AHCA CONTRACT NO. FA615 AMENDMENT NO. 10
Exhibit 10.4
|
WellCare
of Florida, Inc. d/b/a
Staywell Health Plan of Florida
|
AHCA
CONTRACT NO. FA615
AMENDMENT
NO. 10
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 C, Contract Managers, sub-item 1, is hereby
amended to change the Agency's Contract Manager's name to Xxxxxxx X.
Xxxxxxxx. All other contact information remains
unchanged.
|
|
2.
|
Effective
March 1, 2009, Attachment I, Scope of Services, is hereby amended to
include Exhibit III-F, March 1, 2009 - August 31, 2009 Medicaid Non-Reform
HMO Capitation Rates, attached hereto and made a part of the Contract. All
references in the Contract to Exhibit III-E, February 1, 2009 - August 31,
2009 Medicaid Non-Reform HMO Capitation Rates, shall hereinafter also
refer to Exhibit III-F, March 1, 2009 - August 31, 2009 Medicaid
Non-Reform HMO Capitation Rates, as
appropriate.
|
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 part of the
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 (which includes all attachments
hereto) to be executed by their officials thereunto duly
authorized.
|
WELLCARE
OF FLORIDA, INC.
D/B/A STAYWELL HEALTH PLAN
OF FLORIDA
|
STATE
OF FLORIDA, AGENCY FOR
HEALTH
CARE ADMINISTRATION
|
|
SIGNED
BY:
/s/ Xxxxx
Xxxxxxxxx
|
SIGNED
BY: /s/ Xxxxx
Xxxxxx
|
|
NAME:
Xxxxx
Xxxxxxxxx
|
NAME:
Xxxxx
Xxxxxx
|
|
TITLE:
President and
CEO
|
TITLE:
Secretary
|
|
DATE:
|
DATE:
4/22/09
|
List of
attachments/exhibits included as part of this Amendment:
|
Specify
Type
|
Letter/
Number
|
Description
|
|
Exhibit
|
III-F
|
March
1, 2009 - August 31, 2009 Medicaid Non-Reform
HMO
Capitation
Rates (5 Pages)
|
AHCA
Contract No. FA615, Amendment No. 10, Page 1 of 1
AHCA Form
2100-0002 (Rev. NOV03)
EXHIBIT
III-F
March
1, 2009 -August 31, 2009
MEDICAID
Non-Reform HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Revised
on February 16, 2009
TABLE
1
|
General
Rates
|
XXXX
|
XXX-X
|
XXX-X
|
XXX-XX
|
|||||||||||||||
|
Xxxx
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
XXXX0x0X0
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,094.22
|
184.16
|
99.63
|
60.40
|
127.26
|
68.32
|
250.84
|
150.73
|
313.03
|
10,249.54
|
1,491.48
|
438.21
|
195.46
|
209.48
|
684.74
|
688.27
|
300.62
|
93.17
|
84.30
|
|
02
|
1,094.22
|
184.16
|
99.63
|
60.40
|
127.26
|
68.32
|
250.84
|
150.73
|
313.03
|
10,249.54
|
1,491.48
|
438.21
|
195.46
|
209.48
|
684.74
|
688.27
|
300.62
|
93.17
|
84.30
|
|
03
|
1,196.62
|
202.96
|
110.34
|
67.92
|
140.84
|
76.51
|
278.65
|
168.47
|
353.53
|
11,246.01
|
1,651.16
|
486.56
|
222.16
|
237.31
|
773.96
|
781.87
|
334.70
|
88.46
|
80.57
|
|
04
|
1,049.14
|
178.79
|
97.34
|
60.45
|
124.13
|
68.04
|
246.51
|
149.64
|
315.69
|
10,783.85
|
1,587.50
|
468.19
|
215.03
|
229.34
|
748.28
|
757.29
|
292.70
|
88.80
|
80.98
|
|
05
|
1,194.06
|
202.97
|
110.37
|
68.18
|
140.78
|
76.87
|
279.19
|
169.16
|
355.65
|
12,038.26
|
1,765.98
|
519.70
|
236.81
|
252.51
|
825.86
|
834.51
|
221.32
|
79.80
|
74.00
|
|
06
|
1,038.39
|
178.07
|
97.17
|
60.92
|
124.01
|
68.48
|
247.03
|
150.57
|
319.86
|
10,970.19
|
1,617.13
|
476.72
|
220.10
|
233.82
|
764.56
|
774.50
|
270.21
|
77.95
|
71.38
|
|
07
|
1,074.14
|
183.63
|
100.12
|
62.40
|
127.54
|
70.12
|
253.83
|
154.32
|
326.38
|
11,607.26
|
1,714.80
|
505.56
|
234.47
|
249.87
|
814.51
|
826.24
|
367.55
|
83.10
|
76.28
|
|
08
|
1,015.73
|
174.04
|
95.01
|
59.33
|
121.03
|
66.85
|
241.01
|
146.72
|
311.46
|
10,344.94
|
1,523.63
|
449.17
|
206.42
|
220.49
|
718.78
|
727.41
|
251.83
|
77.41
|
70.98
|
|
09
|
1,049.42
|
178.45
|
97.12
|
60.00
|
123.89
|
67.48
|
245.50
|
148.81
|
312.90
|
10,887.75
|
1,607.33
|
473.84
|
219.83
|
233.26
|
762.25
|
772.33
|
215.52
|
82.97
|
75.87
|
|
10
|
1,064.83
|
182.89
|
99.98
|
62.78
|
127.46
|
70.63
|
254.09
|
155.07
|
330.14
|
14,097.57
|
2,095.67
|
618.54
|
292.06
|
308.77
|
1,009.40
|
1,026.88
|
316.67
|
92.40
|
84.73
|
|
11
|
1,348.59
|
228.59
|
124.07
|
76.21
|
158.52
|
85.96
|
313.61
|
189.56
|
397.28
|
14,238.94
|
2,095.21
|
617.24
|
284.21
|
302.64
|
987.26
|
998.51
|
364.12
|
137.86
|
124.45
|
|
6B*
|
1,038.25
|
178.05
|
97.16
|
60.91
|
123.99
|
68.47
|
247.00
|
150.55
|
319.81
|
10,969.70
|
1,617.05
|
476.70
|
220.09
|
233.81
|
764.51
|
774.47
|
270.21
|
77.95
|
71.38
|
TABLE 2
|
General
+ Mental Health Rates:
|
||||||||||||||||||||
|
TANF
|
SSl-N
|
SSI-B
|
SSI-AB
|
|||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO-11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
XXXX0x0X0
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
||||
|
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,094.24
|
184.18
|
101.24
|
71.89
|
138.00
|
79.06
|
255.20
|
155.09
|
316.71
|
10,249.62
|
1,491.56
|
445.52
|
242.68
|
252.71
|
764.74
|
718.72
|
300.83
|
104.62
|
95.75
|
|
|
02
|
1,094.25
|
184.19
|
102.49
|
80.31
|
140.45
|
81.51
|
254.19
|
154.08
|
315.93
|
10,249.69
|
1,491.63
|
451.77
|
272.92
|
253.92
|
736.51
|
712.72
|
320.48
|
107.92
|
99.05
|
|
|
03
|
1,196.63
|
202.97
|
111.64
|
76.94
|
146.82
|
82.49
|
280.17
|
169.99
|
354.85
|
11,246.08
|
1,651.23
|
492.71
|
257.30
|
257.47
|
797.45
|
792.96
|
341.43
|
97.29
|
89.40
|
|
|
04
|
1,049.15
|
178.80
|
98.69
|
69.84
|
130.36
|
74.27
|
248.09
|
151.22
|
317.06
|
10,783.96
|
1,587.61
|
477.78
|
269.81
|
260.77
|
784.90
|
774.58
|
316.83
|
105.28
|
97.46
|
|
|
05
|
1,194.07
|
202.98
|
111.56
|
76.71
|
148.75
|
84.84
|
282.43
|
172.40
|
358.38
|
12,038.31
|
1,766.03
|
524.64
|
268.67
|
281.68
|
879.83
|
855.05
|
224.00
|
92.40
|
86.60
|
|
|
06
|
1,038.41
|
178.09
|
98.99
|
73.94
|
136.17
|
80.64
|
251.97
|
155.51
|
324.03
|
10,970.26
|
1,617.20
|
483.13
|
261.48
|
271.70
|
834.66
|
801.18
|
271.50
|
81.77
|
75.20
|
|
|
07
|
1,074.16
|
183.65
|
101.87
|
74.87
|
139.19
|
81.77
|
258.57
|
159.06
|
330.38
|
11,607.32
|
1,714.86
|
511.58
|
273.30
|
285.42
|
880.29
|
851.28
|
370.10
|
93.44
|
86.62
|
|
|
08
|
1,015.74
|
174.05
|
96.25
|
67.97
|
126.75
|
72.57
|
242.47
|
148.18
|
312.72
|
10,345.01
|
1,523.70
|
455.07
|
240.11
|
239.83
|
741.30
|
738.04
|
258.56
|
90.40
|
83.97
|
|
|
09
|
1,049.44
|
178.47
|
98.64
|
70.62
|
130.92
|
74.51
|
247.29
|
150.60
|
314.45
|
10,887.82
|
1,607.40
|
480.06
|
255.35
|
253.65
|
785.99
|
783.54
|
222.25
|
92.39
|
85.29
|
|
|
10
|
1,064.85
|
182.91
|
101.87
|
75.91
|
136.16
|
79.33
|
256.30
|
157.28
|
332.06
|
14,097.66
|
2,095.76
|
626.75
|
338.95
|
335.68
|
1,040.74
|
1,041.68
|
323.40
|
100.32
|
92.65
|
|
|
11
|
1,348.61
|
228.61
|
125.66
|
87.31
|
165.88
|
93.32
|
315.48
|
191.43
|
398.90
|
14,239.02
|
2,095.29
|
624.09
|
323.33
|
325.08
|
1,013.40
|
1,010.85
|
371.22
|
145.78
|
132.37
|
|
|
6B*
|
1,038.27
|
178.07
|
98.88
|
73.21
|
135.48
|
79.96
|
251.67
|
155.22
|
323.75
|
10,969.77
|
1,617.12
|
483.09
|
261.35
|
271.58
|
834.41
|
801.07
|
271.50
|
81.77
|
75.20
|
|
AHCA
Contract No. FA615, Exhibit III-F, Page 1 of 5
EXHIBIT
III-F
March
1, 2009 - August 31, 2009
MEDICAID
Non-Reform HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Revised
on February 16, 2009
TABLE
3
|
General
+ WIH + Dental Rates
|
|||||||||||||||||||
|
XXXX
|
XXX-X
|
XXX-X
|
XXX-XX
|
||||||||||||||||
|
Xxxx
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20) AGE (21-54) |
AGE
(55+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE (6-13) AGE (14-20)
AGE (21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
||||||
|
|
Female
|
Male
|
Female
|
Male
|
|||||||||||||||
|
01
|
1,094.24
|
184.19
|
102.89
|
74.95
|
141.13
|
81.70
|
256.40
|
156.33
|
319.45
|
10,249.62
|
1,491.56
|
447.11
|
245.04
|
254.73
|
766.05
|
720.55
|
301.27
|
105.72
|
96.60
|
|
02
|
1,094.25
|
184.20
|
104.14
|
83.37
|
143.58
|
84.15
|
255.39
|
155.32
|
318.67
|
10,249.69
|
1,491.63
|
453.36
|
275.28
|
255.94
|
737.82
|
714.55
|
320.92
|
109.02
|
99.90
|
|
03
|
1,196.64
|
202.99
|
114.64
|
82.50
|
152.49
|
87.29
|
281.88
|
171.74
|
358.75
|
11,246.08
|
1,651.24
|
495.79
|
261.86
|
261.39
|
799.30
|
795.56
|
342.44
|
98.91
|
90.64
|
|
04
|
1,049.16
|
178.81
|
100.50
|
73.20
|
133.80
|
77.17
|
249.73
|
152.91
|
320.81
|
10,783.96
|
1,587.61
|
479.53
|
272.40
|
263.00
|
786.75
|
777.17
|
318.97
|
106.84
|
98.65
|
|
05
|
1,194.08
|
203.00
|
114.91
|
82.93
|
155.11
|
90.22
|
285.78
|
175.85
|
366.04
|
12,038.32
|
1,766.04
|
528.79
|
274.83
|
286.97
|
883.47
|
860.16
|
227.60
|
96.12
|
89.44
|
|
06
|
1,038.42
|
178.10
|
101.61
|
78.81
|
141.14
|
84.85
|
253.82
|
157.42
|
328.26
|
10,970.26
|
1,617.21
|
486.12
|
265.90
|
275.50
|
837.12
|
804.63
|
273.23
|
83.98
|
76.88
|
|
07
|
1,074.17
|
183.66
|
104.23
|
79.24
|
143.65
|
85.54
|
259.88
|
160.40
|
333.37
|
11,607.32
|
1,714.87
|
514.53
|
277.66
|
289.17
|
881.81
|
853.42
|
370.57
|
94.93
|
87.76
|
|
08
|
1,015.75
|
174.07
|
99.83
|
74.59
|
133.52
|
78.30
|
244.46
|
150.21
|
317.24
|
10,345.01
|
1,523.71
|
458.43
|
245.10
|
244.12
|
743.54
|
741.18
|
260.07
|
92.04
|
85.22
|
|
09
|
1,049.45
|
178.49
|
101.52
|
75.97
|
136.38
|
79.13
|
248.23
|
151.56
|
316.60
|
10,887.82
|
1,607.41
|
482.61
|
259.13
|
256.90
|
787.15
|
785.16
|
224.05
|
93.44
|
86.09
|
|
10
|
1,064.86
|
182.92
|
104.26
|
80.34
|
140.69
|
83.16
|
257.02
|
158.02
|
333.69
|
14,097.66
|
2,095.77
|
629.49
|
343.02
|
339.18
|
1,041.67
|
1,042.99
|
324.21
|
101.60
|
93.61
|
|
11
|
1,348.62
|
228.62
|
129.33
|
94.86
|
173.71
|
99.92
|
316.33
|
192.29
|
400.83
|
14,239.03
|
2,095.31
|
628.29
|
330.59
|
331.44
|
1,015.15
|
1,013.31
|
374.50
|
147.90
|
133.99
|
|
6B-
|
1,038.28
|
178.08
|
101.50
|
78.08
|
140.45
|
84.17
|
251.67
|
155.22
|
323.75
|
10,969.77
|
1,617.13
|
486.08
|
265.77
|
275.38
|
834.41
|
801.07
|
273.23
|
83.98
|
76.88
|
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+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
||||
|
Female
|
Male
|
Female
|
Male
|
|||||||||||||||||
|
01
|
1,099.50
|
185.53
|
102.06
|
72.38
|
140.00
|
80.38
|
258.44
|
157.56
|
320.16
|
10,288.04
|
1,516.79
|
450.72
|
245.07
|
258.73
|
784.45
|
735.36
|
308.17
|
118.10
|
104.44
|
|
|
02
|
1,099.51
|
185.54
|
103.31
|
80.80
|
142.45
|
82.83
|
257.43
|
156.55
|
319.38
|
10,288.11
|
1,516.86
|
456.97
|
275.31
|
259.94
|
756.22
|
729.36
|
327.82
|
121.40
|
107.74
|
|
|
03
|
1,202.95
|
204.60
|
112.62
|
77.53
|
149.22
|
84.07
|
284.07
|
172.96
|
359.00
|
11,294.54
|
1,683.05
|
499.28
|
260.32
|
265.06
|
822.32
|
813.95
|
349.99
|
116.72
|
101.92
|
|
|
04
|
1,053.64
|
179.96
|
99.39
|
70.26
|
132.07
|
75.40
|
250.86
|
153.32
|
320.01
|
10,821.63
|
1,612.34
|
482.87
|
272.15
|
266.67
|
804.22
|
790.89
|
323.89
|
120.86
|
107.50
|
|
|
05
|
1,197.87
|
203.96
|
112.15
|
77.06
|
150.19
|
85.79
|
284.77
|
174.18
|
360.87
|
12,069.58
|
1,786.55
|
528.88
|
270.62
|
286.57
|
895.87
|
868.59
|
230.44
|
106.24
|
95.51
|
|
|
06
|
1,042.14
|
179.05
|
99.57
|
74.29
|
137.59
|
81.57
|
254.28
|
157.27
|
326.48
|
11,001.22
|
1,637.53
|
487.33
|
263.40
|
276.55
|
850.54
|
814.59
|
277.11
|
93.13
|
82.52
|
|
|
07
|
1,078.12
|
184.66
|
102.49
|
75.24
|
140.69
|
82.77
|
261.02
|
160.93
|
332.97
|
11,641.47
|
1,737.28
|
516.20
|
275.41
|
290.77
|
897.81
|
866.07
|
375.39
|
105.36
|
94.30
|
|
|
08
|
1,020.94
|
175.39
|
97.07
|
68.46
|
128.74
|
73.88
|
245.67
|
150.62
|
316.13
|
10,382.57
|
1,548.36
|
460.15
|
242.45
|
245.71
|
760.56
|
754.32
|
264.39
|
104.94
|
93.33
|
|
|
09
|
1,054.46
|
179.77
|
99.43
|
71.09
|
132.83
|
75.77
|
250.39
|
152.96
|
317.74
|
10,926.48
|
1,632.80
|
485.30
|
257.76
|
259.70
|
805.82
|
800.29
|
228.70
|
107.92
|
95.29
|
|
|
10
|
1,067.79
|
183.68
|
102.33
|
76.19
|
137.28
|
80.07
|
258.11
|
158.66
|
333.99
|
14,123.46
|
2,112.70
|
630.24
|
340.55
|
339.72
|
1,053.97
|
1,052.85
|
328.61
|
112.45
|
100.46
|
|
|
11
|
1,351.65
|
229.39
|
126.13
|
87.60
|
167.04
|
94.09
|
317.36
|
192.86
|
400.90
|
14,265.93
|
2,112.95
|
627.73
|
325.00
|
329.30
|
1,027.20
|
1,022.51
|
376.25
|
158.01
|
140.24
|
|
|
6B*
|
1,042.00
|
179.03
|
99.46
|
73.56
|
136.90
|
80.89
|
253.98
|
156.98
|
326.20
|
11,000.73
|
1,637.45
|
487.29
|
263.27
|
276.43
|
850.29
|
814.48
|
277.11
|
93.13
|
82.52
|
|
AHCA
Contract No. FA615, Exhibit III-F, Page 2 of 5
EXHIBIT
III-F
March
1, 2009 -August31, 2009
MEDICAID
Non-Reform HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Revised
on February 16, 2009
TABLE
5
|
General
+ Transportation Rates:
|
|||||||||||||||||||
|
TANF
|
SSl-N
|
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO-11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,099.48
|
185.51
|
100.45
|
60.89
|
129.26
|
69.64
|
254.08
|
153.20
|
316.48
|
10,287.96
|
1,516.71
|
443.41
|
197.85
|
215.50
|
704.45
|
704.91
|
307.96
|
106.65
|
92.99
|
|
02
|
1,099.48
|
185.51
|
100.45
|
60.89
|
129.26
|
69.64
|
254.08
|
153.20
|
316.48
|
10,287.96
|
1,516.71
|
443.41
|
197.85
|
215.50
|
704.45
|
704.91
|
307.96
|
106.65
|
92.99
|
|
03
|
1,202.94
|
204.59
|
111.32
|
68.51
|
143.24
|
78.09
|
282.55
|
171.44
|
357.68
|
11,294.47
|
1,682.98
|
493.13
|
225.18
|
244.90
|
798.83
|
802.86
|
343.26
|
107.89
|
93.09
|
|
04
|
1,053.63
|
179.95
|
98.04
|
60.87
|
125.84
|
69.17
|
249.28
|
151.74
|
318.64
|
10,821.52
|
1,612.23
|
473.28
|
217.37
|
235.24
|
767.60
|
773.60
|
299.76
|
104.38
|
91.02
|
|
05
|
1,197.86
|
203.95
|
110.96
|
68.53
|
142.22
|
77.82
|
281.53
|
170.94
|
358.14
|
12,069.53
|
1,786.50
|
523.94
|
238.76
|
257.40
|
841.90
|
848.05
|
227.76
|
93.64
|
82.91
|
|
06
|
1,042.12
|
179.03
|
97.75
|
61.27
|
125.43
|
69.41
|
249.34
|
152.33
|
322.31
|
11,001.15
|
1,637.46
|
480.92
|
222.02
|
238.67
|
780.44
|
787.91
|
275.82
|
89.31
|
78.70
|
|
07
|
1,078.10
|
184.64
|
100.74
|
62.77
|
129.04
|
71.12
|
256.28
|
156.19
|
328.97
|
11,641.41
|
1,737.22
|
510.18
|
236.58
|
255.22
|
832.03
|
841.03
|
372.84
|
95.02
|
83.96
|
|
08
|
1,020.93
|
175.38
|
95.83
|
59.82
|
123.02
|
68.16
|
244.21
|
149.16
|
314.87
|
10,382.50
|
1,548.29
|
454.25
|
208.76
|
226.37
|
738.04
|
743.69
|
257.66
|
91.95
|
80.34
|
|
09
|
1,054.44
|
179.75
|
97.91
|
60.47
|
125.80
|
68.74
|
248.60
|
151.17
|
316.19
|
10,926.41
|
1,632.73
|
479.08
|
222.24
|
239.31
|
782.08
|
789.08
|
221.97
|
98.50
|
85.87
|
|
10
|
1,067.77
|
183.66
|
100.44
|
63.06
|
128.58
|
71.37
|
255.90
|
156.45
|
332.07
|
14,123.37
|
2,112.61
|
622.03
|
293.66
|
312.81
|
1,022.63
|
1,038.05
|
321.88
|
104.53
|
92.54
|
|
11
|
1,351.63
|
229.37
|
124.54
|
76.50
|
159.68
|
86.73
|
315.49
|
190.99
|
399.28
|
14,265.85
|
2,112.87
|
620.88
|
285.88
|
306.86
|
1,001.06
|
1,010.17
|
369.15
|
150.09
|
132.32
|
|
6B*
|
1,041.98
|
179.01
|
97.74
|
61.26
|
125.41
|
69.40
|
249.31
|
152.31
|
322.26
|
11,000.66
|
1,637.38
|
480.90
|
222.01
|
238.66
|
780.39
|
787.88
|
275.82
|
89.31
|
78.70
|
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+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,094.22
|
184.17
|
101.28
|
63.46
|
130.39
|
70.96
|
252.04
|
151.97
|
315.77
|
10,249.54
|
1,491.48
|
439.80
|
197.82
|
211.50
|
686.05
|
690.10
|
301.06
|
94.27
|
85.15
|
|
02
|
1,094.22
|
184.17
|
101.28
|
63.46
|
130.39
|
70.96
|
252.04
|
151.97
|
315.77
|
10,249.54
|
1,491.48
|
439.80
|
197.82
|
211.50
|
686.05
|
690.10
|
301.06
|
94.27
|
85.15
|
|
03
|
1,196.63
|
202.98
|
113.34
|
73.48
|
146.51
|
81.31
|
280.36
|
170.22
|
357.43
|
11,246.01
|
1,651.17
|
489.64
|
226.72
|
241.23
|
775.81
|
784.47
|
335.71
|
90.08
|
81.81
|
|
04
|
1,049.15
|
178.80
|
99.15
|
63.81
|
127.57
|
70.94
|
248.15
|
151.33
|
319.44
|
10,783.85
|
1,587.50
|
469.94
|
217.62
|
231.57
|
750.13
|
759.88
|
294.84
|
90.36
|
82.17
|
|
05
|
1,194.07
|
202.99
|
113.72
|
74.40
|
147.14
|
82.25
|
282.54
|
172.61
|
363.31
|
12,038.27
|
1,765.99
|
523.85
|
242.97
|
257.80
|
829.50
|
839.62
|
224.92
|
83.52
|
76.84
|
|
06
|
1,038.40
|
178.08
|
99.79
|
65.79
|
128.98
|
72.69
|
248.88
|
152.48
|
324.09
|
10,970.19
|
1,617.14
|
479.71
|
224.52
|
237.62
|
767.02
|
777.95
|
271.94
|
80.16
|
73.06
|
|
07
|
1,074.15
|
183.64
|
102.48
|
66.77
|
132.00
|
73.89
|
255.14
|
155.66
|
329.37
|
11,607.26
|
1,714.81
|
508.51
|
238.83
|
253.62
|
816.03
|
828.38
|
368.02
|
84.59
|
77.42
|
|
08
|
1,015.74
|
174.06
|
98.59
|
65.95
|
127.80
|
72.58
|
243.00
|
148.75
|
315.98
|
10,344.94
|
1,523.64
|
452.53
|
211.41
|
224.78
|
721.02
|
730.55
|
253.34
|
79.05
|
72.23
|
|
09
|
1,049.43
|
178.47
|
100.00
|
65.35
|
129.35
|
72.10
|
246.44
|
149.77
|
315.05
|
10,887.75
|
1,607.34
|
476.39
|
223.61
|
236.51
|
763.41
|
773.95
|
217.32
|
84.02
|
76.67
|
|
10
|
1,064.84
|
182.90
|
102.37
|
67.21
|
131.99
|
74.46
|
254.81
|
155.81
|
331.77
|
14,097.57
|
2,095.68
|
621.28
|
296.13
|
312.27
|
1,010.33
|
1,028.19
|
317.48
|
93.68
|
85.69
|
|
11
|
1,348.60
|
228.60
|
127.74
|
83.76
|
166.35
|
92.56
|
314.46
|
190.42
|
399.21
|
14,238.95
|
2,095.23
|
621.44
|
291.47
|
309.00
|
989.01
|
1,000.97
|
367.40
|
139.98
|
126.07
|
|
6B*
|
1,038.26
|
178.06
|
99.78
|
65.78
|
128.96
|
72.68
|
247.00
|
150.55
|
319.81
|
10,969.70
|
1,617.06
|
479.69
|
224.51
|
237.61
|
764.51
|
774.47
|
271.94
|
80.16
|
73.06
|
AHCA
Contract No. FA615, Exhibit III-F, Page 3 of 5
EXHIBIT
III-F
March
1, 2009 - August 31, 2009
MEDICAID
Non-Reform HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Revised
on February 16, 2009
TABLE 7
|
General
+ Dental + Transportation Rates:
|
|||||||||||||||||||
|
XXXX
|
XXX-X
|
XXX-X
|
XXX-XX
|
||||||||||||||||
|
Xxxx
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,099.48
|
185.52
|
102.10
|
63.95
|
132.39
|
72.28
|
255.28
|
154.44
|
319.22
|
10,287.96
|
1,516.71
|
445.00
|
200.21
|
217.52
|
705.76
|
706.74
|
308.40
|
107.75
|
93.84
|
|
02
|
1,099.48
|
185.52
|
102.10
|
63.95
|
132.39
|
72.28
|
255.28
|
154.44
|
319.22
|
10,287.96
|
1,516.71
|
445.00
|
200.21
|
217.52
|
705.76
|
706.74
|
308.40
|
107.75
|
93.84
|
|
03
|
1,202.95
|
204.61
|
114.32
|
74.07
|
148.91
|
82.89
|
284.26
|
173.19
|
361.58
|
11,294.47
|
1,682.99
|
496.21
|
229.74
|
248.82
|
800.68
|
805.46
|
344.27
|
109.51
|
94.33
|
|
04
|
1,053.64
|
179.96
|
99.85
|
64.23
|
129.28
|
72.07
|
250.92
|
153.43
|
322.39
|
10,821.52
|
1,612.23
|
475.03
|
219.96
|
237.47
|
769.45
|
776.19
|
301.90
|
105.94
|
92.21
|
|
05
|
1,197.87
|
203.97
|
114.31
|
74.75
|
148.58
|
83.20
|
284.88
|
174.39
|
365.80
|
12,069.54
|
1,786.51
|
528.09
|
244.92
|
262.69
|
845.54
|
853.16
|
231.36
|
97.36
|
85.75
|
|
06
|
1,042.13
|
179.04
|
100.37
|
66.14
|
130.40
|
73.62
|
251.19
|
154.24
|
326.54
|
11,001.15
|
1,637.47
|
483.91
|
226.44
|
242.47
|
782.90
|
791.36
|
277.55
|
91.52
|
80.38
|
|
07
|
1,078.11
|
184.65
|
103.10
|
67.14
|
133.50
|
74.89
|
257.59
|
157.53
|
331.96
|
11,641.41
|
1,737.23
|
513.13
|
240.94
|
258.97
|
833.55
|
843.17
|
373.31
|
96.51
|
85.10
|
|
08
|
1,020.94
|
175.40
|
99.41
|
66.44
|
129.79
|
73.89
|
246.20
|
151.19
|
319.39
|
10,382.50
|
1,548.30
|
457.61
|
213.75
|
230.66
|
740.28
|
746.83
|
259.17
|
93.59
|
81.59
|
|
09
|
1,054.45
|
179.77
|
100.79
|
65.82
|
131.26
|
73.36
|
249.54
|
152.13
|
318.34
|
10,926.41
|
1,632.74
|
481.63
|
226.02
|
242.56
|
783.24
|
790.70
|
223.77
|
99.55
|
86.67
|
|
10
|
1,067.78
|
183.67
|
102.83
|
67.49
|
133.11
|
75.20
|
256.62
|
157.19
|
333.70
|
14,123.37
|
2,112.62
|
624.77
|
297.73
|
316.31
|
1,023.56
|
1,039.36
|
322.69
|
105.81
|
93.50
|
|
11
|
1,351.64
|
229.38
|
128.21
|
84.05
|
167.51
|
93.33
|
316.34
|
191.85
|
401.21
|
14,265.86
|
2,112.89
|
625.08
|
293.14
|
313.22
|
1,002.81
|
1,012.63
|
372.43
|
152.21
|
133.94
|
|
6B*
|
1,041.99
|
179.02
|
100.36
|
66.13
|
130.38
|
73.61
|
249.31
|
152.31
|
322.26
|
11,000.66
|
1,637.39
|
483.89
|
226.43
|
242.46
|
. 780.39
|
787.88
|
277.55
|
91.52
|
80.38
|
TABLE
8
|
General
+ Mental Health + Dental + Transportation Rates:
|
|||||||||||||||||||
|
XXXX
|
XXX-X
|
XXX-X
|
XXX-XX
|
||||||||||||||||
|
Xxxx
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
XXXXXx0XX
|
0XX-00XX
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,099.50
|
185.54
|
103.71
|
75.44
|
143.13
|
83.02
|
259.64
|
158.80
|
322.90
|
10,288.04
|
1,516.79
|
452.31
|
247.43
|
260.75
|
785.76
|
737.19
|
308.61
|
119.20
|
105.29
|
|
02
|
1,099.51
|
185.55
|
104.96
|
83.86
|
145.58
|
85.47
|
258.63
|
157.79
|
322.12
|
10,288.11
|
1,516.86
|
458.56
|
277.67
|
261.96
|
757.53
|
731.19
|
328.26
|
122.50
|
108.59
|
|
03
|
1,202.96
|
204.62
|
115.62
|
83.09
|
154.89
|
88.87
|
285.78
|
174.71
|
362.90
|
11,294.54
|
1,683.06
|
502.36
|
264.88
|
268.98
|
824.17
|
816.55
|
351.00
|
118.34
|
103.16
|
|
04
|
1,053.65
|
179.97
|
101.20
|
73.62
|
135.51
|
78.30
|
252.50
|
155.01
|
323.76
|
10,821.63
|
1,612.34
|
484.62
|
274.74
|
268.90
|
806.07
|
793.48
|
326.03
|
122.42
|
108.69
|
|
05
|
1,197.88
|
203.98
|
115.50
|
83.28
|
156.55
|
91.17
|
288.12
|
177.63
|
368.53
|
12,069.59
|
1,786.56
|
533.03
|
276.78
|
291.86
|
899.51
|
873.70
|
234.04
|
109.96
|
98.35
|
|
06
|
1,042.15
|
179.06
|
102.19
|
79.16
|
142.56
|
85.78
|
256.13
|
159.18
|
330.71
|
11,001.22
|
1,637.54
|
490.32
|
267.82
|
280.35
|
853.00
|
818.04
|
278.84
|
95.34
|
84.20
|
|
07
|
1,078.13
|
184.67
|
104.85
|
79.61
|
145.15
|
86.54
|
262.33
|
162.27
|
335.96
|
11,641.47
|
1,737.29
|
519.15
|
279.77
|
294.52
|
899.33
|
868.21
|
375.86
|
106.85
|
95.44
|
|
08
|
1,020.95
|
175.41
|
100.65
|
75.08
|
135.51
|
79.61
|
247.66
|
152.65
|
320.65
|
10,382.57
|
1,548.37
|
463.51
|
247.44
|
250.00
|
762.80
|
757.46
|
265.90
|
106.58
|
94.58
|
|
09
|
1,054.47
|
179.79
|
102.31
|
76.44
|
138.29
|
80.39
|
251.33
|
153.92
|
319.89
|
10,926.48
|
1,632.81
|
487.85
|
261.54
|
262.95
|
806.98
|
801.91
|
230.50
|
108.97
|
96.09
|
|
10
|
1,067.80
|
183.69
|
104.72
|
80.62
|
141.81
|
83.90
|
258.83
|
159.40
|
335.62
|
14,123.46
|
2,112.71
|
632.98
|
344.62
|
343.22
|
1,054.90
|
1,054.16
|
329.42
|
113.73
|
101.42
|
|
11
|
1,351.66
|
229.40
|
129.80
|
95.15
|
174.87
|
100.69
|
318.21
|
193.72
|
402.83
|
14,265.94
|
2,112.97
|
631.93
|
332.26
|
335.66
|
1,028.95
|
1,024.97
|
379.53
|
160.13
|
141.86
|
|
6B*
|
1,042.01
|
179.04
|
102.08
|
78.43
|
141.87
|
85.10
|
253.98
|
156.98
|
326.20
|
11,000.73
|
1,637.46
|
490.28
|
267.69
|
280.23
|
850.29
|
814.48
|
278.84
|
95.34
|
84.20
|
AHCA
Contract No. FA615, Exhibit III-F, Page 4 of 5
EXHIBIT
III-F
March
1, 2009 -August 31, 2009
MEDICAID
Non-Reform HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Revised on February 16,
2009
|
Area
|
Corresponding
Counties
|
|
Area
1
|
Escambia,
Okaloosa, Santa Rosa, Walton
|
|
Area
2
|
Bay,
Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Xxxxxxxxx, Xxxx,
Liberty, Madison, Taylor, Washington, Wakulla
|
|
Area
3
|
Alachua,
Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, Xxxx, Xxxxxx, Putnam, Sumter, Suwannee,
Union
|
|
Area
4
|
Baker,
Clay, Duval, Flagler, Nassau, St. Xxxxx, Volusia
|
|
Area
5
|
Pasco,
Pinellas
|
|
Area
6
|
Xxxxxx,
Highlands, Manatee, Polk
|
|
Area
6B *
|
Xxxxxxxxxxxx
|
|
Xxxx
0
|
Brevard,
Orange, Osceola, Seminole
|
|
Area
8
|
Charlotte,
Xxxxxxx, De Xxxx, Glades, Hendry, Lee, Sarasota
|
|
Area
9
|
Indian
River, Okeechobee, St. Lucie, Martin, Palm Beach
|
|
Area
00
|
Xxxxxxx
|
|
Xxxx
00
|
Xxxx,
Xxxxxx
|
AHCA
Contract No. FA615, Exhibit III-F, Page 5 of
5
