AHCA CONTRACT NO. FA619 AMENDMENT NO. 4
Exhibit
10.1
HealthEase
of Florida,
Inc.
AHCA
CONTRACT NO. FA619
AMENDMENT
NO. 4
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.
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Attachment
I, Scope of Services, is hereby amended to include Exhibit II-B, Second
Revised Capitation Rates, attached hereto and made a part of the Contract.
All references in the Contract to Exhibit II-A, Revised Capitation Rates,
shall hereinafter also refer to Exhibit II-B, Second Revised Capitation
Rates, as appropriate.
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2.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section V, Covered
Services, Item B, Optional Services, is hereby deleted in its entirety and
replaced with the following:
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B.Optional
Services
The Plan
shall offer the following services within all applicable Medicaid
guidelines:
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Covered
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Not
Covered
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Dental
Services
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X
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Transportation
Services
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X
(Dade only)
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3.
Attachment II, Medicaid Prepaid Health Plan Model Contract, Section V,
Covered Services, Item C, Expanded Services, sub-item 2 is hereby deleted
in its entirety and replaced with the
following:
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2.The
following is a list of the Health Plan’s Expanded Services:
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a.
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Annual
comprehensive oral exam, x-rays (one per year), 2 cleanings per year,
silver amalgam fillings, one periodontic deep cleaning per year, 2
periodontic scaling and root planning per
year;
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b.
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Up
to $25 credit per household each month for selected over the counter drugs
and/or health supplies;
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c.
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Unlimited
eye exams and eyeglasses, if medically
necessary;
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d.
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Free
approved round trip transportation to medical appointments (Dade County
only);
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e.
Circumcision up to 1 year.
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AHCA
Contract No. FA619, Amendment No. 4, Page 1 of
2
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HealthEase of Florida,
Inc.
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4.
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This
Amendment shall have an effective date of March 1, 2008, or the date on
which
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both
parties execute the Amendment, whichever is
later.
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All
provisions in the Contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform with this
amendment.
All
provisions not in conflict with this amendment are still in effect and are to be
performed at the level specified in the Contract.
This
amendment and all its attachments are hereby made a part of the
Contract.
This
amendment cannot be executed unless all previous amendments to this Contract
have been fully executed.
IN
WITNESS WHEREOF, the parties hereto have caused this four (4) page amendment
(which includes all attachments hereto) to be executed by their officials
thereunto duly authorized.
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HEALTHEASE
OF FLORIDA, INC.
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STATE
OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION
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SIGNED
BY: /s/ Xxxxx
Xxxxxxxxx
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SIGNED
BY: /s/ Illegible
for
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NAME:
Xxxxx Xxxxxxxxx
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NAME:
Xxxxx Xxxxxx
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TITLE:
President and CEO
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TITLE:
Secretary
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DATE: 3/27/08
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4/2/08
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List of
attachments included as part of this Amendment:
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Specify
Type
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Letter/Number
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Description
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Exhibit
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II-B
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Second
Revised Capitation Rates (2 pages)
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REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
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AHCA
Contract No. FA619, Amendment No. 4, Page 2 of
2
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EXHIBIT
II-B
SECOND
REVISED CAPITATION RATES
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A.
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Table
2 - General Capitation Rates plus Mental Health
Rates:
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Area
1 Counties:
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County
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Provider
Number
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Escambia
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015019314
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Santa
Xxxx
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015019331
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Area
2 Counties:
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County
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Provider
Number
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Xxxxxxx
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015019340
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Gadsden
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015019315
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Jefferson
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015019318
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Xxxx
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015019320
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Liberty
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015019342
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Madison
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015019322
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Wakulla
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015019336
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Area
3 Counties:
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County
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Provider
Number
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Citrus
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015019309
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Lake
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015019319
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Xxxxxx
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015019323
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Xxxxxx
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015019329
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Area
4 Counties:
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County
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Provider
Number
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Xxxxx
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015019313
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Volusia
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015019335
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Area
5 Counties:
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County
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Provider
Number
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Pasco
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015019302
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Pinellas
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015019303
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AHCA
Contract No. FA619, Exhibit II-B, Page 1 of 2
Area
6 Counties:
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County
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Provider
Number
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Highlands
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015019317
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Hillsborough
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015019300
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Manatee
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015019301
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Polk
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015019304
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Area
7 Counties:
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County
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Provider
Number
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Brevard
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015019308
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Orange
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015019327
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Osceola
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015019328
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Seminole
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015019333
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Area
8 Counties:
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County
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Provider Number
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Sarasota
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015019332
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Area
9 Counties:
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County
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Provider
Number
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Xxxxxx
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015019324
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Palm
Beach
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015019339
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Area
10 Counties:
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County
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Provider Number
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Broward
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015019337
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B.
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Table
4 - General Capitation Rates plus Mental Health Rates and Transportation
Rates:
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Area
11 Counties:
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County
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Provider Number
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Miami-Dade
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015019338
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AHCA Contract No. FA619, Exhibit
II-B, Page 2 of 2
