AHCA CONTRACT NO. FA614 AMENDMENT NO. 4
Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care
AHCA CONTRACT NO. FA614
AMENDMENT NO. 4
THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and AMERIGROUP FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY CARE, hereinafter referred to as the “Vendor” or “Health Plan”, is hereby amended as follows:
| 1. | Attachment I, Scope of Services, is hereby amended to include Exhibit II-D, Fourth Revised Capitation Rates, attached hereto and made a part of the Contract. All references in the Contract to Exhibit II-C, Third Revised Capitation Rates, shall hereinafter also refer to Exhibit II-D, Fourth Revised Capitation Rates, as appropriate. |
| 2. | Attachment I, Scope of Services, is hereby amended to include Exhibit III-A, September 1, 2007-August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, attached hereto and made a part of the Contract. All references in the Contract to Exhibit III, September 1, 2006 — August 31, 2007 HMO Rates, shall hereinafter also refer to Exhibit III-A, September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, as appropriate. |
| 3. | Attachment II, Medicaid Prepaid Health Plan Model Contract, Section V, Covered Services, Item C, Expanded Services, sub-item 2 is hereby deleted in its entirety and replaced with the following: |
2. The following is a list of the Health Plan’s Expanded Services:
a. Adult basic dental benefits, such as cleanings, simple fillings, and/or extractions.
| b. | Up to $25 credit per household each month for selected over-the-counter drugs and/or health supplies. |
| c. | Respite Care services — Annual maximum of not more than an initial home health visit by an R.N. and eight (8) follow-up visits by an aide. Follow-up visits are four (4) hours in length. Maximum of sixteen (16) hours in a given month and thirty-two (32) hours per year. |
| d. | Circumcisions for newborns (routine newborn circumcision up to twelve (12) weeks of age). |
| 4. | This Amendment shall have an effective date of September 1, 2007, or the date on which both parties execute the Amendment, whichever is later. |
All provisions in the Contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to conform with this Amendment.
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the Contract.
This Amendment and all its attachments are hereby made a part of the Contract.
This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.
AHCA Contract No. FA614, Amendment No. 4, Page 1 of 2
AHCA Form 2100-0002 (Rev. NOV03)
Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care
IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which includes all attachments hereto) to be executed by their officials thereunto duly authorized.
| AMERIGROUP FLORIDA, INC.STATE OF FLORIDA, AGENCY FOR | ||||
| D/B/A/ AMERIGROUP COMMUNITY CAREHEALTH CARE ADMINISTRATION | ||||
SIGNED BY: |
SIGNED BY: |
|||
| NAME:Xxxxxxx XxXxxx ....................... |
NAME:Xxxxxx X. Xxxxxxxx, M.D | |||
| |
||||
TITLE: CEO
|
TITLE:Secretary | |||
DATE:
|
DATE: | |||
| List of attachments included as part of this Amendment: |
||||
Specify Type |
Letter/Number ............. |
Description |
||
Exhibit Exhibit |
II-D III-A |
Fourth Revised Capitation Rates (1 Page) September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO |
||
Capitation Rates (5 Pages)
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form 2100-0002 (Rev. NOV03)
Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care
EXHIBIT II-D
FOURTH REVISED CAPITATION RATES
Table 4 — General Capitation Rates plus Mental Health Rates plus Transportation:
Area 3 Counties: |
||||
County: |
Provider Number: | |||
Hernando |
015005350 | |||
Lake |
015005341 | |||
Area 5 Counties: |
||||
County: |
Provider Number: | |||
Pasco |
015005304 | |||
Pinellas |
015005305 | |||
Area 6 Counties: |
||||
County: |
Provider Number: | |||
Hillsborough |
015005300 | |||
Polk |
015005307 | |||
Manatee |
015005318 | |||
Area 7 Counties: |
||||
County: |
Provider Number: | |||
Orange |
015005308 | |||
Seminole |
015005313 | |||
Osceola |
015005314 | |||
Brevard |
015005336 | |||
Area 8 Counties: |
||||
County: |
Provider Number: | |||
Xxx |
015005302 | |||
Sarasota |
015005306 | |||
Area 9 Counties: |
||||
County: |
Provider Number: | |||
Palm Beach |
015005310 | |||
Area 10 Counties: |
||||
County: |
Provider Number: | |||
Broward |
015005311 | |||
Area 11 Counties: |
||||
County: |
Provider Number: | |||
Miami-Dade |
015005312 | |||
AHCA Contract No. FA614, Exhibit II-D, Page 1 of 1
AHCA Form 2100-0002 (Rev. NOV03)
AHCA Contract No. FA614, Exhibit III-A, Page 1 of 5 HMO CapRates—200709-200808 08/10/2007
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| TABLE 1 | ||||||||
General Rates:
|
||||||||
| XXXX | XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||
011,131.99202.30 021,131.99202.30 031,296.42233.58 041,128.87203.75 051,260.50227.66 061,111.64201.87 071,129.81204.44 081,059.95192.36 091,098.82197.96 101,119.46203.01 111,448.96260.41 |
105.58 105.58 122.13 106.78 119.09 106.04 107.10 100.83 103.63 106.51 136.24 |
66.22 66.22 77.48 67.92 75.94 68.10 68.40 64.75 65.91 68.32 86.18 |
135.19 135.19 156.47 136.68 152.59 135.60 137.11 129.15 132.56 136.20 174.38 |
72.29 72.29 84.50 74.01 82.61 74.02 74.43 70.40 71.62 74.23 94.02 |
265.45 265.45 308.68 269.88 301.42 269.07 271.08 255.88 261.85 270.06 343.72 |
167.89 167.89 196.24 171.79 191.81 171.81 172.77 163.25 166.57 172.18 218.26 |
347.47 347.47 408.68 358.59 400.30 360.32 361.05 342.35 346.99 360.84 453.77 |
10,081.87 10,081.87 11,326.29 10,675.98 11,774.49 10,832.05 11,163.75 9,491.26 10,597.24 13,743.01 14,396.52 |
1,458.88 1,458.88 1,656.79 1,563.58 1,721.01 1,590.31 1,640.70 1,388.78 1,556.56 2,028.53 2,111.55 |
435.95 435.95 495.12 467.86 514.94 475.95 490.80 415.62 465.60 606.68 631.62 |
201.26 201.26 233.33 220.87 241.96 225.91 233.68 196.24 221.41 290.75 299.15 |
222.08 222.08 256.55 242.36 266.53 247.84 256.10 215.38 242.54 319.15 329.01 |
716.10 716.10 826.59 781.86 857.42 799.09 824.52 694.16 781.98 1,026.77 1,058.44 |
703.88 703.88 816.63 772.10 846.21 790.01 815.86 685.42 773.10 1,016.73 1,046.51 |
271.50 271.50 273.34 330.41 230.22 284.19 327.20 192.02 205.98 256.37 336.08 |
138.14112.37 138.14112.37 129.66105.80 133.72109.08 127.48104.72 124.63101.81 128.73105.41 118.95 97.25 127.97104.76 143.41117.45 198.00160.77 |
||||||||||||||||
TABLE 2 General + Mental Health Rates: |
||||||||||||||||||||||||||||||||
| XXXX | XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||||||||
01 02 03 04 05 06 07 08 09 10 11 |
1,132.01 1,132.02 1,296.43 1,128.88 1,260.51 1,111.66 1,129.83 1,059.96 1,098.84 1,119.48 1,448.98 |
202.32 202.33 233.59 203.76 227.67 201.89 204.46 192.37 197.98 203.03 260.43 |
107.22 108.49 123.45 108.15 120.30 107.89 108.88 102.09 105.18 108.43 137.86 |
77.91 86.47 86.66 77.48 84.61 81.34 81.08 73.55 76.72 81.68 97.47 |
146.11 148.60 162.55 143.01 160.70 147.98 148.96 134.98 139.72 145.05 181.86 |
83.21 85.70 90.58 80.34 90.72 86.40 86.28 76.23 78.78 83.08 101.50 |
269.89 268.86 310.23 271.49 304.71 274.10 275.90 257.36 263.67 272.31 345.62 |
172.33 171.30 197.79 173.40 195.10 176.84 177.59 164.73 168.39 174.43 220.16 |
351.22 350.43 410.02 359.98 403.08 364.57 365.12 343.63 348.57 362.79 455.42 |
10,081.95 10,082.03 11,326.36 10,676.09 11,774.54 10,832.12 11,163.81 9,491.33 10,597.31 13,743.10 14,396.60 |
1,458.96 1,459.04 1,656.86 1,563.69 1,721.06 1,590.38 1,640.76 1,388.85 1,556.63 2,028.62 2,111.63 |
443.39 449.74 501.38 477.61 519.96 482.47 496.92 421.62 471.93 615.03 638.59 |
249.30 280.06 269.08 276.60 274.37 268.01 273.18 230.52 257.55 338.45 338.94 |
266.06 267.29 277.06 274.33 296.20 286.38 292.26 235.05 263.28 346.52 351.84 |
797.48 768.77 850.48 819.11 912.32 870.40 891.44 717.07 806.13 1,058.65 1,085.04 |
734.86 728.75 827.91 789.69 867.11 817.15 841.33 696.24 784.51 1,031.78 1,059.07 |
271.71 291.70 280.19 354.96 232.95 285.50 329.79 198.87 212.83 263.22 343.31 |
149.79 153.14 138.64 150.49 140.29 128.51 139.24 132.17 137.56 151.46 206.05 |
124.02 127.37 114.78 125.85 117.53 105.69 115.92 110.47 114.35 125.50 168.82 |
AHCA Contract No. FA614, Exhibit III-A, Page 2 of 5 HMO—CapRates—200709-200808 08/10/2007
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| TABLE 3 | ||||||
General + MH + Dental Rates:
|
||||||
XXXX
|
XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||
011,132.02202.33109.31 021,132.03202.34110.58 031,296.44233.60126.52 041,128.89203.77110.20 051,260.52227.69123.77 061,111.67201.90110.53 071,129.84204.47111.04 081,059.97192.38105.11 091,098.85197.99108.10 101,119.49203.04111.29 111,448.99260.44141.58 |
82.23 90.79 93.00 81.71 91.76 86.79 85.54 79.80 82.75 87.56 105.13 |
150.59 153.08 169.14 147.39 168.12 153.63 153.58 141.46 145.98 151.15 189.81 |
86.99 89.48 96.13 84.03 96.98 91.17 90.17 81.69 84.06 88.23 108.20 |
271.74 270.71 313.24 274.30 311.90 277.72 278.43 260.37 264.42 274.13 347.23 |
173.97 172.94 200.46 175.89 201.49 180.05 179.84 167.40 169.94 176.05 221.59 |
354.63 353.84 415.57 365.17 416.36 371.26 369.79 349.19 351.80 366.16 458.40 |
10,081.95 10,082.03 11,326.37 10,676.09 11,774.55 10,832.13 11,163.81 9,491.34 10,597.31 13,743.11 14,396.61 |
1,458.97 1,459.05 1,656.88 1,563.70 1,721.08 1,590.40 1,640.77 1,388.87 1,556.64 2,028.64 2,111.65 |
445.59 451.94 504.76 479.82 524.88 485.64 500.03 424.74 474.66 618.77 642.83 |
253.12269.40 283.88270.63 274.93282.17 280.43277.68 282.89303.65 273.51291.19 278.58296.97 235.93239.77 262.28267.41 344.93352.19 346.28358.26 |
800.35 771.64 854.04 822.42 919.87 874.82 894.55 720.67 807.81 1,060.76 1,088.67 |
738.28 732.17 832.15 793.64 876.10 822.42 845.04 700.54 786.52 1,034.30 1,063.40 |
272.21 292.20 280.73 356.97 237.38 287.34 331.41 200.35 213.56 265.27 347.71 |
152.10 155.45 141.72 153.57 148.63 133.29 142.40 135.32 139.40 154.03 210.11 |
125.50 128.85 116.76 127.83 122.88 108.76 117.95 112.48 115.53 127.15 171.42 |
|||||||||||||||
TABLE 4 General + MH + Transportation Rates: |
||||||||||||||||||||||||||||||
| XXXX | XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||||||||
01 02 03 04 05 06 07 08 09 10 11 |
1,137.56 1,137.57 1,303.13 1,133.91 1,264.71 1,115.71 1.133.77 1,065.54 1,104.22 1,123.27 1,452.24 |
203.71 203.72 235.26 205.01 228.72 202.90 205.44 193.77 199.32 203.97 261.24 |
108.08 109.35 124.49 108.93 120.95 108.52 109.49 102.95 106.02 109.01 138.36 |
78.43 86.99 87.29 77.95 85.01 81.72 81.45 74.07 77.23 82.04 97.78 |
148.03 150.52 164.87 144.75 162.15 149.38 150.32 136.91 141.58 146.35 182.98 |
84.47 86.96 92.09 81.48 91.67 87.31 87.17 77.49 79.99 83.94 102.24 |
272.98 271.95 313.95 274.28 307.04 276.35 278.09 260.46 266.66 274.42 347.43 |
174.71 173.68 200.67 175.56 196.90 178.58 179.28 167.12 170.70 176.05 221.56 |
354.40 353.61 413.86 362.87 405.49 366.89 367.38 346.83 351.65 364.96 457.29 |
10,125.36 10,125.44 11,381.17 10,720.46 11,809.84 10,866.95 11,201.13 9,532.67 10,640.50 13,782.23 14,425.98 |
1,486.99 1,487.07 1,692.25 1,592.34 1,743.85 1,612.87 1,664.85 1,415.54 1,584.51 2,053.89 2,130.60 |
449.03 455.38 508.50 483.38 524.54 487.00 501.77 427.00 477.55 620.11 642.40 |
251.78 282.54 272.20 279.13 276.38 270.00 275.30 232.88 260.02 340.69 340.62 |
272.18 273.41 284.79 280.59 301.18 291.30 297.53 240.88 269.38 352.05 355.99 |
817.47 788.76 875.73 839.55 928.58 886.44 908.63 736.11 826.01 1,076.67 1,098.57 |
751.37 745.26 848.76 806.56 880.53 830.40 855.51 711.96 800.93 1,046.66 1,070.25 |
278.48 298.47 288.81 361.93 238.83 290.82 335.43 204.95 219.75 270.52 348.23 |
163.52 166.87 158.48 166.27 154.32 140.11 151.37 146.97 153.37 169.12 218.56 |
132.78 136.13 127.44 135.91 126.48 113.09 123.67 119.92 124.43 136.76 176.80 |
AHCA Contract No. FA614, Exhibit III-A, Page 3 of 5 HMO CapRates—200709-200808 08/10/2007
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| TABLE 5 | ||||||
General + Transportation Rates:
|
||||||
XXXX
|
XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||||
011,137.54203.69 021,137.54203.69 031,303.12235.25 041,133.90205.00 051,264.70228.71 061,115.69202.88 071,133.75205.42 081,065.53193.76 091,104.20199.30 101,123.25203.95 111,452.22261.22 |
106.44 106.44 123.17 107.56 119.74 106.67 107.71 101.69 104.47 107.09 136.74 |
66.74 66.74 78.11 68.39 76.34 68.48 68.77 65.27 66.42 68.68 86.49 |
137.11 137.11 158.79 138.42 154.04 137.00 138.47 131.08 134.42 137.50 175.50 |
73.55 73.55 86.01 75.15 83.56 74.93 75.32 71.66 72.83 75.09 94.76 |
268.54 268.54 312.40 272.67 303.75 271.32 273.27 258.98 264.84 272.17 345.53 |
170.27 170.27 199.12 173.95 193.61 173.55 174.46 165.64 168.88 173.80 219.66 |
350.65 350.65 412.52 361.48 402.71 362.64 363.31 345.55 350.07 363.01 455.64 |
10,125.28 10,125.28 11,381.10 10,720.35 11,809.79 10,866.88 11,201.07 9,532.60 10,640.43 13,782.14 14,425.90 |
1,486.91 1,486.91 1,692.18 1,592.23 1,743.80 1,612.80 1,664.79 1,415.47 1,584.44 2,053.80 2,130.52 |
441.59 441.59 502.24 473.63 519.52 480.48 495.65 421.00 471.22 611.76 635.43 |
203.74 203.74 236.45 223.40 243.97 227.90 235.80 198.60 223.88 292.99 300.83 |
228.20 228.20 264.28 248.62 271.51 252.76 261.37 221.21 248.64 324.68 333.16 |
736.09 736.09 851.84 802.30 873.68 815.13 841.71 713.20 801.86 1,044.79 1,071.97 |
720.39 720.39 837.48 788.97 859.63 803.26 830.04 701.14 789.52 1,031.61 1,057.69 |
278.27 278.27 281.96 337.38 236.10 289.51 332.84 198.10 212.90 263.67 341.00 |
151.87 151.87 149.50 149.50 141.51 136.23 140.86 133.75 143.78 161.07 210.51 |
121.13 121.13 118.46 119.14 113.67 109.21 113.16 106.70 114.84 128.71 168.75 |
|||||||||||||||||
TABLE 6 General + Dental Rates: |
||||||||||||||||||||||||||||||||||
XXXX
|
XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||||||||
01 02 03 04 05 06 07 08 09 10 11 |
1,132.00 1,132.00 1,296.43 1,128.88 1,260.51 1,111.65 1,129.82 1,059.96 1,098.83 1,119.47 1,448.97 |
202.31 202.31 233.59 203.76 227.68 201.88 204.45 192.37 197.97 203.02 260.42 |
107.67 107.67 125.20 108.83 122.56 108.68 109.26 103.85 106.55 109.37 139.96 |
70.54 70.54 83.82 72.15 83.09 73.55 72.86 71.00 71.94 74.20 93.84 |
139.67 139.67 163.06 141.06 160.01 141.25 141.73 135.63 138.82 142.30 182.33 |
76.07 76.07 90.05 77.70 88.87 78.79 78.32 75.86 76.90 79.38 100.72 |
267.30 267.30 311.69 272.69 308.61 272.69 273.61 258.89 263.60 271.88 345.33 |
169.53 169.53 198.91 174.28 198.20 175.02 175.02 165.92 168.12 173.80 219.69 |
350.88 350.88 414.23 363.78 413.58 367.01 365.72 347.91 350.22 364.21 456.75 |
10,081.87 10,081.87 11,326.30 10,675.98 11,774.50 10,832.06 11,163.75 9,491.27 10,597.24 13,743.02 14,396.53 |
1,458.89 1,458.89 1,656.81 1,563.59 1,721.03 1,590.33 1,640.71 1,388.80 1,556.57 2,028.55 2,111.57 |
438.15 438.15 498.50 470.07 519.86 479.12 493.91 418.74 468.33 610.42 635.86 |
205.08 205.08 239.18 224.70 250.48 231.41 239.08 201.65 226.14 297.23 306.49 |
225.42 225.42 261.66 245.71 273.98 252.65 260.81 220.10 246.67 324.82 335.43 |
718.97 718.97 830.15 785.17 864.97 803.51 827.63 697.76 783.66 1,028.88 1,062.07 |
707.30 707.30 820.87 776.05 855.20 795.28 819.57 689.72 775.11 1,019.25 1,050.84 |
272.00 272.00 273.88 332.42 234.65 286.03 328.82 193.50 206.71 258.42 340.48 |
140.45 140.45 132.74 136.80 135.82 129.41 131.89 122.10 129.81 145.98 202.06 |
113.85 113.85 107.78 111.06 110.07 104.88 107.44 99.26 105.94 119.10 163.37 |
AHCA Contract No. FA614, Exhibit III-A, Page 4 of 5 HMO—CapRates—200709-200808 08/10/2007
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| TABLE 7 | ||||||
General + Dental + Transportation Rates:
|
||||||
XXXX
|
XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||
011,137.55203.70108.5371.06141.59 021,137.55203.70108.5371.06141.59 031,303.13235.26126.2484.45165.38 041,133.91205.01109.6172.62142.80 051,264.71228.73123.2183.49161.46 061,115.70202.89109.3173.93142.65 071,133.76205.43109.8773.23143.09 081,065.54193.77104.7171.52137.56 091,104.21199.31107.3972.45140.68 101,123.26203.96109.9574.56143.60 111,452.23261.23140.4694.15183.45 |
77.33 77.33 91.56 78.84 89.82 79.70 79.21 77.12 78.11 80.24 101.46 |
270.39 270.39 315.41 275.48 310.94 274.94 275.80 261.99 266.59 273.99 347.14 |
171.91 171.91 201.79 176.44 200.00 176.76 176.71 168.31 170.43 175.42 221.09 |
354.06 354.06 418.07 366.67 415.99 369.33 367.98 351.11 353.30 366.38 458.62 |
10,125..28 10,125.28 11,381.10 10,720.35 11,809.79 10,866.88 11,201.07 9,532.60 10,640.43 13,782.14 14,425.90 |
1,486.92 1,486.92 1,692.20 1,592.24 1,743.82 1,612.82 1,664.80 1,415.49 1,584.45 2,053.82 2,130.54 |
443.79 443.79 505.6 475.84 524.44 483.65 498.76 424.12 473.95 615.50 639.67 |
203.74 203.74 242.30 227.23 252.49 233.40 241.20 204.01 228.61 299.47 308.17 |
228.20 228.20 269.39 251.97 278.96 257.57 266.08 225.93 252.77 330.35 339.58 |
736.09 736.09 855.40 805.61 881.23 819.55 844.82 716.80 803.54 1,046.90 1,075.60 |
723.81 723.81 841.72 792.92 868.62 808.53 833.75 705.44 791.53 1,034.13 1,062.02 |
278.77 278.77 282.50 339.39 240.53 291.35 334.46 199.58 213.63 265.72 345.40 |
154.18 154.18 152.58 152.58 149.85 141.01 144.02 136.90 145.62 163.64 214.57 |
122.61 122.61 120.44 121.12 119.02 112.28 115.19 108.71 116.02 130.36 171.35 |
||||||||||||||
TABLE 8 General + Mental Health + Dental + Transportation Rates: |
||||||||||||||||||||||||||||
XXXX
|
XXX-X | XXX-X | XXX-XX |
Xxxx XXXX0x0X0 0X0.00XX AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)
| Female | Male | Female | Male | |||||||||||||||||||||||||||||||||||
01 02 03 04 05 06 07 08 09 10 11 |
1,137.57 1,137.58 1,303.14 1,133.92 1,264.72 1,115.72 1,133.78 1,065.55 1,104.23 1,123.28 1,452.25 |
203.72 203.73 235.27 205.02 228.74 202.91 205.45 193.78 199.33 203.98 261.25 |
110.17 111.44 127.56 110.98 124.42 111.16 111.65 105.97 108.94 111.87 142.08 |
82.75 91.31 93.63 82.18 92.16 87.17 85.91 80.32 83.26 87.92 105.44 |
152.51 155.00 171.46 149.13 169.57 155.03 154.94 143.39 147.84 152.45 190.93 |
88.25 90.74 97.64 85.17 97.93 92.08 91.06 82.95 85.27 89.09 108.94 |
274.83 273.80 316.96 277.09 314.23 279.97 280.62 263.47 268.41 276.24 349.04 |
176.35 175.32 203.34 178.05 203.29 181.79 181.53 169.79 172.25 177.67 222.99 |
357.81 357.02 419.41 368.06 418.77 373.58 372.05 352.39 354.88 368.33 460.27 |
10,125.36 10,125.44 11,381.18 10,720.46 11,809.85 10,866.96 11,201.13 9,532.68 10,640.50 13,782.24 14,425.99 |
1,487.00 1,487.08 1,692.27 1,592.35 1,743.87 1,612.89 1,664.86 1,415.56 1,584.52 2,053.91 2,130.62 |
451.23 457.58 511.88 485.59 529.46 490.17 504.88 430.12 480.28 623.85 646.64 |
255.60 286.36 278.05 282.96 284.90 275.50 280.70 238.29 264.75 347.17 347.96 |
275.52 276.75 289.90 283.94 308.63 296.11 302.24 245.60 273.51 357.72 362.41 |
820.34 791.63 879.29 842.86 936.13 890.86 911.74 739.71 827.69 1,078.78 1,102.20 |
754.79 748.68 853.00 810.51 889.52 835.67 859.22 716.26 802.94 1,049.18 1,074.58 |
278.98 298.97 289.35 363.94 243.26 292.66 337.05 206.43 220.48 272.57 352.63 |
165.83 169.18 161.56 169.35 162.66 144.89 154.53 150.12 155.21 171.69 222.62 |
134.26 137.61 129.42 137.89 131.83 116.16 125.70 121.93 125.61 138.41 179.40 |
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Xxxxxxxx
Xxxx Xxxx 0 Xxxx 0 Xxxx 0 Area 4 Area 5 Xxxx 0 Xxxx 0 Xxxx 0 Xxxx 0 Xxxx 10 Area 11 |
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Corresponding Counties Escambia, Okaloosa, Santa Rosa, Walton Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Xxxxxxxxx, Xxxx, Liberty, Madison, Taylor, Washington, Wakulla Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hemando, Lafayette, Lake, Xxxx, Xxxxxx, Putnam, Sumter, Suwannee, Union Baker, Clay, Duval, Flagler, Nassau, St. Xxxxx, Volusia Pasco, Pinellas Xxxxxx, Highlands, Hillsborough, Manatee, Polk Brevard, Orange, Osceola, Seminole Charlotte, Xxxxxxx, De Xxxx, Glades, Hendry, Lee, Sarasota Indian River, Okeechobee, St. Lucie, Martin, Palm Beach Broward Dade, Monroe |
Created on August 10, 2007
AHCA Contract No. FA614, Exhibit III-A, Page 5 of 5 HMO CapRates_200709-200808 08/10/2007
Amerigroup Florida, Inc. Medicaid HMO Contract d/b/a Amerigroup Community Care
IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which includes all attachments hereto) to be executed by their officials thereunto duly authorized.
| AMERIGROUP FLORIDA, INC. | STATE OF FLORIDA, AGENCY FOR | |||
| D/B/A/ AMERIGROUP COMMUNITY C | HEALTH CARE ADMINISTRATION | |||
SIGNED BY: |
/S/ Xxxxxxx XxXxxx | SIGNED BY: |
||
NAME: Xxxxxxx XxXxxx
|
NAME: Xxxxxx X. Xxxxxxxx, M.D | |||
TITLE:. CEO
|
TITLE: Secretary | |||
DATE: 8-31-07
|
DATE: | |||
List of attachments included as part of this Amendment:
Specify
|
Letter/ | |||
Type
|
Number | Descnption | ||
Exhibit
|
II-D | Fourth Revised Capitation Rates (1 Page) | ||
Exhibit
|
III-A | September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO | ||
| Capitation Rates (5 Pages) |
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form 2100-0002 (Rev. NOV03)
