AHCA CONTRACT NO. FA619 AMENDMENT NO. 5
Exhibit
10.7
AHCA
CONTRACT NO. FA619
AMENDMENT
NO. 5
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
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
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 XXXx BLANK
AHCA
Contract No. FA619, Amendment No. 5, Page 1 of 2
AHCA Form
2100-0002 (Rev. NOV03)
| HealthEase of Florida, Inc. | Medicaid HMO Contract |
IN WITNESS WHEREOF, the parties
hereto have caused this seven (7) page Amendment (which includes all attachments
hereto) to be executed by their officials thereunto duly authorized.
| HEALTHEASE OF FLORIDA, INC. |
STATE OF FLORIDA, AGENCY
FOR
HEALTH
CARE ADMINISTRATION
|
|
SIGNED
|
SIGNED
|
|
BY: /s/
Xxxxx
Xxxxxxxxx
|
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
|
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. FA619, Amendment No. 5, Page 2 of 2
AHCA Form
2100-0002 (Rev. NOV03)
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. FA619, 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. FA619, 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. FA619, 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
|
HCA
Contract No. FA619, Exhibit III-D, Page 4 of
5
EXHIBIT
Ill-D
September
1, 2008 - August 31, 2009
MEDICAID
NON-REFORM HMO CAPBTATION 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
10
|
Broward
|
|
Area
11
|
Dade,
Monroe
|
HCA
Contract No. FA619, Exhibit III-D, Page 5 of
5
