APPENDIX X [Amendment Number 2]
Exhibit
10.4
APPENDIX
X
[Amendment
Number 2]
Agency
Code 12000
Contract
No. C020454
Period
5/1/06-9/30/08
Funding
Amount for Period Based
on approved capitation rates
This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
New York State Department of Health,
having
its principal office at Coming
Tower, Room 0000, Xxxxxx
Xxxxx Xxxxx, Xxxxxx, XX 00000, (hereinafter referred to as the STATE), and
WellCare
of New York,
Inc., (hereinafter referred to as the CONTRACTOR), to modify Contract Number
C020454 by substituting the attached Appendix L "Approved Capitation Payment
Rates," Schedule 1 of Appendix M "Service Area, Program Participation and
Prepaid Benefit Package Optional Covered Services," and Schedule 2 of Appendix
M
"LDSS Election of Enrollment in Medicaid Managed Care for Xxxxxx Care Children
and Homeless Persons." The effective date of these modifications is May 1,
2006.
All
other
provisions of said AGREEMENT shall remain in full force and effect.
IN
WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates
appearing under
|
CONTRACTOR
SIGNATURE
|
STATE
AGENCY SIGNATURE
|
|
|
By:
/s/ Xxxx X.
Xxxxx
|
By:
/s/ Xxxxx
Xxxxxxxxxx
|
|
|
XXXX
X. XXXXX
|
XXXXX
XXXXXXXXXX
|
|
|
Title:
PRESIDENT & CEO
|
Title:
DEPUTY DIRECTOR, OMC
|
|
|
Date:
June 19, 2006
|
Date:
7/7/06
|
|
|
State
Agency Certification:
In
addition to the acceptance of this contract, I also certify that
original
copies of this signature page will be attached to all other exact
copies
of this contract
|
STATE
OF
FLORIDA
SS.:
County
of
HILLSBOROUGH
On
the
19th
day of
June
2006,
before me personally appeared Xxxx
X. Xxxxx to
me
known, who being by me duly sworn, did depose and
say
that he/she resides at Tampa,
Florida, ,
that
he/she is the President
& CEO of
WellCare
of New York, Inc.,
the
corporation
described herein which executed the foregoing instrument; and that he/she signed
his/her
name thereto by order of the board of directors of said
corporation.
(Notary)
/s/
Xxxx
Xxxxx
Xxxx
Xxxxx
|
STATE
COMPTROLLER’S SIGNATURE
|
Title:
State Comptroller
|
|
/s/
Illegible
|
Date:
7/31/06
|
APPENDIX
L
Approved
Capitation Payment Rates
APPENDIX
L
May
1,
2006
L-l
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Northeast
|
|
County:
ALBANY
|
|
|
Reinsurance:
No
|
Status:
Mandatory
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$262.72
|
|
TANF/SN
6mo-14 F
|
$89.50
|
|
TANF/SN
15-20 F
|
$130.92
|
|
TANF/SN
6m-20 M
|
$87.34
|
|
TANF21+
M/F
|
$212.38
|
|
SN
21-29 M/F
|
$201.52
|
|
SN
30+ M/F
|
$365.32
|
|
SSI
6mo-20 M/F
|
$176.65
|
|
SSI
21-64 M/F
|
$493.40
|
|
SSI
65+ M/F
|
$438.91
|
|
Maternity
Kick Payment
|
$5,097.14
|
|
Newborn
Kick Payment
|
$1,734.99
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
þ
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Central
|
|
County:
COLUMBIA
|
|
|
Reinsurance:
No
|
Status:
Mandatory
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$253.60
|
|
TANF/SN
6mo-14 F
|
$82.21
|
|
TANF/SN
15-20 F
|
$139.77
|
|
TANF/SN
6m-20 M
|
$82.59
|
|
TANF21+
M/F
|
$229.28
|
|
SN
21-29 M/F
|
$215.27
|
|
SN
30+ M/F
|
$368.73
|
|
SSI
6mo-20 M/F
|
$179.23
|
|
SSI
21-64 M/F
|
$474.37
|
|
SSI
65+ M/F
|
$392.42
|
|
Maternity
Kick Payment
|
$5,466.64
|
|
Newborn
Kick Payment
|
$1,980.01
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
þ
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
County:
DUTCHESS
|
|
|
Reinsurance:
No
|
Status:
Voluntary
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$266.87
|
|
TANF/SN
6mo-14 F
|
$93.54
|
|
TANF/SN
15-20 F
|
$135.68
|
|
TANF/SN
6m-20 M
|
$103.07
|
|
TANF21+
M/F
|
$229.75
|
|
SN
21-29 M/F
|
$211.13
|
|
SN
30+ M/F
|
$429.08
|
|
SSI
6mo-20 M/F
|
$177.07
|
|
SSI
21-64 M/F
|
$488.19
|
|
SSI
65+ M/F
|
$425.44
|
|
Maternity
Kick Payment
|
$5,651.55
|
|
Newborn
Kick Payment
|
$2,276.59
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Central
|
|
County:
XXXXXX
|
|
|
Reinsurance:
No
|
Status:
Mandatory
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$251.40
|
|
TANF/SN
6mo-14 F
|
$80.40
|
|
TANF/SN
15-20 F
|
$137.50
|
|
TANF/SN
6m-20 M
|
$80.75
|
|
TANF21+
M/F
|
$226.45
|
|
SN
21-29 M/F
|
$212.51
|
|
SN
30+ M/F
|
$365.67
|
|
SSI
6mo-20 M/F
|
$176.18
|
|
SSI
21-64 M/F
|
$470.38
|
|
SSI
65+ M/F
|
$390.73
|
|
Maternity
Kick Payment
|
$5,466.64
|
|
Newborn
Kick Payment
|
$1,980.01
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
County:
ORANGE
|
|
|
Reinsurance:
No
|
Status:
Voluntary
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$263.72
|
|
TANF/SN
6mo-14 F
|
$92.78
|
|
TANF/SN
15-20 F
|
$132.60
|
|
TANF/SN
6m-20 M
|
$102.05
|
|
TANF21+
M/F
|
$226.38
|
|
SN
21-29 M/F
|
$206.72
|
|
SN
30+ M/F
|
$423.04
|
|
SSI
6mo-20 M/F
|
$173.29
|
|
SSI
21-64 M/F
|
$479.96
|
|
SSI
65+ M/F
|
$420.66
|
|
Maternity
Kick Payment
|
$5,651.55
|
|
Newborn
Kick Payment
|
$2,276.59
|
Optional
Benefits Offered:
|
¨
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Northeast
|
|
County:
RENSSELAER
|
|
|
Reinsurance:
No
|
Status:
Mandatory
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$260.53
|
|
TANF/SN
6mo-14 F
|
$87.69
|
|
TANF/SN
15-20 F
|
$128.66
|
|
TANF/SN
6m-20 M
|
$85.51
|
|
TANF21+
M/F
|
$209.55
|
|
SN
21-29 M/F
|
$198.76
|
|
SN
30+ M/F
|
$362.26
|
|
SSI
6mo-20 M/F
|
$173.61
|
|
SSI
21-64 M/F
|
$489.42
|
|
SSI
65+ M/F
|
$437.22
|
|
Maternity
Kick Payment
|
$5,097.14
|
|
Newborn
Kick Payment
|
$1,734.99
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Northern Metro
|
|
County:
ROCKLAND
|
|
|
Reinsurance:
No
|
Status:
Mandatory
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$247.24
|
|
TANF/SN
6mo-14 F
|
$87.55
|
|
TANF/SN
15-20 F
|
$111.50
|
|
TANF/SN
6m-20 M
|
$97.90
|
|
TANF21+
M/F
|
$190.15
|
|
SN
21-29 M/F
|
$262.49
|
|
SN
30+ M/F
|
$413.23
|
|
SSI
6mo-20 M/F
|
$176.29
|
|
SSI
21-64 M/F
|
$548.38
|
|
SSI
65+ M/F
|
$413.23
|
|
Maternity
Kick Payment
|
$4,812.65
|
|
Newborn
Kick Payment
|
$1,569.65
|
Optional
Benefits Offered:
|
þ
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS
ID #: 01182503
|
Effective
Date: 04/01/06
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
County:
ULSTER
|
|
|
Reinsurance:
No
|
Status:
Voluntary
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN
<6mo
M/F
|
$263.72
|
|
TANF/SN
6mo-14 F
|
$92.78
|
|
TANF/SN
15-20 F
|
$132.60
|
|
TANF/SN
6m-20 M
|
$102.05
|
|
TANF21+
M/F
|
$226.38
|
|
SN
21-29 M/F
|
$206.72
|
|
SN
30+ M/F
|
$423.04
|
|
SSI
6mo-20 M/F
|
$173.29
|
|
SSI
21-64 M/F
|
$479.96
|
|
SSI
65+ M/F
|
$420.66
|
|
Maternity
Kick Payment
|
$5,615.55
|
|
Newborn
Kick Payment
|
$2,276.59
|
Optional
Benefits Offered:
|
¨
Emergency Transportation
|
¨
Dental
|
|
¨
Non-Emergent Transportation
|
þ
Family Planning
|
Box
will be checked if the optional benefit is covered by the
plan
WELLCARE
OF NEW YORK, INC.
Family
Health Plus Rates
Effective
April 1, 2006
|
Optional
Benefits
covered
|
||||||
|
County
|
Adults
with
Children
19 - 64
|
Adults
without Children 19 - 29
|
Adults
without Children 30 - 64
|
Maternity
Kick
|
Family
Planning
|
Dental
|
|
ALBANY
|
$253.35
|
$250.47
|
$510.54
|
$5,097.14
|
Yes
|
Yes
|
|
COLUMBIA
|
$270.53
|
$258.71
|
$498.03
|
$5,466.64
|
Yes
|
Yes
|
|
DUTCHESS
|
$260.42
|
$291.38
|
$528.18
|
$5,651.55
|
Yes
|
Yes
|
|
XXXXXX
|
$270.53
|
$258.71
|
$498.03
|
$5,466.64
|
Yes
|
Yes
|
|
ORANGE
|
$260.42
|
$291.38
|
$528.18
|
$5,651.55
|
Yes
|
Yes
|
|
RENSSELAER
|
$253.35
|
$250.47
|
$510.54
|
$5,097.14
|
Yes
|
Yes
|
|
ROCKLAND
|
$256.16
|
$208.81
|
$471.77
|
$4,812.65
|
Yes
|
Yes
|
|
ULSTER
|
$260.42
|
$291.38
|
$528.18
|
$5,651.55
|
Yes
|
Yes
|
|
NEW
YORK
|
$196.82
|
$151.39
|
$245.60
|
$5,114.41
|
Yes
|
Yes
|
APPENDIX
M
Service
Area, Benefit Options, and Enrollment Elections
APPENDIX
M
May
1,
2006
M-l
Schedule
1 of Appendix M
Service
Area, Program Participation and
Prepaid
Benefit Package Optional Covered Services
1. Service
Area
The
Contractor's service area is comprised of the counties listed in Column A of
this schedule in their entirety.
2. Program
Participation and Optional Benefit Package Covered
Services
a)
For
each county listed in Column A below, an entry of "yes" in the subsections
of
Columns B and C means the Contractor offers the MMC and/or FHPlus product and/or
includes the optional service indicated in its Benefit Package.
b)
For
each county listed in Column A below, an entry of "no" in the subsections of
Columns B and C means the Contractor does not offer the MMC and/or FHPlus
product and/or does not include the optional service indicated in its Benefit
Package.
c)
In the
schedule below, an entry of "N/A" means not applicable for the purposes of
this
Agreement.
3. Effective
Date
The
effective date of this Schedule is May 1, 2006.
|
Contractor:
WellCare of New York, Inc.
|
||||||||
|
Column
A
County
|
Column
B
Medicaid
Managed Care
|
Column
C
FHPlus
|
||||||
|
Contractor
Participates
|
Dental
|
Family
Planning
|
Non-Emergency
Transportation
|
Emergency
Transportation
|
Contractor
Participates
|
Dental
|
Family
Planning
|
|
|
Albany
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Columbia
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Dutchess
|
Yes
|
No
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Xxxxxx
|
Yes
|
No
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
|
New
York City - Bronx
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
Yes
|
Yes
|
Yes
|
|
New
York City - Kings
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
Yes
|
Yes
|
Yes
|
|
New
York City - New York
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
Yes
|
Yes
|
Yes
|
|
New
York City - Queens
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
Yes
|
Yes
|
Yes
|
APPENDIX
M
May
1,
2006
M-2
|
Contractor:
WellCare of New York, Inc.
|
||||||||
|
Column
A
County
|
Column
B
Medicaid
Managed Care
|
Column
C
FHPlus
|
||||||
|
Contractor
Participates
|
Dental
|
Family
Planning
|
Non-Emergency
Transportation
|
Emergency
Transportation
|
Contractor
Participates
|
Dental
|
Family
Planning
|
|
|
Orange
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Rensselaer
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Rockland
|
Yes
|
No
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Ulster
|
Yes
|
No
|
Yes
|
No
|
No
|
Yes
|
Yes
|
Yes
|
APPENDIX
M
May
1,
2006
M-3
Schedule
2 of Appendix M
LDSS
Election of Enrollment in Medicaid Managed Care For Xxxxxx Care Children and
Homeless Persons
|
1.
|
Effective
May 1, 2006, in the Contractor's service area, Medicaid Eligible
Persons
in the following categories will be eligible for Enrollment in the
Contractor's Medicaid Managed Care product at LDSS's option as described
in (a) and (b) as follows, and indicated by an "X" in the chart
below:
|
a)
Options for xxxxxx care children in the direct care of LDSS:
i)
Children in LDSS direct care are mandatorily enrolled in MMC (mandatory counties
only);
ii)
Children in LDSS direct care are enrolled in on a case by case basis in MMC
(mandatory
or
voluntary counties);
iii)
All
xxxxxx care children are Excluded from Enrollment in MMC (mandatory or voluntary
counties).
b)
Options for homeless persons living in shelters outside of New York
City:
i)
Homeless persons are mandatorily enrolled in MMC (mandatory counties
only);
ii)
Homeless persons are enrolled in on a case by case basis in MMC (mandatory
or
voluntary counties);
iii)
All
homeless persons are Excluded from Enrollment in MMC (mandatory or voluntary
counties).
c)
In the
schedule below, an entry of "N/A" means not applicable for the purposes of
this
Agreement.
|
Contractor:
WellCare of New York, Inc.
|
||||||
|
County
|
Xxxxxx
Care Children
|
Homeless
Persons
|
||||
|
Mandatorily
Enrolled
|
Enrolled
on Case by Case Basis
|
Excluded
from Enrollment
|
Mandatorily
Enrolled
|
Enrolled
on Case by Case Basis
|
Excluded
from Enrollment
|
|
|
Albany
|
X
|
X
|
||||
|
Columbia
|
X
|
X
|
||||
|
Dutchess
|
X
|
X
|
||||
|
Xxxxxx
|
X
|
X
|
||||
|
Orange
|
X
|
X
|
||||
|
Rensselaer
|
X
|
X
|
||||
|
Rockland
|
X
|
X
|
||||
|
Ulster
|
X
|
X
|
||||
APPENDIX
M
May
1,
2006
M-4
