AHCA AGREEMENT NO. AA051
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AHCA AGREEMENT NO. AA051
AMENDMENT NO. 3
THIS COORDINATION OF BENEFITS AGREEMENT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA, INC., hereinafter referred to as the “Health Plan,” is hereby amended as follows:
1. | Section VII., Miscellaneous, Item E., Contact Information, the Agency contact person information is hereby amended to now read as follows: |
The contact person for the Agency is as follows:
Xxxxx Xxxxxx
Agency for Health Care Administration
0000 Xxxxx Xxxxx, XX# 00
Xxxxxxxxxxx, XX 00000
(000) 000-0000
Xxxxxxx.Xxxxxx@xxxx.xxxxxxxxx.xxx
2. | Effective January 1, 2013, Exhibit B, Applicable Service Areas and Dual Eligible and Other Dual Eligible Categories, is hereby deleted in its entirety and replaced with Exhibit B-1, Revised Applicable Service Areas and Dual Eligible and Other Dual Eligible Categories, attached hereto and made part of the Agreement. All references in the Agreement to Exhibit B shall hereinafter refer to Exhibit B-1. |
3. | Effective January 1, 2013, Exhibit C, Florida Medicaid Benefits, is hereby deleted in its entirety and replaced with Exhibit C-1, Medicare Advantage Special Needs Plans Covered Services, attached hereto and made part of the Agreement. All references in the Agreement to Exhibit C shall hereinafter refer to Exhibit C-1. |
This amendment shall have an effective date of January 1, 2013, or the date on which both parties execute the amendment, 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 Agreement.
This amendment and all its attachments are hereby made a part of the Agreement.
This amendment cannot be executed unless all previous amendments to this Agreement have been fully executed.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Agreement No. AA051, Amendment No. 3, Page 1 of 2
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IN WITNESS WHEREOF, the parties hereto have caused this five (5) page amendment to be executed by their officials thereunto duly authorized.
WELLCARE OF FLORIDA, INC. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED SIGNED
BY: /s/ Xxxxxxxxx Xxxxxx BY: /s/ Xxxxxxxxx Xxxxx
NAME: Xxxxxxxxx Xxxxxx NAME: Xxxxxxxxx Xxxxx
TITLE: President, Florida Division TITLE: Secretary
DATE: 9/21/12 DATE: 9/21/12
Specify Letter/
Type Number Description
Exhibit | B-1 Applicable Service Areas and Dual Eligible and Other Dual Eligible Categories (1 page) |
Exhibit | C-1 Medicare Advantage Special Needs Plans Covered Services (2 pages) |
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Agreement No. AA051, Amendment No. 3, Page 2 of 2
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EXHIBIT B-1
MA SNPS
APPLICABLE SERVICE AREAS AND
DUAL ELIGIBLE AND OTHER DUAL ELIGIBLE CATEGORIES
MA SNP PLAN NAME | H # | SERVICE AREA BY COUNTY OR ZIP CODE | CATEGORY OF SPECIAL NEEDS PLAN (Dual, Chronic, Institutional) | APPLICABLE CATEGORY OF DUAL ELIGIBLE |
WELLCARE SELECT | H1032061 | Brevard, Broward, Clay, Miami-Dade, Xxxxx, Xxxxxxxx, Highlands, Hillsborough, Indian River, Lake, Manatee, Marion, Martin, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Seminole, Sumter, St. Lucie, Volusia | DUAL | QDWI, QI, SLMB |
WELLCARE SELECT | H1032101 | Bay, Alachua, Bradford, Calhoun, Charlotte, Citrus, DeSoto, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry, Holmes, Jefferson, Xxx, Xxxx, Xxxx, Liberty, Madison, Okaloosa, Santa Xxxx, Sarasota, Union, Wakulla, Xxxxxx, Washington | DUAL | QDWI, QI, SLMB |
WELLCARE ACCESS | H1032175 | Alachua, Bay, Bradford, Brevard, Broward, Xxxxxxx, Xxxxxxxxx, Citrus, Clay, DeSoto, Duval, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry, Hernando, Highlands, Hillsborough, Xxxxxx, Indian River, Jefferson, Lake, Xxx, Xxxx, Levy, Liberty, Madison, Manatee, Marion, Martin, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Xxxx, Sarasota, Seminole, St. Lucie, Sumter, Union, Volusia, Wakulla, Xxxxxx, Washington | DUAL | FBDE, SLMB+ |
WELLCARE ACCESS | H1032176 | Miami-Dade | DUAL | FBDE, SLMB+ |
AHCA Agreement No. AA051, Exhibit B-1, Page 1 of 1
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EXHIBIT C-1
Medicare Advantage Special Needs Plans Covered Services
JANUARY 1, 2013 THROUGH DECEMBER 31, 2013
Medicaid Service |
HOSPITAL INPATIENT SERVICES |
HOSPITAL INPATIENT CROSSOVER |
HOSPITAL OUTPATIENT SERVICES |
HOSPTIAL OUTPATIENT CROSSOVER |
NURSING HOME CROSSOVER |
SKILLED NURSING HOME |
INTERMEDIATE CARE FACILITY (ICF) I SERVICES |
ICF II SERVICES |
MENTAL HEALTH HOSPITALS |
INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY DISABLED (ICF/DD) SUNLAND |
ICF/DD SIXBED |
PHYSICIAN SERVICES |
PHYSICIAN SERVICES CROSSOVER |
PRESCRIBED MEDICINES (E.G. BENZODIAZEPINES, BARBITURATES AND SOME OVER THE COUNTER PRODUCTS) |
LAB AND XRAY SERVICES |
LAB AND XRAY CROSSOVER |
PATIENT TRANSPORTATION |
PATIENT TRANSPORTATION CROSSOVER |
FAMILY PLANNING |
HOME HEALTH SERVICES |
HOME HEALTH CROSSOVER |
SCREENING SERVICES |
CHILD DENTAL SERVICES |
CHILD VISUAL SERVICES |
CHILD HEARING SERVICES |
ADULT DENTAL SERVICES |
ADULT VISION SERVICES |
ADULT HEARING SERVICES |
TARGETED CASE MANAGEMENT SERVICES |
NURSE PRACTITIONER |
REGISTERED PHYSICAL THERAPIST |
HOSPICE SERVICES |
COMMUNITY MENTAL HEALTH |
HOME AND COMMUNITY BASED AGING |
HOME AND COMMUNITY BASED DEVELOPMENTAL SERVICES |
AIDS WAIVER SERVICES |
BIRTHING CENTER SERVICES |
AHCA Agreement No. AA051, Exhibit C-1, Page #PageNum# of 2
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EXHIBIT C-1
Medicare Advantage Special Needs Plans Covered Services
JANUARY 1, 2013 THROUGH DECEMBER 31, 2013
Medicaid Service |
RURAL HEALTH SERVICES |
RURAL HEALTH CROSSOVER |
PERSONAL CARE SERVICES |
PRIVATE DUTY NURSING SERVICES |
PHYSICAL THERAPY SERVICES |
SPEECH THERAPY SERVICES |
OCCUPATIONAL THERAPY SERVICES |
RESPIRATORY THERAPY SERVICES |
FEDERALLY QUALIFIED HEALTH CENTERS |
CLINIC SERVICES |
DEVELOPMENTAL SERVICES COMMUNITY SUPPORTED LIVING ARRANGEMENT (DS CSLA) |
MENTAL HEALTH CASE MANAGEMENT |
DEVELOPMENTAL EVALUATION AND INTERVENTION |
CHILD CASE MANAGEMENT SERVICES |
CHILD COMMNNITY MENTAL HEALTH SERVICES |
CHILD THERAPY SERVICES |
ADULT CONGREGATE LIVING FACILITY |
PHYSICIAN ASSISTANT SERVICES |
SCHOOL BASED SERVICES |
DIALYSIS CENTER |
§ 422.101 Requirements relating to basic benefits.
* * * * *
(f) Special needs plan model of care (1) MA organizations offering special needs plans must have a model of care plan specifying how the plan will coordinate and deliver care designed for the plan’s enrollees. The model of care plan must provide for the following:
(i) Coordinate care for eligible beneficiaries.
(ii) Include a network of providers/services having relevant clinical expertise.
(iii) Target a special needs population.
(iv) Deliver care based on appropriate protocol for the target enrollees.
(v) Deliver care to frail/disabled enrollees.
(vi) Deliver care to enrollees who are at the end of life.
(vii) Apply performance measures to evaluate processes and outcomes of the model.
AHCA Agreement No. AA051, Exhibit C-1, Page #PageNum# of 2
