AHCA CONTRACT NO. FA615
Exhibit 10.5
AHCA
CONTRACT NO. FA615
AMENDMENT
NO. 6
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.
|
Effective
September 1, 2008, Standard Contract, Section III, Item C., Contract
Managers, sub-item
1, is hereby amended to now read as
follows:
|
|
|
1. The
Agency’s Contract Manager’s name, address and telephone number for this
Contract is as follows:
|
|
Xxxxxxx
Xxxxxxxx
Agency
for Health Care Administration
0000
Xxxxx Xxxxx, XX #00
Xxxxxxxxxxx,
XX 00000
(850)
487-2355
|
|
2.
|
Effective
December 1, 2008, Attachment I, Scope of Services, is hereby amended to
include Exhibit I-B, Second Revised Maximum Enrollment Levels, attached
hereto and made a part of the Contract. All references in the Contract to
Exhibit I-A, Revised Maximum Enrollment Levels, shall hereinafter also
refer to Exhibit I-B, Second Revised Maximum Enrollment Levels, as
appropriate.
|
|
3.
|
Effective
December 1, 2008, Attachment I, Scope of Services, is hereby amended to
include Exhibit II-D, Fourth Revised Capitation Rates, attached hereto and
made a part of the Contract. All references in the Contract to Exhibit
II-C, Third Revised Capitation Rates, shall hereinafter also refer to
Exhibit II-D, Fourth Revised Capitation Rates, as
appropriate.
|
|
4.
|
Effective
September 1, 2008, Attachment I, Scope of Services, is hereby amended to
include Exhibit III-D, September 1, 2008 - 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-C, January 1, 2008
– August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, shall
hereinafter also refer to Exhibit III-D, September 1, 2008 - 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. | |
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA615, Amendment No. 6, Page 1 of 2
AHCA Form
2100-0002 (Rev. NOV03)
| Wellcare of Florida, Inc. d/b/a | Medicaid HMO Contract |
| Staywell Health Plan of Florida |
IN WITNESS WHEREOF, the parties hereto
have caused this nine (9) 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/
Xxxxxxx X. Xxxxxxx for Xxxxx
Xxxxxx
|
|
NAME:
Xxxxx
Xxxxxxxxx
|
NAME:
Xxxxx
Xxxxxx
|
|
TITLE: President
and
CEO
|
TITLE:
Secretary
|
|
DATE:
8/29/08
|
DATE:
8/29/08
|
List of
attachments/exhibits included as part of this Amendment:
|
Specify
Type
|
Letter/
Number
|
Description
|
|
Exhibit
|
I-B
|
Second
Revised Maximum Enrollment Levels (1 Page)
|
|
Exhibit
|
II-D
|
Fourth
Revised Capitation Rates (1 Page)
|
|
Exhibit
|
III-D
|
September
1, 2008 - August 31, 2009 Medicaid Non-Reform HMO Capitation Rates (5
Pages)
|
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA615, Amendment No. 6, Page 2 of 2
AHCA Form
2100-0002 (Rev. NOV03)
| Wellcare of Florida, Inc. d/b/a | Medicaid HMO Contract |
| Staywell Health Plan of Florida |
EXHIBIT
I-B
SECOND
REVISED MAXIMUM ENROLLMENT LEVELS
|
County
|
Maximum
Enrollment Level
|
|
Brevard
|
14,000
|
|
Broward
|
25,000
|
|
Dade
|
25,000
|
|
Hernando
|
15,000
|
|
Hillsborough
|
28,000
|
|
Xxx
|
15,000
|
|
Manatee
|
12,000
|
|
Palm
Beach
|
15,000
|
|
Pasco
|
7,000
|
|
Pinellas
|
15,000
|
|
Polk
|
25,000
|
|
Orange
|
38,000
|
|
Osceola
|
12,000
|
|
Sarasota
|
6,000
|
|
Seminole
|
6,000
|
|
Sumter
|
4,500
|
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA615, Exhibit I-B, Page 1 of 1
FOURTH
REVISED CAPITATION RATES
A.
Table 2 - General Capitation Rates plus Mental Health
Rates:
Area
3 Counties:
|
County
|
Provider
Number
|
|
Hernando
|
015016901
|
|
Sumter
|
015016916
|
Area
5 Counties:
|
County
|
Provider
Number
|
|
Pasco
|
015016903
|
|
Pinellas
|
015016904
|
Area
6 Counties:
|
County
|
Provider
Number
|
|
Hillsborough
|
015016902
|
|
Manatee
|
015016912
|
|
Polk
|
015016905
|
Area
7 Counties:
|
County
|
Provider
Number
|
|
Orange
|
015016906
|
|
Seminole
|
015016908
|
|
Osceola
|
015016907
|
|
Xxxxxxx
|
000000000
|
Xxxx 0
Xxxxxxxx:
|
Xxxxxx
|
Provider
Number
|
|
Xxx
|
015016911
|
|
Sarasota
|
015016914
|
Area
9 Counties:
|
County
|
Provider
Number
|
|
Palm
Beach
|
015016910
|
Area
10 Counties:
|
County
|
Provider
Number
|
|
Broward
|
015016900
|
Area
11 Counties:
|
County
|
Provider
Number
|
|
Miami-Dade
|
015016909
|
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA615, Exhibit II-D, Page 1 of 1
EXHIBIT
III-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area, Age and Eligibility Category
Table 1
|
General
Rates
|
|||||||||||||||||||
|
TANF
|
SSI-N
|
SSI-B
|
SSS-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20)
|
AGE (21-54)
|
AGE
(55+)
|
XXXXXx0XX
|
0XX-
11MO
|
AGE
(1-5)
|
AGE
AGE
AGE
(6-13)
(14-20)
(21-54)
|
AGE
(55+)
|
AGE
AGE
(65-)
(65+)
|
||||||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,113.37
|
187.38
|
101.38
|
61.45
|
129.49
|
69.52
|
255.23
|
153.37
|
318.51
|
10,428.92
|
1,517.58
|
445.88
|
198.88
|
213.14
|
696.73
|
700.31
|
305.88
|
94.80
|
85.77
|
|
02
|
1,113.37
|
187.38
|
101.38
|
61.45
|
129.49
|
69.52
|
255.23
|
153.37
|
318.51
|
10,428.92
|
1,517.58
|
445.88
|
198.88
|
213.14
|
696.73
|
700.31
|
305.88
|
94.80
|
85.77
|
|
03
|
1,217.57
|
206.51
|
112.28
|
69.11
|
143.30
|
77.85
|
283.53
|
171.42
|
359.72
|
11,442.82
|
1,680.06
|
495.07
|
226.05
|
241.47
|
787.51
|
795.55
|
340.56
|
90.01
|
81.98
|
|
04
|
1,067.51
|
181.92
|
99.04
|
61.51
|
126.30
|
69.23
|
250.83
|
152.26
|
321.21
|
10,972.58
|
1,615.28
|
476.38
|
218.79
|
233.36
|
761.37
|
770.55
|
297.82
|
90.35
|
82.40
|
|
05
|
1,214.96
|
206.53
|
112.30
|
69.38
|
143.25
|
78.21
|
284.08
|
172.12
|
361.87
|
12,248.94
|
1,796.88
|
528.79
|
240.95
|
256.93
|
840.31
|
849.11
|
225.19
|
81.19
|
75.29
|
|
06
|
1,056.56
|
181.19
|
98.87
|
61.99
|
126.18
|
69.68
|
251.35
|
153.20
|
325.45
|
11,162.18
|
1,645.44
|
485.06
|
223.95
|
237.92
|
777.94
|
788.05
|
274.94
|
79.31
|
72.63
|
|
07
|
1,092.94
|
186.84
|
101.87
|
63.49
|
129.77
|
71.35
|
258.27
|
157.02
|
332.09
|
11,810.40
|
1,744.81
|
514.41
|
238.57
|
254.24
|
828.77
|
840.70
|
373.98
|
84.56
|
77.61
|
|
08
|
1,033.51
|
177.08
|
96.67
|
60.37
|
123.15
|
68.03
|
245.23
|
149.29
|
316.91
|
10,525.98
|
1,550.30
|
457.03
|
210.03
|
224.35
|
731.36
|
740.14
|
256.24
|
78.77
|
72.23
|
|
09
|
1,067.78
|
181.58
|
96.82
|
61.05
|
126.06
|
68.67
|
249.80
|
151.41
|
318.38
|
11,078.29
|
1,635.46
|
482.13
|
223.68
|
237.34
|
775.59
|
785.85
|
219.29
|
84.42
|
77.20
|
|
10
|
1,083.46
|
186.09
|
101.73
|
63.88
|
129.70
|
71.87
|
258.53
|
157.78
|
335.92
|
14,344.29
|
2,132.34
|
629.36
|
297.17
|
314.18
|
1,027.07
|
1,044.85
|
322.21
|
94.02
|
86.21
|
|
11
|
1,372.19
|
232.59
|
126.24
|
77.54
|
161.30
|
87.46
|
319.10
|
192.88
|
404.23
|
14,488.14
|
2,131.88
|
628.05
|
289.19
|
307.93
|
1,004.54
|
1,015.98
|
370.49
|
140.27
|
126.63
|
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+)
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,113.39
|
187.40
|
103.02
|
73.14
|
140.42
|
80.45
|
259.67
|
157.81
|
322.25
|
10,429.00
|
1,517.66
|
453.32
|
246.93
|
257.13
|
778.13
|
731.29
|
306.09
|
106.45
|
97.42
|
|
02
|
1,113.40
|
187.41
|
104.29
|
81.71
|
142.91
|
82.94
|
258.64
|
156.78
|
321.46
|
10,429.08
|
1,517.74
|
459.67
|
277.70
|
258.36
|
749.41
|
725.19
|
326.08
|
109.81
|
100.78
|
|
03
|
1,217.58
|
206.52
|
113.60
|
78.29
|
149.38
|
83.93
|
285.07
|
172.96
|
361.06
|
11,442.89
|
1,680.13
|
501.33
|
261.81
|
261.99
|
811.41
|
806.83
|
347.41
|
98.99
|
90.96
|
|
04
|
1,067.52
|
181.93
|
100.42
|
71.07
|
132.64
|
75.57
|
252.44
|
153.87
|
322.61
|
10,972.69
|
1,615.39
|
486.14
|
274.53
|
265.34
|
798.63
|
788.14
|
322.37
|
107.12
|
99.17
|
|
05
|
1,.214.97
|
206.54
|
113.51
|
78.06
|
151.36
|
86.32
|
287.37
|
175.41
|
364.65
|
12,248.99
|
1,796.93
|
533.81
|
273.37
|
286.61
|
835.23
|
870.01
|
227.92
|
94.01
|
88.11
|
|
06
|
1,056.58
|
181.21
|
100.72
|
75.24
|
138.56
|
82.06
|
256.38
|
158.23
|
329.70
|
11,162.25
|
1,645.51
|
491.58
|
266.06
|
276.46
|
849.27
|
815.20
|
276.25
|
83.20
|
76.52
|
|
07
|
1,092.96
|
186.86
|
103.65
|
76.18
|
141.63
|
83.21
|
263.09
|
161.84
|
336.16
|
11,810.46
|
1,744.87
|
520.53
|
278.08
|
290.41
|
895.70
|
866.18
|
376.57
|
95.08
|
88.13
|
|
08
|
1,033.52
|
177.09
|
97.93
|
69.16
|
128.97
|
73.85
|
246.72
|
150.78
|
318.20
|
10,526.05
|
1,550.37
|
463.03
|
244.31
|
244.03
|
754.27
|
750.96
|
263.09
|
91.99
|
85.45
|
|
09
|
1,067.80
|
181.60
|
100.37
|
71.86
|
133.22
|
75.83
|
251.62
|
153.23
|
319.95
|
11,078.36
|
1,635.53
|
488.46
|
259.82
|
258.08
|
799.75
|
797.26
|
226.14
|
94.01
|
86.73
|
|
10
|
1,083.48
|
186.11
|
103.65
|
77.24
|
138.55
|
80.72
|
260.78
|
160.03
|
337.87
|
14,344.39
|
2,132.44
|
637.71
|
344.88
|
341.56
|
1,058.95
|
1,059.91
|
329.06
|
102.08
|
94.27
|
|
11
|
1,372.21
|
232.61
|
127.86
|
88.83
|
168.79
|
94.95
|
321.01
|
194.79
|
405.88
|
14,488.22
|
2,131.96
|
635.02
|
328.99
|
330.76
|
1,031.14
|
1,028.54
|
377.72
|
148.33
|
134.69
|
AHCA
Contract No. FA615, Exhibit III-D, Page 1 of 5
EXHIBIT
III-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area, Age and Eligibility Category
TABLE 3
|
General
+ MH + Dental Rates:
|
|||||||||||||||||||
|
TANF
|
SSI-N |
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MC-11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
|
Female
|
Male
|
Female
|
Male
|
|||||||||||||||
|
01
|
1,113.39
|
187.41
|
104.70
|
76.25
|
143.60
|
83.14
|
260.89
|
159.07
|
325.04
|
10,429.00
|
1,517.66
|
454.94
|
249.33
|
259.19
|
773.46
|
733.15
|
306.54
|
107.57
|
98.28
|
|
02
|
1,113.40
|
187.42
|
105.97
|
84.82
|
146.09
|
85.63
|
259.86
|
158.04
|
324.25
|
10,429.08
|
1,517.74
|
461.29
|
280.10
|
260.42
|
750.74
|
727.05
|
326.53
|
110.93
|
101.64
|
|
03
|
1,217.59
|
206.54
|
116.65
|
83.95
|
155.15
|
88.81
|
286.81
|
174.74
|
365.03
|
11,442.89
|
1,680.14
|
504.46
|
266.45
|
265.98
|
813.29
|
809.48
|
348.44
|
100.64
|
92.22
|
|
04
|
1,067.53
|
181.94
|
102.26
|
74.48
|
136.14
|
78.52
|
254.11
|
155.59
|
326.43
|
10,972.69
|
1,615.39
|
487.92
|
277.17
|
267.61
|
800.51
|
790.78
|
324.55
|
108.71
|
100.38
|
|
05
|
1,214.98
|
206.56
|
116.92
|
84.39
|
157.83
|
91.79
|
290.78
|
178.92
|
372.44
|
12,249.00
|
1,796.94
|
538.03
|
279.64
|
291.99
|
898.93
|
875.21
|
231.58
|
97.80
|
91.00
|
|
06
|
1,056.59
|
181.22
|
103.39
|
80.20
|
143.62
|
86.34
|
258.26
|
160.17
|
334.00
|
11,162.25
|
1,645.52
|
494.62
|
270.56
|
280.33
|
851.77
|
818.71
|
278.01
|
85.45
|
78.23
|
|
07
|
1,092.97
|
186.87
|
106.05
|
80.63
|
146.17
|
87.05
|
264.42
|
163.20
|
339.20
|
11,810.46
|
1,744.88
|
523.53
|
282.52
|
294.23
|
897.25
|
868.36
|
377.05
|
96.60
|
89.29
|
|
08
|
1,033.53
|
177.11
|
101.57
|
75.90
|
135.86
|
79.68
|
248.74
|
152.85
|
322.80
|
10,526.05
|
1,550.38
|
466.45
|
249.39
|
248.39
|
756.55
|
754.16
|
264.63
|
93.66
|
86.72
|
|
09
|
1,067.81
|
181.62
|
103.30
|
77.30
|
138.78
|
80.53
|
252.58
|
154.21
|
322.14
|
11,078.36
|
1,635.54
|
491.05
|
263.67
|
261.39
|
800.93
|
798.91
|
227.97
|
95.08
|
87.60
|
|
10
|
1,083.49
|
186.12
|
106.08
|
81.75
|
143.16
|
84.62
|
261.51
|
160.78
|
339.53
|
14,344.39
|
2,132.45
|
640.50
|
349.02
|
345.12
|
1,059.90
|
1,061.24
|
329.88
|
103.38
|
95.25
|
|
11
|
1,372.22
|
232.62
|
131.59
|
96.51
|
176.76
|
101.67
|
321.87
|
195.67
|
407.84
|
14,488.23
|
2,131.98
|
639.29
|
336.38
|
337.23
|
1,032.92
|
1,031.04
|
381.06
|
150.49
|
136.34
|
TABLE 4
|
General
+ MH + Transportation Rates:
|
|
||||||||||||||||||
|
TANF
|
SSI-N
|
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,118.74
|
188.77
|
103.85
|
73.64
|
142.45
|
81.79
|
262.97
|
160.32
|
325.76
|
10,468.09
|
1,543.33
|
458.61
|
249.36
|
263.26
|
798.19
|
748.22
|
313.56
|
120.17
|
106.26
|
|
02
|
1,118.75
|
188.78
|
105.12
|
82.21
|
144.94
|
84.28
|
261.94
|
159.29
|
324.97
|
10,468.17
|
1,543.41
|
464.96
|
280.13
|
264.49
|
769.47
|
742.12
|
333.55
|
123.53
|
109.62
|
|
03
|
1,224.01
|
208.18
|
114.60
|
78.89
|
151.82
|
85.54
|
289.04
|
175.98
|
365.28
|
11,492.20
|
1,712.51
|
508.01
|
264.88
|
269.71
|
836.72
|
828.19
|
356.12
|
118.76
|
103.70
|
|
04
|
1,072.09
|
183.11
|
101.13
|
71.50
|
134.38
|
76.72
|
255.26
|
156.01
|
325.61
|
11,011.02
|
1,640.55
|
491.32
|
276.91
|
271.34
|
818.29
|
804.74
|
329.55
|
122.97
|
109.39
|
|
05
|
1,218.84
|
207.54
|
114.11
|
78.42
|
152.83
|
87.29
|
289.75
|
177.22
|
367.18
|
12,280.81
|
1,817.81
|
538.12
|
275.35
|
291.59
|
911.55
|
883.79
|
234.47
|
108.09
|
97.18
|
|
06
|
1,060.38
|
182.19
|
101.31
|
75.60
|
140.00
|
83.01
|
258.73
|
160.02
|
332.19
|
11,193.75
|
1,666.20
|
495.85
|
268.01
|
281.39
|
865.43
|
828.84
|
281.96
|
94.76
|
83.97
|
|
07
|
1,096.99
|
187.89
|
104.28
|
76.56
|
143.16
|
84.23
|
265.58
|
163.74
|
338.80
|
11,845.21
|
1,767.68
|
525.23
|
280.23
|
295.85
|
913.53
|
881.23
|
381.95
|
107.21
|
95.94
|
|
08
|
1,038.81
|
178.45
|
98.76
|
69.66
|
130.99
|
75.18
|
249.98
|
153.26
|
321.67
|
10,564.27
|
1,575.46
|
468.20
|
246.69
|
250.01
|
773.87
|
767.52
|
269.02
|
106.78
|
94.97
|
|
09
|
1,072.91
|
182.92
|
101.17
|
72.34
|
135.16
|
77.11
|
254.77
|
155.63
|
323.30
|
11,117.70
|
1,661.37
|
493.79
|
262.27
|
264.24
|
819.93
|
814.30
|
232.70
|
109.81
|
96.97
|
|
10
|
1,086.47
|
186.89
|
104.12
|
77.52
|
139.69
|
81.47
|
262.62
|
161.43
|
339.83
|
14,370.64
|
2,149.68
|
641.26
|
346.51
|
345.67
|
1,072.41
|
1,071.28
|
334.36
|
114.42
|
102.22
|
|
11
|
1,375.30
|
233.40
|
128.34
|
89.12
|
169.97
|
95.73
|
322.92
|
196.24
|
407.91
|
14,515.60
|
2,149.93
|
638.72
|
330.69
|
335.05
|
1,045.18
|
1,040.40
|
382.84
|
160.77
|
142.70
|
AHCA Contract No. FA615, Exhibit III-D, Page 2 of 5
EXHIBIT
III-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area, Age and Eligibility Category
TABLE 5
|
General
+ Transportation Rates:
|
|||||||||||||||||||
|
TANF
|
SSI-N |
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20)
|
AGE (21-54)
|
AGE (55+)
|
BTHMO+2MO
|
3MO- 11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
(65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,118.72
|
188.75
|
102.21
|
61.95
|
131.52
|
70.86
|
258.53
|
155.88
|
322.02
|
10,468.01
|
1,543.25
|
451.17
|
201.31
|
219.27
|
716.79
|
717.24
|
313.35
|
108.52
|
94.61
|
|
02
|
1,118.72
|
188.75
|
102.21
|
61.95
|
131.52
|
70.86
|
258.53
|
155.88
|
322.02
|
10,468.01
|
1,543.25
|
451.17
|
201.31
|
219.27
|
716.79
|
717.24
|
313.35
|
108.52
|
94.61
|
|
03
|
1,224.00
|
208.17
|
113.28
|
69.71
|
145.74
|
79.46
|
287.50
|
174.44
|
363.94
|
11,492.13
|
1,712.44
|
501.75
|
229.12
|
249.19
|
812.82
|
816.91
|
349.27
|
109.78
|
94.72
|
|
04
|
1,072.08
|
183.10
|
99.75
|
61.94
|
128.04
|
70.38
|
253.65
|
154.04
|
324.21
|
11,010.91
|
1,640.44
|
481.56
|
221.17
|
239.36
|
781.03
|
787.15
|
305.00
|
106.20
|
92.62
|
|
05
|
1,218.83
|
207.53
|
112.90
|
69.74
|
144.72
|
79.18
|
286.46
|
173.93
|
364.40
|
12,280.76
|
1,817.76
|
533.10
|
242.93
|
261.91
|
856.63
|
862.89
|
231.74
|
95.27
|
84.36
|
|
06
|
1,060.36
|
182.17
|
99.46
|
62.35
|
127.62
|
70.63
|
253.70
|
154.99
|
327.94
|
11,193.68
|
1,666.13
|
489.33
|
225.90
|
242.85
|
794.10
|
801.69
|
280.65
|
90.87
|
80.08
|
|
07
|
1,096.97
|
187.87
|
102.50
|
63.87
|
131.30
|
72.37
|
260.76
|
158.92
|
334.73
|
11,845.15
|
1,767.62
|
519.11
|
240.72
|
259.68
|
846.60
|
855.75
|
379.36
|
96.69
|
85.42
|
|
08
|
1,038.80
|
178.44
|
97.50
|
60.87
|
125.17
|
69.36
|
248.49
|
151.77
|
320.38
|
10,564.20
|
1,575.39
|
462.20
|
212.41
|
230.33
|
750.96
|
756.70
|
262.17
|
93.56
|
81.75
|
|
09
|
1,072.89
|
182.90
|
99.62
|
61.53
|
128.00
|
69.95
|
252.95
|
153.81
|
321.73
|
11,117.63
|
1,661.30
|
487.46
|
226.13
|
243.50
|
795.77
|
802.89
|
225.85
|
100.22
|
87.38
|
|
10
|
1,086.45
|
186.87
|
102.20
|
64.16
|
130.84
|
72.62
|
260.37
|
159.18
|
337.88
|
14,370.54
|
2,149.58
|
632.91
|
298.80
|
318.29
|
1,040.53
|
1,056.22
|
327.51
|
106.36
|
94.16
|
|
11
|
1,375.28
|
233.38
|
126.72
|
77.83
|
162.48
|
88.24
|
321.01
|
194.33
|
406.26
|
14,515.52
|
2,149.85
|
631.75
|
290.89
|
312.22
|
1,018.58
|
1,027.84
|
375.61
|
152.71
|
134.64
|
TABLE 6
| General + Dental Rates: | |||||||||||||||||||
|
TANF
|
|
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO- 11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE (21-54)
|
AGE
(55+)
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE (65-)
|
AGE
(65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,113.37
|
187.39
|
103.06
|
64.56
|
132.67
|
72.21
|
256.45
|
154.63
|
321.30
|
10,428.92
|
1,517.58
|
447.50
|
201.28
|
215.20
|
698.06
|
702.17
|
306.33
|
95.92
|
86.63
|
|
02
|
1,113.37
|
187.39
|
103.06
|
64.56
|
132.67
|
72.21
|
256.45
|
154.63
|
321.30
|
10,428.92
|
1,517.58
|
447.50
|
201.28
|
215.20
|
698.06
|
702.17
|
306.33
|
95.92
|
86.63
|
|
03
|
1,217.58
|
206.53
|
115.33
|
74.77
|
149.07
|
82.73
|
285.27
|
173.20
|
363.69
|
11,442.82
|
1,680.07
|
498.20
|
230.69
|
245.46
|
789.39
|
798.20
|
341.59
|
91.66
|
83.24
|
|
04
|
1,067.52
|
181.93
|
100.88
|
64.93
|
129.80
|
72.18
|
252.50
|
153.98
|
325.03
|
10,972.58
|
1,615.28
|
478.16
|
221.43
|
235.63
|
763.25
|
773.19
|
300.00
|
91.94
|
83.61
|
|
05
|
1,214.97
|
206.55
|
115.71
|
75.71
|
149.72
|
83.68
|
287.49
|
175.63
|
369.66
|
12,248.95
|
1,796.89
|
533.01
|
247.22
|
262.31
|
844.01
|
854.31
|
228.85
|
84.96
|
78.18
|
|
06
|
1,056.57
|
181.20
|
101.54
|
66.95
|
131.24
|
73.96
|
253.23
|
155.14
|
329.75
|
11,162.18
|
1,645.45
|
488.10
|
228.45
|
241.79
|
780.44
|
791.56
|
276.70
|
81.56
|
74.34
|
|
07
|
1,092.95
|
186.85
|
104.27
|
67.94
|
134.31
|
75.19
|
259.60
|
158.38
|
335.13
|
11,810.40
|
1,744.82
|
517.41
|
243.01
|
258.06
|
830.32
|
842.88
|
374.46
|
86.08
|
78.77
|
|
08
|
1,033.52
|
177.10
|
100.31
|
67.11
|
130.04
|
73.86
|
247.25
|
151.36
|
321.51
|
10,525.98
|
1,550.31
|
460.45
|
215.11
|
228.71
|
733.64
|
743.34
|
257.78
|
80.44
|
73.50
|
|
09
|
1,067.79
|
181.60
|
101.75
|
66.49
|
131.62
|
73.37
|
250.76
|
152.39
|
320.57
|
11,078.29
|
1,635.47
|
484.72
|
227.53
|
240.65
|
776.77
|
787.50
|
221.12
|
85.49
|
78.01
|
|
10
|
1,083.47
|
186.10
|
104.16
|
68.39
|
134.31
|
75.77
|
259.26
|
158.53
|
337.58
|
14,344.29
|
2,132.35
|
632.15
|
301.31
|
317.74
|
1,028.02
|
1,046.18
|
323.03
|
95.32
|
87.19
|
|
11
|
1,372.20
|
232.60
|
129.97
|
85.22
|
169.27
|
94.18
|
319.96
|
193.76
|
406.19
|
14,488.15
|
2,131.90
|
632.32
|
296.58
|
314.40
|
1,006.32
|
1,018.48
|
373.83
|
142.43
|
128.28
|
AHCA
Contract No. FA615, Exhibit IlI-D, Page 3 of 5
EXHIBIT
IlI-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area, Age and Eligibility Category
TABLE
7
|
General
+ Dental + Transportation Rates:
|
|||||||||||||||||||
|
TANF
|
SSI-N
|
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO- 11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20)
|
AGE (21-54)
|
AGE
(55+)
|
BTHMO+2MO
|
3MO-
11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE
(14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
AGE
AGE
(65-)
(65+)
|
||||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
1,118.72
|
188.76
|
103.89
|
65.06
|
134.70
|
73.55
|
259.75
|
157.14
|
324.81
|
10,468.01
|
1,543.25
|
452.79
|
203.71
|
221.33
|
718.12
|
719.10
|
313.80
|
109.64
|
95.47
|
|
02
|
1,118.72
|
188.76
|
103.89
|
65.06
|
134.70
|
73.55
|
259.75
|
157.14
|
324.81
|
10,468.01
|
1,543.25
|
452.79
|
203.71
|
221.33
|
718.12
|
719.10
|
313.80
|
109.64
|
95.47
|
|
03
|
1,224.01
|
208.19
|
116.33
|
75.37
|
151.51
|
84.34
|
289.24
|
176.22
|
367.91
|
11,492.13
|
1,712.45
|
504.88
|
233.76
|
253.18
|
814.70
|
819.56
|
350.30
|
111.43
|
95.98
|
|
04
|
1,072.09
|
183.11
|
101.59
|
65.36
|
131.54
|
73.33
|
255.32
|
156.12
|
328.03
|
11,010.91
|
1,640.44
|
483.34
|
223.81
|
241.63
|
782.91
|
789.79
|
307.18
|
107.79
|
93.83
|
|
05
|
1,218.84
|
207.55
|
116.31
|
76.07
|
151.19
|
84.65
|
289.87
|
177.44
|
372.19
|
12,280.77
|
1,817.77
|
537.32
|
249.20
|
267.29
|
860.33
|
868.09
|
235.40
|
99.06
|
87.25
|
|
06
|
1,060.37
|
182.18
|
102.13
|
67.31
|
132.68
|
74.91
|
255.58
|
156.93
|
332.24
|
11,193.68
|
1,666.14
|
492.37
|
230.40
|
246.72
|
796.60
|
805.20
|
282.41
|
93.12
|
81.79
|
|
07
|
1,096.98
|
187.88
|
104.90
|
68.32
|
135.84
|
76.21
|
262.09
|
160.28
|
337.77
|
11,845.15
|
1,767.63
|
522.11
|
245.16
|
263.50
|
848.15
|
857.93
|
379.84
|
98.21
|
86.58
|
|
08
|
1,038.81
|
178.46
|
101.14
|
67.61
|
132.06
|
75.19
|
250.51
|
153.84
|
324.98
|
10,564.20
|
1,575.40
|
465.62
|
217.49
|
234.69
|
753.24
|
759.90
|
263.71
|
95.23
|
83.02
|
|
09
|
1,072.90
|
182.92
|
102.55
|
66.97
|
133.56
|
74.65
|
253.91
|
154.79
|
323.92
|
11,117.63
|
1,661.31
|
490.05
|
229.98
|
246.81
|
796.95
|
804.54
|
227.68
|
101.29
|
88.19
|
|
10
|
1,086.46
|
186.88
|
104.63
|
68.67
|
135.45
|
76.52
|
261.10
|
159.93
|
339.54
|
14,370.54
|
2,149.59
|
635.70
|
302.94
|
321.85
|
1,041.48
|
1,057.55
|
328.33
|
107.66
|
95.14
|
|
11
|
1,375.29
|
233.39
|
130.45
|
85.51
|
170.45
|
94.96
|
321.87
|
195.21
|
408.22
|
14,515.53
|
2,149.87
|
636.02
|
298.28
|
318.69
|
1,020.36
|
1,030.34
|
378.95
|
154.87
|
136.29
|
TABLE 8
|
General + Mental Health
+ Dental + Transportation Rates:
|
|||||||||||||||||||
|
TANF
|
SSI-N
|
SSI-B
|
SSI-AB
|
||||||||||||||||
|
Area
|
BTHMO+2MO
|
3MO- 11MO
|
AGE
(1-5)
|
AGE
(6-13)
|
AGE (14-20)
|
AGE
(21-54)
|
AGE
(55+)
|
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
|
1,118.74
|
188.78
|
105.53
|
76.75
|
145.63
|
84.48
|
264.19
|
161.58
|
328.55
|
10,468.09
|
1,543.33
|
460.23
|
251.76
|
265.32
|
799.52
|
750.08
|
314.01
|
121.29
|
107.12
|
|
02
|
1,116.75
|
188.79
|
106.80
|
85.32
|
148.12
|
86.97
|
263.16
|
160.55
|
327.76
|
10,468.17
|
1,543.41
|
466.58
|
282.53
|
266.55
|
770.80
|
743.98
|
334.00
|
124.65
|
110.48
|
|
03
|
1,224.02
|
206.20
|
117.65
|
84.55
|
157.59
|
90.42
|
290.78
|
177.76
|
369.25
|
11,492.20
|
1,712.52
|
511.14
|
269.52
|
273.70
|
838.60
|
830.84
|
357.15
|
120.41
|
104.96
|
|
04
|
1,072.10
|
183.12
|
102.97
|
74.92
|
137.88
|
79.67
|
256.93
|
157.73
|
329.43
|
11,011.02
|
1,640.55
|
493.10
|
279.55
|
273.61
|
820.17
|
807.38
|
331.73
|
124.56
|
110.60
|
|
05
|
1,218.85
|
207.56
|
117.52
|
84.75
|
159.30
|
92.76
|
293.16
|
180.73
|
374.97
|
12,280.82
|
1,817.82
|
542.34
|
281.62
|
296.97
|
915.25
|
888.99
|
238.13
|
111.88
|
100.07
|
|
06
|
1,060.39
|
182.20
|
103.98
|
80.56
|
145.06
|
87.29
|
260.61
|
161.96
|
336.49
|
11,193.75
|
1,666.21
|
498.89
|
272.51
|
285.26
|
867.93
|
832.35
|
283.72
|
97.01
|
85.68
|
|
07
|
1,097.00
|
187.90
|
106.68
|
81.01
|
147.70
|
88.07
|
266.91
|
165.10
|
341.84
|
11,845.21
|
1,767.69
|
528.23
|
284.67
|
299.67
|
915.08
|
883.41
|
382.43
|
108.73
|
97.10
|
|
08
|
1,038.82
|
178.47
|
102.40
|
76.40
|
137.88
|
81.01
|
252.00
|
155.33
|
326.27
|
10,564.27
|
1,575.47
|
471.62
|
251.77
|
254.37
|
776.15
|
770.72
|
270.56
|
108.45
|
96.24
|
|
09
|
1,072.92
|
182.94
|
104.10
|
77.78
|
140.72
|
81.81
|
255.73
|
156.61
|
325.49
|
11,117.70
|
1,661.38
|
496.38
|
266.12
|
267.55
|
821.11
|
815.95
|
234.53
|
110.88
|
97.78
|
|
10
|
1,086.48
|
186.90
|
106.55
|
82.03
|
144.30
|
85.37
|
263.35
|
162.18
|
341.49
|
14,370.64
|
2,149.69
|
644.05
|
350.65
|
349.23
|
1,073.36
|
1,072.61
|
335.18
|
115.72
|
103.20
|
|
11
|
1,375.31
|
233.41
|
132.07
|
96.80
|
177.94
|
102.45
|
323.78
|
197.12
|
409.87
|
14,515.61
|
2,149.95
|
642.99
|
338.08
|
341.52
|
1,046.96
|
1,042.90
|
386.18
|
162.93
|
144.35
|
AHCA
Contract No. FA615, Exhibit III-D, Page 4 of 5
EXHIBIT
III-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPITATION RATES
By
Area, Age and Eligibility Category
|
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, Hillsborough, Manatee, Polk
|
|
Area
7
|
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-D, Page 5 of 5
