractors in the
                county.

            

    

    

    
      	
              T.

            	
              MyFloridaMarketPlace
                Vendor Registration

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan is exempt under Rule 60A-1.030(3)d(ii), Florida Administrative
                Code, from being required to register in MyFloridaMarketPlace for
                this
                Contract.

            

    

    

    
      	
              U.

            	
              MyFloridaMarketplace
                Vendor Registration and Transaction Fee Exemption 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan is exempted from paying the 1% transaction fee per
                60A-1.032(1)(g) of the Florida Administrative Code for this
                Contract.

            

    

    

    
      	
              V.

            	
              Ownership
                and Management Disclosure 

            

    

    

    
      	 	
              1.

            	
              Federal
                and State laws require full disclosure of ownership, management and
                control of Disclosing Entities. 

            

    

    

    
      	 	
              a.

            	
              Disclosure
                shall be made on forms prescribed by the Agency for the areas of
                ownership
                and control interest (42 CFR 455.104, Form CMS 1513), business
                transactions (42 CFR 455.105), public entity crimes (Section
                287.133(3)(a), F.S.), and disbarment and suspension (52 Fed. Reg.,
                pages
                20360-20369, and Section 4707 of the Balanced Budget Act of 1997).
                The
                forms are available through the Agency and are to be submitted to
                the
                Agency with the initial application for a Medicaid Health Plan and
                then
                submitted on an annual basis. The Health Plan shall disclose any
                changes
                in management as soon as those occur. In addition, the Health Plan
                shall
                submit to the Agency full disclosure of ownership and control of
                the
                Health Plan at least sixty (60) Calendar Days before any change in
                the
                Health Plan’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 percent (5%) or more of the Health Plan's
                capital or stock, or receives five percent (5%) 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 Health Plan or by its property
                or
                assets and that interest is equal to or exceeds five percent (5%)
                of the
                total property or assets; or

            

    

    

    
      	 	
              (c)

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

            

    

    

    
      	 	
              (2)

            	
              The
                percentage of direct ownership or control is calculated by multiplying
                the
                percent of interest which a person owns, by the percent of the Health
                Plan’s assets used to secure the obligation. Thus, if a person owns ten
                percent (10%) of a note secured by sixty percent (60%) of the Health
                Plan’s assets, the person owns six percent (6%) of the Health
                Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                percent of indirect ownership or control is calculated by multiplying
                the
                percentage of ownership in each organization. Thus, if a person owns
                ten
                percent (10%) of the stock in a corporation, which owns eighty percent
                (80%) of the Health Plan’s stock, the person owns eight percent (8%) of
                the Health Plan.

            

    

    

    
      	 	
              c.

            	
              The
                following definitions apply to management
                disclosure:

            

    

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (a)

            	
              Changes
                in the board of directors or officers of the Health Plan, medical
                director, chief executive officer, administrator, and chief financial
                officer.

            

    

    

    
      	 	
              (b)

            	
              Changes
                in the management of the Health Plan where the Health Plan has decided
                to
                contract out the operation of the Health Plan to a management corporation.
                The Health Plan shall disclose such changes in management control
                and
                provide a copy of the contract to the Agency for approval at least
                sixty
                (60) Calendar Days prior to the management contract start
                date.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall conduct an annual background check with the Florida
                Department of Law Enforcement on all persons with five percent (5%)
                or
                more ownership interest in the Health Plan, or who have executive
                management responsibility for the Health Plan, or have the ability
                to
                exercise effective control of the Health Plan (see Section 409.912,
                F.S.).
                The Health Plan shall submit information to the Agency for such persons
                who have a record of illegal conduct according to the background
                check.
                The Health Plan shall keep a record of all background checks to be
                available for Agency review upon
                request.

            

    

    

    
      	 	
              (1)

            	
              The
                Health Plan shall submit, prior to execution of a contract, complete
                sets
                of fingerprints of principals of the Health Plan to the Agency for
                the
                purpose of conducting a criminal history record check (see Section
                409.907, F.S.).

            

    

    

    
      	 	
              (2)

            	
              Principals
                of the Health Plan shall be as defined in Section 409.907,
                F.S.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall submit to the Agency, within five (5) Business
                Days, any
                information on any officer, director, agent, managing employee, or
                owner
                of stock or beneficial interest in excess of five percent (5%) of
                the
                Health Plan who has been found guilty of, regardless of adjudication,
                or
                who entered a plea of nolo
                contendere
                or
                guilty to, any of the offenses listed in Section 435.03,
                F.S.

            

    

    

    
      	 	
              f.

            	
              The
                Agency shall not contract with a Health Plan that has an officer,
                director, agent, managing employee, or owner of stock or beneficial
                interest in excess of five percent (5%) of the Health Plan, who has
                committed any of the above listed offenses (see Section 409.912,
                F.S.). In
                order to avoid termination, the Health Plan must submit a corrective
                action plan, acceptable to the Agency, which ensures that such person
                is
                divested of all interest and/or control and has no role in the operation
                and/or management of the Health
                Plan.

            

    

    

    
      	
              W.

            	
              Minority
                Recruitment and Retention
                Plan

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall implement and maintain a minority recruitment and
                retention plan in accordance with section 641.217, F.S. The Health
                Plan
                shall have policies and procedures for the implementation and maintenance
                of such a plan. The minority recruitment and retention plan may be
                company-wide for all product lines.

            

    

    

    
      	
              X.

            	
              Independent
                Provider

            

    

    

    
      	 	
              1.

            	
              It
                is expressly agreed that the Health Plan and any Subcontractors,
                and any
                agents, officers, and/or employees of the Health Plan or any
                Subcontractors, in the performance of this Contract shall act in
                an
                independent capacity and not as officers and employees of the Agency
                or
                the State of Florida. It is further expressly agreed that this Contract
                shall not be construed as a partnership or joint venture between
                the
                Health Plan or any Subcontractor and the Agency and the State of
                Florida.

            

    

    

    
      	
              Y.

            	
              General
                Insurance Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall obtain and maintain the same adequate insurance
                coverage
                including general liability insurance, professional liability and
                malpractice insurance, fire and property insurance, and directors’
                omission and error insurance. All insurance coverage must comply
                with the
                provisions set forth for HMOs in Rule 69O-191.069, F.A.C.; excepting
                that
                the reporting, administrative, and approval requirements shall be
                to the
                Agency rather than to the Department of Financial Services. All insurance
                policies must be written by insurers licensed to do business in the
                State
                of Florida and in good standing with the Department of Financial
                Services.
                All policy declaration pages must be submitted to the Agency annually.
                Each certificate of insurance shall provide for notification to the
                Agency
                in the event of termination of the
                policy.

            

    

    

    
      	
              Z.

            	
              Worker's
                Compensation Insurance

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall secure and maintain during the life of the Contract,
                worker's compensation insurance for all of its employees connected
                with
                the work under this Contract. Such insurance shall comply with the
                Florida
                Worker's Compensation Law (see Chapter 440, F.S.). Policy declaration
                pages must be submitted to the Agency
                annually.

            

    

    

    
      	
              AA.

            	
              State
                Ownership

            

    

    

    
      	 	
              1.

            	
              The
                Agency shall have the right to use, disclose, or duplicate all information
                and data developed, derived, documented, or furnished by the Health
                Plan
                resulting from this Contract. Nothing herein shall entitle the Agency
                to
                disclose to third parties data or information which would otherwise
                be
                protected from disclosure by State or federal
                law.

            

    

    

    
      	
              BB.

            	
              Disaster
                Plan

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit a plan describing procedures guaranteeing
                the
                continuation of services during an emergency, including but not limited
                to
                localized acts of nature, accidents, and technological and/or
                attack-related emergencies. 

            

    

    

    REMAINDER
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      BUSINESS
        ASSOCIATE AGREEMENT

      

      The
        parties to this Attachment agree that the following provisions constitute
        a
        business associate agreement for purposes of complying with the requirements
        of
        the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
        This
        Attachment is applicable if the Vendor is a business associate within the
        meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.

      

      The
        Vendor certifies and agrees as to abide by the following:

      

      
        	1.  	
                Definitions.
                  Unless specifically stated in this Attachment, the definition of
                  the terms
                  contained herein shall have the same meaning and effect as defined
                  in 45
                  C.F.R. 160 and 164.

              

      

      

      1.a.
        Protected
        Health Information.
        For
        purposes of this Attachment, protected health information shall have the
        same
        meaning and effect as defined in 45 C.F.R.
        160 and
164,
        limited to the information created, received, maintained or transmitted by
        the
        Vendor from, or on behalf of, the Agency. 

      

      1.b.
        Security
        Incident.
        For
        purposes of this Attachment, security incident shall mean any
        event
        resulting in computer systems, networks, or data being viewed, manipulated,
        damaged, destroyed or made inaccessible by an unauthorized activity. See
        National Institute of Standards and Technology (NIST) Special Publication
        800-61, "Computer Security Incident Handling Guide,” for more
        information.

      

      
        	2.  	
                Use
                  and Disclosure of Protected Health Information.
                  The Vendor shall not use or disclose protected health information
                  other
                  than as permitted by this Contract or by federal and state law.
                  The Vendor
                  will use appropriate safeguards to prevent the use or disclosure
                  of
                  protected health information for any purpose not in conformity
                  with this
                  Contract and federal and state law. The Vendor will implement
                  administrative, physical, and technical safeguards that reasonably
                  and
                  appropriately protect the confidentiality, integrity, and availability
                  of
                  electronic protected health information the Vendor creates, receives,
                  maintains, or transmits on behalf of the Agency.
                  

              

      

      

      3. Use
        and Disclosure of Information for Management, Administration, and Legal
        Responsibilities.
        The
        Vendor is permitted to use and disclose protected health information received
        from the Agency for the proper management and administration of the Vendor
        or to
        carry out the legal responsibilities of the Vendor, in accordance with 45
        C.F.R.
        164.504(e)(4). Such disclosure is only permissible where required by law,
        or
        where the
        Vendor obtains reasonable assurances from the person to whom the protected
        health information is disclosed that: (1) the protected health information
        will
        be held confidentially, (2) the protected health information will be used
        or
        further disclosed only as required by law or for the purposes for which it
        was
        disclosed to the person, and (3) the person notifies the Vendor of any instance
        of which it is aware in which the confidentiality of the protected health
        information has been breached.

      

      4. Disclosure
        to Third Parties.
        The
        Vendor will not divulge, disclose, or communicate protected health information
        to any third party for any purpose not in conformity with this Contract without
        prior written approval from the Agency. The Vendor shall ensure that any
        agent,
        including a subcontractor, to whom it provides protected health information
        received from, or created or received by the Vendor on behalf of, the Agency
        agrees to the same terms, conditions, and restrictions that apply to the
        Vendor
        with respect to protected health information.

      

      5. Access
        to Information.
        The
        Vendor shall make protected health information available in accordance with
        federal and state law, including providing a right of access to persons who
        are
        the subjects of the protected health information in accordance with 45 C.F.R.
        164.524. 

      

      6. Amendment
        and Incorporation of Amendments.
        The
        Vendor shall make protected health information available for amendment and
        to
        incorporate any amendments to the protected health information in accordance
        with 45 C.F.R. § 164.526.

      

      7. Accounting
        for Disclosures.
        The
        Vendor shall make protected health information available as required to provide
        an accounting of disclosures in accordance with 45 C.F.R. § 164.528. The Vendor
        shall document all disclosures of protected health information as needed
        for the
        Agency to respond to a request for an accounting of disclosures in accordance
        with 45 C.F.R. § 164.528.

      

      8. Access
        to Books and Records.
        The
        Vendor shall make its internal practices, books, and records relating to
        the use
        and disclosure of protected health information received from, or created
        or
        received by the Vendor on behalf of the Agency, available to the Secretary
        of
        the Department of Health and Human Services or the Secretary’s designee for
        purposes of determining compliance with the Department of Health and Human
        Services Privacy Regulations.

      

      9. Reporting.
        The
        Vendor shall make a good faith effort to identify any use or disclosure of
        protected health information not provided for in this Contract. The Vendor
        will
        report to the Agency, within ten (10) business days of discovery, any use
        or
        disclosure of protected health information not provided for in this Contract
        of
        which the Vendor is aware. The Vendor will report to the Agency, within
        twenty-four (24) hours of discovery, any security incident of which the Vendor
        is aware. A violation of this paragraph shall be a material violation of
        this
        Contract.

      

      10.
        Termination.
        Upon the
        Agency’s discovery of a material breach of this Attachment, the Agency shall
        have the right to terminate this Contract. 

      

      10.a.
        Effect
        of Termination.
        At the
        termination of this Contract, the Vendor shall return all protected health
        information that the Vendor still maintains in any form, including any copies
        or
        hybrid or merged databases made by the Vendor; or with prior written approval
        of
        the Agency, the protected health information may be destroyed by the Vendor
        after its use. If the protected health information is destroyed pursuant
        to the
        Agency’s prior written approval, the Vendor must provide a written confirmation
        of such destruction to the Agency. If return or destruction of the protected
        health information is determined not feasible by the Agency, the Vendor agrees
        to protect the protected health information and treat it as strictly
        confidential.

      

      

      

      The
        Vendor has caused this Attachment to be signed and delivered by its duly
        authorized representative, as of the date set forth below.

      

      Vendor
        Name:

       

        
        /s/  Paul Behrens      

      Signature 

       

      8/31/06  

      Date

       

       
        Paul Behrens, SVP & Chief Financial
        Officer   

      Name
        and
        Title of Authorized Signer

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    

      CERTIFICATION
        REGARDING LOBBYING

      CERTIFICATION
        FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

      

      

      The
        undersigned certifies, to the best of his or her knowledge and belief,
        that:

      

      
        	(1)  	
                No
                  federal appropriated funds have been paid or will be paid, by or
                  on behalf
                  of the undersigned, to any person for influencing or attempting
                  to
                  influence an officer or employee of any agency, a member of congress,
                  an
                  officer or employee of congress, or an employee of a member of
                  congress in
                  connection with the awarding of any federal contract, the making
                  of any
                  federal grant, the making of any federal loan, the entering into
                  of any
                  cooperative agreement, and the extension, continuation, renewal,
                  amendment, or modification of any federal contract, grant, loan,
                  or
                  cooperative agreement.

              

      

       

      
        	(2)  	
                If
                  any funds other than federal appropriated funds have been paid
                  or will be
                  paid to any person for influencing or attempting to influence an
                  officer
                  or employee of any agency, a member of congress, an officer or
                  employee of
                  congress, or an employee of a member of congress in connection
                  with this
                  federal contract, grant, loan, or cooperative agreement, the undersigned
                  shall complete and submit Standard Form-LLL, “Disclosure Form to Report
                  Lobbying,” in accordance with its
                  instructions.

              

      

       

      
        	(3)  	
                The
                  undersigned shall require that the language of this certification
                  be
                  included in the award documents for all sub-awards at all tiers
                  (including
                  subcontracts, sub-grants, and contracts under grants, loans, and
                  cooperative agreements) and that all sub-recipients shall certify
                  and
                  disclose accordingly.

              

      

      

      This
        certification is a material representation of fact upon which reliance was
        placed when this transaction was made or entered into. Submission of this
        certification is a prerequisite for making or entering into this transaction
        imposed by section 1352, Title 31, U.S. Code. Any person who fails to file
        the
        required certification shall be subject to a civil penalty of not less than
        $10,000 and not more than $100,000 for each such failure.

       

      

      
        	
                  /s/  Paul Behrens     
                  

                Signature 

              	
                 8/31/06 

                Date

              	 
	
                 

                Paul
                  Behrens             
                  

                Name of Authorized Individual

              	
                 

                 FA 615

                Application or Contract Number

              	 
	
                 

                WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida

                8735 Henderson Rd, Ren 1 Tampa, FL 33634

                Name and Address of Organization

              	 

      

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    CERTIFICATION
      REGARDING

    DEBARMENT,
      SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

    CONTRACTS/SUBCONTRACTS

    

    This
      certification is required by the regulations implementing Executive Order 12549,
      Debarment and Suspension, signed February 18, 1986. The guidelines were
      published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
      20360-20369).

    

    INSTRUCTIONS

    

    
      	
              1.

            	
              Each
                Vendor whose contract/subcontract equals or exceeds $25,000 in federal
                monies must sign this certification prior to execution of each
                contract/subcontract. Additionally, Vendors who audit federal programs
                must also sign, regardless of the contract amount. The
                Agency for Health Care Administration cannot contract with these
                types of
                Vendors if they are debarred or suspended by the federal
                government.

            

    

    

    
      	
              2.

            	
              This
                certification is a material representation of fact upon which reliance
                is
                placed when this contract/subcontract is entered into. If it is later
                determined that the signer knowingly rendered an erroneous certification,
                the Federal Government may pursue available remedies, including suspension
                and/or debarment.

            

    

    

    
      	
              3.

            	
              The
                Vendor shall provide immediate written notice to the contract manager
                at
                any time the Vendor learns that its certification was erroneous when
                submitted or has become erroneous by reason of changed
                circumstances.

            

    

    

    
      	
              4.

            	
              The
                terms "debarred," "suspended," "ineligible," "person," "principal,"
                and
                "voluntarily excluded," as used in this certification, have the meanings
                set out in the Definitions and Coverage sections of rules implementing
                Executive Order 12549. You may contact the contract manager for assistance
                in obtaining a copy of those
                regulations.

            

    

    

    
      	
              5.

            	
              The
                Vendor agrees by submitting this certification that, it shall not
                knowingly enter into any subcontract with a person who is debarred,
                suspended, declared ineligible, or voluntarily excluded from participation
                in this contract/subcontract unless authorized by the Federal
                Government.

            

    

    

    
      	
              6.

            	
              The
                Vendor further agrees by submitting this certification that it will
                require each subcontractor of this contract/subcontract, whose payment
                will equal or exceed $25,000 in federal monies, to submit a signed
                copy of
                this certification.

            

    

    

    
      	
              7.

            	
              The
                Agency for Health Care Administration may rely upon a certification
                of a
                Vendor that it is not debarred, suspended, ineligible, or voluntarily
                excluded from contracting/subcontracting unless it knows that the
                certification is erroneous.

            

    

    

    
      	
              8.

            	
              This
                signed certification must be kept in the contract manager's contract
                file.
                Subcontractor's certifications must be kept at the contractor's business
                location.

            

    

    

     

    CERTIFICATION

    

    
      	
              (1)

            	
              The
                prospective Vendor certifies, by signing this certification, that
                neither
                he nor his principals is presently debarred, suspended, proposed
                for
                debarment, declared ineligible, or voluntarily excluded from participation
                in this contract/subcontract by any federal department or
                agency.

            

    

    

    
      	
              (2)

            	
              Where
                the prospective Vendor is unable to certify to any of the statements
                in
                this certification, such prospective Vendor shall attach an explanation
                to
                this certification.

            

    

    

     

    
      	
            	   /s/  Paul
              Behrens    
              Signature

            	
               8/31/06

              Date

            

    

    
      	
               

              Paul
                Behrens, SVP & CFO

              Name
                and Title of Authorized Signer

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