AHCA CONTRACT NO. FA905 AMENDMENT NO. 2
Exhibit
10.55.2
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
AHCA
CONTRACT NO. FA905
AMENDMENT
NO. 2
THIS CONTRACT, entered into
between the STATE OF FLORIDA,
AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter
referred to as the "Agency"
and HEALTHEASE OF
FLORIDA, INC., hereinafter referred to as the "Vendor" or "Health Plan", is hereby
amended as follows:
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1.
|
Attachment
I, Scope of Services, Capitated Health Plans, Section B. Population(s) to
be Served, Item 1., the
third paragraph is hereby amended to now read as
follows:
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|
**
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Enrolled
in an Agency-authorized specialty plan for children with chronic
conditions and screened by the Florida Department of Health as clinically
eligible for Children's Medical Services using an Agency-approved
screening tool as specified in Attachment II, Section III, Eligibility and
Enrollment, Exhibit 3.
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|
2.
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Attachment
I, Scope of Services, Capitated Health Plans, Section F.,
Applicable Exhibits, Table 9, Applicable
Exhibits, is hereby deleted in its entirety and replaced with the
following:
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|
Table
9-A
Revised
Applicable Exhibits
|
|||||||||
|
Attachment/
Exhibit*
|
HMO
Reform
|
HMO
Non-
Reform
|
Specialty
Plan
for
Recipients
Living
with
HIV/AIDS
Reform
|
Fee-
for-
Service
PSN
Non-
Reform
|
Capitated
PSN
Non-
Reform
|
Fee-
for-
Service
PSN
Reform
|
Capitated
PSN
Reform
|
Specialty
Plan
for
Children
with
Chronic
Conditions
Reform
|
HMO
Non-
Reform
with
Frail/
Elderly
Program
|
|
Xxx.
0, Xxx. 1
|
X
|
X
|
X
|
X/X
|
X
|
X/X
|
X
|
X/X
|
X
|
|
Xxx.
X, Xxx. 1-
FFS
|
N/A
|
N/A
|
N/A
|
X
|
N/A
|
X
|
N/A
|
X
|
N/A
|
|
Att.
I, Xxx.
0-XX
|
X/X
|
X
|
X/X
|
X/X
|
X
|
N/A
|
N/A
|
N/A
|
X
|
|
Att.
I, Xxx. 0-X
|
X
|
X/X
|
X
|
X/X
|
X/X
|
X/X
|
X
|
N/A
|
N/A
|
|
Att.
I, Exh.
2-FFS-NR
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N/A
|
N/A
|
N/A
|
X
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
Att.
I, Exh.
2-FFS-R
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N/A
|
N/A
|
N/A
|
X/X
|
X/X
|
X
|
X/X
|
X
|
X/X
|
|
Xxx.
XX, Xxx. 1
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N/A
|
N/A
|
X
|
N/A
|
X/X
|
X/X
|
X/X
|
X
|
X/X
|
|
Xxx.
XX, Xxx. 2
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Xxx.
0, Xxx. 3
|
X
|
X/X
|
X
|
X
|
X/X
|
X
|
X
|
X
|
X
|
|
Xxx.
XX, Xxx. 4
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X
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N/A
|
X
|
X/X
|
X/X
|
X
|
X
|
X
|
X
|
|
Xxx.
XX, Xxx. 5
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Att.
II, Exh. 6-
HMO&R
|
X
|
X
|
X
|
X/X
|
X/X
|
X
|
X
|
X
|
X
|
|
Xxx.
XX, Xxx. 6-
PSN-NR
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N/A
|
N/A
|
N/A
|
X
|
X
|
X/X
|
X/X
|
X/X
|
X/X
|
|
Xxx.
XX, Xxx. 7
|
X
|
N/A
|
X
|
X
|
N/A
|
X
|
X
|
X
|
N/A
|
|
Att.
II, Xxx. 0
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Xxx.
XX, Xxx. 9
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
Att.
II, Exh. 10
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
|
Att.
II, Exh.
11
|
N/A
|
N/A
|
N/A
|
N/A
|
X/X
|
X/X
|
X/X
|
X/X
|
X/X
|
|
Xxx.
XX, Xxx.
12
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
AHCA
Contract No. FA905, Amendment No. 2, Page 1 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Table
9-A
Revised
Applicable Exhibits
|
|||||||||
|
Attachment/
Exhibit*
|
HMO
Reform
|
HMO
Non-
Reform
|
Specialty
Plan
for
Recipients
Living
with
HIV/AIDS
Reform
|
Fee-
for-Service
PSN
Non-
Reform
|
Capitated
PSN
Non-
Reform
|
Fee-
for-
Service
PSN
Reform
|
Capitated
PSN
Reform
|
Specialty
Plan
for
Children
with
Chronic
Conditions
Reform
|
HMO
Non-
Reform
with
Frail/
Elderly
Program
|
|
Att.
II, Exh.
13-CAP-R
|
X | N/A | X | X/X | X/X | X | X | X/X | X/X |
|
Xxx.
XX, Xxx.
13-CAP-NR
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N/A | X | N/A | N/A | X | X/X | X/X | X/X | X |
|
Xxx.
XX, Xxx.
13-FFS
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N/A | N/A | X/X | X | X/X | X | X/X | X | X/X |
|
Xxx.
XX, Xxx. 14
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N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
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Att.
II, Exh. 15
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X | X | X | X | X | X | X | X | X |
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Att.
II, Exh. 16
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X | X | X | X | X | X | X | X | X |
* Plans
offering certain optional coverage also will have additional language in the
exhibits as follows: Exhibits 3, 4, 5, 8 and 13 -Frail/Elderly Program; Exhibit
5 - dental and transportation. Safety net hospital-based PSNs will have
additional language in the exhibits as follows: - Exhibit 13 - Method of
Payment.
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3.
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Effective
November 1, 2009, Attachment I, Scope of Services, Capitated Health Plans,
is hereby amended to include Exhibit 2-NR-A, Medicaid Non-Reform HMO
Capitation Rates, Effective November 1, 2009 - August 31, 2012, attached
hereto and made a part of this Contract. All references to Exhibit 2-NR,
Medicaid Non-Reform HMO Capitation Rates, September 1, 2009 - August 31,
2010, shall hereinafter also refer to Exhibit 2-NR-A, as
appropriate.
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4.
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Attachment
II, Core Contract Provisions, Section I, Definitions and Acronyms, Item
A., Definitions, the following definitions are hereby amended to now read
as follows:
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Catastrophic
Component Threshold - (Capitated Reform
Health Plans in counties where no HMO is present, Reform FFS PSNs, and the
Specialty Plan for Children with Chronic Conditions only) - The point at which
the cost of covered services, based on Medicaid fee-for-service payment levels,
reaches $50,000 for an enrollee in a Contract year. For a Health Plan that
accepts the comprehensive capitation rate only, the Agency begins reimbursing
the Health Plan for the cost of covered services received by the enrollee for
the remainder of the Contract year. This reimbursement is based on a percentage
of Medicaid fee-for-service payment levels.
Comprehensive
Component -
(Capitated Reform Health Plans in counties where no HMOs are present, Reform FFS
PSNs, and the Specialty Plan for Children with Chronic Conditions only) - The
amount of financial risk assumed by a Health Plan to provide covered service up
to $50,000 per enrollee based on Medicaid fee-for-service payment
levels.
Contested
Claim - (FFS
PSNs and the Specialty Plan for Children with Chronic Conditions only) - A claim
that has not been authorized and forwarded to the Medicaid fiscal agent by the
Health Plan because it has a material defect or impropriety.
Federally
Qualified Health Center (FQHC) - An entity that is
receiving a grant under section 330 of the Public Health Service Act, as
amended. (Also see Section 1905(I)(2)(B) of the Social Security Act.) FQHCs
provide primary health care and related diagnostic services and may provide
dental, optometric, podiatry, chiropractic and behavioral health
services.
Share of
Cost-Savings - (FFS PSNs and the
Specialty Plan for Children with Chronic Conditions only) -Potential payment to
the Health Plan when amount of the savings pool exceeds the administrative
allocation to the Health Plan as determined through a reconciliation
process.
AHCA
Contract No. FA905, Amendment No. 2, Page 2 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
5.
|
Attachment
II, Core Contract Provisions, Section I, Definitions and Acronyms, Item
B., Acronyms, the following
acronym is hereby amended to now read as
follows:
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APD — Agency for Persons with
Disabilities
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6.
|
Attachment
II, Core Contract Provisions, Section II, General Overview, Item D.,
General Responsibilities of the
Health Plan, sub-item 1., the first sentence is hereby amended to now read
as follows:
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The
Health Plan shall comply with all provisions of this Contract, including all
attachments, applicable exhibits, Health Plan Report Guide (Report Guide)
requirements and any amendments and shall act in good faith in the performance
of the Contract provisions.
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7.
|
Attachment
II, Core Contract Provisions, Section III, Eligibility and Enrollment,
Item B., Enrollment, sub-item
3.c.(3), the third sentence is hereby amended to now read as
follows:
|
(Special
provisions apply to fee-for-service PSNs and the Specialty Plan for Children
with Chronic Conditions; see Exhibit 3.)
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8.
|
Attachment
II, Core Contract Provisions, Section III, Eligibility and Enrollment,
Item B., Enrollment, sub-item
3.c.(8) is hereby amended to now read as
follows:
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|
|
(8)
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If the unborn activation process is properly completed by the FFS PSN and the Specialty Plan for Children with Chronic Conditions, the newborn will be enrolled using the process in Attachment II, Exhibit 3. |
|
9.
|
Attachment
II, Core Contract Provisions, Section IV, Enrollee Services, Community
Outreach and Marketing,
Item A., Enrollee Services, sub-item 1.c. is hereby amended to now read as
follows:
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c.
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The
Health Plan shall mail all enrollee materials to the enrollee's payee
address provided by the Agency on the Health Plan's monthly enrollment
file. Mailing envelopes for enrollee materials shall contain a request for
address correction. When enrollee materials are returned to the Health
Plan as undeliverable, the Health Plan shall remail the materials to the
enrollee residence address provided by the Agency if that address is
different from the payee address. The Health Plan shall use and maintain
in a file a record of all of the following methods to contact the
enrollee:
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|
(1)
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Routine
checks of the Agency enrollment reports for changes of address and/or
presence of the enrollee's residence address, maintaining a record of
returned mail and attempts to remail to either a new payee address or
residence address as provided by the
Agency;
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|
(2)
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Telephone
contact at the number obtained from Agency enrollment reports, the local
telephone directory, directory assistance, city directory, or other
directory; and
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|
(3)
|
Routine
checks (at least once a month for the first three (3) months of
enrollment) on services or claims authorized or denied by the Health Plan
to determine if the enrollee has received services, and to locate updated
address and telephone number
information.
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|
10.
|
Attachment
II, Core Contract Provisions, Section IV, Enrollee Services, Community
Outreach and Marketing,
Item A., Enrollee Services, sub-item 7.d. is hereby amended to include the
following:
|
If the
Health Plan uses the Medicaid fee-for-service pharmacy network as its pharmacy
network, the provider directory shall include a statement to this
effect.
|
11.
|
Attachment
II, Core Contract Provisions, Section IV, Enrollee Services, Community
Outreach and Marketing,
Item A., Enrollee Services, sub-item 15., Enhanced Services is hereby
deleted in its entirety and replaced
as follows:
|
AHCA
Contract No. FA905, Amendment No. 2, Page 3 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
15. Enhanced Benefits Program
(Reform Only; See Attachment II,
Exhibit
4)
|
12.
|
Attachment
II, Core Contract Provisions, Section V, Covered Services, Item F., Moral
or Religious Objections,
sub-item 1. is hereby amended to now read as
follows:
|
|
|
1.
BMHC within one-hundred and twenty (120) calendar days before implementing
the policy with respect to any service;
and
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|
13.
|
Attachment
II, Core Contract Provisions, Section V, Covered Services, Item H.,
Coverage Provisions, sub-item
1., Requirements, the first sentence is hereby amended to now read as
follows:
|
The
Health Plan shall provide the services listed in Section V in accordance with
the provisions herein, and in accordance with the Florida Medicaid Coverage and
Limitations Handbooks and the Florida Medicaid State Plan unless, for Reform
HMOs, a customized benefit package is certified in the benefit grid in
Attachment I.
|
14.
|
Attachment
II, Core Contract Provisions, Section V, Covered Services, Item H.,
Coverage Provisions, is hereby
amended to include sub-item 10.a.(11) as
follows:
|
|
(11)
|
The
Health Plan shall report quarterly to BMHC, within thirty (30) calendar
days after the end of the quarter being reported, the Health Plan's
complete listing of all Medicaid enrollees discharged from inpatient
hospitalization, using the format provided in the Health Plan Report Guide
referenced in Attachment II, Section XII, Reporting
Requirements.
|
|
15.
|
Attachment
II, Core Contract Provisions, Section V, Covered Services, Item H.,
Coverage Provisions, sub-item
14.e. is hereby amended to now read as
follows:
|
|
e.
|
Submit
an attestation with accompanying documentation annually, by October 1 of
each Contract year, to BMHC that the Health Plan has advised its providers
to enroll in the VFC program. The Agency may waive this requirement in
writing if the Health Plan provides documentation to BMHC that the Health
Plan is enrolled in the VFC
program;
|
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16.
|
Attachment
II, Core Contract Provisions, Section V, Covered Services, Item H.,
Coverage Provisions, is hereby
amended to include sub-item 16.k. as
follows:
|
|
k.
|
Capitated
Health Plans covering Reform populations shall submit a complete pharmacy
drug list to the Agency's Reform choice counseling vendor annually by
December 1, using the format provided in the Health Plan Report Guide
referenced in Attachment II, Section XII, Reporting
Requirements.
|
|
17.
|
Attachment
II, Core Contract Provisions, Section VII, Provider Network, Item C,
Network Changes, sub-item
6. is hereby amended to now read as
follows:
|
|
6.
|
The
Health Plan shall notify BMHC of any new network providers by the
fifteenth (15th)
of the month following
execution of the provider agreement and terminated providers by the
fifteenth (15th)
of the month
following the report month using the format provided in the Health Plan
Report Guide referenced in Attachment II, Section XII,
Reporting Requirements.
|
|
18.
|
Attachment
II, Core Contract Provisions, Section VII, Provider Network, Item E.,
Provider Termination, sub-item 3., the second sentence is hereby deleted
in its entirety.
|
|
19.
|
Attachment
II, Core Contract Provisions, Section IX, Grievance
System, Item E., Resolution and Notification,
sub-item 7.c. is hereby amended to now read as
follows:
|
AHCA
Contract No. FA905, Amendment No. 2, Page 4 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
c.
|
The
right to appeal an adverse decision on an appeal to the Subscriber
Assistance Program (SAP) for HMOs or the Beneficiary Assistance Program
(BAP) for PSNs, including how to initiate such a review and the
following:
|
| (1) | Before filing with the SAP or BAP, the enrollee must complete the Health Plan's appeal process; | |
| (2) |
The
enrollee must submit the appeal to the SAP or BAP within one (1) year
after receipt of the final decision letter from the Health
Plan;
|
|
| (3) |
Neither
the SAP nor the BAP will consider an appeal that has already been to a
Medicaid Fair Hearing;
|
|
| (4) | The address and toll-free telephone numbers of the SAP/BAP: |
| Agency
for Health Care Administration
Subscriber
Assistance Program / Beneficiary Assistance Program
Xxxxxxxx
0, XX #00
0000
Xxxxx Xxxxx
Xxxxxxxxxxx,
Xxxxxxx 00000
(850)
921-5458
(000)
000-0000
(toll-free)
|
|
20.
|
Attachment
II, Core Contract Provisions, Section XI, Information Management and
Systems, Item D., Systems
Availability, Performance and Problem Management Requirements, sub-item
8.a. is hereby amended
to include the
following:
|
If the
approved plan is unchanged from the previous year, the Health Plan shall submit
a certification to BMHC that the prior year's plan is still in place annually by
April 30th of
each Contract year. Changes in the plan are due to BMHC within ten (10) business
days after the change.
|
21.
|
Attachment
II, Core Contract Provisions, Section XII, Reporting Requirements, Item
A., Health Plan Reporting
Requirements, Table 1, Summary of Reporting Requirements, is hereby
deleted in its entirety and
replaced with the following Table 1-A, Revised Summary of Reporting
Requirements. All references in the
Contract to Table 1 shall hereinafter refer to Table
1-A.
|
TABLE
1-A
REVISED
SUMMARY OF REPORTING REQUIREMENTS
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
II
and
Exhibit 2
|
Benefit
Maximum Report
|
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC
|
Monthly, fifteen (15)
calendar
days
after
the end of the
reporting
month in which
claims reach $450,000 in
enrollee
costs
|
HSD
Contract
Manager
once
$450,000
is
reached,
and to
BMHC
that initial
month
and
monthly
thereafter
through
end
of state fiscal
year
|
AHCA
Contract No. FA905, Amendment No. 2, Page 5 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
III
and
Exhibit 3
|
Newborn
Enrollment
Report
|
NR
FFS PSN;
Ref
FFS PSN;
CCC
|
Weekly, on
Wednesday
|
Medicaid
Area Office
|
|
Section
III
and
Exhibit 3
|
Involuntary
Disenrollment
Report
|
Ref
HMO; Ref
FFS
PSN; Ref
Cap
PSN;
CCC;
HIV/AIDS
|
Monthly, first Thursday
of month
|
Choice
Counseling
Vendor
|
|
Section
IV
|
Medicaid
Redetermination
Notice
Summary
Report
|
All
Plans that
participate
per
Attachment
I
|
Quarterly, forty-five
(45) calendar days
after
end of reporting quarter
|
BMHC
|
|
Section
IV
|
Community
Outreach
Health
Fairs/Public
Events
Notification
|
All
Plans
|
Monthly, no later than
20th
calendar day of
month
before event month;
amendments
two (2) weeks before event
|
BMHC
|
|
Section
IV
|
Community
Outreach
Representative
Report
|
All
Plans
|
Two (2)
weeks before activity
Quarterly, forty-five
(45) calendar days
after
end of reporting quarter
|
BMHC
|
|
Section
IV and
Exhibit
4
|
Enhanced
Benefits Report
|
Ref
HMO; Ref
FFS
PSN; Ref
Cap
PSN;
CCC;
HIV/AIDS
|
Monthly, ten (10)
calendar days after end
of
reporting month
|
BMHC
|
|
Section
V,
Exhibit
5
|
Customized
Benefit
Notifications
Report
|
Ref
HMO; Ref
Cap
PSN
|
Monthly, fifteen (15)
calendar days after
end
of reporting month
|
BMHC
|
|
Section
V
|
CHCUP
(CMS-416) & FL
60%
Screening (Child
Health
Check Up report)
|
All
Plans
|
Annually,
unaudited
by
January
15th
for
prior
federal fiscal
year;
Annually,
audited
report
by October
1st
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 6 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
V
|
Inpatient
Discharge
Report
|
NR
Ref HMO;
NR
Cap PSN;
Ref
HMO;
Ref
Cap
PSN;
HIV/AIDS
|
Quarterly, thirty (30)
calendar days after end
of reporting quarter
|
BMHC
|
|
Section
V
|
Xxxxxxxxx
Settlement
Ombudsman
Log
|
NR
HMO;
NR
FFS
PSN*;
NR
Cap
PSN;
Ref
HMO;
Ref
FFS PSN*;
Ref
Cap PSN;
CCC*;
HIV/AIDS
*
If the FFS
Health
Plan
has
authorization
requirements
for
prescribed
drug
services
|
Quarterly, fifteen (15)
calendar days after end
of reporting quarter
|
BMHC
|
|
Section
V
|
Xxxxxxxxx
Settlement
Agreement
Survey
|
NR
HMO;
NR
FFS
PSN*;
NR
Cap
PSN;
Ref
HMO;
Ref
FFS PSN*;
Ref
Cap PSN;
CCC*;
HIV/AIDS
*
If the FFS
Health
Plan
has
authorization
requirements
for
prescribed
drug
services
|
Annually,
on
August
1st
|
BMHC
|
|
Section
V
|
Quarterly
Pharmacy (RX
Quarterly)
Encounter Data
Submissions
|
NR
HMO;
NR
Cap
PSN;
Ref
HMO;
Ref
Cap PSN;
HIV/AIDS
|
Quarterly,
thirty
(30)
calendar days after end of reporting quarter
|
MEDS
Team
|
|
Section
V and
Exhibit
6
|
Behavioral
Health -
Pharmacy
Encounter
Data Report
|
NR
HMO;
Ref
HMO;
Ref
Cap PSN;
HIV/AIDS
|
Quarterly, forty-five
(45) calendar days after
end of reporting quarter
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 7 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
V
|
Pharmacy
Navigator
Report
|
Ref
HMO;
Ref
Cap PSN;
HIV/AIDS
|
Annually, by
December
1st
|
Choice
Counseling
Vendor
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health Annual 80/20 Expenditure Report
|
NR
HMO
|
Annually, by
April
1st
|
BMHC
|
|
Section
VI,
Exhibit 6
|
Behavioral
Health Critical Incident Report - Individual
|
NR
HMO;
Ref-HMO;
Ref. FFS PSN;
Ref Cap. PSN;
CCC;
HIV/AIDS
|
Immediately,
no later than
twenty-four (24) hours
after
occurrence or
knowledge
of incident
|
BMHC
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health Critical Incident Report - Summary
|
NR
HMO;
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC;
HIV/AIDS
|
Monthly, by the 15th
|
BMHC
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health - Required
Staff/Providers Report
|
NR
HMO;
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC;
HIV/AIDS
|
Quarterly, forty-five
(45) calendar days after end of
reporting quarter
for Health Plans operating
less than one (1) year;
Annually, by
August
15th,
for all other Health
Plans
|
BMHC
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health - FARS/CFARS
|
NR
HMO
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC;
HIV/AIDS
|
Semi-Annually,
August 15th
and February 15th
|
BMHC
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health - Enrollee Satisfaction Survey Summary
|
NR
HMO;
Ref
HMO;
Ref
FFS PSN;
Ref
Cap
PSN;
CCC;
HIV/AIDS
|
Annually
by March 1st
|
BMHC
behavioral
health
analyst
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health -Stakeholders' Satisfaction Survey - Summary
|
NR
HMO;
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC;
HIV/AIDS
|
Annually, by March
1st
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 8 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
VI,
Exhibit
6
|
Behavioral
Health - Encounter Data Report
|
NR
HMO;
Ref
HMO;
Ref
Cap PSN;
HIV/AIDS
|
Quarterly, forty-five
(45) calendar days
after
end of reporting
quarter
|
BMHC
|
|
Section
VII
|
Provider
Network File
|
All
Plans
|
Monthly, first Thursday
of
month
(optional weekly
submissions
each
Thursday
for remainder of
month)
|
AHCA
Choice
Counseling
Vendor
for
Reform;
For
non-Reform, to
Medicaid
fiscal
agent
and BMHC
|
|
Section
VII
|
Provider
Termination and New
Provider
Notification Report
|
All
Plans
|
Summary
of new and
terminated
providers due
monthly, by the
fifteenth
(15th)
calendar day of the
month
following the
reportinq
month
|
BMHC
|
|
Section
VII
|
PCP
Wait Times Report
|
All
Plans
|
Annually,
by
February
1st
|
BMHC
|
|
Section
VIII
|
Cultural
Competency Plan (and Annual Evaluation)
|
All
Plans
|
Annually,
October 1st
|
BMHC
|
|
Section
VIII and Exhibit 5
|
Performance
Measures
|
All
Plans
|
Annually, on July 1st
|
BMQM
|
|
Section
IX
|
Complaints,
Grievance, and Appeals
Report
|
All
Plans
|
Quarterly, fifteen (15)
calendar
days after end of
quarter
|
BMHC
|
|
Section
X
|
MPI
- Quarterly Fraud & Abuse
Activity
Report
|
All
Plans
|
Quarterly, fifteen
(15)
calendar
days after the end
of
reporting quarter
|
MPI
|
|
Section
X
|
MPI
- Suspected/ Confirmed Fraud &
Abuse
Reporting
|
All
Plans
|
Within fifteen
(15)
calendar
days of detection
|
MPI
|
AHCA
Contract No. FA905, Amendment No. 2, Page 9 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Report
Name
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
X
|
Claims
Aging Report & Supplemental
Filing
Report
|
All
Plans
|
Quarterly, forty-five
(45)
calendar
days after end of
reporting
quarter;
Capitated
Plans,
optional
supplemental
filing - one-
hundred
and five (105)
calendar
days after end of
reporting
quarter
|
BMHC
|
|
Section
XIII,
Exhibit
13
|
Medicaid
Reform Supplemental
HIV/AIDS
Report
|
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC;
HIV/AIDS
|
Monthly,
by
second
Thursday of month
|
BMHC
|
|
Section
XIII,
Exhibit
13
|
Catastrophic
Component Threshold
Report
|
Ref
HMO;
Ref
FFS PSN;
Ref
Cap PSN;
CCC
per Attachment
I
|
Monthly, fifteen (15)
calendar
days after end of
reporting
month
|
BMHC
|
|
Section
XV,
Exhibit
15
|
Insolvency
Protection Multiple
Signatures
Agreement Form
|
NR
HMO;
NR
Cap PSN;
Ref
HMO;
Ref
Cap PSN;
HIV/AIDS
|
Annually,
by
April
1st;
Thirty
(30) calendar days
after
any change
|
BMHC
|
|
Section
XV
|
Audited
Annual and Unaudited
Quarterly
Financial Reports
|
All
Plans except CCC
|
Audited -Annually by April
1st
for calendar year;
Unaudited - Quarterly,
forty-five
(45) calendar
days
after end of reporting
quarter
|
BMHC
|
|
Section
XVI, 0.
and
Section XVI,
W.
|
Minority
Participation Report
|
All
Plans
|
Monthly, fifteen
(15)
calendar
days after month
being
reported
|
BMHC
and HSD
|
NR
HMO = Non-Reform health maintenance organization, includes Health Plans
covering
Frail/Elderly
Program services as specified in Attachment I
Ref
HMO = Reform health maintenance organization
Ref
Cap PSN = Reform capitated provider service network
Ref
FFS PSN = Reform Fee-for-Service Provider Service Network
NR
Cap PSN = Non-Reform Capitated Provider Service Network
NR
FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC
= Specialty plan for children with chronic conditions
HIV/AIDS
= Specialty plan for recipients living with HIV/AIDS
AHCA
Contract No. FA905, Amendment No. 2, Page 10 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
22.
|
Attachment
II, Core Contract Provisions, Section XII, Reporting Requirements, Item
A., Health Plan Reporting Requirements, Table 2, Summary of Submission
Requirements, is hereby deleted in its entirety and replaced with the
following Table 2-A, Revised Summary of Submission Requirements. All
references in the Contract to Table 2 shall hereinafter refer to Table
2-A.
|
TABLE
2-A
REVISED
SUMMARY OF SUBMISSION REQUIREMENTS
2. Other
Health Plan submissions (not in Table 1-A) required by the Agency are as
follows:
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Attachment
I, Section B., Item 3.a.
|
Increase
in enrollment levels
|
Capitated
Health Plans;
FFS
PSNs;
CCC
|
Before
increases occur
|
BMHC
and HSD
|
|
Attachment
I, Section D., Item 3.b.
|
Changes
to optional or expanded services
|
FFS
PSNs;
CCC
|
Annually,
by June
15th
|
HSD
|
|
Attachment
I, Section D., Item 3.c.
|
Changes
to optional or expanded services
|
Capitated
Health Plans
|
Annually,
by June
15th
|
HSD
|
|
Subsequent
references are to Attachment II and its Exhibits
|
||||
|
Section
II,
Item
D.4.
|
Policies,
procedures, model
provider agreements
&
amendments,
subcontracts,
All
materials related to
Contract
for distribution
to
enrollees,
providers, public
|
All
|
Before
beginning use; whenever changes occur
|
BMHC
|
|
Section
II,
Item
D.4.a.
|
Written
materials
|
All
|
Forty-five
(45) calendar days before effective date
|
BMHC
|
|
Section
II,
Item
D.4.b
|
Written
notice of change to enrollees
|
All
|
Thirty
(30) calendar days before effective date
|
Enrollees
affected by change
|
|
Section
II, Item D.6.
|
Enrollee
materials, PDL, provider & enrollee handbooks
|
All
|
Available
on Health Plan's web site without log-in
|
Plan
web site
|
|
Section
III,
Item
B.3.c.(l)
|
Enrollee
pregnancy
|
All
|
Upon
confirmation
|
DCF
& MPI
|
|
Section
III,
Item
B.3.c.(3)
|
Unborn
activation notice
|
All
|
Presentation
for delivery
|
DCF
& MPI
|
AHCA
Contract No. FA905, Amendment No. 2, Page 11 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
III,
Item
B.3.d.
|
Birth
information if no unborn
activation
|
All
|
Upon
delivery
|
DCF
|
|
Section
III,
Item
C.4.b.
|
Involuntary
disenrollment
request
|
All
|
Forty-five
(45) calendar
days before effective date
|
BMHC
|
|
Section
III,
Item
C.4.e.
|
Notice
that Health Plan
is requesting disenrollment in next Contract month
|
All
|
Before
effective date
|
Enrollee
affected
|
|
Section
IV,
Item
A.l.e.
|
Notice
of reinstatement
of enrollee
|
All
|
By
1st
calendar day
of
month after learning of reinstatement or within five (5) calendar days
from receipt of enrollment file, whichever is
later
|
Person
being
reinstated
|
|
Section
IV,
Item
A.2.a.
and
Item A.
6.a.(17);
Section
VIII,
Item
A.4.
|
How
to get Health
Plan
information in
alternative
formats
|
All
|
Include
in cultural
competency
plan and
enrollee
handbook,
and upon
request
|
Enrollees
&
potential
enrollees
|
|
Section
IV,
Item
A.2.c.
|
Right
to get
information
about Health Plan
|
All
|
Annually
|
Enrollees
|
|
Section
IV,
Item
A.7.c.
|
Provider
directory
online
file
|
All
|
Update
monthly &
submit
attestation
|
BMHC
|
|
Section
IV,
Item
A.9.a.
|
Enrollee
assessments
|
All
|
Within
thirty (30)
days
of enrollment notify about pregnancy screening
|
Enrollees
|
|
Section
IV,
Item
A.9.c.
|
Enrollees
more than 2
months
behind in periodicity screening
|
All
|
Contact
twice, if
needed
|
Enrollees
who
meet
criteria
|
|
Section
IV,
Item
A.ll.f.
|
Toll-free
help line
performance
standards
|
All
|
Get
approval
before
beginning operation
|
BMHC
|
|
Section
IV,
Item
A.12.
and
Item
A.,6.a.(17);
Section
VIII,
Item
A.4.
|
How
to access
translation
services
|
All
|
Include
in cultural
competence
plan
and
enrollee
handbook
|
Enrollees
|
|
Section
IV,
Item
A.14.a.
|
Incentive
program
|
All
|
Get
approval
before
offering
|
BMHC
|
|
Section
IV,
Item
A.14.g.
|
Pre-natal
care
programs
|
All
|
Before
implementation
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 12 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
IV,
Item
A.17.c.
|
Notice
of change in
participation
in
redetermination
notices
|
All
|
If
change in
participation,
annually, by June 1st
|
BMHC
|
|
Section
IV,
Item
A.17.c.(1)
|
Redetermination
policies
& procedures
|
All
|
When
Health Plan
agrees
to
participate
|
BMHC
|
|
Section
IV,
Item
A.17.c.(l)(a)
|
Notice
in writing to
discontinue
Medicaid
redetermination
date data use
|
All
|
Thirty
(30)
calendar
days
before
stopping
|
BMHC
|
|
Section
IV,
Item
B.3.c.
|
Member
services
phone
script responding to community outreach calls and outreach
materials
|
All
|
Before
use
|
BMHC
|
|
Section
IV,
Item
B.4.c.
|
In
case of force
majeure,
notice of participation in health fair or other public
event
|
All
|
By
day of event
|
BMHC
|
|
Section
IV,
Item
B.6.f.
|
Report
of staff or
community
outreach rep. violations
|
All
|
Within
fifteen (15)
calendar
days of knowledge
|
BMHC
|
|
Section
V,
Item
C.l.
|
Written
details of
expanded
services
|
All
|
Before
implementation
|
HSD
|
|
Section
V,
Item
F.
|
Decision
to not offer a
service
on
moral/religious
grounds
|
All
|
One-hundred
and
twenty
(120) calendar days before implementation
Thirty
(30) calendar days before implementation
|
BMHC
Enrollees
|
|
Section
V,
Item
H.10.b.2.
|
UNOS
form &
disenrollment
request
for
specified transplants
|
All
|
When
enrollee
listed
|
BMHC
|
|
Section
V,
Item
H.14.e.
|
Attestation
that the
Health
Plan has advised providers to enroll in VFC program
|
All
|
Annually,
by
October
1st
|
BMHC
|
|
Section
V,
Item
H.16.a.(4)
|
PDL
update
|
All
|
Annually,
by
October
1st.
Thirty
(30) calendar days written notice of
change.
|
BMHC
and Bureau
of
Medicaid
Pharmacy
Services
|
AHCA
Contract No. FA905, Amendment No. 2, Page 13 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
VII,
Item
A.2.
|
Capacity
to provide
covered
services
|
All
|
Before
taking
enrollment
|
BMHC
|
|
Section
VII,
Item
C.l.
|
Request
for initial or
expansion
review
|
All
|
When
requesting
initial
enrollment or expansion into a county.
|
BMHC
and HSD
|
|
Section
VII,
Item
C.2.
|
Compliance
with
access
requirements following significant changes in service area or new
populations
|
All
|
Before
expansion
|
BMHC
and HSD
|
|
Section
VII,
Item
C.3.
|
Significant
network
changes
|
All
|
Within
seven (7)
business
days
|
BMHC
|
|
Section
VII,
Item
C.5.
|
When
PCP leaves
network
|
All
|
Within
fifteen (15)
calendar
days of knowledge.
A
copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after
receipt of the PCP termination
notice.
|
BMHC
& affected
enrollees
|
|
Section
VII,
Item
D.2.jj.
|
Waiver
of provider
agreement
indemnifying clause
|
All
|
Approval
before
use
|
BMHC
|
|
Section
VII,
Item
E.3.
|
Notice
of terminated
providers
due to
imminent
danger/impairment
|
All
|
Immediate
|
BMHC
and Provider
|
|
Section
VII,
Item
E.4.
|
Termination
or
suspension
of
providers;
for "for
cause"
terminations,
include
reasons for
termination
|
All
|
Sixty
(60) calendar
days
before
termination
effective
date
|
BMHC,
affected
enrollees,
&
provider
|
|
Section
VIII,
Item
A.l.b.
|
Written
Quality
Improvement
Plan
|
All
|
Within
thirty (30)
calendar
days of initial Contract execution; Thereafter, Annually by April 1st
|
BMHC
|
|
Section
VIII,
Item
A.3.a.(6)
|
Measurement
periods
and
methodologies
|
All
|
Any
new PIPs
before
initiation
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 14 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
VIII,
Item
A.3.a.(7)
|
Proposal
for each
planned
PIP
|
All
|
Ninety
(90)
calendar
days after
Contract
execution; Thereafter, Annually by June 1st
|
BMHC
|
|
Section
VIII,
Item
A.3.c.(l)
|
Performance
measure
data
and auditor
certification
|
All
|
Annually
by July 1st
|
BMQM
|
|
Section
VIII,
Item
A.3.c.(4)
|
Performance
measure
action
plan
|
All
|
Within
thirty (30)
calendar
days of
determination
of
unacceptable
performance
|
BMQM
|
|
Section
VIII,
Item
A.3.e.(7)
|
Written
strategies for
medical
record review
|
All
|
Before
use
|
BMHC
|
|
Section
VIII,
Item
B.l.a.(4)(a)
|
Service
authorization
protocols
& any
changes
|
All
|
Before
use
|
BMHC
|
|
Section
VIII,
Item
B.4.
|
Changes
to UM
component
|
All
|
Thirty
(30)
calendar
days before
effective
date
|
BMHC
|
|
Section
IX,
Item
A.8.
|
Complaint
log
|
All
|
Upon
request
|
BMHC
|
|
Section
X,
Item
B.2.
|
Changes
in staffing
|
All
|
Five
(5) business
days
of any change
|
BMHC
& HSD
|
|
Section
X,
Item
B.2.b.
|
Full-Time
Administrator
|
All
|
Before
designating
duties
of any other position
|
BMHC
|
|
Section
X,
Item
D. 3. a.
|
Reform
and non-
Reform
historical encounter data for all typical and atypical
services
|
All
|
According
to
Agency-approved
schedules and no later than 10/31/09
|
MEDS
team &
Fiscal
Agent
|
|
Section
X,
Item
D.3.b.
|
Encounter
data for all
typical
and atypical
services
|
All
|
Within
sixty (60)
calendar
days
following
end of month in which Health Plan paid claims for services, and as
specified in MEDS Companion Guide
|
MEDS
Team &
Agency
Fiscal
Agent
|
|
Section
X,
Item
E.4.
|
Fraud
& abuse
compliance
plan & policies & procedures
|
All
|
Before
implementation
|
MPI
|
|
Section
XI,
Item
D.4.a.
|
Any
problem that
threatens
system performance
|
All
|
Within
one (1)
hour
|
Applicable
Agency
staff
|
AHCA
Contract No. FA905, Amendment No. 2, Page 15 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
XI, Item D.8.a.
|
Business
Continuity-Disaster Recovery Plan
|
All
|
Before
beginning operation and certification if plan is unchanged by April 30
annually thereafter;
Changes
within ten (10) business days of change
|
BMHC
|
|
Section
XI, Item E.l.
|
System
changes
|
All
|
Ninety
(90) calendar days before change
|
HSD
|
|
Section
XIV, Item A.l.(a.)
|
Corrective
action plan
|
All
|
Within
ten (10) business days of notice of violation or non-compliance with
Contract
|
Agency
Bureau sending violation notice
|
|
Section
XIV, Item A.l.(b)
|
Performance
measure action plan
|
All
|
Within
thirty (30) calendar days of notice of failure to meet a performance
standard
|
Agency
Bureau sending violation notice
|
|
Section
XV, Item C.
|
Proof
of working capital
|
All
|
Before
enrollment
|
BMHC
|
|
Section
XV, Item G.2.
|
Physician
incentive plan
|
All
|
Written
description before use
|
BMHC
|
|
Section
XV, Item H.
|
Third
party coverage identified
|
All
|
As
soon as known
|
Medicaid
Third Party Liability Vendor
|
|
Section
XV, Item I.
|
Proof
of fidelity bond coverage
|
All
|
Within
sixty (60) calendar days of Contract execution & before delivering
health care
|
HSD
Contract manager
|
|
Section
XVI, Item C.l.
|
Request
for Assignment or Transfer of Contract in approved
merger/acquisition
|
All
|
Ninety
(90) days before effective date
|
HSD
|
|
Section
XVI, Item M.
|
Use
of "Medicaid" or "AHCA"
|
All
|
Before
use
|
BMHC
|
|
Section
XVI, Item O.
|
All
subcontracts for Agency approval
|
All
|
Before
effective date
|
BMHC
|
|
Section
XVI, Item O.l.f.
|
Subcontract
monitoring schedule
|
All
|
Annually,
by December 1
|
BMHC
|
|
Section
XVI, Item X.x.
|
Ownership
& management disclosure forms
|
All
|
With
initial application; and then annually by
September
1
|
HSD
- for initial application; BMHC & HSD for
annual
|
AHCA
Contract No. FA905, Amendment No. 2, Page 16 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Section
XVI, Item V.I.
|
Changes
in ownership & control
|
All
|
Within
five (5) calendar days of knowledge & sixty (60) days before effective
date
|
BMHC
& HSD
|
|
Section
XVI, Item V.4.
|
Fingerprints
for principals
|
All
|
Before
Contract execution; Thereafter, annually by September
1
|
HSD
|
|
Section
XVI, Item V.4.c.
|
Fingerprints
of newly hired principals
|
All
|
Within
thirty (30) calendar days of hire date
|
HSD
|
|
Section
XVI, Item V.5.
|
Information
about offenses listed in 435.03
|
All
|
Within
five (5) business days of knowledge
|
HSD
|
|
Section
XVI, Item V.6.
|
Corrective
action plan related to principals committing offenses under
435.03
|
All
|
As
prescribed by the Agency
|
HSD
|
|
Section
XVI, Item Y.
|
General
insurance policy declaration pages
|
All
|
Annually
upon renewal
|
BMHC
|
|
Section
XVI, Item Z.
|
Workers'
compensation insurance declaration page
|
All
|
Annually
upon renewal
|
BMHC
|
|
Section
XVI, Item BB.
|
Emergency
Management Plan
|
All
|
Before
beginning operation and by May 31 annually
thereafter
|
BMHC
|
|
Exhibit
2, Section II, Item D.4.c.
|
Policies
& procedures for screening for clinical eligibility & any changes
to them
|
CCC
|
Before
implementation
|
BMHC
|
|
Exhibit
3, Section III, Item C.5.
|
Disenrollment
notice
|
CCC
|
Get
template approved before use
At
least two (2) months before anticipated effective date of involuntary
disenrollment
|
BMHC
Enrollee
|
|
Exhibit
5, Section V, Item A.6.
|
Letters
about exhaustion of benefits under customized benefit
package
|
Reform
capitated
Health Plans
|
Before
use
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 17 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
| Contract
Section
|
Submission
|
Plan
Type
|
Frequency Submit
To
|
|
|
Exhibit
5, Section V, Item H.20.g.
|
Transportation
subcontract
|
NR
HMO offering transportation; Reform Health Plans
|
Before
execution
|
BMHC
|
|
Exhibit
5, Section V, Item H.20.h.
|
Transportation
policies & procedures
|
NR
HMO offering transportation; Reform Health Plans
|
Before
use
|
BMHC
|
|
Exhibit
5, Section V, Item H.20.i.
|
Transportation
adverse incidents
|
NR
HMO offering transportation; Reform Health Plans
|
Within
two (2) business days of the occurrence
|
BMHC
|
|
Exhibit
5, Section V, Item H.20.i
|
Transportation
suspected fraud
|
NR
HMO offering transportation; Reform Health Plans
|
Immediately
upon identification
|
MPI
|
|
Exhibit
5, Section V, Item H.20.p.
|
Performance
measures
|
NR
HMO offering transportation; Reform Health Plans
|
Annually
report by July l
|
BMQM
|
|
Exhibit
5, Section V, Item H.20.q. &r.
|
Attestation
that Health Plan complies with transportation policies & procedures
& drivers pass background checks & meet
qualifications
|
NR
HMO offering transportation; Reform Health Plans
|
Annually
by January 1
|
BMHC
|
|
Exhibit
6, Item A.3.
|
Review
& approval of behavioral health services staff & subcontractors
for licensure compliance
|
Reform
Health Plans & NR HMOs
|
Before
providing services
|
BMHC
|
|
Exhibit
6, Item B.9.
|
Model
agreement with community mental health centers
|
Reform
Health Plans & NR HMOs
|
Before
agreement is executed
|
BMHC
|
|
Exhibit
6, Item C.3.e.
|
Denied
appeals from providers for emergency services claims
|
Plans
covering
behavioral
health
|
Within
ten (10) calendar days after Health Plan's final
denial
|
BMHC
|
|
Exhibit
6,
Item
C.5.a.(3)
|
Medical
necessity criteria for community mental health
services
|
Plans
covering
behavioral
health
|
Before
use and before changes implemented
|
BMHC
|
|
Exhibit
6, Item L.2.
|
MBHO
staff psychiatrist and model contracts for each specialty
type
|
Plans
covering
behavioral
health
|
Before
execution
|
BMHC
|
AHCA
Contract No. FA905, Amendment No. 2, Page 18 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
Contract
Section
|
Submission
|
Plan
Type
|
Frequency
|
Submit
To
|
|
Exhibit
6, Item M.
|
Optional
services
|
Plans
covering
behavioral
health
|
Before
offering
|
BMHC
|
|
Exhibit
6, Item R.3.a.
|
Schedule
for administrative and program monitoring and clinical record
review
|
Plans
covering
behavioral
health
|
Annually
by July 1
|
BMHC
|
|
Exhibit
8, Section VIII, Item B. 5.
|
Substitute
disease
management
initiatives
|
CCC
|
Within
sixty (60) calendar days of Contract execution
|
BMHC
|
|
Exhibit
8, Section VIII, Item A.3.f.
|
Provider
satisfaction survey
|
All
Reform Health Plans
|
By
end of 8th
month of Contract
|
BMHC
|
|
Exhibit
8, Section VIII, Item B.5.b.
|
Policies
and procedures and program descriptions for each disease management
program
|
All
Reform Health Plans
|
Annually,
by April
1
|
BMHC
|
|
Exhibit
8, Section VIII, Item B. 1. e. (5)
|
Caseload
maximums for case managers
|
HIV/AIDS
specialty plan
|
Before
providing services
|
BMHC
|
|
Exhibit
10, Section X, Item C. 5. a.
|
Discrepancies
in ERV
|
FFS
Health
Plans;
CCC
|
Within
ten (10) business days of discovery
|
HSD
analyst
|
|
Exhibit
15, Section XV, Item A. 1. a.
|
Plan
for transition from FFS to prepaid capitated plan
|
FFS
PSNs; CCC
|
Last
calendar day of 24th
month of Health Plan's initial Reform operation
|
HSD
|
|
Exhibit
15, Section XV, Item A. 1. b.
|
Conversion
application to capitated Health Plan
|
FFS
PSNs; CCC
|
By
August 1 of 4th
year of Reform operation
|
HSD
|
|
Exhibit
15, Section XV, Item I.
|
Proof
of coverage for any non-government subcontractor
|
CCC
|
Within
sixty (60) calendar days of execution and before delivery of
care
|
BMHC
|
NR
HMO = Non-Reform health maintenance organization, includes Health Plans
covering
Frail/Elderly
Program services as specified in Attachment I
Ref
HMO = Reform health maintenance organization
Ref
Cap PSN = Reform capitated provider service network
Ref
FFS PSN = Reform Fee-for-Service Provider Service Network
NR
Cap PSN = Non-Reform Capitated Provider Service Network
NR
FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC
= Specialty plan for children with chronic conditions
HIV/AIDS
= Specialty plan for recipients living with HIV/AIDS
|
23.
|
Attachment
II, Core Contract Provisions, Section XIV, Sanctions, Item F., Notice of
Sanction, sub-item 4. is hereby amended to now read as
follows:
|
AHCA
Contract No. FA905, Amendment No. 2, Page 19 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
4.
|
For
FFS PSNs and the Specialty Plan for Children with Chronic Conditions, the
Agency reserves the right to withhold all or a portion of the Health
Plan's monthly administrative allocation for any amount owed pursuant to
this section.
|
|
24.
|
Attachment
II, Core Contract Provisions, Section XVI, Terms and Conditions, Item C,
Assignment, sub-item
1., the second sentence is hereby amended to now read as
follows:
|
The
entity requesting the assignment or transfer shall notify HSD of the request
ninety (90) calendar days before the anticipated effective
date.
|
25.
|
Attachment
II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O.,
Subcontracts, sub-item
1.e., the third sentence is hereby amended to now read as
follows:
|
The
Health Plan shall provide a monthly Minority Participation Report (see
Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the
HSD designated minority participation report contact, summarizing the business
it does with minority subcontractors or vendors.
|
26.
|
Attachment
II, Core Contract Provisions, Section XVI, Terms and Conditions, Item V.,
Ownership and Management
Disclosure, sub-item 4.c. is hereby amended to now read as
follows:
|
|
c.
|
The
Health Plan shall submit to the Agency Contract Manager complete sets of
fingerprints of newly hired principals (officers, directors, agents, and
managing employees) within thirty (30) calendar days of the hire
date.
|
|
27.
|
Attachment
II, Core Contract Provisions, Section XVI, Terms and Conditions, Item BB.,
Emergency Management
Plan, the first sentence is hereby amended to now read as
follows:
|
Before
beginning operations and annually by May 31 of each Contract year, the Health
Plan shall submit to BMHC for approval an emergency management plan specifying
what actions the Health Plan shall conduct to ensure the ongoing provision of
health services in a disaster or man-made emergency including, but not limited
to, localized acts of nature, accidents, and technological and/or attack-related
emergencies.
|
28.
|
Attachment
II, Core Contract Provisions, Exhibit 5, Covered Services, Item 3,
Non-Reform HMOs covering transportation
as an optional service and Reform Health Plans, Section V, Covered
Services, Item H., Coverage
Provisions, sub-item 20.i. is hereby amended to now read as
follows:
|
|
i.
|
The
Health Plan shall report within two (2) business days of the occurrence,
in writing to BMHC, any transportation-related adverse or untoward
incident (see s. 641.55, F.S.). The Health Plan shall also report,
immediately upon identification, in writing to MPI, all instances of
suspected enrollee or transportation services provider fraud or abuse. (As
defined in s. 409.913, F.S. See also Attachment II, Section X,
Administration and Management, on fraud and
abuse.)
|
|
29.
|
Attachment
II, Core Contract Provisions, Exhibit 5, Covered Services, Item 6,
Non-Reform HMOs covering transportation
as an optional service and Reform Health Plans, Section V, Covered
Services, Item H., Coverage
Provisions, sub-item 20.p. is hereby amended to now read as
follows:
|
|
p.
|
The
Health Plan shall submit data on transportation performance measures as
defined by the Agency and as specified in the Agency's Performance
Measures Specifications Manual. The Health Plan shall report on those
measures to the Agency as specified in Attachment II, Section VIII,
Quality Management, Item A., Quality Improvement, sub-item 3.c. and
Attachment II, Section XII, Reporting Requirements, and the Health Plan
Report Guide.
|
|
30.
|
Attachment
II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans,
Behavioral Health Care, Item
1., Reform Health Plans and Non-Reform HMOs, sub-item K.4. is hereby
amended to now read as follows:
|
AHCA
Contract No. FA905, Amendment No. 2, Page 20 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
4. The Health Plan shall submit the
FARS/CFARS reports to BMHC semi-annually August 15th and
February
15th, as
required in Attachment II, Section XII, Reporting
Requirements, and the Health Plan Report Guide.
|
31.
|
Attachment
II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans,
Behavioral Health Care, Item
1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral
Health Reporting Requirements
is hereby amended to now read as
follows:
|
S. Behavioral Health Reporting
Requirements
Additional
behavioral health reporting requirements are listed below. Behavioral health
reporting requirements are also listed in Attachment II, Section XII, Reporting
Requirements, and must be submitted as required in Attachment II, Section XII,
Reporting Requirements, and the Health Plan Report Guide.
|
1.
|
Behavioral
Health Critical Incident Report - Individual - The Health Plan shall
report the following events immediately, no later than twenty-four (24)
hours after occurrence or knowledge of incident, to the BMHC behavioral
health analyst and in accordance with Attachment II, Section XII,
Reporting Requirements, and the Health Plan Report
Guide.
|
|
2.
|
Behavioral
Health Critical Incident Report - Summary - The Health Plan shall submit
to BMHC a summary of the previous calendar month's incidents regarding
behavioral health critical incidents, involving Health Plan enrollees, by
the 15th
calendar day of every month, in accordance with Attachment II, Section
XII, Reporting Requirements, and the Health Plan Report
Guide.
|
|
3.
|
Behavioral
Health Encounter Data Report - The Health Plan shall submit to BMHC,
quarterly within forty-five (45) calendar days of the end of the quarter
being reported, an electronic representation of the Health Plan's complete
listing of behavioral health services provided during the report period
and in accordance with Attachment II, Section XII, Reporting Requirements,
and the Health Plan Report
Guide.
|
|
4.
|
Behavioral
Health Pharmacy Encounter Data Report - The Health Plan shall submit to
BMHC quarterly, within forty-five (45) calendar days after the end of the
quarter being reported, an accurate electronic representation of the
Health Plan's complete listing of behavioral health prescription services
administered during the quarter being reported and in accordance with
Attachment II, Section XII, Reporting Requirements, and the Health Plan
Report Guide.
|
|
5.
|
Behavioral
Health Required Staff/Providers Report - The Health Plan shall submit to
BMHC the Behavioral Health Required Staff/Providers Report annually, by
August 15. For Health Plans operating less than one (1) year, the Health
Plan shall submit this report to BMHC quarterly, forty-five (45) days
after the end of the quarter being reported. Submissions shall be
submitted in accordance with Attachment II, Section XII, Reporting
Requirements, and the Health Plan Report
Guide.
|
|
32.
|
Attachment
II, Core Contract Provisions, Exhibit 10, Administration and Management,
Item 1., All Capitated Health
Plans, Section X, Administration and Management, Item C, Claims Payment,
is hereby amended to include
sub-item 7. as
follows:
|
|
7.
|
The
Health Plan shall reimburse providers for Medicare deductibles and
co-insurance payments for Medicare dually eligible members according to
the lesser of the following:
|
a. The
rate negotiated with the provider; or
b. The
reimbursement amount as stipulated in s. 409.908 F.S.
AHCA
Contract No. FA905, Amendment No. 2, Page 21 of 22
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
Unless
otherwise stated, this Amendment is effective upon execution by both parties or
January 1, 2010, (whichever is later).
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 twenty-seven (27) page Amendment (including all
attachments) to be executed by their officials thereunto duly
authorized.
|
HEALTHEASE OF FLORIDA,
INC.
|
STATE OF FLORIDA, AGENCY
FOR
HEALTH CARE
ADMINISTRATION
|
|
SIGNED
BY:
|
/s/
Xxxxxx X. Xxxx
|
SIGNED
BY:
|
[Illegible] for
|
||
| NAME: | Xxxxxx Xxxx | NAME: | Xxxxxx X. Xxxxxx | ||
| TITLE: | Chief Financial Officer | TITLE: | Secretary | ||
| DATE: | January 13, 2010 | DATE: | 1-14-10 |
List of
Attachments/Exhibits included as part of this Amendment:
|
Specify
Type
|
Letter/
Number
|
Description | |||
| Attachment I | Exhibit 2-NR-A |
Medicaid
Non-Reform HMO Capitation Rates, Effective
November
1, 2009 - August 31, 2012 (5 Pages)
|
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA905, Amendment No. 2, Page 22 of 22
ATTACHMENT
I
EXHIBIT
2-NR-A
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area , Age and Eligibility Category
Effective
November 1, 2009 - August 31, 2012
AGE
(65+)
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+)
|
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
|
1,130.45
|
171.80
|
102.22
|
61.92
|
136.81
|
72.25
|
266.35
|
158.36
|
341.82
|
12,166.98
|
1,661.31
|
450.32
|
195.11
|
211.04
|
684.60
|
713.62
|
345.23
|
81.01
|
75.25
|
|
02
|
1,130.45
|
171.80
|
102.22
|
61.92
|
136.81
|
72.25
|
266.35
|
158.36
|
341.82
|
12,166.98
|
1,661.31
|
450.32
|
195.11
|
211.04
|
684.60
|
713.62
|
345.23
|
81.01
|
75.25
|
|
03
|
1,204.98
|
184.85
|
110.04
|
67.83
|
147.39
|
78.95
|
288.08
|
172.19
|
374.81
|
12,984.80
|
1,788.35
|
485.21
|
215.10
|
232.17
|
751.31
|
786.48
|
219.92
|
78.09
|
72.84
|
|
04
|
1,050.61
|
162.46
|
96.93
|
60.59
|
129.54
|
70.25
|
254.54
|
152.86
|
335.21
|
12,420.29
|
1,720.68
|
467.26
|
210.34
|
226.43
|
732.37
|
768.88
|
158.79
|
76.07
|
71.40
|
|
05
|
1,184.66
|
182.33
|
108.66
|
67.27
|
145.40
|
78.31
|
284.72
|
170.59
|
372.41
|
14,030.18
|
1,934.34
|
524.96
|
233.58
|
251.40
|
814.40
|
853.04
|
257.97
|
63.54
|
59.91
|
|
06
|
1,065.08
|
165.73
|
99.12
|
62.65
|
132.43
|
72.63
|
260.83
|
157.38
|
347.13
|
12,740.87
|
1,765.91
|
479.44
|
216.29
|
232.64
|
751.93
|
789.61
|
332.29
|
65.62
|
61.55
|
|
07
|
1,094.60
|
170.03
|
101.66
|
64.09
|
135.85
|
74.27
|
267.33
|
161.18
|
354.76
|
13,685.78
|
1,905.44
|
518.10
|
236.50
|
253.97
|
819.80
|
862.97
|
278.88
|
68.32
|
64.02
|
|
08
|
1,037.09
|
161.01
|
96.20
|
60.62
|
128.67
|
70.25
|
253.12
|
152.46
|
335.67
|
12,799.17
|
1,774.58
|
482.11
|
218.12
|
234.44
|
756.47
|
794.55
|
315.60
|
66.83
|
62.63
|
|
09
|
1,052.10
|
161.97
|
96.51
|
59.97
|
129.16
|
69.61
|
253.28
|
151.74
|
331.35
|
12,607.35
|
1,749.19
|
475.00
|
215.23
|
231.33
|
746.37
|
783.86
|
278.68
|
73.65
|
68.75
|
|
10
|
1,097.08
|
171.38
|
102.63
|
65.26
|
137.12
|
75.61
|
270.62
|
163.74
|
362.13
|
16,173.96
|
2,267.27
|
616.85
|
286.58
|
306.25
|
989.86
|
1,043.17
|
351.29
|
80.41
|
75.32
|
|
11
|
1,387.45
|
213.12
|
126.92
|
78.43
|
169.76
|
91.10
|
332.48
|
199.01
|
433.39
|
16,510.81
|
2,276.81
|
618.22
|
275.31
|
296.69
|
960.17
|
1,005.22
|
380.51
|
117.49
|
109.41
|
|
6B*
|
1,064.96
|
165.71
|
99.11
|
62.64
|
132.41
|
72.62
|
260.80
|
157.36
|
347.08
|
12,740.29
|
1,765.81
|
479.42
|
216.27
|
232.63
|
751.89
|
789.57
|
332.29
|
65.62
|
61.55
|
TABLE
2
|
General
+ Mental Health Rates:
|
|||||||||||||||||||
|
TANF
|
SSI-N
|
SSI-B
|
XXxXX
|
||||||||||||||||
|
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
|
1,130.48
|
171.83
|
104.08
|
74.27
|
148.20
|
83.64
|
270.41
|
162.42
|
345.39
|
12,167.05
|
1,661.38
|
458.53
|
246.95
|
257.82
|
765.70
|
745.22
|
353.34
|
93.55
|
87.79
|
|
02
|
1,130.47
|
171.82
|
103.70
|
73.65
|
148.12
|
83.56
|
271.15
|
163.16
|
346.04
|
12,167.09
|
1,661.42
|
462.52
|
271.63
|
281.47
|
815.81
|
764.75
|
353.34
|
93.55
|
87.79
|
|
03
|
1,205.00
|
184.87
|
111.59
|
80.12
|
159.24
|
90.80
|
293.11
|
177.22
|
379.23
|
12,984.86
|
1,788.41
|
491.82
|
256.56
|
270.33
|
822.40
|
814.18
|
228.03
|
90.63
|
85.38
|
|
04
|
1,050.63
|
162.48
|
98.39
|
72.22
|
140.75
|
81.46
|
259.29
|
157.61
|
339.39
|
12,420.35
|
1,720.74
|
474.10
|
253.25
|
265.92
|
805.95
|
797.55
|
166.90
|
88.61
|
83.94
|
|
05
|
1,184.68
|
182.35
|
110.60
|
82.70
|
160.27
|
93.18
|
291.03
|
176.90
|
377.96
|
14,030.25
|
1,934.41
|
532.58
|
281.37
|
295.39
|
896.35
|
884.97
|
266.08
|
76.08
|
72.45
|
|
06
|
1,065.10
|
165.75
|
100.09
|
69.11
|
138.39
|
78.59
|
262.96
|
159.51
|
349.00
|
12,740.90
|
1,765.94
|
483.54
|
242.20
|
256.02
|
792.46
|
805.41
|
340.40
|
78.16
|
74.09
|
|
07
|
1,094.63
|
170.06
|
104.05
|
83.04
|
154.12
|
92.54
|
275.08
|
168.93
|
361.57
|
13,685.85
|
1,905.51
|
525.43
|
282.49
|
296.30
|
898.66
|
893.70
|
286.99
|
80.86
|
76.56
|
|
08
|
1,037.10
|
161.02
|
97.18
|
66.36
|
136.14
|
77.72
|
256.29
|
155.63
|
338.45
|
12,799.21
|
1,774.62
|
486.19
|
243.72
|
258.00
|
800.37
|
811.65
|
323.71
|
79.37
|
75.17
|
|
09
|
1,052.12
|
161.99
|
98.40
|
74.97
|
143.62
|
84.07
|
259.41
|
157.87
|
336.74
|
12,607.42
|
1,749.26
|
482.36
|
261.41
|
273.83
|
825.55
|
814.71
|
286.79
|
86.19
|
81.29
|
|
10
|
1,097.10
|
171.40
|
104.57
|
80.68
|
151.99
|
90.48
|
276.93
|
170.05
|
367.67
|
16,174.08
|
2,267.39
|
629.65
|
366.88
|
380.16
|
1,127.55
|
1,096.82
|
359.40
|
92.95
|
87.86
|
|
11
|
1,387.47
|
213.14
|
128.49
|
90.88
|
181.77
|
103.11
|
337.57
|
204.10
|
437.87
|
16,510.92
|
2,276.92
|
630.84
|
354.52
|
369.60
|
1,096.00
|
1,058.15
|
388.62
|
130.03
|
121.95
|
|
6B*
|
1,064.97
|
165.72
|
99.83
|
66.35
|
137.92
|
78.13
|
263.14
|
159.70
|
349.13
|
12,740.32
|
1,765.84
|
483.29
|
240.54
|
254.97
|
793.50
|
805.79
|
340.40
|
78.16
|
74.09
|
AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 1 of
5
ATTACHMENT
I
EXHIBIT
2-NR-A
MEDICAID NON-REFORM HMO CAPITATION
RATES
By Area , Age and Eligibility
Category
Effective
November 1, 2009 -August 31, 2012
TABLE
3
|
General
|
+
MH + Dental Rates:
|
SSI-N
|
SSI-B
|
SSI-AB
|
|||||||||||||||
| TANF | |||||||||||||||||||
|
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
|
1,130.49
|
171.84
|
105.46
|
76.79
|
150.71
|
85.83
|
271.81
|
163.93
|
348.70
|
12,167.05
|
1,661.38
|
459.71
|
248.69
|
259.34
|
767.10
|
747.24
|
353.34
|
94.73
|
88.76
|
|
02
|
1,130.48
|
171.83
|
105.08
|
76.17
|
150.63
|
85.75
|
272.55
|
164.67
|
349.35
|
12,167.09
|
1,661.42
|
463.70
|
273.37
|
282.99
|
817.21
|
766.77
|
353.34
|
94.73
|
88.76
|
|
03
|
1,205.01
|
184.89
|
114.60
|
85.61
|
164.70
|
95.58
|
295.67
|
179.97
|
385.26
|
12,984.86
|
1,788.42
|
494.65
|
260.76
|
273.98
|
824.81
|
817.66
|
229.28
|
92.63
|
87.02
|
|
04
|
1,050.64
|
162.49
|
100.16
|
75.45
|
143.97
|
84.27
|
261.36
|
159.84
|
344.27
|
12,420.35
|
1,720.74
|
475.76
|
255.71
|
268.06
|
808.10
|
800.67
|
168.79
|
90.28
|
85.30
|
|
05
|
1,184.69
|
182.37
|
114.20
|
89.29
|
166.83
|
98.92
|
294.84
|
181.00
|
386.95
|
14,030.26
|
1,934.42
|
536.45
|
287.10
|
300.37
|
899.47
|
889.49
|
266.16
|
79.19
|
75.00
|
|
06
|
1,065.11
|
165.77
|
102.78
|
74.04
|
143.29
|
82.87
|
265.06
|
161.76
|
353.94
|
12,740.90
|
1,765.95
|
486.45
|
246.51
|
259.76
|
795.04
|
809.15
|
343.25
|
80.33
|
75.87
|
|
07
|
1,094.64
|
170.08
|
106.68
|
87.86
|
158.91
|
96.73
|
276.71
|
170.68
|
365.40
|
13,685.85
|
1,905.52
|
528.40
|
286.88
|
300.12
|
900.23
|
895.97
|
287.74
|
82.30
|
77.75
|
|
08
|
1,037.12
|
161.05
|
101.81
|
76.83
|
144.58
|
85.09
|
258.91
|
158.45
|
344.63
|
12,799.22
|
1,774.63
|
489.94
|
249.27
|
262.83
|
802.91
|
815.32
|
326.18
|
81.28
|
76.74
|
|
09
|
1,052.13
|
162.01
|
101.61
|
80.84
|
149.46
|
89.17
|
260.82
|
159.38
|
340.05
|
12,607.42
|
1,749.27
|
485.15
|
265.54
|
277.43
|
827.10
|
816.96
|
292.18
|
87.67
|
82.50
|
|
10
|
1,097.11
|
171.41
|
106.64
|
84.47
|
155.76
|
93.78
|
277.61
|
170.79
|
369.29
|
16,174.08
|
2,267.40
|
631.84
|
370.13
|
382.99
|
1,128.63
|
1,098.38
|
359.53
|
94.31
|
88.97
|
|
11
|
1,387.53
|
213.20
|
134.76
|
98.83
|
189.24
|
110.58
|
338.63
|
205.24
|
440.36
|
16,511.00
|
2,277.00
|
637.97
|
361.66
|
375.08
|
1,097.92
|
1,060.93
|
391.98
|
132.45
|
123.94
|
|
6B*
|
1,064.98
|
165.74
|
102.52
|
73.28
|
142.82
|
82.41
|
263.14
|
159.70
|
349.13
|
12,740.32
|
1,765.85
|
486.20
|
244.85
|
258.71
|
793.50
|
805.79
|
343.25
|
80.33
|
75.87
|
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
|
1,135.62
|
173.12
|
104.94
|
74.77
|
150.36
|
85.08
|
273.90
|
165.08
|
349.30
|
12,218.57
|
1,694.83
|
463.16
|
249.41
|
263.76
|
785.58
|
762.27
|
361.36
|
106.87
|
97.94
|
|
02
|
1,135.61
|
173.11
|
104.56
|
74.15
|
150.28
|
85.00
|
274.64
|
165.82
|
349.95
|
12,218.61
|
1,694.87
|
467.15
|
274.09
|
287.41
|
835.69
|
781.80
|
361.36
|
106.87
|
97.94
|
|
03
|
1,211.17
|
186.41
|
112.62
|
80.72
|
161.83
|
92.53
|
297.30
|
180.41
|
383.92
|
13,050.22
|
1,830.85
|
497.71
|
259.69
|
277.85
|
847.61
|
835.81
|
236.53
|
109.68
|
99.91
|
|
04
|
1,054.64
|
163.49
|
99.06
|
72.61
|
142.43
|
82.58
|
262.02
|
159.69
|
342.45
|
12,468.39
|
1,751.95
|
478.42
|
255.56
|
271.46
|
824.49
|
813.45
|
173.13
|
103.96
|
95.64
|
|
05
|
1,188.16
|
183.22
|
111.18
|
83.04
|
161.73
|
94.16
|
293.39
|
178.70
|
380.61
|
14,071.98
|
1,961.51
|
536.34
|
283.37
|
300.20
|
912.45
|
898.78
|
272.12
|
89.99
|
83.06
|
|
06
|
1,068.60
|
166.62
|
100.67
|
69.45
|
139.86
|
79.57
|
265.34
|
161.32
|
351.66
|
12,781.60
|
1,792.38
|
487.20
|
244.15
|
260.70
|
808.15
|
818.87
|
346.35
|
89.27
|
82.57
|
|
07
|
1,098.45
|
171.02
|
104.69
|
83.42
|
155.72
|
93.60
|
277.67
|
170.90
|
364.47
|
13,731.89
|
1,935.41
|
529.58
|
284.70
|
301.60
|
916.43
|
908.94
|
293.06
|
92.62
|
85.52
|
|
08
|
1,042.08
|
162.27
|
98.01
|
68.84
|
138.22
|
79.11
|
259.67
|
158.21
|
342.24
|
12,849.85
|
1,807.50
|
490.75
|
246.15
|
263.83
|
819.90
|
828.40
|
329.66
|
93.23
|
85.73
|
|
09
|
1,057.08
|
163.23
|
99.23
|
75.46
|
145.70
|
85.46
|
262.78
|
160.44
|
340.51
|
12,659.96
|
1,783.38
|
487.10
|
263.94
|
279.88
|
845.83
|
832.09
|
292.82
|
101.59
|
93.03
|
|
10
|
1,099.02
|
171.88
|
104.89
|
80.87
|
152.79
|
91.02
|
278.23
|
171.04
|
369.13
|
16,191.10
|
2,278.44
|
631.18
|
367.69
|
382.12
|
1,134.12
|
1,102.45
|
361.29
|
98.42
|
92.03
|
|
11
|
1,390.39
|
213.87
|
128.97
|
91.16
|
183.00
|
103.93
|
339.56
|
205.61
|
440.10
|
16,547.82
|
2,300.88
|
634.16
|
356.30
|
373.85
|
1,110.23
|
1,070.36
|
394.15
|
141.29
|
130.53
|
|
6B*
|
1,068.47
|
166.59
|
100.41
|
68.69
|
139.39
|
79.11
|
265.52
|
161.51
|
351.79
|
12,781.02
|
1,792.28
|
486.95
|
242.49
|
259.65
|
809.19
|
819.25
|
346.35
|
89.27
|
82.57
|
AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 2 of
5
ATTACHMENT
I
EXHIBIT
2-NR-A
MEDICAID NON-REFORM HMO CAPITATION
RATES
By Area , Age and Eligibility Category
Effective
November 1, 2009 -August 31, 2012
TABLE
5
|
General
|
+
Transportation Rates:
|
||||||||||||||||||
|
XXXX
|
XXX-X
|
0XX-X
|
X0X-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
|
1,135.59
|
173.09
|
103.08
|
62.42
|
138.97
|
73.69
|
269.84
|
161.02
|
345.73
|
12,218.50
|
1,694.76
|
454.95
|
197.57
|
216.98
|
704.48
|
730.67
|
353.25
|
94.33
|
85.40
|
|
02
|
1,135.59
|
173.09
|
103.08
|
62.42
|
138.97
|
73.69
|
269.84
|
161.02
|
345.73
|
12,218.50
|
1,694.76
|
454.95
|
197.57
|
216.98
|
704.48
|
730.67
|
353.25
|
94.33
|
85.40
|
|
03
|
1,211.15
|
186.39
|
111.07
|
68.43
|
149.98
|
80.68
|
292.27
|
175.38
|
379.50
|
13,050.16
|
1,830.79
|
491.10
|
218.23
|
239.69
|
776.52
|
808.11
|
228.42
|
97.14
|
87.37
|
|
04
|
1,054.62
|
163.47
|
97.60
|
60.98
|
131.22
|
71.37
|
257.27
|
154.94
|
338.27
|
12,468.33
|
1,751.89
|
471.58
|
212.65
|
231.97
|
750.91
|
784.78
|
165.02
|
91.42
|
83.10
|
|
05
|
1,188.14
|
183.20
|
109.24
|
67.61
|
146.86
|
79.29
|
287.08
|
172.39
|
375.06
|
14,071.91
|
1,961.44
|
528.72
|
235.58
|
256.21
|
830.50
|
866.85
|
264.01
|
77.45
|
70.52
|
|
06
|
1,068.58
|
166.60
|
99.70
|
62.99
|
133.90
|
73.61
|
263.21
|
159.19
|
349.79
|
12,781.57
|
1,792.35
|
483.10
|
218.24
|
237.32
|
767.62
|
803.07
|
338.24
|
76.73
|
70.03
|
|
07
|
1,098.42
|
170.99
|
102.30
|
64.47
|
137.45
|
75.33
|
269.92
|
163.15
|
357.66
|
13,731.82
|
1,935.34
|
522.25
|
238.71
|
259.27
|
837.57
|
878.21
|
284.95
|
80.08
|
72.98
|
|
06
|
1,042.07
|
162.26
|
97.03
|
61.10
|
130.75
|
71.64
|
256.50
|
155.04
|
339.46
|
12,849.81
|
1,807.46
|
486.67
|
220.55
|
240.27
|
776.00
|
811.30
|
321.55
|
80.69
|
73.19
|
|
09
|
1,057.06
|
163.21
|
97.34
|
60.46
|
131.24
|
71.00
|
256.65
|
154.31
|
335.12
|
12,659.89
|
1,783.31
|
479.74
|
217.76
|
237.38
|
766.65
|
801.24
|
284.71
|
89.05
|
80.49
|
|
10
|
1,099.00
|
171.86
|
102.95
|
65.45
|
137.92
|
76.15
|
271.92
|
164.73
|
363.59
|
16,190.98
|
2,278.32
|
618.38
|
287.39
|
308.21
|
996.43
|
1,048.80
|
353.18
|
85.88
|
79.49
|
|
11
|
1,390.37
|
213.85
|
127.40
|
78.71
|
170.99
|
91.92
|
334.47
|
200.52
|
435.62
|
16,547.71
|
2,300.77
|
621.54
|
277.09
|
300.94
|
974.40
|
1,017.43
|
386.04
|
128.75
|
117.99
|
|
6B*
|
1,068.46
|
166.58
|
99.69
|
62.98
|
133.88
|
73.60
|
263.18
|
159.17
|
349.74
|
12,780.99
|
1,792.25
|
483.08
|
218.22
|
237.31
|
767.58
|
803.03
|
338.24
|
76.73
|
70.03
|
TABLE
6
| General | + Dental Rates: | ||||||||||||||||||
|
XXXX
|
XXX-X
|
0XX-X
|
X0X-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+) |
|||
|
01
|
1,130.46
|
171.81
|
103.60
|
64.44
|
139.32
|
74.44
|
267.75
|
159.87
|
345.13
|
12,166.98
|
1,661.31
|
451.50
|
196.85
|
212.56
|
686.00
|
715.64
|
345.23
|
82.19
|
76.22
|
|
02
|
1,130.46
|
171.81
|
103.60
|
64.44
|
139.32
|
74.44
|
267.75
|
159.87
|
345.13
|
12,166.98
|
1,661.31
|
451.50
|
196.85
|
212.56
|
686.00
|
715.64
|
345.23
|
82.19
|
76.22
|
|
03
|
1,204.99
|
184.87
|
113.05
|
73.32
|
152.85
|
83.73
|
290.64
|
174.94
|
380.84
|
12,984.80
|
1,788.36
|
488.04
|
219.30
|
235.82
|
753.72
|
789.96
|
221.17
|
80.09
|
74.48
|
|
04
|
1,050.62
|
162.47
|
98.70
|
63.82
|
132.76
|
73.06
|
256.61
|
155.09
|
340.09
|
12,420.29
|
1,720.68
|
468.92
|
212.80
|
228.57
|
734.52
|
772.00
|
160.68
|
77.74
|
72.76
|
|
05
|
1,184.67
|
182.35
|
112.26
|
73.86
|
151.96
|
84.05
|
288.53
|
174.69
|
381.40
|
14,030.19
|
1,934.35
|
528.83
|
239.31
|
256.38
|
817.52
|
857.56
|
258.05
|
66.65
|
62.46
|
|
06
|
1,065.09
|
165.75
|
101.81
|
67.58
|
137.33
|
76.91
|
262.93
|
159.63
|
352.07
|
12,740.87
|
1,765.92
|
482.35
|
220.60
|
236.38
|
754.51
|
793.35
|
335.14
|
67.79
|
63.33
|
|
07
|
1,094.61
|
170.05
|
104.29
|
68.91
|
140.64
|
78.46
|
268.96
|
162.93
|
358.59
|
13,685.78
|
1,905.45
|
521.07
|
240.89
|
257.79
|
821.37
|
865.24
|
279.63
|
69.76
|
65.21
|
|
08
|
1,037.11
|
161.04
|
100.83
|
69.09
|
137.11
|
77.62
|
255.74
|
155.28
|
341.85
|
12,799.18
|
1,774.59
|
485.86
|
223.67
|
239.27
|
759.01
|
798.22
|
318.07
|
68.74
|
64.20
|
|
09
|
1,052.11
|
161.99
|
99.72
|
65.84
|
135.00
|
74.71
|
254.69
|
153.25
|
334.66
|
12,607.35
|
1,749.20
|
477.79
|
219.36
|
234.93
|
747.92
|
786.11
|
284.07
|
75.13
|
69.96
|
|
10
|
1,097.09
|
171.39
|
104.70
|
69.05
|
140.89
|
78.91
|
271.30
|
164.48
|
363.75
|
16,173.96
|
2,267.28
|
619.04
|
289.83
|
309.08
|
990.94
|
1,044.73
|
351.42
|
81.77
|
76.43
|
|
11
|
1,387.51
|
213.18
|
133.19
|
86.38
|
177.23
|
98.57
|
333.54
|
200.15
|
435.86
|
16,510.89
|
2,276.89
|
625.35
|
282.45
|
302.17
|
962.09
|
1,008.00
|
383.87
|
119.91
|
111.40
|
|
6B*
|
1,064.97
|
165.73
|
101.80
|
67.57
|
137.31
|
76.90
|
260.80
|
157.36
|
347.08
|
12,740.29
|
1,765.82
|
482.33
|
220.58
|
236.37
|
751.89
|
789.57
|
335.14
|
67.79
|
63.33
|
AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 3 of
5
ATTACHMENT
I
EXHIBIT 2-NR-A
MEDICAID NON-REFORM
HMO CAPITATION RATES
By Area , Age and
Eligibility Category
Effective
November 1, 2009 -August 31, 2012
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
|
1,135.60
|
173.10
|
104.46
|
64.94
|
141.48
|
75.88
|
271.24
|
162.53
|
349.04
|
12,218.50
|
1,694.76
|
456.13
|
199.31
|
218.50
|
705.68
|
732.69
|
353.25
|
95.51
|
86.37
|
|
02
|
1,135.60
|
173.10
|
104.46
|
64.94
|
141.48
|
75.88
|
271.24
|
162.53
|
349.04
|
12,218.50
|
1,694.76
|
456.13
|
199.31
|
218.50
|
705.88
|
732.69
|
353.25
|
95.51
|
86.37
|
|
03
|
1,211.16
|
186.41
|
114.06
|
73.92
|
155.44
|
85.46
|
294.83
|
178.13
|
385.53
|
13,050.16
|
1,830.60
|
493.93
|
222.43
|
243.34
|
778.93
|
811.59
|
229.67
|
99.14
|
89.01
|
|
04
|
1,054.63
|
163.48
|
99.37
|
64.21
|
134.44
|
74.18
|
259.34
|
157.17
|
343.15
|
12,468.33
|
1,751.89
|
473.24
|
215.11
|
234.11
|
753.06
|
787.90
|
166.91
|
93.09
|
84.46
|
|
05
|
1,186.15
|
183.22
|
112.84
|
74.20
|
153.42
|
85.03
|
290.89
|
176.49
|
384.05
|
14,071.92
|
1,961.45
|
532.59
|
241.31
|
261.19
|
833.62
|
871.37
|
264.09
|
80.56
|
73.07
|
|
06
|
1,068.59
|
166.62
|
102.39
|
67.92
|
138.80
|
77.89
|
265.31
|
161.44
|
354.73
|
12,781.57
|
1,792.36
|
486.01
|
222.55
|
241.06
|
770.20
|
806.81
|
341.09
|
78.90
|
71.81
|
|
07
|
1,098.43
|
171.01
|
104.93
|
69.29
|
142.24
|
79.52
|
271.55
|
164.90
|
361.49
|
13,731.82
|
1,935.35
|
525.22
|
243.10
|
263.09
|
839.14
|
880.46
|
285.70
|
81.52
|
74.17
|
|
08
|
1,042.09
|
162.29
|
101.66
|
69.57
|
139.19
|
79.01
|
259.12
|
157.86
|
345.64
|
12,849.82
|
1,807.47
|
490.42
|
226.10
|
245.10
|
778.54
|
814.97
|
324.02
|
82.60
|
74.76
|
|
09
|
1,057.07
|
163.23
|
100.55
|
66.33
|
137.08
|
76.10
|
258.06
|
155.82
|
338.43
|
12,659.89
|
1,783.32
|
482.53
|
221.89
|
240.98
|
768.20
|
803.49
|
290.10
|
90.53
|
81.70
|
|
10
|
1,099.01
|
171.87
|
105.02
|
69.24
|
141.69
|
79.45
|
272.60
|
165.47
|
365.21
|
16,190.98
|
2,278.33
|
620.57
|
290.64
|
311.04
|
997.51
|
1,050.36
|
353.31
|
87.24
|
80.60
|
|
11
|
1,390.43
|
213.91
|
133.67
|
86.66
|
178.46
|
99.39
|
335.53
|
201.66
|
438.11
|
16,547.79
|
2,300.85
|
628.67
|
284.23
|
306.42
|
976.32
|
1,020.21
|
389.40
|
131.17
|
119.98
|
|
6B*
|
1,068.47
|
166.60
|
102.38
|
67.91
|
138.78
|
77.88
|
263.18
|
159.17
|
349.74
|
12,780.99
|
1,792.26
|
485.99
|
222.53
|
241.05
|
767.55
|
803.03
|
341.09
|
78.90
|
71.81
|
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
|
1,135.63
|
173.13
|
106.32
|
77.29
|
152.87
|
87.27
|
275.30
|
166.59
|
352.61
|
12,218.57
|
1,694.83
|
464.34
|
251.15
|
265.28
|
786.98
|
764.29
|
361.36
|
108.05
|
98.91
|
|
02
|
1,135.62
|
173.12
|
105.94
|
76.67
|
152.79
|
87.19
|
276.04
|
167.33
|
353.26
|
12,218.61
|
1,694.87
|
468.33
|
275.83
|
288.93
|
837.09
|
783.82
|
361.36
|
108.05
|
98.91
|
|
03
|
1,211.18
|
186.43
|
115.63
|
86.21
|
167.29
|
97.31
|
299.86
|
183.16
|
389.95
|
13,050.22
|
1,830.86
|
500.54
|
263.89
|
281.50
|
850.02
|
839.29
|
237.78
|
111.68
|
101.55
|
|
04
|
1,054.65
|
163.50
|
100.83
|
75.84
|
145.65
|
85.39
|
264.09
|
161.92
|
347.33
|
12,468.39
|
1,751.95
|
480.08
|
258.02
|
273.60
|
826.64
|
816.57
|
175.02
|
105.63
|
97.00
|
|
05
|
1,188.17
|
183.24
|
114.78
|
89.63
|
168.29
|
99.90
|
297.20
|
182.80
|
389.60
|
14,071.99
|
1,961.52
|
540.21
|
289.10
|
305.18
|
915.57
|
903.30
|
272.20
|
93.10
|
85.61
|
|
06
|
1,068.61
|
166.64
|
103.36
|
74.38
|
144.76
|
83.85
|
267.44
|
163.57
|
356.60
|
12,781.60
|
1,792.39
|
490.11
|
248.46
|
264.44
|
810.73
|
822.61
|
349.20
|
91.44
|
84.35
|
|
07
|
1,098.46
|
171.04
|
107.32
|
88.24
|
160.51
|
97.79
|
279.30
|
172.65
|
368.30
|
13,731.89
|
1,935.42
|
532.55
|
289.09
|
305.42
|
918.00
|
911.21
|
293.81
|
94.06
|
86.71
|
|
08
|
1,042.10
|
162.30
|
102.64
|
77.31
|
146.66
|
86.48
|
262.29
|
161.03
|
348.42
|
12,849.86
|
1,807.51
|
494.50
|
251.70
|
268.66
|
822.44
|
832.07
|
332.13
|
95.14
|
87.30
|
|
09
|
1,057.09
|
163.25
|
102.44
|
81.33
|
151.54
|
90.56
|
264.19
|
161.95
|
343.82
|
12,659.96
|
1,783.39
|
489.89
|
268.07
|
283.48
|
847.38
|
834.34
|
298.21
|
103.07
|
94.24
|
|
10
|
1,099.03
|
171.89
|
106.96
|
84.66
|
156.56
|
94.32
|
278.91
|
171.78
|
370.75
|
16,191.10
|
2,278.45
|
633.37
|
370.94
|
384.95
|
1,135.20
|
1,104.01
|
361.42
|
99.78
|
93.14
|
|
11
|
1,390.45
|
213.93
|
135.24
|
99.11
|
190.47
|
111.40
|
340.62
|
206.75
|
442.59
|
16,547.90
|
2,300.96
|
641.29
|
363.44
|
379.33
|
1,112.15
|
1,073.14
|
397.51
|
143.71
|
132.52
|
|
6B*
|
1,068.48
|
166.61
|
103.10
|
73.62
|
144.29
|
83.39
|
265.52
|
161.51
|
351.79
|
12,781.02
|
1,792.29
|
489.86
|
246.80
|
263.39
|
809.19
|
819.25
|
349.20
|
91.44
|
84.35
|
AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 4 of
5
ATTACHMENT
I
EXHIBIT 2-NR-A
MEDICAID NON-REFORM
HMO CAPITATION RATES
By Area, Age and
Eligibility Category
Effective
November 1, 2009 -August 31, 2012
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, Hamiliton, 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. FA905, Attachment I, Exhibit 2-NR-A, Page 5 of
5
