Common use of Covered Medicaid Services Clause in Contracts

Covered Medicaid Services. a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an “X” in Table 5 below and as specified in applicable exhibits to Attachment I, Scope of Services, and as defined in Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms; Section V, Covered Services; and Section VI, Behavioral Health Care. b. For non-Reform populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of an “X” in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Item 3, Other Service Requirements, of this subsection and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non-Reform population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- Reform populations. The only county for which optional transportation services may be authorized is Miami-Dade County. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. (c) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (d) If an “X” is listed in the Non-Reform column, the Agency has authorized the Health Plan to provide such transportation services in Miami-Dade County. See Item 3, Other Service Requirements, of this subsection for more information regarding optional services. (3) For the optional frail/elderly program for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- Reform populations. The only county for which optional frail/elderly services may be authorized is Miami-Dade County. When the SMMC program for the Managed Long-Term Care (LTC) component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Core Contract Provisions, Exhibit 3, Non-Reform HMO Frail/Elderly Program. (c) If an “X” is listed in the Non-Reform column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami-Dade County. Advanced Registered Nurse Practitioner Services X Ambulatory Surgical Center Services X Birth Center Services X Child Health Check-Up Services X Chiropractic Services X Community Behavioral Health Services X County Health Department Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract Durable Medical Equipment and Medical Supplies X Dialysis Services X Emergency Room Services X Family Planning Services X Federally Qualified Health Center Services X Freestanding Dialysis Centers X Hearing Services X Home Health Care Services X Hospital Services – Inpatient X Hospital Services – Outpatient X Immunizations X Independent Laboratory Services X Licensed Midwife Services X Optometric Services X Physician Services X Physician Assistant Services X Podiatry Services X Portable X-ray Services X Prescribed Drugs X Primary Care Case Management Services X Rural Health Clinic Services X Targeted Case Management X Therapy Services: Occupational X Therapy Services: Physical X Therapy Services: Respiratory X Therapy Services: Speech X Transplant Services X Vision Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract

Covered Medicaid Services. a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an listed below in Table 5 with “X” in Table 5 below and as specified in applicable exhibits to Attachment I, Scope of Services, this attachment and as defined in Attachment II, Core Contract Provisions, Section I, Definitions and AcronymsDefinitions; Section V, Covered Services; and Section VI, Behavioral Health Care., and as specified in applicable exhibits to Attachment I. b. For non-Reform populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of an “X” in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Attachment II, Exhibit 5, for more information regarding the provision of these optional benefits. See Item 3., Other Service Requirements, of this subsection and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non-Reform population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- non-Reform populations. The only county for which optional transportation services may be authorized is Miami-Miami Dade County. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract. (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. (c) . In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (dc) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such transportation services in Miami-Miami Dade County. See Item 3., Other Service Requirements, of this subsection for more information regarding optional services.. WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract (3) For the optional frail/elderly program for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- non-Reform populations. The only county for which optional frail/elderly services may be authorized is Miami-Miami Dade County. When the SMMC program for the Managed Long-Term Care (LTC) component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Core Contract Provisions, Exhibit 3III, Non-Reform HMO Frail/Elderly Program. (c) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami-Miami Dade County. Advanced Registered Nurse Practitioner Services X Ambulatory Surgical Center Services X Birth Center Services X Child Health Check-Up Services X Chiropractic Services X Community Behavioral Health Services X County Health Department Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract Durable Medical Equipment and Medical Supplies X Dialysis Services X Emergency Room Services X Family Planning Services X Federally Qualified Health Center Services X Freestanding Dialysis Centers X Hearing Services X Home Health Care Services X Hospital Services – Inpatient X Hospital Services – Outpatient X Immunizations X Independent Laboratory Services X Licensed Midwife Services X WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract Optometric Services X Physician Services X Physician Assistant Services X Podiatry Services X Portable X-ray Services X Prescribed Drugs X Primary Care Case Management Services X Rural Health Clinic Services X Targeted Case Management X Therapy Services: Occupational X Therapy Services: Physical X Therapy Services: Respiratory X Therapy Services: Speech X Transplant Services X Vision Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform ContractX

Covered Medicaid Services. a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an listed below in Table 5 with “X” in Table 5 below and as specified in applicable exhibits to Attachment I, Scope of Services, this attachment and as defined in Attachment II, Core Contract Provisions, Section I, Definitions and AcronymsDefinitions; Section V, Covered Services; and Section VI, Behavioral Health Care., and as specified in applicable exhibits to Attachment I. b. For non-Reform populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of an “X” in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Attachment II, Exhibit 5, for more information regarding the provision of these optional benefits. See Item 3., Other Service Requirements, of this subsection and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non-Reform population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- non-Reform populations. The only county for which optional transportation services may be authorized is Miami-Miami Dade County. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract. (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. (c) . In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (dc) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such transportation services in Miami-Miami Dade County. See Item 3., Other Service Requirements, of this subsection for more information regarding optional services.. AHCA Contract No. FA905, Attachment I, Page 3 of 9 HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract (3) For the optional frail/elderly program for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- non-Reform populations. The only county for which optional frail/elderly services may be authorized is Miami-Miami Dade County. When the SMMC program for the Managed Long-Term Care (LTC) component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Core Contract Provisions, Exhibit 3III, Non-Reform HMO Frail/Elderly Program. (c) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami-Miami Dade County. Advanced Registered Nurse Practitioner Services X Ambulatory Surgical Center Services X Birth Center Services X Child Health Check-Up Services X Chiropractic Services X Community Behavioral Health Services X County Health Department Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract Durable Medical Equipment and Medical Supplies X Dialysis Services X Emergency Room Services X Family Planning Services X Federally Qualified Health Center Services X Freestanding Dialysis Centers X Hearing Services X Home Health Care Services X Hospital Services – Inpatient X Hospital Services – Outpatient X Immunizations X Independent Laboratory Services X Licensed Midwife Services X AHCA Contract No. FA905, Attachment I, Page 4 of 9 HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract Optometric Services X Physician Services X Physician Assistant Services X Podiatry Services X Portable X-ray Services X Prescribed Drugs X Primary Care Case Management Services X Rural Health Clinic Services X Targeted Case Management X Therapy Services: Occupational X Therapy Services: Physical X Therapy Services: Respiratory X Therapy Services: Speech X Transplant Services X Transportation Services* X Vision Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform ContractX

Covered Medicaid Services. a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an listed below in Table 5 with “X” in Table 5 below and as specified in applicable exhibits to Attachment I, Scope of Services, this attachment and as defined in Attachment II, Core Contract Provisions, Section I, Definitions and AcronymsDefinitions; Section V, Covered Services; and Section VI, Behavioral Health Care., and as specified in applicable exhibits to Attachment I. b. For non-Reform populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of an “X” in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Attachment II, Exhibit 5, for more information regarding the provision of these optional benefits. See Item 3., Other Service Requirements, of this subsection and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non-Reform population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- Reform populations. The only county for which optional transportation services may be authorized is Miami-Miami Dade County. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract. (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. (c) . In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (dc) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such transportation services in Miami-Miami Dade County. See Item 3., Other Service Requirements, of this subsection for more information regarding optional services.. AMERIGROUP Florida, Inc. Medicaid Non-Reform and Reform d/b/a AMERIGROUP Community Care HMO Contract (3) For the optional frail/elderly program for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- Reform populations. The only county for which optional frail/elderly services may be authorized is Miami-Miami Dade County. When the SMMC program for the Managed Long-Term Care (LTC) component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Core Contract Provisions, Exhibit 3III, Non-Reform HMO Frail/Elderly Program. (c) If an “X” is listed in the Nonnon-Reform column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami-Miami Dade County. Advanced Registered Nurse Practitioner Services X X Ambulatory Surgical Center Services X X Birth Center Services X X Child Health Check-Up Services X X Chiropractic Services X X Community Behavioral Health Services X X County Health Department Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract X Dental Services* X Durable Medical Equipment and Medical Supplies X X Dialysis Services X X Emergency Room Services X X Family Planning Services X X Federally Qualified Health Center Services X X Freestanding Dialysis Centers X X Hearing Services X X Home Health Care Services X Hospital Services – Inpatient X Hospital Services – — Inpatient X X Hospital Services — Outpatient X X Immunizations X X Independent Laboratory Services X X Licensed Midwife Services X X AMERIGROUP Florida, Inc. Medicaid Non-Reform and Reform d/b/a AMERIGROUP Community Care HMO Contract Optometric Services X X Physician Services X X Physician Assistant Services X X Podiatry Services X X Portable X-ray Services X X Prescribed Drugs X X Primary Care Case Management Services X X Rural Health Clinic Services X X Targeted Case Management X X Therapy Services: Occupational X X Therapy Services: Physical X X Therapy Services: Respiratory X X Therapy Services: Speech X X Transplant Services X X Transportation Services* X Vision Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform ContractX

Covered Medicaid Services. a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an “X” in Table 5 below and as specified in applicable exhibits to Attachment I, Scope of Services, and as defined in Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms; Section V, Covered Services; and Section VI, Behavioral Health Care. b. For non-Reform populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of an “X” in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Item 3, Other Service Requirements, of this subsection and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non-Reform population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- Reform populations. The only county for which optional transportation services may be authorized is Miami-Dade County. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. (c) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (d) If an “X” is listed in the Non-Reform column, the Agency has authorized the Health Plan to provide such transportation services in Miami-Dade County. See Item 3, Other Service Requirements, of this subsection for more information regarding optional services. (3) For the optional frail/elderly program for the non-Reform population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- Reform populations. The only county for which optional frail/elderly services may be authorized is Miami-Dade County. When the SMMC program for the Managed Long-Term Care (LTC) component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Core Contract Provisions, Exhibit 3, Non-Reform HMO Frail/Elderly Program. (c) If an “X” is listed in the Non-Reform column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami-Dade County. Advanced Registered Nurse Practitioner Services X Ambulatory Surgical Center Services X Birth Center Services X Child Health Check-Up Services X Chiropractic Services X Community Behavioral Health Services X County Health Department Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract TABLE 5 Effective Date: 09/01/12 – 08/31/15 Health Plan Covered Services Chart Non-Reform Covered Reform Covered Durable Medical Equipment and Medical Supplies X Dialysis Services X Emergency Room Services X Family Planning Services X Federally Qualified Health Center Services X Freestanding Dialysis Centers X Hearing Services X Home Health Care Services X Hospital Services – Inpatient X Hospital Services – Outpatient X Immunizations X Independent Laboratory Services X Licensed Midwife Services X Optometric Services X Physician Services X Physician Assistant Services X Podiatry Services X Portable X-ray Services X Prescribed Drugs X Primary Care Case Management Services X Rural Health Clinic Services X Targeted Case Management X Therapy Services: Occupational X Therapy Services: Physical X Therapy Services: Respiratory X Therapy Services: Speech X Transplant Services X Vision Services X WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract