AHCA CONTRACT NO. FA971 AMENDMENT NO. 3
Exhibit 10.2
AMENDMENT NO. 3
THIS CONTRACT, entered into between the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA, INC., D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the "Vendor," or “Health Plan,” is hereby amended as follows:
1. | Standard Contract, Section III., Item B., Contract Managers, sub-item 1., is hereby amended to now read as follows: |
1. | The Agency’s Contract Manager’s contact information is as follows: |
Xxxxxxxx Xxxxx
Agency for Health Care Administration
0000 Xxxxx Xxxxx, XX #00
Xxxxxxxxxxx, XX 00000
(000) 000-0000
2. | Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a., Table 6, Effective Date: 09/01/12 – 08/31/15, Non-Reform Expanded Services,, is hereby deleted in its entirety and replaced with Table 6, Effective Date 01/01/13 – 08/31/15 (010113), Non-Reform Expanded Services, as follows: |
TABLE 6 Effective Date: 01/01/13 – 08/31/15 (010113) |
Non-Reform Expanded Services |
Not limited to three (3) home health visits per day |
One (1) general office visit per day |
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies. |
3. | Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health Plans, Section G., Benefit Grid/Customized Benefit Package – Reform Capitated Plans Only, is hereby amended to include the Benefit Grids as follows:: |
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AHCA Contract No. FA971, Amendment No. 3, Page 1 of 6
Exhibit 10.2
Area 10 Broward- Children and Families
COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
Hospital Inpatient | ||||||
Behavioral Health | $ | admit | ||||
Physical Health | $ | admit | ||||
Transplant Services | ||||||
Outpatient Services | ||||||
Emergency Room | ||||||
Medical/Drug Therapies (Chemo, Dialysis) | ||||||
Ambulatory Surgery – ASC | ||||||
Hospital Outpatient Surgery | $ | visit | ||||
Lab / X-ray | $ | day | ||||
Hospital Outpatient Services NOS | Annual | $ | visit | |||
Outpatient Therapy (PT/RT) | Annual | |||||
Outpatient Therapy (OT/ST) | ||||||
Maternity and Family Planning Services | ||||||
Inpatient Hospital | ||||||
Birthing Centers | ||||||
Physician Care | ||||||
Family Planning | ||||||
Pharmacy | ||||||
Physician and Phys Extender Services (non maternity) | ||||||
EPSDT | ||||||
Primary Care Physician | $ | visit | ||||
Specialty Physician | $ | visit | ||||
ARNP / Physician Assistant | $ | visit | ||||
Clinic (FQHC, RHC) | $ | visit | ||||
Clinic (CHD) | ||||||
Other | ||||||
Other Outpatient Professional Services | ||||||
Home Health Services | Annual | Annual | $ | visit | ||
Chiropractor | Annual | Annual | $ | visit | ||
Podiatrist | Annual | Annual | $ | visit | ||
Dental Services | $ | Annual | 0% | coinsurance | ||
Vision Services | Annual | $ | visit | |||
Hearing Services | Annual | |||||
Outpatient Mental Health | $ | visit | ||||
Outpatient Pharmacy | 10 | Monthly | Annual | |||
Other Services | ||||||
Ambulance | ||||||
Non-emergent Transportation | $ | trip | ||||
Durable Medical Equipment | Annual | |||||
Expanded benefits | ||||||
Not limited to three (3) home health visits per day | ||||||
One (1) general office visit per day | ||||||
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies. | ||||||
AHCA Contract No. FA971, Amendment No. 3, Page 2 of 6
Exhibit 10.2
Area 10 Broward- Aged and Disabled
COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
Hospital Inpatient | ||||||
Behavioral Health | $ | admit | ||||
Physical Health | $ | admit | ||||
Transplant Services | ||||||
Outpatient Services | ||||||
Emergency Room | ||||||
Medical/Drug Therapies (Chemo, Dialysis) | ||||||
Ambulatory Surgery – ASC | ||||||
Hospital Outpatient Surgery | $ | visit | ||||
Lab / X-ray | $ | day | ||||
Hospital Outpatient Services NOS | Annual | $ | visit | |||
Outpatient Therapy (PT/RT) | Annual | |||||
Outpatient Therapy (OT/ST) | ||||||
Maternity and Family Planning Services | ||||||
Inpatient Hospital | ||||||
Birthing Centers | ||||||
Physician Care | ||||||
Family Planning | ||||||
Pharmacy | ||||||
Physician and Phys Extender Services (non maternity) | ||||||
EPSDT | ||||||
Primary Care Physician | $ | visit | ||||
Specialty Physician | $ | visit | ||||
ARNP / Physician Assistant | $ | visit | ||||
Clinic (FQHC, RHC) | $ | visit | ||||
Clinic (CHD) | ||||||
Other | ||||||
Other Outpatient Professional Services | ||||||
Home Health Services | Annual | Annual | $ | visit | ||
Chiropractor | Annual | Annual | $ | visit | ||
Podiatrist | Annual | Annual | $ | visit | ||
Dental Services | $ | Annual | 0% | coinsurance | ||
Vision Services | Annual | $ | visit | |||
Hearing Services | Annual | |||||
Outpatient Mental Health | $ | visit | ||||
Outpatient Pharmacy | 20 | Monthly | Annual | |||
Other Services | ||||||
Ambulance | ||||||
Non-emergent Transportation | $ | trip | ||||
Durable Medical Equipment | Annual | |||||
Expanded benefits | ||||||
Not limited to three (3) home health visits per day | ||||||
One (1) general office visit per day | ||||||
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies. | ||||||
AHCA Contract No. FA971, Amendment No. 3, Page 3 of 6
Exhibit 10.2
Area 4 Baker, Clay, Xxxxx & Nassau- Children and Families
COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
Hospital Inpatient | ||||||
Behavioral Health | $ | admit | ||||
Physical Health | $ | admit | ||||
Transplant Services | ||||||
Outpatient Services | ||||||
Emergency Room | ||||||
Medical/Drug Therapies (Chemo, Dialysis) | ||||||
Ambulatory Surgery – ASC | ||||||
Hospital Outpatient Surgery | $ | visit | ||||
Lab / X-ray | $ | day | ||||
Hospital Outpatient Services NOS | Annual | $ | visit | |||
Outpatient Therapy (PT/RT) | Annual | |||||
Outpatient Therapy (OT/ST) | ||||||
Maternity and Family Planning Services | ||||||
Inpatient Hospital | ||||||
Birthing Centers | ||||||
Physician Care | ||||||
Family Planning | ||||||
Pharmacy | ||||||
Physician and Phys Extender Services (non maternity) | ||||||
EPSDT | ||||||
Primary Care Physician | $ | visit | ||||
Specialty Physician | $ | visit | ||||
ARNP / Physician Assistant | $ | visit | ||||
Clinic (FQHC, RHC) | $ | visit | ||||
Clinic (CHD) | ||||||
Other | ||||||
Other Outpatient Professional Services | ||||||
Home Health Services | Annual | Annual | $ | visit | ||
Chiropractor | Annual | Annual | $ | visit | ||
Podiatrist | Annual | Annual | $ | visit | ||
Dental Services | $ | Annual | 0% | coinsurance | ||
Vision Services | Annual | $ | visit | |||
Hearing Services | Annual | |||||
Outpatient Mental Health | $ | visit | ||||
Outpatient Pharmacy | 10 | Monthly | Annual | |||
Other Services | ||||||
Ambulance | ||||||
Non-emergent Transportation | $ | trip | ||||
Durable Medical Equipment | Annual | |||||
Expanded benefits | ||||||
Not limited to three (3) home health visits per day | ||||||
One (1) general office visit per day | ||||||
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies. | ||||||
AHCA Contract No. FA971, Amendment No. 3, Page 4 of 6
Exhibit 10.2
Area 4 Baker, Clay, Xxxxx & Nassau- Aged and Disabled
COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
Hospital Inpatient | ||||||
Behavioral Health | $ | admit | ||||
Physical Health | $ | admit | ||||
Transplant Services | ||||||
Outpatient Services | ||||||
Emergency Room | ||||||
Medical/Drug Therapies (Chemo, Dialysis) | ||||||
Ambulatory Surgery – ASC | ||||||
Hospital Outpatient Surgery | $ | visit | ||||
Lab / X-ray | $ | day | ||||
Hospital Outpatient Services NOS | Annual | $ | visit | |||
Outpatient Therapy (PT/RT) | Annual | |||||
Outpatient Therapy (OT/ST) | ||||||
Maternity and Family Planning Services | ||||||
Inpatient Hospital | ||||||
Birthing Centers | ||||||
Physician Care | ||||||
Family Planning | ||||||
Pharmacy | ||||||
Physician and Phys Extender Services (non maternity) | ||||||
EPSDT | ||||||
Primary Care Physician | $ | visit | ||||
Specialty Physician | $ | visit | ||||
ARNP / Physician Assistant | $ | visit | ||||
Clinic (FQHC, RHC) | $ | visit | ||||
Clinic (CHD) | ||||||
Other | ||||||
Other Outpatient Professional Services | ||||||
Home Health Services | Annual | Annual | $ | visit | ||
Chiropractor | Annual | Annual | $ | visit | ||
Podiatrist | Annual | Annual | $ | visit | ||
Dental Services | $ | Annual | 0% | coinsurance | ||
Vision Services | Annual | $ | visit | |||
Hearing Services | Annual | |||||
Outpatient Mental Health | $ | visit | ||||
Outpatient Pharmacy | 20 | Monthly | Annual | |||
Other Services | ||||||
Ambulance | ||||||
Non-emergent Transportation | $ | trip | ||||
Durable Medical Equipment | Annual | |||||
Expanded benefits | ||||||
Not limited to three (3) home health visits per day | ||||||
One (1) general office visit per day | ||||||
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies. | ||||||
AHCA Contract No. FA971, Amendment No. 3, Page 5 of 6
Exhibit 10.2
Unless otherwise stated, this Amendment shall be effective upon execution by both Parties.
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.
This Amendment and all its attachments are hereby made part of this Contract.
This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.
IN WITNESS WHEREOF, the Parties hereto have caused this six (6) page Amendment to be executed by their officials thereunto duly authorized.
WELLCARE OF FLORIDA, INC., D/B/A | STATE OF FLORIDA, AGENCY FOR | |||
STAYWELL HEALTH PLAN OF | HEALTH CARE ADMINISTRATION | |||
FLORIDA | ||||
SIGNED | SIGNED | |||
BY: | /s/ Xxxxxxxxx Xxxxxx | BY: | /s/ Xxxxxxxxx Xxxxx | |
NAME: | Xxxxxxxxx Xxxxxx | NAME: | Xxxxxxxxx Xxxxx | |
TITLE: | President, FL and HI Division | TITLE: | Secretary | |
DATE: | 3/13/2013 | DATE: | 3/14/2013 | |
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AHCA Contract No. FA971, Amendment No. 3, Page 6 of 6
