WellCare of Florida, Inc. Medicaid HMO Non-Reform Contract d/b/a Staywell Health Plan of Florida AHCA CONTRACT NO. FA904 AMENDMENT NO. 7 THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter...
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract |
| d/b/a Staywell Health Plan of Florida |
| AHCA CONTRACT NO. FA904 |
| AMENDMENT NO. 7 |
| 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: |
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1.
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Effective January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a. is hereby amended to include Table 6-B, Revised Expanded Services, as follows. All references in the Contract to Table 6, Expanded Services and Table 6-A, Revised Expanded Services, shall hereinafter also refer to Table 6-B, as appropriate.
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TABLE 6-B
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Revised Expanded Services
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Effective January 1, 2012
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Up to $25 credit per household each month for selected over the counter drugs and/or health supplies.
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2.
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Effective September 1, 2011, Attachment I, Scope of Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non- Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract. All references in the Contract to Exhibit 2-NR-B, shall hereinafter also refer to Exhibit 2-NR-C, as appropriate.
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3.
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Attachment II, Core Contract Provisions, Section XVI., Terms and Conditions, is hereby amended to include Item HH. as follows:
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HH.
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Scrutinized Companies Lists
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The Vendor shall complete Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, attached hereto and made a part of the Contract, certifying that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to section 215.473, Florida Statutes (F.S.). Pursuant to section 287.135(5), F.S., the Vendor agrees the Agency may immediately terminate this Contract for cause if the Vendor is found to have submitted a false certification or if the Vendor is placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List during the term of the Contract
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4.
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Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, is hereby attached and made a part of the Contract.
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Unless otherwise stated, this amendment is effective upon execution by both Parties.
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All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the Contract.
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AHCA Contract No. FA904, Amendment No. 7, Page 1 of 2
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| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract |
| d/b/a Staywell Health Plan of Florida |
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This amendment and all its attachments are hereby made a part of the Contract.
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This amendment cannot be executed unles all previous amendments to this Contract have been fully executed.
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IN WITNESS WHEREOF, the Parties hereto have caused this eight (8) page amendment (including all attachments) to be executed by their officials thereunto duly authorized.
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WELLCARE OF FLORIDA, INC., D/B/A
STAYWELL HEALTH PLAN OF FLORIDA
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STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION
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SIGNED
BY:
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/s/ Xxxxxxxxx Xxxxxx |
SIGNED
BY:
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/s/Xxxxx Xxxx for
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| NAME: |
Xxxxxxxxx Xxxxxx
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NAME: |
Xxxxxxxxx Xxxxx
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| TITLE: |
President, FL & HI Division
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TITLE: |
Secretary
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DATE:
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12/27/11
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DATE: |
12/29/11
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List of Attachments/Exhibits included as part of this amendment:
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Specify
Type
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Letter/
Number
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Description
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Attachment I
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Exhibit 2-NR-C
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Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011 (5 pages) |
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Attachment
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VI | Vendor Certification Regarding Scrutinized Companies Lists (1Page) |
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REMAINDER OF XXXX INTENTIONALLY LEFT BLANK
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
General Rates:
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|||||||||||||||||||
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TANF
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SSI-N
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SSI-B
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SSI-AB
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Area
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BTHMO+2MO
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3MO-11MO
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AGE(1-5)
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AGE(6-13)
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AGE(14-20)
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AGE(21-54)
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AGE(55+)
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BTHMO+2MO
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3MO-11MO
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AGE(1-5)
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AGE(6-13)
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AGE(14-20)
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AGE(21-54)
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AGE(55+)
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AGE (65-)
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AGE (65+)
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Female
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Male
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Female
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Male
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||||||||||||||||
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01
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944.58
|
184.93
|
99.14
|
62.81
|
127.84
|
67.50
|
271.85
|
155.86
|
430.03
|
12,534.08
|
1,853.67
|
459.10
|
183.60
|
219.90
|
719.01
|
846.95
|
304.31
|
95.72
|
75.16
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|
02
|
809.74
|
158.54
|
85.26
|
55.17
|
110.84
|
59.12
|
234.16
|
134.73
|
369.40
|
10,634.20
|
1,571.89
|
378.61
|
129.11
|
165.06
|
567.50
|
702.50
|
304.31
|
85.34
|
66.80
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|
03
|
977.48
|
191.38
|
102.88
|
66.37
|
133.57
|
71.13
|
282.47
|
162.44
|
445.78
|
13,033.48
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1,927.78
|
480.73
|
199.09
|
235.25
|
760.70
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885.63
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304.31
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86.58
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67.80
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04
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982.26
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192.25
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101.91
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59.51
|
127.52
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64.77
|
277.81
|
157.18
|
443.92
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13,413.62
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1,983.70
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490.64
|
194.84
|
234.00
|
766.84
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905.39
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304.31
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79.94
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62.45
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05
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1,109.71
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217.27
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116.92
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75.94
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152.20
|
81.32
|
321.19
|
184.92
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506.42
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14,476.72
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2,141.09
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531.81
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215.85
|
257.04
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836.50
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980.51
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304.31
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74.93
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58.42
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06
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1,021.04
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199.94
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108.39
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73.89
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143.78
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78.57
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298.90
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173.52
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468.21
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13,062.91
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1,932.30
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484.19
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205.34
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240.45
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771.66
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891.12
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304.31
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73.50
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57.26
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07
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966.83
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189.24
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100.39
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58.99
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125.91
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64.15
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273.80
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155.07
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437.19
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13,593.51
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2,010.10
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494.41
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190.58
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231.59
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766.17
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913.39
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304.31
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72.84
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56.74
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08
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952.04
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186.41
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100.57
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66.44
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131.76
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70.95
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276.63
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159.73
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435.19
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12,412.16
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1,835.77
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456.44
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186.23
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221.31
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719.07
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841.38
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304.31
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80.42
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62.84
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09
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1,032.49
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202.14
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108.41
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68.86
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139.93
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73.98
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297.32
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170.54
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470.17
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14,347.56
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2,121.42
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519.54
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195.54
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239.92
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799.72
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960.67
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304.31
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82.17
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64.25
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10
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1,028.53
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201.37
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108.26
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69.90
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140.62
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74.92
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297.28
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170.98
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469.11
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17,915.36
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2,649.60
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657.40
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265.37
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316.67
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1,032.39
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1,212.35
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304.31
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92.58
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72.64
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11
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1,187.84
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232.59
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125.70
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84.02
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165.46
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89.59
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346.10
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200.24
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543.62
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15,014.29
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2,220.47
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549.99
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220.03
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263.49
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861.45
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1,014.60
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304.31
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120.99
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95.51
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6B *
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1,020.54
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199.85
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108.39
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74.07
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143.91
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78.73
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298.94
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173.63
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468.11
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13,061.73
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1,932.14
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484.22
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205.49
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240.58
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771.87
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891.14
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304.31
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73.50
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57.26
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TABLE 2
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General + Mental Health Rates:
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TANF
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SSI-N
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SSI-B
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SSI-AB
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Area
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BTHMO+2MO
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3MO-11MO
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AGE(1-5)
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AGE(6-13)
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AGE(14-20)
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AGE(21-54)
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AGE(55+)
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BTHMO+2MO
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3MO-11MO
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AGE(1-5)
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AGE(6-13)
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AGE(14-20)
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AGE(21-54)
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AGE(55+)
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AGE (65-)
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AGE (65+)
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Female
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Male
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Female
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Male
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01
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944.69
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185.04
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101.42
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73.90
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138.20
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77.86
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281.21
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165.22
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436.32
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12,535.85
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1,855.44
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479.56
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233.51
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260.16
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798.67
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877.14
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321.65
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105.67
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85.11
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02
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809.82
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158.62
|
86.94
|
63.35
|
118.47
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66.75
|
241.06
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141.63
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374.03
|
10,636.65
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1,574.34
|
406.90
|
198.14
|
220.74
|
677.67
|
744.25
|
321.65
|
95.29
|
76.75
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|
03
|
977.58
|
191.48
|
104.95
|
76.48
|
143.01
|
80.57
|
291.00
|
170.97
|
451.51
|
13,035.03
|
1,929.33
|
498.65
|
242.81
|
270.52
|
830.48
|
912.07
|
321.65
|
96.53
|
77.75
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|
04
|
982.44
|
192.43
|
105.47
|
76.86
|
143.72
|
80.97
|
292.45
|
171.82
|
453.76
|
13,415.57
|
1,985.65
|
513.21
|
249.90
|
278.41
|
854.72
|
938.69
|
321.65
|
89.89
|
72.40
|
|
05
|
1,109.82
|
217.38
|
119.15
|
86.82
|
162.35
|
91.47
|
330.37
|
194.10
|
512.59
|
14,478.63
|
2,143.00
|
553.88
|
269.70
|
300.48
|
922.45
|
1,013.08
|
321.65
|
84.88
|
68.37
|
|
06
|
1,021.10
|
200.00
|
109.62
|
79.88
|
149.37
|
84.16
|
303.96
|
178.58
|
471.61
|
13,064.26
|
1,933.65
|
499.77
|
243.36
|
271.12
|
832.34
|
914.11
|
321.65
|
83.45
|
67.21
|
|
07
|
967.00
|
189.41
|
103.81
|
75.65
|
141.46
|
79.70
|
287.85
|
169.12
|
446.63
|
13,595.73
|
2,012.32
|
520.10
|
253.26
|
282.15
|
866.20
|
951.30
|
321.65
|
82.79
|
66.69
|
|
08
|
952.12
|
186.49
|
102.22
|
74.49
|
139.28
|
78.47
|
283.42
|
166.52
|
439.76
|
12,413.76
|
1,837.37
|
474.89
|
231.24
|
257.62
|
790.90
|
868.60
|
321.65
|
90.37
|
72.79
|
|
09
|
1,032.61
|
202.26
|
110.86
|
80.78
|
151.06
|
85.11
|
307.38
|
180.60
|
476.93
|
14,350.11
|
2,123.97
|
548.96
|
267.31
|
297.81
|
914.26
|
1,004.08
|
321.65
|
92.12
|
74.20
|
|
10
|
1,028.64
|
201.48
|
110.43
|
80.47
|
150.48
|
84.78
|
306.20
|
179.90
|
475.10
|
17,917.79
|
2,652.03
|
685.44
|
333.77
|
371.85
|
1,141.56
|
1,253.72
|
321.65
|
102.53
|
82.59
|
|
11
|
1,187.93
|
232.68
|
127.53
|
92.93
|
173.78
|
97.91
|
353.62
|
207.76
|
548.67
|
15,016.41
|
2,222.59
|
574.45
|
279.72
|
311.64
|
956.71
|
1,050.70
|
321.65
|
130.94
|
105.46
|
|
6B *
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1,020.60
|
199.91
|
109.57
|
79.84
|
149.30
|
84.12
|
303.81
|
178.50
|
471.38
|
13,063.07
|
1,933.48
|
499.73
|
243.33
|
271.10
|
832.26
|
914.03
|
321.65
|
83.45
|
67.21
|
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 1 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
|
MEDICAID NON-REFORM HMO CAPITATION RATES
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| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
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By Area, Age and Eligibility Category
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| Effective September 1, 2011 |
TABLE 3
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General + MH + Dental Rates:
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TANF
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SSI-N
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SSI-B
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SSI-AB
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Area
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BTHMO+2MO
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3MO-11MO
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AGE (1-5)
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AGE (6-13)
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AGE (14-20)
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AGE (21-54)
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AGE (55+)
|
BTHMO+2MO
|
3MO-11MO
|
AGE (1-5)
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AGE (6-13)
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AGE (14-20)
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AGE (21-54)
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AGE (55+)
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AGE (65-)
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AGE (65+)
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|||
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Female
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Male
|
Female
|
Male
|
||||||||||||||||
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01
|
944.69
|
185.06
|
103.23
|
76.91
|
140.85
|
80.79
|
282.97
|
166.83
|
439.41
|
12,535.91
|
1,855.47
|
481.31
|
235.72
|
262.09
|
800.18
|
879.25
|
323.95
|
106.76
|
86.03
|
|
02
|
809.83
|
158.64
|
89.86
|
68.21
|
122.74
|
71.49
|
243.79
|
144.12
|
378.82
|
10,636.74
|
1,574.39
|
409.58
|
201.51
|
223.69
|
679.30
|
746.53
|
323.95
|
96.63
|
77.87
|
|
03
|
977.59
|
191.53
|
110.77
|
86.18
|
151.54
|
90.02
|
294.80
|
174.45
|
458.19
|
13,035.24
|
1,929.45
|
504.95
|
250.74
|
277.45
|
832.71
|
915.19
|
323.95
|
98.64
|
79.52
|
|
04
|
982.45
|
192.46
|
108.89
|
82.56
|
148.73
|
86.53
|
296.76
|
175.76
|
461.32
|
13,415.69
|
1,985.72
|
516.72
|
254.31
|
282.27
|
857.39
|
942.42
|
323.95
|
92.21
|
74.35
|
|
05
|
1,109.84
|
217.44
|
125.83
|
97.95
|
172.14
|
102.32
|
334.38
|
197.77
|
519.63
|
14,478.85
|
2,143.13
|
560.70
|
278.28
|
307.98
|
924.69
|
1,016.22
|
323.95
|
87.28
|
70.38
|
|
06
|
1,021.11
|
200.04
|
114.54
|
88.08
|
156.58
|
92.15
|
306.21
|
180.64
|
475.56
|
13,064.42
|
1,933.74
|
504.77
|
249.66
|
276.62
|
833.92
|
916.32
|
323.95
|
85.20
|
68.68
|
|
07
|
967.01
|
189.46
|
109.65
|
85.37
|
150.01
|
89.18
|
290.76
|
171.78
|
451.74
|
13,595.93
|
2,012.43
|
526.15
|
260.87
|
288.80
|
868.02
|
953.84
|
323.95
|
84.50
|
68.13
|
|
08
|
952.14
|
186.58
|
112.21
|
91.13
|
153.91
|
94.69
|
286.81
|
169.62
|
445.71
|
12,414.04
|
1,837.53
|
483.35
|
241.89
|
266.93
|
792.93
|
871.43
|
323.95
|
92.29
|
74.40
|
|
09
|
1,032.63
|
202.32
|
118.34
|
93.24
|
162.01
|
97.26
|
310.56
|
183.50
|
482.50
|
14,350.33
|
2,124.09
|
555.67
|
275.75
|
305.19
|
916.18
|
1,006.76
|
323.95
|
93.99
|
75.77
|
|
10
|
1,028.65
|
201.51
|
114.40
|
87.08
|
156.30
|
91.23
|
307.29
|
180.90
|
477.01
|
17,917.96
|
2,652.12
|
690.55
|
340.20
|
377.47
|
1,142.86
|
1,255.53
|
323.95
|
103.74
|
83.61
|
|
11
|
1,188.00
|
232.75
|
137.40
|
108.70
|
186.71
|
110.84
|
355.80
|
209.75
|
552.50
|
15,016.42
|
2,222.60
|
586.08
|
291.88
|
320.59
|
959.38
|
1,054.43
|
323.95
|
134.01
|
108.03
|
|
6B *
|
1,020.61
|
199.95
|
114.49
|
88.04
|
156.51
|
92.11
|
306.06
|
180.56
|
475.33
|
13,063.23
|
1,933.57
|
504.73
|
249.63
|
276.60
|
833.84
|
916.24
|
323.95
|
85.20
|
68.68
|
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
|
951.62
|
187.12
|
102.70
|
74.71
|
140.05
|
80.81
|
284.50
|
169.78
|
440.86
|
12,591.13
|
1,898.82
|
487.69
|
238.50
|
269.54
|
826.05
|
900.84
|
324.43
|
109.55
|
88.28
|
|
02
|
816.21
|
160.54
|
88.12
|
64.09
|
120.17
|
69.47
|
244.09
|
145.84
|
378.22
|
10,685.88
|
1,612.98
|
414.14
|
202.58
|
229.10
|
702.06
|
765.36
|
324.43
|
98.51
|
79.37
|
|
03
|
984.48
|
193.55
|
106.22
|
77.28
|
144.85
|
83.50
|
294.27
|
175.51
|
456.03
|
13,083.83
|
1,967.63
|
505.83
|
247.21
|
278.80
|
854.65
|
932.99
|
324.43
|
100.56
|
81.04
|
|
04
|
988.24
|
194.17
|
106.54
|
77.53
|
145.26
|
83.43
|
295.20
|
175.63
|
457.56
|
13,465.86
|
2,025.12
|
520.61
|
254.44
|
286.95
|
879.63
|
960.26
|
324.43
|
94.30
|
75.99
|
|
05
|
1,114.99
|
218.93
|
120.10
|
87.42
|
163.73
|
93.67
|
332.82
|
197.50
|
515.98
|
14,525.16
|
2,179.52
|
560.72
|
273.90
|
308.38
|
945.50
|
1,033.03
|
324.43
|
88.93
|
71.67
|
|
06
|
1,026.36
|
201.58
|
110.59
|
80.49
|
150.77
|
86.40
|
306.46
|
182.04
|
475.06
|
13,112.00
|
1,971.11
|
506.79
|
247.67
|
279.22
|
855.98
|
934.58
|
324.43
|
87.18
|
70.25
|
|
07
|
972.68
|
191.11
|
104.86
|
76.31
|
142.97
|
82.11
|
290.54
|
172.85
|
450.35
|
13,646.03
|
2,051.80
|
527.50
|
257.80
|
290.69
|
891.11
|
972.87
|
324.43
|
85.88
|
69.21
|
|
08
|
958.75
|
188.48
|
103.44
|
75.26
|
141.04
|
81.29
|
286.56
|
170.88
|
444.10
|
12,462.04
|
1,875.26
|
481.99
|
235.60
|
265.82
|
814.81
|
889.30
|
324.43
|
93.02
|
74.95
|
|
09
|
1,039.33
|
204.28
|
112.10
|
81.56
|
152.85
|
87.97
|
310.57
|
185.02
|
481.33
|
14,399.99
|
2,163.12
|
556.29
|
271.81
|
306.28
|
938.96
|
1,025.47
|
324.43
|
96.06
|
77.41
|
|
10
|
1,034.50
|
203.24
|
111.51
|
81.15
|
152.04
|
87.27
|
308.98
|
183.75
|
478.93
|
17,971.60
|
2,694.26
|
693.35
|
338.63
|
380.98
|
1,168.21
|
1,276.79
|
324.43
|
106.30
|
85.66
|
|
11
|
1,192.81
|
234.14
|
128.43
|
93.50
|
175.08
|
99.98
|
355.93
|
210.97
|
551.86
|
15,061.69
|
2,258.13
|
581.11
|
283.81
|
319.33
|
979.14
|
1,070.12
|
324.43
|
134.22
|
108.13
|
|
6B *
|
1,025.86
|
201.49
|
110.54
|
80.45
|
150.70
|
86.36
|
306.31
|
181.96
|
474.83
|
13,110.81
|
1,970.94
|
506.75
|
247.64
|
279.20
|
855.90
|
934.50
|
324.43
|
87.18
|
70.25
|
ACHAContract No. FA904, Attachment I, Exhibit 2-NR, Page 2 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
|
MEDICAID NON-REFORM HMO CAPITATION RATES
|
|
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
|
|
By Area, Age and Eligibility Category
|
| Effective September 1, 2011 |
|
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
|
951.51
|
187.01
|
100.42
|
63.62
|
129.69
|
70.45
|
275.14
|
160.42
|
434.57
|
12,589.36
|
1,897.05
|
467.23
|
188.59
|
229.28
|
746.39
|
870.65
|
307.09
|
99.60
|
78.33
|
|
02
|
816.13
|
160.46
|
86.44
|
55.91
|
112.54
|
61.84
|
237.19
|
138.94
|
373.59
|
10,683.43
|
1,610.53
|
385.85
|
133.55
|
173.42
|
591.89
|
723.61
|
307.09
|
88.56
|
69.42
|
|
03
|
984.38
|
193.45
|
104.15
|
67.17
|
135.41
|
74.06
|
285.74
|
166.98
|
450.30
|
13,082.28
|
1,966.08
|
487.91
|
203.49
|
243.53
|
784.87
|
906.55
|
307.09
|
90.61
|
71.09
|
|
04
|
988.06
|
193.99
|
102.98
|
60.18
|
129.06
|
67.23
|
280.56
|
160.99
|
447.72
|
13,463.91
|
2,023.17
|
498.04
|
199.38
|
242.54
|
791.75
|
926.96
|
307.09
|
84.35
|
66.04
|
|
05
|
1,114.88
|
218.82
|
117.87
|
76.54
|
153.58
|
83.52
|
323.64
|
188.32
|
509.81
|
14,523.25
|
2,177.61
|
538.65
|
220.05
|
264.94
|
859.55
|
1,000.46
|
307.09
|
78.98
|
61.72
|
|
06
|
1,026.30
|
201.52
|
109.36
|
74.50
|
145.18
|
80.81
|
301.40
|
176.98
|
471.66
|
13,110.65
|
1,969.76
|
491.21
|
209.65
|
248.55
|
795.30
|
911.59
|
307.09
|
77.23
|
60.30
|
|
07
|
972.51
|
190.94
|
101.44
|
59.65
|
127.42
|
66.56
|
276.49
|
158.80
|
440.91
|
13,643.81
|
2,049.58
|
501.81
|
195.12
|
240.13
|
791.08
|
934.96
|
307.09
|
75.93
|
59.26
|
|
08
|
958.67
|
188.40
|
101.79
|
67.21
|
133.52
|
73.77
|
279.77
|
164.09
|
439.53
|
12,460.44
|
1,873.66
|
463.54
|
190.59
|
229.51
|
742.98
|
862.08
|
307.09
|
83.07
|
65.00
|
|
09
|
1,039.21
|
204.16
|
109.65
|
69.64
|
141.72
|
76.84
|
300.51
|
174.96
|
474.57
|
14,397.44
|
2,160.57
|
526.87
|
200.04
|
248.39
|
824.42
|
982.06
|
307.09
|
86.11
|
67.46
|
|
10
|
1,034.39
|
203.13
|
109.34
|
70.58
|
142.18
|
77.41
|
300.06
|
174.83
|
472.94
|
17,969.17
|
2,691.83
|
665.31
|
270.23
|
325.80
|
1,059.04
|
1,235.42
|
307.09
|
96.35
|
75.71
|
|
11
|
1,192.72
|
234.05
|
126.60
|
84.59
|
166.76
|
91.66
|
348.41
|
203.45
|
546.81
|
15,059.57
|
2,256.01
|
556.65
|
224.12
|
271.18
|
883.88
|
1,034.02
|
307.09
|
124.27
|
98.18
|
|
6B *
|
1,025.80
|
201.43
|
109.36
|
74.68
|
145.31
|
80.97
|
301.44
|
177.09
|
471.56
|
13,109.47
|
1,969.60
|
491.24
|
209.80
|
248.68
|
795.51
|
911.61
|
307.09
|
77.23
|
60.30
|
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
|
944.58
|
184.95
|
100.95
|
65.82
|
130.49
|
70.43
|
273.61
|
157.47
|
433.12
|
12,534.14
|
1,853.70
|
460.85
|
185.81
|
221.83
|
720.52
|
849.06
|
306.61
|
96.81
|
76.08
|
|
02
|
809.75
|
158.56
|
88.18
|
60.03
|
115.11
|
63.86
|
236.89
|
137.22
|
374.19
|
10,634.29
|
1,571.94
|
381.29
|
132.48
|
168.01
|
569.13
|
704.78
|
306.61
|
86.68
|
67.92
|
|
03
|
977.49
|
191.43
|
108.70
|
76.07
|
142.10
|
80.58
|
286.27
|
165.92
|
452.46
|
13,033.69
|
1,927.90
|
487.03
|
207.02
|
242.18
|
762.93
|
888.75
|
306.61
|
88.69
|
69.57
|
|
04
|
982.27
|
192.28
|
105.33
|
65.21
|
132.53
|
70.33
|
282.12
|
161.12
|
451.48
|
13,413.74
|
1,983.77
|
494.15
|
199.25
|
237.86
|
769.51
|
909.12
|
306.61
|
82.26
|
64.40
|
|
05
|
1,109.73
|
217.33
|
123.60
|
87.07
|
161.99
|
92.17
|
325.20
|
188.59
|
513.46
|
14,476.94
|
2,141.22
|
538.63
|
224.43
|
264.54
|
838.74
|
983.65
|
306.61
|
77.33
|
60.43
|
|
06
|
1,021.05
|
199.98
|
113.31
|
82.09
|
150.99
|
86.56
|
301.15
|
175.58
|
472.16
|
13,063.07
|
1,932.39
|
489.19
|
211.64
|
245.95
|
773.24
|
893.33
|
306.61
|
75.25
|
58.73
|
|
07
|
966.84
|
189.29
|
106.23
|
68.71
|
134.46
|
73.63
|
276.71
|
157.73
|
442.30
|
13,593.71
|
2,010.21
|
500.46
|
198.19
|
238.24
|
767.99
|
915.93
|
306.61
|
74.55
|
58.18
|
|
08
|
952.06
|
186.50
|
110.56
|
83.08
|
146.39
|
87.17
|
280.02
|
162.83
|
441.14
|
12,412.44
|
1,835.93
|
464.90
|
196.88
|
230.62
|
721.10
|
844.21
|
306.61
|
82.34
|
64.45
|
|
09
|
1,032.51
|
202.20
|
115.89
|
81.32
|
150.88
|
86.13
|
300.50
|
173.44
|
475.74
|
14,347.78
|
2,121.54
|
526.25
|
203.98
|
247.30
|
801.64
|
963.35
|
306.61
|
84.04
|
65.82
|
|
10
|
1,028.54
|
201.40
|
112.23
|
76.51
|
146.44
|
81.37
|
298.37
|
171.98
|
471.02
|
17,915.53
|
2,649.69
|
662.51
|
271.80
|
322.29
|
1,033.69
|
1,214.16
|
306.61
|
93.79
|
73.66
|
|
11
|
1,187.91
|
232.66
|
135.57
|
99.79
|
178.39
|
102.52
|
348.28
|
202.23
|
547.45
|
15,014.30
|
2,220.48
|
561.62
|
232.19
|
272.44
|
864.12
|
1,018.33
|
306.61
|
124.06
|
98.08
|
|
6B *
|
1,020.55
|
199.89
|
113.31
|
82.27
|
151.12
|
86.72
|
301.19
|
175.69
|
472.06
|
13,061.89
|
1,932.23
|
489.22
|
211.79
|
246.08
|
773.45
|
893.35
|
306.61
|
75.25
|
58.73
|
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 3 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
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
|
951.51
|
187.03
|
102.23
|
66.63
|
132.34
|
73.38
|
276.90
|
162.03
|
437.66
|
12,589.42
|
1,897.08
|
468.98
|
190.80
|
231.21
|
747.90
|
872.76
|
309.39
|
100.69
|
79.25
|
|
02
|
816.14
|
160.48
|
89.36
|
60.77
|
116.81
|
66.58
|
239.92
|
141.43
|
378.38
|
10,683.52
|
1,610.58
|
388.53
|
136.92
|
176.37
|
593.52
|
725.89
|
309.39
|
89.90
|
70.54
|
|
03
|
984.39
|
193.50
|
109.97
|
76.87
|
143.94
|
83.51
|
289.54
|
170.46
|
456.98
|
13,082.49
|
1,966.20
|
494.21
|
211.42
|
250.46
|
787.10
|
909.67
|
309.39
|
92.72
|
72.86
|
|
04
|
988.07
|
194.02
|
106.40
|
65.88
|
134.07
|
72.79
|
284.87
|
164.93
|
455.28
|
13,464.03
|
2,023.24
|
501.55
|
203.79
|
246.40
|
794.42
|
930.69
|
309.39
|
86.67
|
67.99
|
|
05
|
1,114.90
|
218.88
|
124.55
|
87.67
|
163.37
|
94.37
|
327.65
|
191.99
|
516.85
|
14,523.47
|
2,177.74
|
545.47
|
228.63
|
272.44
|
861.79
|
1,003.60
|
309.39
|
81.38
|
63.73
|
|
06
|
1,026.31
|
201.56
|
114.28
|
82.70
|
152.39
|
88.80
|
303.65
|
179.04
|
475.61
|
13,110.81
|
1,969.85
|
496.21
|
215.95
|
254.05
|
796.88
|
913.80
|
309.39
|
78.98
|
61.77
|
|
07
|
972.52
|
190.99
|
107.28
|
69.37
|
135.97
|
76.04
|
279.40
|
161.46
|
446.02
|
13,644.01
|
2,049.69
|
507.86
|
202.73
|
246.78
|
792.90
|
937.50
|
309.39
|
77.64
|
60.70
|
|
08
|
958.69
|
188.49
|
111.78
|
83.85
|
148.15
|
89.99
|
283.16
|
167.19
|
445.48
|
12,460.72
|
1,873.82
|
472.00
|
201.24
|
238.82
|
745.01
|
864.91
|
309.39
|
84.99
|
66.61
|
|
09
|
1,039.23
|
204.22
|
117.13
|
82.10
|
152.67
|
88.99
|
303.69
|
177.86
|
480.14
|
14,397.66
|
2,160.69
|
533.58
|
208.48
|
255.77
|
826.34
|
984.74
|
309.39
|
87.98
|
69.03
|
|
10
|
1,034.40
|
203.16
|
113.31
|
77.19
|
148.00
|
83.86
|
301.15
|
175.83
|
474.85
|
17,969.34
|
2,691.92
|
670.42
|
276.66
|
331.42
|
1,060.34
|
1,237.23
|
309.39
|
97.56
|
76.73
|
|
11
|
1,192.79
|
234.12
|
136.47
|
100.36
|
179.69
|
104.59
|
350.59
|
205.44
|
550.64
|
15,059.58
|
2,256.02
|
568.28
|
236.28
|
280.13
|
886.55
|
1,037.75
|
309.39
|
127.34
|
100.75
|
|
6B *
|
1,025.81
|
201.47
|
114.28
|
82.88
|
152.52
|
88.96
|
303.69
|
179.15
|
475.51
|
13,109.63
|
1,969.69
|
496.24
|
216.10
|
254.18
|
797.09
|
913.82
|
309.39
|
78.98
|
61.77
|
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
|
951.62
|
187.14
|
104.51
|
77.72
|
142.70
|
83.74
|
286.26
|
171.39
|
443.95
|
12,591.19
|
1,898.85
|
489.44
|
240.71
|
271.47
|
827.56
|
902.95
|
326.73
|
110.64
|
89.20
|
|
02
|
816.22
|
160.56
|
91.04
|
68.95
|
124.44
|
74.21
|
246.82
|
148.33
|
383.01
|
10,685.97
|
1,613.03
|
416.82
|
205.95
|
232.05
|
703.69
|
767.64
|
326.73
|
99.85
|
80.49
|
|
03
|
984.49
|
193.60
|
112.04
|
86.98
|
153.38
|
92.95
|
298.07
|
178.99
|
462.71
|
13,084.04
|
1,967.75
|
512.13
|
255.14
|
285.73
|
856.88
|
936.11
|
326.73
|
102.67
|
82.81
|
|
04
|
988.25
|
194.20
|
109.96
|
83.23
|
150.27
|
88.99
|
299.51
|
179.57
|
465.12
|
13,465.98
|
2,025.19
|
524.12
|
258.85
|
290.81
|
882.30
|
963.99
|
326.73
|
96.62
|
77.94
|
|
05
|
1,115.01
|
218.99
|
126.78
|
98.55
|
173.52
|
104.52
|
336.83
|
201.17
|
523.02
|
14,525.38
|
2,179.65
|
567.54
|
282.48
|
315.88
|
947.74
|
1,036.17
|
326.73
|
91.33
|
73.68
|
|
06
|
1,026.37
|
201.62
|
115.51
|
88.69
|
157.98
|
94.39
|
308.71
|
184.10
|
479.01
|
13,112.16
|
1,971.20
|
511.79
|
253.97
|
284.72
|
857.56
|
936.79
|
326.73
|
88.93
|
71.72
|
|
07
|
972.69
|
191.16
|
110.70
|
86.03
|
151.52
|
91.59
|
293.45
|
175.51
|
455.46
|
13,646.23
|
2,051.91
|
533.55
|
265.41
|
297.34
|
892.93
|
975.41
|
326.73
|
87.59
|
70.65
|
|
08
|
958.77
|
188.57
|
113.43
|
91.90
|
155.67
|
97.51
|
289.95
|
173.98
|
450.05
|
12,462.32
|
1,875.42
|
490.45
|
246.25
|
275.13
|
816.84
|
892.13
|
326.73
|
94.94
|
76.50
|
|
09
|
1,039.35
|
204.34
|
119.58
|
94.02
|
163.80
|
100.12
|
313.75
|
187.92
|
486.90
|
14,400.21
|
2,163.24
|
563.00
|
280.25
|
313.66
|
940.88
|
1,028.15
|
326.73
|
97.93
|
78.98
|
|
10
|
1,034.51
|
203.27
|
115.48
|
87.76
|
157.86
|
93.72
|
310.07
|
184.75
|
480.84
|
17,971.77
|
2,694.35
|
698.46
|
345.06
|
386.60
|
1,169.51
|
1,278.60
|
326.73
|
107.51
|
86.68
|
|
11
|
1,192.88
|
234.21
|
138.30
|
109.27
|
188.01
|
112.91
|
358.11
|
212.96
|
555.69
|
15,061.70
|
2,258.14
|
592.74
|
295.97
|
328.28
|
981.81
|
1,073.85
|
326.73
|
137.29
|
110.70
|
|
6B *
|
1,025.87
|
201.53
|
115.46
|
88.65
|
157.91
|
94.35
|
308.56
|
184.02
|
478.78
|
13,110.97
|
1,971.03
|
511.75
|
253.94
|
284.70
|
857.48
|
936.71
|
326.73
|
88.93
|
71.72
|
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 4 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
Area
|
Corresponding Counties
|
|
Area 1
|
Escambia, Okaloosa, Santa Rosa, Walton
|
|
Area 2
|
Bay, Xxxxxxx, Xxxxxxxx, Gadsden, Xxxx, Xxxxxx, Xxxxxxx, Xxxxxxxxx, Xxxx, Xxxxxxx, Xxxxxxx, Xxxxxx, Washington, Wakulla
|
|
Area 3
|
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Xxxxxxxx, Xxxxxxxxx, Xxxx, Xxxx, Xxxxxx, Xxxxxx, Xxxxxx, Suwannee, Union
|
|
Area 4
|
Xxxxx, Xxxx, Xxxxx, Xxxxxxx, Nassau, St. Xxxxx, Volusia
|
|
Area 0
|
Xxxxx, Xxxxxxxx
|
|
Area 6
|
Xxxxxx, Highlands, Manatee, Polk
|
|
Area 6B *
|
Hillsborough
|
|
Area 0
|
Xxxxxxx, Xxxxxx, Xxxxxxx, Xxxxxxxx
|
|
Area 8
|
Charlotte, Xxxxxxx, Xx Xxxx, Glades, Xxxxxx, Xxx, Sarasota
|
|
Area 0
|
Xxxxxx Xxxxx, Xxxxxxxxxx, Xx. Xxxxx, Xxxxxx, Xxxx Xxxxx
|
|
Area 10
|
Broward
|
|
Area 11
|
Dade, Monroe
|
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 5 of 5
| ATTACHMENT VI |
| VENDOR CERTIFICATION REGARDING |
| SCRUTINIZED COMPANIES LIST |
| Vendor Name: | WellCare of Florida Inc. |
| Vendor FEIN: | 00-0000000 | ||||
| Xxxxxx's Authorized Representative Name and Title: | Xxxxxxxxx Xxxxxx, President | ||||
| Address: | 0000 Xxxxxxxxx Xxxx | ||
| City: | Tampa | State: | FL | Zip: | 33634 | ||
| Telephone Number: | 000-000-0000 | ||||
| Email Address: | xxxxxxxx.xxxxxx@xxxxxxxx.xxx | |
| Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. Both lists are created pursuant to section 215.473, Florida Statutes. |
| As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified above in the section entitled "Vendor Name" is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney's fees, and/or costs. |
| Certified By: | /s/Xxxxxxxxx Xxxxxx | , | ||
| who is authorized to sign on behalf of the above referenced company. | ||||
| Authorized Signature Print Name and Title: | Xxxxxxxxx Xxxxxx, President | |||
AHCA Contract No. FA904, Attachment VI, Page 1of 1
