HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract AHCA CONTRACT NO. FA905 AMENDMENT NO. 8 THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and...
Return to Form 8-k
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 5 of 5
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| AHCA CONTRACT NO. FA905 | ||
| AMENDMENT NO. 8 | ||
| 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.
|
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 1., Covered Medicaid Services, sub-item b.(3)(c), is hereby amended to include Table 5-A, Revised Health Plan Covered Services Chart, as follows. All references in the Contract to Table 5, Health Plan Covered Services Chart shall hereinafter also refer to Table 5-A, Revised Health Plan Covered Services Chart, as appropriate.
|
|
TABLE 5-A
|
||
|
Revised Health Plan Covered Services Chart
|
Non- Reform Covered
|
Reform
Covered
|
|
Advanced Registered Nurse Practitioner Services
|
X
|
|
|
Ambulatory Surgical Center Services
|
X
|
|
|
Birth Center Services
|
X
|
|
|
Child Health Check-Up Services
|
X
|
|
|
Chiropractic Services
|
X
|
|
|
Community Behavioral Health Services
|
X
|
|
|
County Health Department Services
|
X
|
|
|
Dental Services*
|
||
|
Durable Medical Equipment and Medical Supplies
|
X
|
|
|
Dialysis Services
|
X
|
|
|
Emergency Room Services
|
X
|
|
|
Family Planning Services
|
X
|
|
|
Federally Qualified Health Center Services
|
X
|
|
|
Frail/Elderly Program Services*
|
||
|
Freestanding Dialysis Centers
|
X
|
|
|
Hearing Services
|
X
|
|
|
Home Health Care Services
|
X
|
|
|
Hospital Services – Inpatient
|
X
|
|
|
Hospital Services – Outpatient
|
X
|
|
|
Immunizations
|
X
|
|
|
Independent Laboratory Services
|
X
|
|
|
Licensed Midwife Services
|
X
|
|
|
Optometric Services
|
X
|
|
|
Physician Services
|
X
|
|
|
Physician Assistant Services
|
X
|
|
|
Podiatry Services
|
X
|
|
AHCA Contract No. FA905, Amendment No. 8, Page 1 of 3
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform Contract |
|
TABLE 5-A
|
||
|
Revised Health Plan Covered Services Chart
|
Non- Reform Covered
|
Reform
Covered
|
|
Portable X-ray Services
|
X
|
|
|
Prescribed Drugs
|
X
|
|
|
Prescribed Pediatric Extended Care Services
|
||
|
Primary Care Case Management Services
|
X
|
|
| Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY) |
|
|
|
Rural Health Clinic Services
|
X
|
|
|
Targeted Case Management
|
X
|
|
|
Therapy Services: Occupational
|
X
|
|
|
Therapy Services: Physical
|
X
|
|
|
Therapy Services: Respiratory
|
X
|
|
|
Therapy Services: Speech
|
X
|
|
|
Transplant Services
|
X
|
|
|
Transportation Services*
|
||
|
Vision Services
|
X
|
|
2.
|
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a., is hereby amended to include Table 6-B, Revised Expanded Services, as follows. All references in the Contract to Table 6, Expanded Services, and Table 6-A, Revised Expanded Services shall hereinafter also refer to Table 6-B, as appropriate.
|
|
TABLE 6-B
|
|
Revised Expanded Services
|
|
Effective January 1, 2012
|
|
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies.
|
|
3.
|
Effective September 1, 2011, Attachment I, Scope of Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract. All references in the Contract to Exhibit 2-NR-B, shall hereinafter refer to Exhibit 2- NR-C, as appropriate.
|
| Unless otherwise stated, this amendment is effective upon execution. |
| 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. |
AHCA Contract No. FA905, Amendment No. 8, Page 2 of 3
| HealthEase of Florida, Inc. | Medicaid HMO Non-Reform 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 eight (8) 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 | |||||
| By: | /s/Xxxxxxxxx Xxxxxx | By: | /s/ Xxxxx Xxxx for | ||
| Name: | Xxxxxxxxx Xxxxxx | Name: | Xxxxxxxxx Xxxxx | ||
| Title: | President, FL & HI Division | Title: | Secretary | ||
| Date: | 12/27/11 | Date: | 12/29/11 | ||
List of Attachments/Exhibits included as part of this amendment:
|
Specify
Type
|
Letter/
Number
|
Description
|
| Attachment I | Exhibit 2-NR-C |
Medicaid Non-Reform HMO Capitation Rates,
Effective September 1, 2011 (5 pages)
|
REMAINDER OF XXXX INTENTIONALLY LEFT BLANK
AHCA Contract No. FA905, Amendment No. 8, Page 3 of 3
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
General 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
|
944.58
|
184.93
|
99.14
|
62.81
|
127.84
|
67.50
|
271.85
|
155.86
|
430.03
|
12,534.08
|
1,853.67
|
459.10
|
183.60
|
219.90
|
719.01
|
846.95
|
304.31
|
95.72
|
75.16
|
|
02
|
809.74
|
158.54
|
85.26
|
55.17
|
110.84
|
59.12
|
234.16
|
134.73
|
369.40
|
10,634.20
|
1,571.89
|
378.61
|
129.11
|
165.06
|
567.50
|
702.50
|
304.31
|
85.34
|
66.80
|
|
03
|
977.48
|
191.38
|
102.88
|
66.37
|
133.57
|
71.13
|
282.47
|
162.44
|
445.78
|
13,033.48
|
1,927.78
|
480.73
|
199.09
|
235.25
|
760.70
|
885.63
|
304.31
|
86.58
|
67.80
|
|
04
|
982.26
|
192.25
|
101.91
|
59.51
|
127.52
|
64.77
|
277.81
|
157.18
|
443.92
|
13,413.62
|
1,983.70
|
490.64
|
194.84
|
234.00
|
766.84
|
905.39
|
304.31
|
79.94
|
62.45
|
|
05
|
1,109.71
|
217.27
|
116.92
|
75.94
|
152.20
|
81.32
|
321.19
|
184.92
|
506.42
|
14,476.72
|
2,141.09
|
531.81
|
215.85
|
257.04
|
836.50
|
980.51
|
304.31
|
74.93
|
58.42
|
|
06
|
1,021.04
|
199.94
|
108.39
|
73.89
|
143.78
|
78.57
|
298.90
|
173.52
|
468.21
|
13,062.91
|
1,932.30
|
484.19
|
205.34
|
240.45
|
771.66
|
891.12
|
304.31
|
73.50
|
57.26
|
|
07
|
966.83
|
189.24
|
100.39
|
58.99
|
125.91
|
64.15
|
273.80
|
155.07
|
437.19
|
13,593.51
|
2,010.10
|
494.41
|
190.58
|
231.59
|
766.17
|
913.39
|
304.31
|
72.84
|
56.74
|
|
08
|
952.04
|
186.41
|
100.57
|
66.44
|
131.76
|
70.95
|
276.63
|
159.73
|
435.19
|
12,412.16
|
1,835.77
|
456.44
|
186.23
|
221.31
|
719.07
|
841.38
|
304.31
|
80.42
|
62.84
|
|
09
|
1,032.49
|
202.14
|
108.41
|
68.86
|
139.93
|
73.98
|
297.32
|
170.54
|
470.17
|
14,347.56
|
2,121.42
|
519.54
|
195.54
|
239.92
|
799.72
|
960.67
|
304.31
|
82.17
|
64.25
|
|
10
|
1,028.53
|
201.37
|
108.26
|
69.90
|
140.62
|
74.92
|
297.28
|
170.98
|
469.11
|
17,915.36
|
2,649.60
|
657.40
|
265.37
|
316.67
|
1,032.39
|
1,212.35
|
304.31
|
92.58
|
72.64
|
|
11
|
1,187.84
|
232.59
|
125.70
|
84.02
|
165.46
|
89.59
|
346.10
|
200.24
|
543.62
|
15,014.29
|
2,220.47
|
549.99
|
220.03
|
263.49
|
861.45
|
1,014.60
|
304.31
|
120.99
|
95.51
|
|
6B *
|
1,020.54
|
199.85
|
108.39
|
74.07
|
143.91
|
78.73
|
298.94
|
173.63
|
468.11
|
13,061.73
|
1,932.14
|
484.22
|
205.49
|
240.58
|
771.87
|
891.14
|
304.31
|
73.50
|
57.26
|
TABLE 2
|
General + Mental Health 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
|
944.69
|
185.04
|
101.42
|
73.90
|
138.20
|
77.86
|
281.21
|
165.22
|
436.32
|
12,535.85
|
1,855.44
|
479.56
|
233.51
|
260.16
|
798.67
|
877.14
|
321.65
|
105.67
|
85.11
|
|
02
|
809.82
|
158.62
|
86.94
|
63.35
|
118.47
|
66.75
|
241.06
|
141.63
|
374.03
|
10,636.65
|
1,574.34
|
406.90
|
198.14
|
220.74
|
677.67
|
744.25
|
321.65
|
95.29
|
76.75
|
|
03
|
977.58
|
191.48
|
104.95
|
76.48
|
143.01
|
80.57
|
291.00
|
170.97
|
451.51
|
13,035.03
|
1,929.33
|
498.65
|
242.81
|
270.52
|
830.48
|
912.07
|
321.65
|
96.53
|
77.75
|
|
04
|
982.44
|
192.43
|
105.47
|
76.86
|
143.72
|
80.97
|
292.45
|
171.82
|
453.76
|
13,415.57
|
1,985.65
|
513.21
|
249.90
|
278.41
|
854.72
|
938.69
|
321.65
|
89.89
|
72.40
|
|
05
|
1,109.82
|
217.38
|
119.15
|
86.82
|
162.35
|
91.47
|
330.37
|
194.10
|
512.59
|
14,478.63
|
2,143.00
|
553.88
|
269.70
|
300.48
|
922.45
|
1,013.08
|
321.65
|
84.88
|
68.37
|
|
06
|
1,021.10
|
200.00
|
109.62
|
79.88
|
149.37
|
84.16
|
303.96
|
178.58
|
471.61
|
13,064.26
|
1,933.65
|
499.77
|
243.36
|
271.12
|
832.34
|
914.11
|
321.65
|
83.45
|
67.21
|
|
07
|
967.00
|
189.41
|
103.81
|
75.65
|
141.46
|
79.70
|
287.85
|
169.12
|
446.63
|
13,595.73
|
2,012.32
|
520.10
|
253.26
|
282.15
|
866.20
|
951.30
|
321.65
|
82.79
|
66.69
|
|
08
|
952.12
|
186.49
|
102.22
|
74.49
|
139.28
|
78.47
|
283.42
|
166.52
|
439.76
|
12,413.76
|
1,837.37
|
474.89
|
231.24
|
257.62
|
790.90
|
868.60
|
321.65
|
90.37
|
72.79
|
|
09
|
1,032.61
|
202.26
|
110.86
|
80.78
|
151.06
|
85.11
|
307.38
|
180.60
|
476.93
|
14,350.11
|
2,123.97
|
548.96
|
267.31
|
297.81
|
914.26
|
1,004.08
|
321.65
|
92.12
|
74.20
|
|
10
|
1,028.64
|
201.48
|
110.43
|
80.47
|
150.48
|
84.78
|
306.20
|
179.90
|
475.10
|
17,917.79
|
2,652.03
|
685.44
|
333.77
|
371.85
|
1,141.56
|
1,253.72
|
321.65
|
102.53
|
82.59
|
|
11
|
1,187.93
|
232.68
|
127.53
|
92.93
|
173.78
|
97.91
|
353.62
|
207.76
|
548.67
|
15,016.41
|
2,222.59
|
574.45
|
279.72
|
311.64
|
956.71
|
1,050.70
|
321.65
|
130.94
|
105.46
|
|
6B *
|
1,020.60
|
199.91
|
109.57
|
79.84
|
149.30
|
84.12
|
303.81
|
178.50
|
471.38
|
13,063.07
|
1,933.48
|
499.73
|
243.33
|
271.10
|
832.26
|
914.03
|
321.65
|
83.45
|
67.21
|
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 1 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
TABLE 3
|
|||||||||||||||||||
|
General + MH + Dental 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
|
944.69
|
185.06
|
103.23
|
76.91
|
140.85
|
80.79
|
282.97
|
166.83
|
439.41
|
12,535.91
|
1,855.47
|
481.31
|
235.72
|
262.09
|
800.18
|
879.25
|
323.95
|
106.76
|
86.03
|
|
02
|
809.83
|
158.64
|
89.86
|
68.21
|
122.74
|
71.49
|
243.79
|
144.12
|
378.82
|
10,636.74
|
1,574.39
|
409.58
|
201.51
|
223.69
|
679.30
|
746.53
|
323.95
|
96.63
|
77.87
|
|
03
|
977.59
|
191.53
|
110.77
|
86.18
|
151.54
|
90.02
|
294.80
|
174.45
|
458.19
|
13,035.24
|
1,929.45
|
504.95
|
250.74
|
277.45
|
832.71
|
915.19
|
323.95
|
98.64
|
79.52
|
|
04
|
982.45
|
192.46
|
108.89
|
82.56
|
148.73
|
86.53
|
296.76
|
175.76
|
461.32
|
13,415.69
|
1,985.72
|
516.72
|
254.31
|
282.27
|
857.39
|
942.42
|
323.95
|
92.21
|
74.35
|
|
05
|
1,109.84
|
217.44
|
125.83
|
97.95
|
172.14
|
102.32
|
334.38
|
197.77
|
519.63
|
14,478.85
|
2,143.13
|
560.70
|
278.28
|
307.98
|
924.69
|
1,016.22
|
323.95
|
87.28
|
70.38
|
|
06
|
1,021.11
|
200.04
|
114.54
|
88.08
|
156.58
|
92.15
|
306.21
|
180.64
|
475.56
|
13,064.42
|
1,933.74
|
504.77
|
249.66
|
276.62
|
833.92
|
916.32
|
323.95
|
85.20
|
68.68
|
|
07
|
967.01
|
189.46
|
109.65
|
85.37
|
150.01
|
89.18
|
290.76
|
171.78
|
451.74
|
13,595.93
|
2,012.43
|
526.15
|
260.87
|
288.80
|
868.02
|
953.84
|
323.95
|
84.50
|
68.13
|
|
08
|
952.14
|
186.58
|
112.21
|
91.13
|
153.91
|
94.69
|
286.81
|
169.62
|
445.71
|
12,414.04
|
1,837.53
|
483.35
|
241.89
|
266.93
|
792.93
|
871.43
|
323.95
|
92.29
|
74.40
|
|
09
|
1,032.63
|
202.32
|
118.34
|
93.24
|
162.01
|
97.26
|
310.56
|
183.50
|
482.50
|
14,350.33
|
2,124.09
|
555.67
|
275.75
|
305.19
|
916.18
|
1,006.76
|
323.95
|
93.99
|
75.77
|
|
10
|
1,028.65
|
201.51
|
114.40
|
87.08
|
156.30
|
91.23
|
307.29
|
180.90
|
477.01
|
17,917.96
|
2,652.12
|
690.55
|
340.20
|
377.47
|
1,142.86
|
1,255.53
|
323.95
|
103.74
|
83.61
|
|
11
|
1,188.00
|
232.75
|
137.40
|
108.70
|
186.71
|
110.84
|
355.80
|
209.75
|
552.50
|
15,016.42
|
2,222.60
|
586.08
|
291.88
|
320.59
|
959.38
|
1,054.43
|
323.95
|
134.01
|
108.03
|
|
6B *
|
1,020.61
|
199.95
|
114.49
|
88.04
|
156.51
|
92.11
|
306.06
|
180.56
|
475.33
|
13,063.23
|
1,933.57
|
504.73
|
249.63
|
276.60
|
833.84
|
916.24
|
323.95
|
85.20
|
68.68
|
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
|
951.62
|
187.12
|
102.70
|
74.71
|
140.05
|
80.81
|
284.50
|
169.78
|
440.86
|
12,591.13
|
1,898.82
|
487.69
|
238.50
|
269.54
|
826.05
|
900.84
|
324.43
|
109.55
|
88.28
|
|
02
|
816.21
|
160.54
|
88.12
|
64.09
|
120.17
|
69.47
|
244.09
|
145.84
|
378.22
|
10,685.88
|
1,612.98
|
414.14
|
202.58
|
229.10
|
702.06
|
765.36
|
324.43
|
98.51
|
79.370
|
|
03
|
984.48
|
193.55
|
106.22
|
77.28
|
144.85
|
83.50
|
294.27
|
175.51
|
456.03
|
13,083.83
|
1,967.63
|
505.83
|
247.21
|
278.80
|
854.65
|
932.99
|
324.43
|
100.56
|
81.04
|
|
04
|
988.24
|
194.17
|
106.54
|
77.53
|
145.26
|
83.43
|
295.20
|
175.63
|
457.56
|
13,465.86
|
2,025.12
|
520.61
|
254.44
|
286.95
|
879.63
|
960.26
|
324.43
|
94.30
|
75.99
|
|
05
|
1,114.99
|
218.93
|
120.10
|
87.42
|
163.73
|
93.67
|
332.82
|
197.50
|
515.98
|
14,525.16
|
2,179.52
|
560.72
|
273.90
|
308.38
|
945.50
|
1,033.03
|
324.43
|
88.93
|
71.67
|
|
06
|
1,026.36
|
201.58
|
110.59
|
80.49
|
150.77
|
86.40
|
306.46
|
182.04
|
475.06
|
13,112.00
|
1,971.11
|
506.79
|
247.67
|
279.22
|
855.98
|
934.58
|
324.43
|
87.18
|
70.25
|
|
07
|
972.68
|
191.11
|
104.86
|
76.31
|
142.97
|
82.11
|
290.54
|
172.85
|
450.35
|
13,646.03
|
2,051.80
|
527.50
|
257.80
|
290.69
|
891.11
|
972.87
|
324.43
|
85.88
|
69.21
|
|
08
|
958.75
|
188.48
|
103.44
|
75.26
|
141.04
|
81.29
|
286.56
|
170.88
|
444.10
|
12,462.04
|
1,875.26
|
481.99
|
235.60
|
265.82
|
814.81
|
889.30
|
324.43
|
93.02
|
74.95
|
|
09
|
1,039.33
|
204.28
|
112.10
|
81.56
|
152.85
|
87.97
|
310.57
|
185.02
|
481.33
|
14,399.99
|
2,163.12
|
556.29
|
271.81
|
306.28
|
938.96
|
1,025.47
|
324.43
|
96.06
|
77.41
|
|
10
|
1,034.50
|
203.24
|
111.51
|
81.15
|
152.04
|
87.27
|
308.98
|
183.75
|
478.93
|
17,971.60
|
2,694.26
|
693.35
|
338.63
|
380.98
|
1,168.21
|
1,276.79
|
324.43
|
106.30
|
85.66
|
|
11
|
1,192.81
|
234.14
|
128.43
|
93.50
|
175.08
|
99.98
|
355.93
|
210.97
|
551.86
|
15,061.69
|
2,258.13
|
581.11
|
283.81
|
319.33
|
979.14
|
1,070.12
|
324.43
|
134.22
|
108.13
|
|
6B *
|
1,025.86
|
201.49
|
110.54
|
80.45
|
150.70
|
86.36
|
306.31
|
181.96
|
474.83
|
13,110.81
|
1,970.94
|
506.75
|
247.64
|
279.20
|
855.90
|
934.50
|
324.43
|
87.18
|
70.25
|
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 2 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
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
|
951.51
|
187.01
|
100.42
|
63.62
|
129.69
|
70.45
|
275.14
|
160.42
|
434.57
|
12,589.36
|
1,897.05
|
467.23
|
188.59
|
229.28
|
746.39
|
870.65
|
307.09
|
99.60
|
78.33
|
|
02
|
816.13
|
160.46
|
86.44
|
55.91
|
112.54
|
61.84
|
237.19
|
138.94
|
373.59
|
10,683.43
|
1,610.53
|
385.85
|
133.55
|
173.42
|
591.89
|
723.61
|
307.09
|
88.56
|
69.42
|
|
03
|
984.38
|
193.45
|
104.15
|
67.17
|
135.41
|
74.06
|
285.74
|
166.98
|
450.30
|
13,082.28
|
1,966.08
|
487.91
|
203.49
|
243.53
|
784.87
|
906.55
|
307.09
|
90.61
|
71.09
|
|
04
|
988.06
|
193.99
|
102.98
|
60.18
|
129.06
|
67.23
|
280.56
|
160.99
|
447.72
|
13,463.91
|
2,023.17
|
498.04
|
199.38
|
242.54
|
791.75
|
926.96
|
307.09
|
84.35
|
66.04
|
|
05
|
1,114.88
|
218.82
|
117.87
|
76.54
|
153.58
|
83.52
|
323.64
|
188.32
|
509.81
|
14,523.25
|
2,177.61
|
538.65
|
220.05
|
264.94
|
859.55
|
1,000.46
|
307.09
|
78.98
|
61.72
|
|
06
|
1,026.30
|
201.52
|
109.36
|
74.50
|
145.18
|
80.81
|
301.40
|
176.98
|
471.66
|
13,110.65
|
1,969.76
|
491.21
|
209.65
|
248.55
|
795.30
|
911.59
|
307.09
|
77.23
|
60.30
|
|
07
|
972.51
|
190.94
|
101.44
|
59.65
|
127.42
|
66.56
|
276.49
|
158.80
|
440.91
|
13,643.81
|
2,049.58
|
501.81
|
195.12
|
240.13
|
791.08
|
934.96
|
307.09
|
75.93
|
59.26
|
|
08
|
958.67
|
188.40
|
101.79
|
67.21
|
133.52
|
73.77
|
279.77
|
164.09
|
439.53
|
12,460.44
|
1,873.66
|
463.54
|
190.59
|
229.51
|
742.98
|
862.08
|
307.09
|
83.07
|
65.00
|
|
09
|
1,039.21
|
204.16
|
109.65
|
69.64
|
141.72
|
76.84
|
300.51
|
174.96
|
474.57
|
14,397.44
|
2,160.57
|
526.87
|
200.04
|
248.39
|
824.42
|
982.06
|
307.09
|
86.11
|
67.46
|
|
10
|
1,034.39
|
203.13
|
109.34
|
70.58
|
142.18
|
77.41
|
300.06
|
174.83
|
472.94
|
17,969.17
|
2,691.83
|
665.31
|
270.23
|
325.80
|
1,059.04
|
1,235.42
|
307.09
|
96.35
|
75.71
|
|
11
|
1,192.72
|
234.05
|
126.60
|
84.59
|
166.76
|
91.66
|
348.41
|
203.45
|
546.81
|
15,059.57
|
2,256.01
|
556.65
|
224.12
|
271.18
|
883.88
|
1,034.02
|
307.09
|
124.27
|
98.18
|
|
6B *
|
1,025.80
|
201.43
|
109.36
|
74.68
|
145.31
|
80.97
|
301.44
|
177.09
|
471.56
|
13,109.47
|
1,969.60
|
491.24
|
209.80
|
248.68
|
795.51
|
911.61
|
307.09
|
77.23
|
60.30
|
TABLE 6
|
General + Dental 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
|
944.58
|
184.95
|
100.95
|
65.82
|
130.49
|
70.43
|
273.61
|
157.47
|
433.12
|
12,534.14
|
1,853.70
|
460.85
|
185.81
|
221.83
|
720.52
|
849.06
|
306.61
|
96.81
|
76.08
|
|
02
|
809.75
|
158.56
|
88.18
|
60.03
|
115.11
|
63.86
|
236.89
|
137.22
|
374.19
|
10,634.29
|
1,571.94
|
381.29
|
132.48
|
168.01
|
569.13
|
704.78
|
306.61
|
86.68
|
67.92
|
|
03
|
977.49
|
191.43
|
108.70
|
76.07
|
142.10
|
80.58
|
286.27
|
165.92
|
452.46
|
13,033.69
|
1,927.90
|
487.03
|
207.02
|
242.18
|
762.93
|
888.75
|
306.61
|
88.69
|
69.57
|
|
04
|
982.27
|
192.28
|
105.33
|
65.21
|
132.53
|
70.33
|
282.12
|
161.12
|
451.48
|
13,413.74
|
1,983.77
|
494.15
|
199.25
|
237.86
|
769.51
|
909.12
|
306.61
|
82.26
|
64.40
|
|
05
|
1,109.73
|
217.33
|
123.60
|
87.07
|
161.99
|
92.17
|
325.20
|
188.59
|
513.46
|
14,476.94
|
2,141.22
|
538.63
|
224.43
|
264.54
|
838.74
|
983.65
|
306.61
|
77.33
|
60.43
|
|
06
|
1,021.05
|
199.98
|
113.31
|
82.09
|
150.99
|
86.56
|
301.15
|
175.58
|
472.16
|
13,063.07
|
1,932.39
|
489.19
|
211.64
|
245.95
|
773.24
|
893.33
|
306.61
|
75.25
|
58.73
|
|
07
|
966.84
|
189.29
|
106.23
|
68.71
|
134.46
|
73.63
|
276.71
|
157.73
|
442.30
|
13,593.71
|
2,010.21
|
500.46
|
198.19
|
238.24
|
767.99
|
915.93
|
306.61
|
74.55
|
58.18
|
|
08
|
952.06
|
186.50
|
110.56
|
83.08
|
146.39
|
87.17
|
280.02
|
162.83
|
441.14
|
12,412.44
|
1,835.93
|
464.90
|
196.88
|
230.62
|
721.10
|
844.21
|
306.61
|
82.34
|
64.45
|
|
09
|
1,032.51
|
202.20
|
115.89
|
81.32
|
150.88
|
86.13
|
300.50
|
173.44
|
475.74
|
14,347.78
|
2,121.54
|
526.25
|
203.98
|
247.30
|
801.64
|
963.35
|
306.61
|
84.04
|
65.82
|
|
10
|
1,028.54
|
201.40
|
112.23
|
76.51
|
146.44
|
81.37
|
298.37
|
171.98
|
471.02
|
17,915.53
|
2,649.69
|
662.51
|
271.80
|
322.29
|
1,033.69
|
1,214.16
|
306.61
|
93.79
|
73.66
|
|
11
|
1,187.91
|
232.66
|
135.57
|
99.79
|
178.39
|
102.52
|
348.28
|
202.23
|
547.45
|
15,014.30
|
2,220.48
|
561.62
|
232.19
|
272.44
|
864.12
|
1,018.33
|
306.61
|
124.06
|
98.08
|
|
6B *
|
1,020.55
|
199.89
|
113.31
|
82.27
|
151.12
|
86.72
|
301.19
|
175.69
|
472.06
|
13,061.89
|
1,932.23
|
489.22
|
211.79
|
246.08
|
773.45
|
893.35
|
306.61
|
75.25
|
58.73
|
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 3 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
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 (65-)
|
AGE (65+)
|
|||
|
Female
|
Male
|
Female
|
Male
|
||||||||||||||||
|
01
|
951.51
|
187.03
|
102.23
|
66.63
|
132.34
|
73.38
|
276.90
|
162.03
|
437.66
|
12,589.42
|
1,897.08
|
468.98
|
190.80
|
231.21
|
747.90
|
872.76
|
309.39
|
100.69
|
79.25
|
|
02
|
816.14
|
160.48
|
89.36
|
60.77
|
116.81
|
66.58
|
239.92
|
141.43
|
378.38
|
10,683.52
|
1,610.58
|
388.53
|
136.92
|
176.37
|
593.52
|
725.89
|
309.39
|
89.90
|
70.54
|
|
03
|
984.39
|
193.50
|
109.97
|
76.87
|
143.94
|
83.51
|
289.54
|
170.46
|
456.98
|
13,082.49
|
1,966.20
|
494.21
|
211.42
|
250.46
|
787.10
|
909.67
|
309.39
|
92.72
|
72.86
|
|
04
|
988.07
|
194.02
|
106.40
|
65.88
|
134.07
|
72.79
|
284.87
|
164.93
|
455.28
|
13,464.03
|
2,023.24
|
501.55
|
203.79
|
246.40
|
794.42
|
930.69
|
309.39
|
86.67
|
67.99
|
|
05
|
1,114.90
|
218.88
|
124.55
|
87.67
|
163.37
|
94.37
|
327.65
|
191.99
|
516.85
|
14,523.47
|
2,177.74
|
545.47
|
228.63
|
272.44
|
861.79
|
1,003.60
|
309.39
|
81.38
|
63.73
|
|
06
|
1,026.31
|
201.56
|
114.28
|
82.70
|
152.39
|
88.80
|
303.65
|
179.04
|
475.61
|
13,110.81
|
1,969.85
|
496.21
|
215.95
|
254.05
|
796.88
|
913.80
|
309.39
|
78.98
|
61.77
|
|
07
|
972.52
|
190.99
|
107.28
|
69.37
|
135.97
|
76.04
|
279.40
|
161.46
|
446.02
|
13,644.01
|
2,049.69
|
507.86
|
202.73
|
246.78
|
792.90
|
937.50
|
309.39
|
77.64
|
60.7
|
|
008
|
958.69
|
188.49
|
111.78
|
83.85
|
148.15
|
89.99
|
283.16
|
167.19
|
445.48
|
12,460.72
|
1,873.82
|
472.00
|
201.24
|
238.82
|
745.01
|
864.91
|
309.39
|
84.99
|
66.61
|
|
09
|
1,039.23
|
204.22
|
117.13
|
82.10
|
152.67
|
88.99
|
303.69
|
177.86
|
480.14
|
14,397.66
|
2,160.69
|
533.58
|
208.48
|
255.77
|
826.34
|
984.74
|
309.39
|
87.98
|
69.03
|
|
10
|
1,034.40
|
203.16
|
113.31
|
77.19
|
148.00
|
83.86
|
301.15
|
175.83
|
474.85
|
17,969.34
|
2,691.92
|
670.42
|
276.66
|
331.42
|
1,060.34
|
1,237.23
|
309.39
|
97.56
|
76.73
|
|
11
|
1,192.79
|
234.12
|
136.47
|
100.36
|
179.69
|
104.59
|
350.59
|
205.44
|
550.64
|
15,059.58
|
2,256.02
|
568.28
|
236.28
|
280.13
|
886.55
|
1,037.75
|
309.39
|
127.34
|
100.75
|
|
6B *
|
1,025.81
|
201.47
|
114.28
|
82.88
|
152.52
|
88.96
|
303.69
|
179.15
|
475.51
|
13,109.63
|
1,969.69
|
496.24
|
216.10
|
254.18
|
797.09
|
913.82
|
309.39
|
78.98
|
61.77
|
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+)
|
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
|
951.62
|
187.14
|
104.51
|
77.72
|
142.70
|
83.74
|
286.26
|
171.39
|
443.95
|
12,591.19
|
1,898.85
|
489.44
|
240.71
|
271.47
|
827.56
|
902.95
|
326.73
|
110.64
|
89.20
|
|
02
|
816.22
|
160.56
|
91.04
|
68.95
|
124.44
|
74.21
|
246.82
|
148.33
|
383.01
|
10,685.97
|
1,613.03
|
416.82
|
205.95
|
232.05
|
703.69
|
767.64
|
326.73
|
99.85
|
80.49
|
|
03
|
984.49
|
193.60
|
112.04
|
86.98
|
153.38
|
92.95
|
298.07
|
178.99
|
462.71
|
13,084.04
|
1,967.75
|
512.13
|
255.14
|
285.73
|
856.88
|
936.11
|
326.73
|
102.67
|
82.81
|
|
04
|
988.25
|
194.20
|
109.96
|
83.23
|
150.27
|
88.99
|
299.51
|
179.57
|
465.12
|
13,465.98
|
2,025.19
|
524.12
|
258.85
|
290.81
|
882.30
|
963.99
|
326.73
|
96.62
|
77.94
|
|
05
|
1,115.01
|
218.99
|
126.78
|
98.55
|
173.52
|
104.52
|
336.83
|
201.17
|
523.02
|
14,525.38
|
2,179.65
|
567.54
|
282.48
|
315.88
|
947.74
|
1,036.17
|
326.73
|
91.33
|
73.68
|
|
06
|
1,026.37
|
201.62
|
115.51
|
88.69
|
157.98
|
94.39
|
308.71
|
184.10
|
479.01
|
13,112.16
|
1,971.20
|
511.79
|
253.97
|
284.72
|
857.56
|
936.79
|
326.73
|
88.93
|
71.72
|
|
07
|
972.69
|
191.16
|
110.70
|
86.03
|
151.52
|
91.59
|
293.45
|
175.51
|
455.46
|
13,646.23
|
2,051.91
|
533.55
|
265.41
|
297.34
|
892.93
|
975.41
|
326.73
|
87.59
|
70.65
|
|
08
|
958.77
|
188.57
|
113.43
|
91.90
|
155.67
|
97.51
|
289.95
|
173.98
|
450.05
|
12,462.32
|
1,875.42
|
490.45
|
246.25
|
275.13
|
816.84
|
892.13
|
326.73
|
94.94
|
76.56
|
|
09
|
1,039.35
|
204.34
|
119.58
|
94.02
|
163.80
|
100.12
|
313.75
|
187.92
|
486.90
|
14,400.21
|
2,163.24
|
563.00
|
280.25
|
313.66
|
940.88
|
1,028.15
|
326.73
|
97.93
|
78.98
|
|
10
|
1,034.51
|
203.27
|
115.48
|
87.76
|
157.86
|
93.72
|
310.07
|
184.75
|
480.84
|
17,971.77
|
2,694.35
|
698.46
|
345.06
|
386.60
|
1,169.51
|
1,278.60
|
326.73
|
107.51
|
86.68
|
|
11
|
1,192.88
|
234.21
|
138.30
|
109.27
|
188.01
|
112.91
|
358.11
|
212.96
|
555.69
|
15,061.70
|
2,258.14
|
592.74
|
295.97
|
328.28
|
981.81
|
1,073.85
|
326.73
|
137.29
|
110.70
|
|
6B *
|
1,025.87
|
201.53
|
115.46
|
88.65
|
157.91
|
94.35
|
308.56
|
184.02
|
478.78
|
13,110.97
|
1,971.03
|
511.75
|
253.94
|
284.70
|
857.48
|
936.71
|
326.73
|
88.93
|
71.72
|
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 4 of 5
| ATTACHMENT I |
| EXHIBIT 2-NR-C |
| MEDICAID NON-REFORM HMO CAPITATION RATES |
| ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS |
| By Area, Age and Eligibility Category |
| Effective September 1, 2011 |
|
Area
|
Corresponding Counties
|
|
Area 1
|
Escambia, Okaloosa, Santa Rosa, Walton
|
|
Area 2
|
Bay, Xxxxxxx, Xxxxxxxx, Gadsden, Xxxx, Xxxxxx, Xxxxxxx, Xxxxxxxxx, Xxxx, Xxxxxxx, Xxxxxxx, Xxxxxx, Washington, Wakulla
|
|
Area 3
|
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Xxxxxxxx, Xxxxxxxxx, Xxxx, Xxxx, Xxxxxx, Xxxxxx, Xxxxxx, Suwannee, Union
|
|
Area 4
|
Xxxxx, Xxxx, Xxxxx, Xxxxxxx, Nassau, St. Xxxxx, Volusia
|
|
Area 0
|
Xxxxx, Xxxxxxxx
|
|
Area 6
|
Xxxxxx, Highlands, Manatee, Polk
|
|
Area 6B *
|
Hillsborough
|
|
Area 0
|
Xxxxxxx, Xxxxxx, Xxxxxxx, Xxxxxxxx
|
|
Area 8
|
Charlotte, Xxxxxxx, Xx Xxxx, Glades, Xxxxxx, Xxx, Sarasota
|
|
Area 0
|
Xxxxxx Xxxxx, Xxxxxxxxxx, Xx. Xxxxx, Xxxxxx, Xxxx Xxxxx
|
|
Area 10
|
Broward
|
|
Area 11
|
Dade, Monroe
|
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 5 of 5
