AHCA CONTRACT NO. FA619 AMENDMENT NO. 7

Exhibit 10.17

HealthEase of Florida, Inc.

Medicaid HMO Contract

AHCA CONTRACT NO. FA619

AMENDMENT NO. 7

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:

1.	Attachment II, Table of Contents, is hereby amended as follows:

Section IV Enrollee Services and Marketing is hereby amended to now read:

Section IV Enrollee Services, Community Outreach and Marketing

Section IV, Item B. is hereby amended to now read:

Community Outreach and Marketing

2.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section I, Item A., Definitions, is hereby amended as follows:

The definition of Community Outreach Representative is hereby included as follows:

Community Outreach Representative – A person who provides Community Outreach, including health information, information that promotes healthy lifestyles, information that provides guidance about social assistance programs, and information that provides culturally and linguistically appropriate health or nutritional education. Such representatives must be appropriately trained, certified and/or licensed, including but not limited to, social workers, nutritionists, physical therapists and other health care professionals.

The definition of Community Outreach is hereby included as follows:

Community Outreach – The provision of health or nutritional information, or information for the benefit and education of, or assistance to, a community in regard to health-related matters or public awareness that promotes healthy lifestyles. Community Outreach also includes the provision of information about health care services, preventive techniques and other health care projects and the provision of information related to health, welfare, and social services or social assistance programs offered by the State of Florida or local communities. or information for the benefit and education of, or assistance to, a community in regard to health-related matters or public awareness that promotes healthy lifestyles.

The definition of Community Outreach Materials is hereby included as follows:

Community Outreach Materials – Materials regarding health or nutritional information, or information for the benefit and education of, or assistance to, a community in regard to health-related matters or public awareness that promotes healthy lifestyles; such materials are specifically meant for the community at-large and may also include information about health care services, preventive techniques and other health care projects and the provision of information related to health, welfare, and social services or social assistance programs offered by the State of Florida or local communities. Community Outreach Materials are limited to brochures, fact sheets, posters, and ad copy for radio, television, print or the Internet.

The definition of Market Area is hereby amended to now read as follows:

Market Area – The geographic area in which the Health Plan is authorized to conduct Community Outreach.

AHCA Contract No. FA619, Amendment No. 7, Page 1 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

	--	The definition of Marketing Representative is hereby deleted in its entirety.

	--	The definition of Pre-Enrollment is hereby amended to now read as follows:

Pre-Enrollment – The provision of Marketing materials to a Medicaid Recipient.

The definition of Pre-Enrollment Application is hereby deleted in its entirety.

The definition of Public Event is hereby amended to now read as follows:

Public Event – An event that is organized or sponsored by an organization, for the benefit and education of, or assistance to, a community in regard to health-related matters or public awareness.

The definition of Remediation is hereby included as follows:

Remediation - Remediation of encounter claims; where remediation is “the act or process of correcting a fault or deficiency.”

The definition of Request for Benefit Information (RBI) is hereby deleted in its entirety.

3.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section I, Item B., Acronyms, is hereby amended as follows:

The acronym ACCESS is hereby included as follows:

ACCESS – Automated Community Connection to Economic Self-Sufficiency: The Department of Children and Families’ (DCF’s) public assistance service delivery system.

The acronym WEDI is hereby included as follows:

WEDI – Workgroup for Electronic Data Interchange

4.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section III, Eligibility and Enrollment, Item C., Disenrollment, sub-item 2.a.(4), is hereby amended as follows:

(4)

A substantiated Marketing or Community Outreach violation has occurred.

5.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section IV, Enrollee Services and Marketing, is hereby retitled “Enrollee Services, Community Outreach and Marketing.”

6.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, is hereby amended to include sub-items 10. and 11. as follows:

10.

Prescribed Drug List (PDL)

The Health Plan’s website must include the Health Plan’s PDL. The Health Plan may update the online PDL by providing thirty (30) days written notice of any change to the Bureaus of Managed Health Care and Pharmacy Services.

11.

Medicaid Redetermination Notices

Upon implementation of a systems change relative to this section, the Agency will provide Medicaid recipient redetermination date information to the Health Plan.

AHCA Contract No. FA619, Amendment No. 7, Page 2 of 3

HealthEase of Florida, Inc.

Medicaid HMO Contract

	a.	This information may be used by the Health Plan only as indicated in this subsection.

	b.	The Agency will notify the Health Plan sixty (60) Calendar Days prior to transmitting this information to the Health Plan and, at that time, will provide the Health Plan with the file format for this information. The Agency will decide whether or not to continue to provide this information to Health Plan annually and will notify the Health Plans of its decision by May 1 for the coming Contract Year. In addition, the Agency reserves the right to provide thirty (30) Calendar Days notice prior to discontinuing this subsection at any time.

Within thirty (30) Calendar Days after the date of the Agency’s notice of transmitting this redetermination date information, and annually by June 1 thereafter, the Health Plan must notify the Agency’s Bureau of Managed Health Care (BMHC), in writing, if it will participate in the use of this information for the Contract Year. The Health Plan’s participation in using this information is optional/voluntary.

(1)

If the Health Plan does not respond in writing to the Agency within thirty (30) Calendar Days after the date of the Agency’s notice, the Health Plan forfeits its ability to receive and use this information until the next Contract Year.

(2)

If the Health Plan chooses to participate in the use of this information, it must provide with its response indicating it will participate, to the Agency for its approval, its policies and procedures regarding this subsection.

(a)

A Health Plan that chooses to participate in the use of this information may decide to discontinue using this information at any time. In this circumstance, the Health Plan must notify the Agency’s BMHC of such in writing. The Agency will then delete the Health Plan from the list of Health Plans receiving this information for the remainder of the Contract Year.

(b)

A Health Plan that chooses to participate in the use of this information must train all affected staff, prior to implementation, on its policies and procedures and the Agency’s requirements regarding this subsection. The Health Plan must document such training has been provided including a record of those trained for the Agency review within five (5) Business days after the Agency’s request.

(3)

If the Health Plan has opted-out of participating in the use of this information, it may not opt back in until the next Contract Year.

(4)

Regardless of whether or not the Health Plan has declined to participate in the use of this information, it is subject to the sanctioning indicated in this subsection if this information has been or is misused by the Health Plan.

If the Health Plan chooses to participate in using this information, it may use the redetermination date information only in the methods listed below, and may choose to use both methods to communicate this information or just one method.

(1)

The Health Plan may use redetermination date information in written notices to be sent to their Enrollees reminding them that their Medicaid eligibility may end soon and to reapply for Medicaid if needed. If the Health Plan chooses to use this method to provide this information to its Enrollees, it must adhere to the following requirements:

(a)

The Health Plan must mail the redetermination date notice to each Enrollee for whom the Health Plan received a redetermination date. The Health Plan may send one notice to the Enrollee’s household when there are multiple Enrollees within a family that have the same Medicaid redetermination date provided that these Enrollees share the same mailing address.

AHCA Contract No. FA619, Amendment No. 7, Page 3 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

(b)

The Health Plan must use the Agency’s redetermination date notice template provided to the Health Plan for its notices. The Health Plan may put this template on its letterhead for mailing; however, the Health Plan may make no other changes, additions or deletions to the letter text.

(c)

The Health Plan must mail the redetermination date notices to each Enrollee no more than sixty (60) Calendar Days and no less than thirty (30) Calendar Days prior to the redetermination date received from the Agency.

(2)

The Health Plan may use redetermination date information in automated voice response (AVR) or integrated voice response (IVR) automated messages sent to Enrollees reminding them that their Medicaid eligibility may end soon and to reapply for Medicaid if needed. If the Health Plan chooses to use this method to provide this information to its Enrollees, it must adhere to the following requirements:

(a)

The Health Plan must send the redetermination date messages to each Enrollee for whom the Health Plan has received a redetermination date and for whom the Health Plan has a telephone number. The Health Plan may send an automated message to the Enrollee’s household when there are multiple Enrollees within a family that have the same Medicaid redetermination date provided that these Enrollees share the same mailing address/phone number.

(b)

For the voice messages, the Health Plan must use only the language in the Agency’s redetermination date notice template provided to the Health Plan. The Health Plan may add its name to the message but may make no other changes, additions or deletions to the message text.

(c)

The Health Plan must make such automated calls to each Enrollee no more than sixty (60) Calendar Days and no less than thirty (30) Calendar Days prior to the redetermination date received from the Agency.

(3)

The Health Plan may not include the redetermination date information in any file viewable by customer service or Community Outreach staff. This information may only be used in the letter templates and automated scripts provided by the Agency and cannot be verbally referenced or discussed by the Health Plan with the Enrollees, unless in response to an Enrollee inquiry regarding the letter received, nor may it be used a future time by the Health Plan. If the Health Plan receives Enrollee inquiries regarding the notices, such inquiries must be referred to the Department of Children and Families.

If the Health Plan chooses to participate in using this information, the Health Plan must keep the following information available regarding each mailing made for the Agency’s review within five (5) Business Days after the Agency’s request:

(1)

For each month of mailings, a dated hard copy or pdf of the monthly template used for that specific mailing.

(a)

A list of each Enrollee for whom a monthly mailing was sent. This list shall include each Enrollee’s name and Medicaid identification number to whom the notice was mailed, the address to which the notice was mailed, and the date of the Agency’s enrollment file used to create the mailing list.

(b)

A log of returned, undeliverable mail received for these notices, by month, for each Enrollee for whom a returned notice was received.

AHCA Contract No. FA619, Amendment No. 7, Page 4 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

(2)

For each month of automated calls made, a list including of each Enrollee for whom a call was made, the Enrollee’s Medicaid identification number, telephone number to which the call was made, and the date each call was made, and the date of the Agency’s enrollment file used to create the automated call list.

The Health Plan must retain this documentation in accordance with the Agency’s Standard Contract, I.D., Retention of Records.

If the Health Plan chooses to participate in using this information, the Health Plan must keep up-to-date and approved policies and procedures regarding the use, storage and securing of this information as well as addressing all requirements of this subsection.

If the Health Plan chooses to participate in using this information, the Health Plan must submit to the Agency’s BMHC a completed quarterly summary report in accordance with Section XII, X., of this Attachment.

Should any complaint or investigation by the Agency result in a finding that the Health Plan has violated this subsection, the Health Plan will be sanctioned in accordance with Section XIV, B. The first such violation will result in a 30-day suspension of use of Medicaid redetermination dates; any subsequent violations will result in 30-day incremental increases in the suspension of use of Medicaid redetermination dates. In the event of any subsequent violations, additional penalties may be imposed in accordance with Section XIV, B. Additional or subsequent violations may result in the Agency’s rescinding of the provision of redetermination date information to the Health Plan.

7.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section IV, Item B., Marketing, is hereby deleted in its entirety and replaced as follows:

Community Outreach and Marketing

General Provisions

The Health Plan’s Community Outreach Representative(s) may provide Community Outreach at Health Fairs/Public events as noticed by the Health Plan to the Agency in accordance with sub-item 4. of this Section. The main purpose of a Health Fair/Public Event shall be to provide Community Outreach and shall not be for the purpose of Medicaid Health Plan Marketing.

For each new Contract Period, the Health Plan shall submit to the Agency Bureau of Managed Health Care for written approval, all Community Outreach material no later than sixty (60) Calendar Days prior to Contract renewal, and for any changes in the Community Outreach Material, no later than thirty (30) Calendar Days prior to implementation. All materials developed shall be governed by the requirements set forth in this Section.

To announce participation at a specific event (Health Fair/Public Event), the Health Plan shall submit a notice to the Agency in accordance with sub-item B.3., Permitted Activities.

The Health Plan shall be responsible for developing and implementing a written plan designed to control the actions of its Community Outreach Representatives.

All of the Community Outreach policies set forth in this Contract apply to staff, Subcontractors, Health Plan volunteers and all persons acting for or on behalf of the Health Plan.

The Health Plan is vicariously liable for any Outreach and Marketing violations of its employees, agents or Subcontractors. Any violations of this section shall subject the health plan to administrative action by the Agency as determined by the Agency. The health plan may dispute any such administrative action pursuant to Section XVI, Item I., Disputes.

AHCA Contract No. FA619, Amendment No. 7, Page 5 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

Nothing in this Section shall preclude a Health Plan from donating to or sponsoring an event with a community organization where time, money or expertise is provided for the benefit of the community. If such events are not Health Fairs/Public Events, no Community Outreach Materials or Marketing Materials may be distributed by the Health Plan, but the Health Plan may engage in brand-awareness activities, including the display of Health Plan or Product logos. Inquiries at such events from prospective enrollees must be referred to the Health Plan’s member services section or the Agency’s Choice Counselor/Enrollment Broker.

Prohibited Activities

The Health Plan is prohibited from engaging in the following non-exclusive list of activities:

Marketing for Enrollment to any potential members or conducting any Pre-Enrollment activities not expressly allowed under this Contract.

Any of the prohibited practices or activities listed in Section 409.912, F.S.

Engaging in activities for the purpose of recruitment or Enrollment.

In accordance with sections 409.912 and 409.91211, F.S., practices that are discriminatory, including, but not limited to, attempts to discourage Enrollment or reenrollment on the basis of actual or perceived health status.

Direct or indirect Cold Call Marketing or other solicitation of Medicaid Recipients, either by door-to-door, telephone or other means, in accordance with section 4707 of the Balanced Budget Act of 1997, and section 409.912, F.S.

In accordance with section 409.912, F.S., activities that could mislead or confuse Medicaid Recipients, or misrepresent the Health Plan, it’s Community Outreach Representatives, or the Agency. No fraudulent, misleading, or misrepresentative information shall be used in Community Outreach, including information regarding other governmental programs. Statements that could mislead or confuse include, but are not limited to, any assertion, statement or claim (whether written or oral) that:

(1)

The Medicaid Recipient must enroll in the Health Plan in order to obtain Medicaid, or in order to avoid losing Medicaid benefits;

(2)

The Health Plan is endorsed by any federal, State or county government, the Agency, or CMS, or any other organization which has not certified its endorsement in writing to the Health Plan;

(3)

Community Outreach Representatives are employees or representatives of the federal, State or county government, or of anyone other than the Health Plan or the organization by whom they are reimbursed;

(4)

The State or county recommends that a Medicaid Recipient enroll with the Health Plan; and/or

(5)

A Medicaid Recipient will lose benefits under the Medicaid program, or any other health or welfare benefits to which the Recipient is legally entitled, if the Recipient does not enroll with the Health Plan.

AHCA Contract No. FA619, Amendment No. 7, Page 6 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

Granting or offering of any monetary or other valuable consideration for Enrollment.

Offers of insurance, such as but not limited to, accidental death, dismemberment, disability or life insurance.

Enlisting the assistance of any employee, officer, elected official or agent of the State in recruitment of Medicaid Recipients except as authorized in writing by the Agency.

Offers of material or financial gain to any persons soliciting, referring or otherwise facilitating Medicaid Recipient Enrollment. The Health Plan shall ensure that no plan staff market the Health Plan to Medicaid Recipients at any location including State offices or DCF ACCESS centers.

Giving away promotional items in excess of $5.00 retail value. Items to be given away shall bear the Health Plan's name and shall only be given away at Health Fairs/Public Events. In addition, such promotional items must be offered to the general public and shall not be limited to Medicaid Recipients.

Providing any gift, commission, or any form of compensation to the Choice Counselor/Enrollment Broker, including the Choice Counselor/Enrollment Broker's full-time, part-time or temporary employees and Subcontractors.

Provide information, prior to the Enrollment, about the incentives that shall be offered to the Enrollee as described in Section VIII.B.7., Incentive Programs. The Health Plan may inform Enrollees on or after their Enrollment effective date about the specific incentives or programs available.

Discussing, explaining or speaking to a potential member about Health-Plan-benefit-specific information other than to refer all Health Plan inquiries to the Member Services section of the Health Plan or the Agency’s Choice Counselor/Enrollment Broker.

Distributing any Community Outreach Materials without prior written notice to the Agency except as otherwise allowed under Permitted Activities and Provider Compliance subsections.

Distributing any Marketing materials.

Subcontract with any brokerage firm or independent agent as defined in Chapters 624-651, F.S., for purposes of Marketing or Community Outreach.

Pay commission compensation to Community Outreach Representatives for new Enrollees. The payment of a bonus to a Community Outreach Representative shall not be considered a commission if such bonus is not related to enrollment or membership growth.

All activities included in Section 641.3903, F.S.

Permitted Activities

The Health Plan may engage in the following activities upon prior written notice to the Agency Bureau of Managed Health Care:

The Health Plan may attend Health Fairs/Public Events upon request by the sponsor and after written notification to the Agency as described in sub-item 4.

AHCA Contract No. FA619, Amendment No. 7, Page 7 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

	b.	The Health Plan may leave Community Outreach Materials at Health Fairs/Public Events at which the Health Plan participates.

	c.	The Health Plan may provide Agency-approved Community Outreach Materials. Such Materials may include Medicaid enrollment and eligibility information and information related to other health care projects and health, welfare and social services provided by the State of Florida or local communities. The Health Plan staff, including Community Outreach Representatives, must refer all Health Plan inquiries to the member services section of the Health Plan or the Agency’s Choice Counselor/Enrollment Broker. The Agency must approve the script used by the Health Plan’s member services section before usage.

Health Plans may distribute Community Outreach Materials to community agencies.

Community Outreach Notification Process

The Health Plan shall submit in writing to the Agency Bureau of Managed Health Care, a notice of its intent to attend and provide Community Outreach Materials at Health Fairs/Public Events at least two (2) weeks prior to the event (see 4.b. and c. below for further notice information). Such submission shall include the items listed below:

(1)

The following Health Fair/Public Event disclosure information and other information as may be required by the Agency:

(a)

The announcement of the event that will be given out to the public;

(b)

The date, time and location of the event;

(c)

The name and type of organization sponsoring the event;

(d)

The event contact person and contact information;

(e)

The Health Plan contact person and contact information; and

(f)

Names of participating Community Outreach Representative(s), their contact information and services they will provide at the event.

(2)

In addition to the disclosure information listed in (1) above, if the Health Plan is the primary organizer of the Health Fair, the Health Plan shall submit complete disclosure of information from each organization participating in a Health Fair prior to the event. Such information shall include the name of the organization, contact person information, and confirmation of participation.

(3)

In addition to the disclosure information listed in (1) above, if the Health Plan has been invited by a community organization to be a sponsor or attendee of an event, the Health Plan shall provide to the Agency Bureau of Managed Health Care a copy of the letter of invitation from the Health Fair/Public Event sponsor(s) to the Health Plan requesting sponsorship of, or attendance at, the event.

The Health Plan shall submit notice to the Agency of Health Fairs/Public Events no later than ten (10) Business Days after the Health Plan’s receipt of the invitation to attend or, if the Health Plan is the primary organizer of the Health Fair, no later than ten (10) days after a decision has been made to organize the event.

Notwithstanding the other notice requirements in this subsection, the two week and the 10-day advance notice requirements are waived in cases of force majeure provided the Health Plan notices the Bureau of Managed Health Care by the time of the event. Force majeure events includes destruction due to hurricanes, fires, war, riots, and other similar acts. When providing the Agency with notice of attendance at such events, the Health Plan shall include a description of the force majeure event requiring waiver of notice.

AHCA Contract No. FA619, Amendment No. 7, Page 8 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

The Agency will establish a statewide log to track the Community Outreach notifications received and may monitor such events.

Provider Compliance

The Health Plan shall ensure, through provider education and outreach, that its health care Providers are aware and comply with the following requirements:

Health care Providers may display Health-Plan-specific materials in their own offices.

Health Care Providers cannot orally or in writing compare Benefits or provider networks among Health Plans, other than to confirm Health Plan network participation.

Health care Providers may announce a new affiliation with a Health Plan or give a list of Health Plans with which they contract to their patients.

Health care Providers may co-sponsor events, such as Health Fairs, and advertise with the Health Plan in indirect ways; such as television, radio, posters, fliers, and print advertisement.

Health care Providers shall not furnish lists of their Medicaid Recipients to Health Plans with which they contract, or any other entity, nor can Providers furnish other Health Plans' membership lists to any Health Plan, nor can Providers assist with Health Plan Enrollment.

For the Health Plan, health care Providers may distribute information about non-Health-Plan-specific health care services and the provision of health, welfare, and social services provided by the State of Florida or local communities as long as any inquiries from prospective enrollees are referred to the member services section of the health plan and the Agency’s Choice Counselor/Enrollment Broker.

Community Outreach Representatives

The Health Plan shall report to the Agency Bureau of Managed Health Care any Health Plan staff or Community Outreach Representative who violates any requirements of this Contract, within fifteen (15) Calendar Days of knowledge of such violation.

While attending Health Fairs/Public Events, Community Outreach Representatives shall wear picture identification that identifies the Health Plan represented.

If asked, the Community Outreach Representative shall inform the Medicaid Recipient that the Representative is not an employee of the State and is not a Choice Counseling Specialist, but is a Representative of the Health Plan.

The Health Plan shall instruct and provide initial and periodic training to its Community Outreach Representatives regarding the Community Outreach and Marketing provisions of this Contract.

The Health Plan shall implement procedures for background and reference checks for use in its Community Outreach Representative hiring practices.

The Health Plan shall register each Community Outreach Representative with the Agency’s Bureau of Managed Health Care in accordance with Section XII of this Contract.

8.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration and Management, Item B., Staffing, sub-item 1.g., is hereby deleted in its entirety and replaced as follows:

AHCA Contract No. FA619, Amendment No. 7, Page 9 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

Community Outreach Oversight Coordinator: If the Health Plan engages in Community Outreach, the Health Plan shall have a designated person, qualified by training and experience, to assure the Health Plan adheres to the community outreach and marketing requirements of this Contract.

9.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration and Management, Item C., Provider Contract Requirements, sub-item 2.s., is hereby deleted in its entirety and replaced as follows:

Require that any Community Outreach Materials related to this Contract that are displayed by the Provider be submitted to the Agency for written approval before use;

10.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration and Management, Item E., Provider Services, sub-item 5.d., is hereby deleted in its entirety and replaced as follows:

The Health Plan’s call center systems shall have the capability to track call management metrics identified in Section IV, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 7., Toll-Free Help Line.

11.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration and Management, Item H., Encounter Data, is hereby deleted in its entirety and replaced as follows:

Encounter Data

The Health Plan shall submit Encounter Data that meets established Agency data quality standards as defined herein. These standards are defined by the Agency to ensure receipt of complete and accurate data for program administration and will be closely monitored and enforced. The Agency will revise and amend these standards with ninety (90) Calendar Days advance notice to the Health Plan to ensure continuous quality improvement. The Health Plan shall make changes or corrections to any systems, processes or data transmission formats as needed to comply with Agency data quality standards as originally defined or subsequently amended.

The Encounter Data submission standards required to support encounter reporting and submission are defined by the Agency in the Medicaid Encounter Data System (MEDS) Companion Guide and this Section. In addition, the Agency will post encounter reporting requirements on its MEDS website for the Health Plans to follow: xxxx://xxxx.xxxxxxxxx.xxx/Xxxxxxxx/xxxx/.

The Health Plan shall adhere to the following requirements for the Encounter Data submission process:

The Agency shall notify the Health Plan, in writing, of the start date for resuming the submission of encounters through the current Fiscal Agent.

Once the Health Plan is notified by the Agency of the date for recommencing encounter submissions (submission start date), the Health Plan shall submit its schedule for transmitting Encounter Data for all typical and atypical services collected for historical claims beginning July 1, 2008, and up to the submission start date.

(1)

The Health Plan shall submit this schedule for approval to the Agency’s Medicaid Encounter Data System team (at xxxxxxxx@xxxx.xxxxxxxxx.xxx) within ten (10) Business days after the date of the Agency’s notice to begin submitting encounters.

AHCA Contract No. FA619, Amendment No. 7, Page 10 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

(2)

At a minimum, such submission schedule must include that historical encounter transmissions will begin no later than sixty (60) Calendar Days after the submission start date.

In accordance with the submission schedule approved by the Agency, the Health Plan shall submit the historical encounters for all typical and atypical services with Health Plan paid dates of July 1, 2008, up to the submission start date.

The Health Plan shall submit encounters for all typical and atypical services with Health Plan paid dates on or after the submission start date on an ongoing basis within sixty (60) Calendar Days following the end of the month in which the Health Plan paid the claims for services.

For all encounters submitted after the recommencing of encounter submissions (submission start date), including historical and ongoing claims, if the Agency or its Fiscal Agent notifies the Health Plan of encounters failing X12 Electronic Data Interface (EDI) compliance edits or FMMIS threshold and repairable compliance edits, the Health Plan shall Remediate all such encounters within sixty (60) Calendar Days after such notice.

There will be no requirement to submit encounters for Health Plan paid dates prior to July 1, 2008.

The Health Plan shall have a comprehensive automated and integrated Encounter Data system that is capable of meeting the requirements below. The Health Plan shall comply as follows:

All Health Plan encounters shall be submitted to the Agency in the standard HIPAA transaction formats, namely the ANSI X12N 837 Transaction formats (P - Professional, I - Institutional, and D – Dental), and, for Pharmacy services, in the National Council for Prescription Drug Programs (NCPDP) format. Health Plan paid amounts must be provided for non-capitated network providers.

The Health Plan shall collect and submit to the Agency’s Fiscal Agent, Enrollee service level Encounter Data for all Covered Services. Health Plans will be held responsible for errors or noncompliance resulting from their own actions or the actions of an agent authorized to act on their behalf.

The Health Plan shall convert all information that enters their claims systems via hard copy paper claims or other proprietary formats to Encounter Data to be submitted in the appropriate HIPAA compliant formats.

The Health Plan shall provide complete and accurate encounters to the Agency. Health Plans will implement review procedures to validate Encounter Data submitted by providers.

(1)

Complete: A Health Plan submitting encounters that represent at least 95% of the Covered Services provided by the Health Plan’s Providers and non-participating providers. It is expected that the Health Plan will strive to make every effort to achieve a 100% complete submission rate.

(2)

Accurate: 95% of the records in a Health Plan’s encounter batch submission pass X12 EDI compliance edits and the FMMIS threshold and repairable compliance edits. The X12 EDI compliance edits are established through SNIP levels 1 through 4. FMMIS threshold and repairable edits that report exceptions are defined in the MEDS Companion Guide.

The Health Plan shall designate sufficient IT and staffing resources to perform these encounter functions as determined by generally accepted best industry practices.

AHCA Contract No. FA619, Amendment No. 7, Page 11 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

The Health Plan shall retain submitted historical Encounter Data for a period not less than five years as specified in I.D., Retention of Records, in the Agency’s Standard Contract.

Where a Health Plan has entered into capitation reimbursement arrangements with Providers, the Health Plan must comply with sub-item 4. of this Section. The Health Plan shall require timely submissions from its Providers as a condition of the capitation payment.

The Health Plan shall participate in Agency sponsored workgroups directed at continuous improvements in Encounter Data quality and operations.

If the Agency determines that the Health Plan’s MEDS performance is not acceptable, the Agency shall require the Health Plan to submit a corrective action plan (CAP). If the Health Plan fails to provide a CAP or to implement an approved CAP within the time specified by the Agency, the Agency shall sanction the Health Plan in accordance with the provisions of Section XIV, Sanctions, and may immediately terminate all Enrollment activities and Mandatory Assignments. When considering whether to impose a Sanction, the Agency will take into account the Health Plan’s cumulative performance on all MEDS activities, including progress made toward completeness and accuracy of Encounter Data as defined in sub-item H.4.d. of this Section.

The Encounter Data submission time frames specified in this Section do not affect time frames specified in Section XII for either pharmacy data encounter reporting for risk adjustment or behavioral health encounter (including pharmacy) reporting.

12.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, sub-item 7., Digit 1 Report Identifiers table, is hereby deleted in its entirety and replaced as follows:

Digit 1 Report Identifiers
R	Community Outreach Representative
I	Information Systems Availability
G	Grievance System Reporting
H	Inpatient Discharge Reporting
F	Financial Reporting
M	Minority Reporting
C	Claims Inventory
T	Transportation
S	Critical Incident Summary
E	Behavioral Health Encounter Data
B	Behavioral Health Pharmacy Encounter Data
P	Behavioral Health Required Staff/Providers
O	FARS/CFARS

13.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting Requirements, Table 1, Summary of Reporting Requirements, “Marketing Representative Report” is hereby retitled “Community Outreach Representative Report.”

14.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting Requirements, Item E., Marketing Representative Report, is hereby deleted in its entirety and replaced as follows:

AHCA Contract No. FA619, Amendment No. 7, Page 12 of 13

HealthEase of Florida, Inc.

Medicaid HMO Contract

Community Outreach Representative Report

The Health Plan shall register each Community Outreach Representative with the Agency as specified below. The registration file must be submitted to the Agency at the following e-mail address prior to any initial Community Outreach activity: XXXXXXX@xxxx.xxxxxxxxx.xxx. The Agency-supplied template must be used – Community Outreach Representative Registration Template.xls. This template is provided at xxxx://xxx.xxxx.xxxxxxxxx.xxx/xxxx/xxxxxxx_xxxxxx_xxxx/xxxx/xxx_xxxx.xxxxx.

Changes to the Community Outreach Representative’s initial registration must be submitted to the Agency immediately upon occurrence at e-mail address: XXXXXXX@xxxx.xxxxxxxxx.xxx. The Agency-supplied template must be used. The Health Plan shall not change or alter the template. This template contains the following required data elements:

15.	Attachment II, Medicaid Prepaid Health Plan Model Contract, Section XVI, Terms and Conditions, Item Q., Termination Procedures, sub-item 2.c., is hereby deleted in its entirety and replaced as follows:

Terminate all Community Outreach activities and subcontracts relating to Community Outreach.

This Amendment shall have an effective date of March 1, 2009, or the date on which both parties execute the Amendment, whichever is later.

All provisions in the Contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to conform with this Amendment.

All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the Contract.

This Amendment, and all its attachments, are hereby made part of the Contract.

This Amendment cannot be executed unless all previous Amendments to this Contract have been fully executed.

IN WITNESS WHEREOF, the parties hereto have caused this thirteen (13) 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/ Xxxxx Xxxxxxxxx	SIGNED BY:	/s/ Xxxxx Xxxxxx
NAME:	Xxxxx Xxxxxxxxx	NAME:	Xxxxx Xxxxxx
TITLE:	President and CEO	TITLE:	Secretary
DATE:	24 March 2009	DATE:	3/25/09

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA619, Amendment No. 7, Page 13 of 13

Document Metadata

Table of Contents

AHCA CONTRACT NO. FA619 AMENDMENT NO. 7

Document Metadata