Eligibility Category. Children and Family Month 0-2 All $ 75% $ $ 25% $ $ $ Month 3-11 All $ 75% $ $ 25% $ $ $ 1-5 All $ 75% $ $ 25% $ $ $ 6-13 All $ 75% $ $ 25% $ $ $ 14-20 Female $ 75% $ $ 25% $ $ $ 14-20 Male $ 75% $ $ 25% $ $ $ 21-54 Female $ 75% $ $ 25% $ $ $ 21-54 Male $ 75% $ $ 25% $ $ $ 55+ All $ 75% $ $ 25% $ $ $ Composite $ $ Eligibility Category: Aged and Disabled Month 0-2 All $ 75% $ $ 25% $ $ $ Month 3-11 All $ 75% $ $ 25% $ $ $ 1-5 All $ 75% $ $ 25% $ $ $ 6-13 All $ 75% $ $ 25% $ $ $ 14-20 All $ 75% $ $ 25% $ $ $ 21-54 All $ 75% $ $ 25% $ $ $ 55+ All $ 75% $ $ 25% $ $ $ Composite $ $ REMAINDER OF PAGE INTENTIONALLY LEFT BLANK HEALTHEASE OF FLORIDA EXHIBIT 5 CAPITATION RATES SSI MEDICARE PART B ONLY AND SSI MEDICARE PARTS A AND B ENROLLEES FOR ALL MEDICAID REFORM COUNTIES TABLE 4 Area: 4 County: Dxxxx ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Under Age 65 Age 65 & Over SSI/Parts A & B $146.72 $98.34 SSI/Part B Only $300.24 $300.24 Area: 10 County: Broward ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Under Age 65 Age 65 & Over SSI/Parts A & B $136.17 $91.25 SSI/Part B Only $210.84 $210.84 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK HEALTHEASE OF FLORIDA EXHIBIT 6 CAPITATION RATES FOR HIV/AIDS POPULATIONS FOR EACH MEDICAID REFORM COUNTY TABLE 5 Area: 4 County: Dxxxx ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Capitation Rate HIV (No Medicare) $950.48 AIDS (No Medicare) $2133.29 HIV-SSI/Parts A & B, SSI Part B Only $177.88 AIDS-SSI/Parts A & B, SSI Part B Only $249.55 Area: 10 County: Broward ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Capitation Rate HIV (No Medicare) $1484.87 AIDS (No Medicare) $3155.16 HIV-SSI/Parts A & B, SSI Part B Only $213.18 AIDS-SSI/Parts A & B, SSI Part B Only $299.07 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK HEALTHEASE OF FLORIDA EXHIBIT 7 CAPITATION RATES FOR MEDICAID REFORM COUNTIES FOR ALL MEDICAID REFORM COUNTIES TABLE 6 Area: __________________ County: ____________________ ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Age < 1 Yr Age 1 Yr Age 2 - 20 Yrs Children with Chronic Conditions $ $ $ REMAINDER OF PAGE INTENTIONALLY LEFT BLANK HEALTHEASE OF FLORIDA EXHIBIT 8 KICK PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES TABLE 7 Area: __10_______ County: ____Broward_______ Area: ___04______ County: _____Duval________ CPT Code Transplant CPT Code Description Children/Adolescents or Adult Payment Amount 32851 lung single, without bypass Ch...
Eligibility Category. Children and Families Month 0-2 All $1,254.43 $1,290.08 Month 3-11 All $202.78 $208.54 1-5 All $147.67 $142.05 6-13 All $147.67 $142.05 14-20 Female $147.67 $142.05 14-20 Male $147.67 $142.05 21-54 Female $147.67 $142.05 21-54 Male $147.67 $142.05 55+ All $147.67 $142.05
Eligibility Category. Aged and Disabled Month 0-2 All $25,030.37 $25,626.47 Month 3-11 All $3,918.32 $4,011.64 1-5 All $891.10 $945.83 6-13 All $891.10 $945.83 14-20 All $891.10 $945.83 21-54 All $891.10 $945.83 55+ All $891.10 $945.83 Eligibility Category: Aged and Disabled with Medicare Parts A & B Under Age 65 $175.41 $152.49 Age 65 and Over $124.04 $107.83 Eligibility Category: Aged and Disabled with Medicare Part B Only All Ages $372.25 $372.66 Population: HIV/AIDS Specialty Population No Medicare HIV $2,181.02 $3,317.61 No Medicare AIDS $3,005.04 $3,825.06 Medicare HIV $228.70 $235.50 Medicare AIDS $194.36 $199.91 AHCA Contract No. FA971, Attachment I, Exhibit 2-R (90113), Page 1 of 2 TABLE 2: KICK PAYMENT AMOUNTS FOR COVERED OBSTETRICAL DELIVERY SERVICES Effective September 1, 2013 – August 31, 2014 CPT Code Obstetrical Delivery CPT Xxxx Xxxxxxxxxxx Xxxx 0 Xxxx 00 00000 Vaginal delivery only $4,125.39 $4,071.76 59410 Vaginal delivery including postpartum care 59515 Cesarean delivery including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery 59614 Vaginal delivery only, after previous cesarean delivery including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery inc postpartum care TABLE 3: KICK PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES Effective September 1, 2013 – August 31, 2014 CPT Code Transplant CPT Code Description Children/Adolescents or Adult All Areas 32851 Lung single, without bypass Children/Adolescents $320,800.00 32851 Lung single, without bypass Adult $238,000.00 32852 Lung single, with bypass Children/Adolescents $320,800.00 32852 Lung single, with bypass Adult $238,000.00 32853 Lung double, without bypass Children/Adolescents $320,800.00 32853 Lung double, without bypass Adult $238,000.00 32854 Lung double, with bypass Children/Adolescents $320,800.00 32854 Lung double, with bypass Adult $238,000.00 33945 Heart transplant with or without recipient cardiectomy All Age Groups $162,000.00 47135 Liver, allotransplation, orthotopic, partial or whole from cadaver or living donor All Age Groups $122,600.00 47136 Liver, heterotopic, partial or whole from cadaver or living donor any age All Age Groups $122,600.00
