Amendment

Ahca Contract No. Fa905 Amendment No. 2

Exhibit 10.55.2
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
AHCA CONTRACT NO. FA905
AMENDMENT NO. 2
 
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 I, Scope of Services, Capitated Health Plans, Section B. Population(s) to be Served, Item 1., the third paragraph is hereby amended to now read as follows:
 
    **
Enrolled in an Agency-authorized specialty plan for children with chronic conditions and screened by the Florida Department of Health as clinically eligible for Children's  Medical Services using an Agency-approved screening tool as specified in Attachment II, Section III, Eligibility and Enrollment, Exhibit 3.
 
2.
Attachment I, Scope of Services,  Capitated Health Plans, Section F., Applicable Exhibits, Table 9, Applicable Exhibits, is hereby deleted in its entirety and replaced with the following:
 
 Table 9-A
Revised Applicable Exhibits
Attachment/
Exhibit*
HMO
Reform
HMO
Non-
Reform
Specialty
Plan for
Recipients
Living with
HIV/AIDS
Reform
Fee-
for-
Service
PSN
Non-
Reform
Capitated
PSN
Non-
Reform
Fee-
for-
Service
PSN
Reform
Capitated
PSN
Reform
Specialty
Plan for
Children with
Chronic
Conditions
Reform
HMO
Non-
Reform
with Frail/
Elderly
Program
Att. 1, Exh. 1
X
X
X
N/A
X
N/A
X
N/A
X
Att. I, Exh. 1-
FFS
N/A
N/A
N/A
X
N/A
X
N/A
X
N/A
Att. I, Exh.
2-NR
N/A
X
N/A
N/A
X
N/A
N/A
N/A
X
Att. I, Exh. 2-R
X
N/A
X
N/A
N/A
N/A
X
N/A
N/A
Att. I, Exh.
2-FFS-NR
N/A
N/A
N/A
X
N/A
N/A
N/A
N/A
N/A
Att. I, Exh.
2-FFS-R
N/A
N/A
N/A
N/A
N/A
X
N/A
X
N/A
Att. II, Exh. 1
N/A
N/A
X
N/A
N/A
N/A
N/A
X
N/A
Att. II, Exh. 2
X
X
X
X
X
X
X
X
X
Att. 2, Exh. 3
X
N/A
X
X
N/A
X
X
X
X
Att. II, Exh. 4
X
N/A
X
N/A
N/A
X
X
X
X
Att. II, Exh. 5
X
X
X
X
X
X
X
X
X
Att. II, Exh. 6-
HMO&R
X
X
X
N/A
N/A
X
X
X
X
Att. II, Exh. 6-
PSN-NR
N/A
N/A
N/A
X
X
N/A
N/A
N/A
N/A
Att. II, Exh. 7
X
N/A
X
X
N/A
X
X
X
N/A
Att. II, Exh. 8
X
X
X
X
X
X
X
X
X
Att. II, Exh. 9
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Att. II, Exh. 10
X
X
X
X
X
X
X
X
X
Att. II, Exh. 11
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Att. II, Exh. 12
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
 
AHCA Contract No. FA905, Amendment No. 2, Page 1 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
                                                                                                                             
 Table 9-A
Revised Applicable Exhibits
Attachment/
Exhibit*
HMO
Reform
HMO
Non-
Reform
Specialty
Plan for
Recipients
Living with
HIV/AIDS
Reform
Fee-
for-Service
PSN
Non-
Reform
Capitated
PSN
Non-
Reform
Fee-
for-
Service
PSN
Reform
Capitated
PSN
Reform
Specialty
Plan for
Children with
Chronic
Conditions
Reform
HMO
Non-
Reform
with Frail/
Elderly
Program
Att. II, Exh.
13-CAP-R
X N/A X N/A N/A X X N/A N/A
Att. II, Exh.
13-CAP-NR
N/A X N/A N/A X N/A N/A N/A X
Att. II, Exh.
13-FFS
N/A N/A N/A X N/A X N/A X N/A
Att. II, Exh. 14
N/A N/A N/A N/A N/A N/A N/A N/A N/A
Att. II, Exh. 15
X X X X X X X X X
Att. II, Exh. 16
X X X X X X X X X
 
* Plans offering certain optional coverage also will have additional language in the exhibits as follows: Exhibits 3, 4, 5, 8 and 13 -Frail/Elderly Program; Exhibit 5 - dental and transportation. Safety net hospital-based PSNs will have additional language in the exhibits as follows: - Exhibit 13 - Method of Payment.
 
3.  
Effective November 1, 2009, Attachment I, Scope of Services, Capitated Health Plans, is hereby amended to include Exhibit 2-NR-A, Medicaid Non-Reform HMO Capitation Rates, Effective November 1, 2009 - August 31, 2012, attached hereto and made a part of this Contract. All references to Exhibit 2-NR, Medicaid Non-Reform HMO Capitation Rates, September 1, 2009 - August 31, 2010, shall hereinafter also refer to Exhibit 2-NR-A, as appropriate.
 
4.  
Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms, Item A., Definitions, the following definitions are hereby amended to now read as follows:
 
Catastrophic Component Threshold - (Capitated Reform Health Plans in counties where no HMO is present, Reform FFS PSNs, and the Specialty Plan for Children with Chronic Conditions only) - The point at which the cost of covered services, based on Medicaid fee-for-service payment levels, reaches $50,000 for an enrollee in a Contract year. For a Health Plan that accepts the comprehensive capitation rate only, the Agency begins reimbursing the Health Plan for the cost of covered services received by the enrollee for the remainder of the Contract year. This reimbursement is based on a percentage of Medicaid fee-for-service payment levels.
 
Comprehensive Component - (Capitated Reform Health Plans in counties where no HMOs are present, Reform FFS PSNs, and the Specialty Plan for Children with Chronic Conditions only) - The amount of financial risk assumed by a Health Plan to provide covered service up to $50,000 per enrollee based on Medicaid fee-for-service payment levels.
 
Contested Claim - (FFS PSNs and the Specialty Plan for Children with Chronic Conditions only) - A claim that has not been authorized and forwarded to the Medicaid fiscal agent by the Health Plan because it has a material defect or impropriety.
 
Federally Qualified Health Center (FQHC) - An entity that is receiving a grant under section 330 of the Public Health Service Act, as amended. (Also see Section 1905(I)(2)(B) of the Social Security Act.) FQHCs provide primary health care and related diagnostic services and may provide dental, optometric, podiatry, chiropractic and behavioral health services.
 
Share of Cost-Savings - (FFS PSNs and the Specialty Plan for Children with Chronic Conditions only) -Potential payment to the Health Plan when amount of the savings pool exceeds the administrative allocation to the Health Plan as determined through a reconciliation process.
 
AHCA Contract No. FA905, Amendment No. 2, Page 2 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
5.
Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms, Item B., Acronyms, the following acronym is hereby amended to now read as follows:
 
APD — Agency for Persons with Disabilities
 
6.
Attachment II, Core Contract Provisions, Section II, General Overview, Item D., General Responsibilities of the Health Plan, sub-item 1., the first sentence is hereby amended to now read as follows:
 
The Health Plan shall comply with all provisions of this Contract, including all attachments, applicable exhibits, Health Plan Report Guide (Report Guide) requirements and any amendments and shall act in good faith in the performance of the Contract provisions.
 
7.
Attachment II, Core Contract Provisions, Section III, Eligibility and Enrollment, Item B., Enrollment, sub-item 3.c.(3), the third sentence is hereby amended to now read as follows:
 
(Special provisions apply to fee-for-service PSNs and the Specialty Plan for Children with Chronic Conditions; see Exhibit 3.)
 
8.
Attachment II, Core Contract Provisions, Section III, Eligibility and Enrollment, Item B., Enrollment, sub-item 3.c.(8) is hereby amended to now read as follows:
 
 
 (8)
If the unborn activation process is properly completed by the FFS PSN and the Specialty Plan for Children with Chronic Conditions, the newborn will be enrolled using the process in Attachment II, Exhibit 3.
 
9.
Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 1.c. is hereby amended to now read as follows:
 
 
 c.
The Health Plan shall mail all enrollee materials to the enrollee's payee address provided by the Agency on the Health Plan's monthly enrollment file. Mailing envelopes for enrollee materials shall contain a request for address correction. When enrollee materials are returned to the Health Plan as undeliverable, the Health Plan shall remail the materials to the enrollee residence address provided by the Agency if that address is different from the payee address. The Health Plan shall use and maintain in a file a record of all of the following methods to contact the enrollee:
 
(1)  
Routine checks of the Agency enrollment reports for changes of address and/or presence of the enrollee's residence address, maintaining a record of returned mail and attempts to remail to either a new payee address or residence address as provided by the Agency;
 
(2)  
Telephone contact at the number obtained from Agency enrollment reports, the local telephone directory, directory assistance, city directory, or other directory; and
 
(3)  
Routine checks (at least once a month for the first three (3) months of enrollment) on services or claims authorized or denied by the Health Plan to determine if the enrollee has received services, and to locate updated address and telephone number information.
 
10.
Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 7.d. is hereby amended to include the following:
 
If the Health Plan uses the Medicaid fee-for-service pharmacy network as its pharmacy network, the provider directory shall include a statement to this effect.
 
11.
Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 15., Enhanced Services is hereby deleted in its entirety and replaced as follows:
 
AHCA Contract No. FA905, Amendment No. 2, Page 3 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
15.  Enhanced Benefits Program (Reform Only; See Attachment II, Exhibit 4)
 
12.
Attachment II, Core Contract Provisions, Section V, Covered Services, Item F., Moral or Religious Objections, sub-item 1. is hereby amended to now read as follows:
 
 
1.      BMHC within one-hundred and twenty (120) calendar days before implementing the policy with respect to any service; and
 
13.
Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, sub-item 1., Requirements, the first sentence is hereby amended to now read as follows:
 
The Health Plan shall provide the services listed in Section V in accordance with the provisions herein, and in accordance with the Florida Medicaid Coverage and Limitations Handbooks and the Florida Medicaid State Plan unless, for Reform HMOs, a customized benefit package is certified in the benefit grid in Attachment I.
 
14.
Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, is hereby amended to include sub-item 10.a.(11) as follows:
 
        (11)
The Health Plan shall report quarterly to BMHC, within thirty (30) calendar days after the end of the quarter being reported, the Health Plan's complete listing of all Medicaid enrollees discharged from inpatient hospitalization, using the format provided in the Health Plan Report Guide referenced in Attachment II, Section XII, Reporting Requirements.
 
15.
Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, sub-item 14.e. is hereby amended to now read as follows:
 
        e.
Submit an attestation with accompanying documentation annually, by October 1 of each Contract year, to BMHC that the Health Plan has advised its providers to enroll in the VFC program. The Agency may waive this requirement in writing if the Health Plan provides documentation to BMHC that the Health Plan is enrolled in the VFC program;
 
16.
Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, is hereby amended to include sub-item 16.k. as follows:
 
        k.
Capitated Health Plans covering Reform populations shall submit a complete pharmacy drug list to the Agency's Reform choice counseling vendor annually by December 1, using the format provided in the Health Plan Report Guide referenced in Attachment II, Section XII, Reporting Requirements.
 
17.
Attachment II, Core Contract Provisions, Section VII, Provider Network, Item C, Network Changes, sub-item 6. is hereby amended to now read as follows:
 
        6.
The Health Plan shall notify BMHC of any new network providers by the fifteenth (15th) of the month following execution of the provider agreement and terminated providers by the fifteenth (15th) of the month following the report month using the format provided in the Health Plan Report Guide referenced in Attachment II, Section XII, Reporting Requirements.
 
18.  
Attachment II, Core Contract Provisions, Section VII, Provider Network, Item E., Provider Termination, sub-item 3., the second sentence is hereby deleted in its entirety.
 
19.  
Attachment II,  Core Contract Provisions, Section  IX, Grievance System, Item  E.,  Resolution and Notification, sub-item 7.c. is hereby amended to now read as follows:
 
AHCA Contract No. FA905, Amendment No. 2, Page 4 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
        c.
The right to appeal an adverse decision on an appeal to the Subscriber Assistance Program (SAP) for HMOs or the Beneficiary Assistance Program (BAP) for PSNs, including how to initiate such a review and the following:
 
 
       (1) Before filing with the SAP or BAP, the enrollee must complete the Health Plan's appeal process;
     
       (2)
The enrollee must submit the appeal to the SAP or BAP within one (1) year after receipt of the final decision letter from the Health Plan;
     
       (3)
Neither the SAP nor the BAP will consider an appeal that has already been to a Medicaid Fair Hearing;
     
        (4) The address and toll-free telephone numbers of the SAP/BAP:
 
   Agency for Health Care Administration
 Subscriber Assistance Program / Beneficiary Assistance Program
 Building 1, MS #26
 2727 Mahan Drive
 Tallahassee, Florida 32308
 (850) 921-5458
 (888) 419-3456 (toll-free)
 
20.
Attachment II, Core Contract Provisions, Section XI, Information Management and Systems, Item D., Systems Availability, Performance and Problem Management Requirements, sub-item 8.a. is hereby amended to include the following:
 
If the approved plan is unchanged from the previous year, the Health Plan shall submit a certification to BMHC that the prior year's plan is still in place annually by April 30th of each Contract year. Changes in the plan are due to BMHC within ten (10) business days after the change.
 
21.
Attachment II, Core Contract Provisions, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, Table 1, Summary of Reporting Requirements, is hereby deleted in its entirety and replaced with the following Table 1-A, Revised Summary of Reporting Requirements. All references in the Contract to Table 1 shall hereinafter refer to Table 1-A.
 
TABLE 1-A
 
REVISED SUMMARY OF REPORTING REQUIREMENTS
 
Contract
Section
Report
Name
Plan
Type
Frequency
Submit To
Section II
and Exhibit 2
Benefit Maximum Report
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC
Monthly, fifteen (15) calendar
days after the end of the
reporting month in which
claims reach $450,000 in
enrollee costs
HSD
Contract
Manager
once
$450,000 is
reached, and to  
BMHC that initial
month and 
monthly thereafter
 through 
end of state fiscal year

AHCA Contract No. FA905, Amendment No. 2, Page 5 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
                                                                                                            
Contract
Section
Report Name
Plan Type
Frequency
Submit To
Section III
and Exhibit 3
Newborn Enrollment 
Report
NR FFS PSN; 
Ref FFS PSN; 
CCC
Weekly, on
Wednesday
Medicaid Area Office
Section III
and Exhibit 3
Involuntary
Disenrollment Report
Ref HMO; Ref 
FFS PSN; Ref 
Cap PSN;
CCC;
HIV/AIDS
Monthly, first Thursday of month
Choice
Counseling
Vendor
Section IV
Medicaid
Redetermination Notice  
Summary Report
All Plans that
participate per
Attachment I
Quarterly, forty-five (45) calendar days 
after end of reporting quarter
BMHC
Section IV
Community Outreach  
Health Fairs/Public
Events Notification
All Plans
Monthly, no later than 20th calendar day of
month before event month;
amendments two (2) weeks before event
BMHC
Section IV
Community Outreach  
Representative Report
All Plans
Two (2) weeks before activity
 
Quarterly, forty-five (45) calendar days  
after end of reporting quarter
BMHC
Section IV and
Exhibit 4
Enhanced Benefits Report
Ref HMO; Ref 
FFS PSN; Ref
Cap PSN;
CCC;
HIV/AIDS
Monthly, ten (10) calendar days after end
of reporting month
BMHC
Section V,
Exhibit 5
Customized Benefit  
Notifications Report
Ref HMO; Ref 
Cap PSN
Monthly, fifteen (15) calendar days after
end of reporting month
BMHC
Section V
CHCUP (CMS-416) & FL 
60% Screening (Child 
Health Check Up report)
All Plans
Annually,
unaudited by
January 15th for
prior federal fiscal
year;
Annually, audited
report by October
1st
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 6 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
                                                                                                                 
Contract Section
Report Name
Plan Type
Frequency
Submit To
Section V
Inpatient Discharge
Report
NR Ref HMO;               
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Quarterly, thirty (30) calendar days after end of reporting quarter
BMHC
Section V
Hernandez Settlement  
Ombudsman Log
NR HMO;
NR FFS PSN*;
NR Cap PSN;
Ref HMO;
Ref FFS PSN*;
Ref Cap PSN;
CCC*;
HIV/AIDS
 
* If the FFS  
Health Plan
has authorization
requirements
for prescribed
drug services
Quarterly, fifteen (15) calendar days after end of reporting quarter
BMHC
Section V
Hernandez Settlement
Agreement Survey
NR HMO;
NR FFS PSN*;
NR Cap PSN;
Ref HMO;
Ref FFS PSN*;
Ref Cap PSN;
CCC*;
HIV/AIDS
 
* If the FFS
Health Plan
has authorization
requirements
for prescribed
drug services
Annually, on
August 1st
BMHC
Section V
Quarterly Pharmacy (RX
Quarterly) Encounter Data
Submissions
NR HMO;
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Quarterly, thirty
(30) calendar days after end of reporting quarter
MEDS Team
Section V and
Exhibit 6
Behavioral Health -
Pharmacy Encounter
Data Report
NR HMO;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Quarterly, forty-five (45) calendar days after end of reporting quarter
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 7 of 22

 
 

 

 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
                                                                                                                                  
Contract
Section
Report Name
Plan Type
Frequency
Submit To
Section V
Pharmacy Navigator
Report
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Annually, by
December 1st
Choice
Counseling
Vendor
Section VI,
Exhibit 6
Behavioral Health Annual 80/20 Expenditure Report
NR HMO
Annually, by
April 1st
BMHC
Section VI,
Exhibit 6
Behavioral Health Critical Incident Report - Individual
NR HMO;
Ref-HMO;
Ref. FFS PSN;
Ref Cap. PSN;
CCC;
HIV/AIDS
Immediately, no later than twenty-four (24) hours
after occurrence or
knowledge of incident
BMHC
Section VI,
Exhibit 6
Behavioral Health Critical Incident Report - Summary
NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS
Monthly, by the 15th
BMHC
Section VI,
Exhibit 6
Behavioral Health - Required Staff/Providers  Report
NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS
Quarterly, forty-five (45) calendar days after end of
reporting quarter for Health Plans operating less than one (1) year;
 
Annually, by August 15th, for all other Health Plans
BMHC
Section VI,
Exhibit 6
Behavioral Health - FARS/CFARS
NR HMO
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC; 
HIV/AIDS
Semi-Annually, August 15th and February 15th
BMHC
Section VI,
Exhibit 6
Behavioral Health - Enrollee Satisfaction Survey Summary
NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap  
PSN;
CCC;
HIV/AIDS
Annually by March 1st
BMHC  behavioral
health analyst
Section VI,
Exhibit 6
Behavioral Health -Stakeholders' Satisfaction Survey - Summary
NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS
Annually, by March 1st
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 8 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
                                                                                                                  
Contract
Section
Report Name
Plan Type
Frequency
Submit To
Section VI,
Exhibit 6
Behavioral Health - Encounter Data Report
NR HMO;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Quarterly, forty-five (45) calendar days
after end of reporting
quarter
BMHC
Section VII
Provider Network File
All Plans
Monthly, first Thursday of
month (optional weekly
submissions each
Thursday for remainder of
month)
AHCA Choice
Counseling
Vendor for
Reform;
 
For non-Reform, to
Medicaid fiscal
agent and BMHC
Section VII
Provider Termination and New 
Provider Notification Report
All Plans
Summary of new and 
terminated providers due
monthly, by the fifteenth
(15th) calendar day of the
month following the
reportinq month
BMHC
Section VII
PCP Wait Times Report
All Plans
Annually, by
February 1st
BMHC
Section VIII
Cultural Competency Plan (and Annual Evaluation)
All Plans
Annually, October 1st
BMHC
Section  VIII and Exhibit 5
Performance Measures
All Plans
Annually, on July 1st
BMQM
Section IX
Complaints, Grievance, and Appeals
Report
All Plans
Quarterly, fifteen (15)
calendar days after end of
quarter
BMHC
Section X
MPI - Quarterly Fraud & Abuse
Activity Report
All Plans
Quarterly, fifteen (15)  
calendar days after the end
of reporting quarter
MPI
Section X
MPI - Suspected/ Confirmed Fraud &
Abuse Reporting
All Plans
Within fifteen (15) 
calendar days of detection
MPI

 
AHCA Contract No. FA905, Amendment No. 2, Page 9 of 22

 
 

 

 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
                                                                                                                                   
Contract Section
Report Name
Plan Type
Frequency
Submit To
Section X
Claims Aging Report & Supplemental
Filing Report
All Plans
Quarterly, forty-five (45)
calendar days after end of
reporting quarter;
 
Capitated Plans,
optional
supplemental filing - one-
hundred and five (105)
calendar days after end of
reporting quarter
BMHC
Section XIII,  
Exhibit 13
Medicaid Reform Supplemental
HIV/AIDS Report
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS
Monthly, by
second Thursday of month
BMHC
Section XIII,
Exhibit 13
Catastrophic Component Threshold
Report
Ref HMO;
Ref FFS PSN; 
Ref Cap PSN;
CCC per Attachment I
Monthly, fifteen (15)
calendar days after end of
reporting month
BMHC
Section XV,
Exhibit 15
Insolvency Protection Multiple
Signatures Agreement Form
NR HMO;
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS
Annually, by
April 1st;
 
Thirty (30) calendar days
after any change
BMHC
Section XV
Audited Annual and Unaudited
Quarterly Financial Reports
All Plans except CCC
Audited -Annually by April
1st for calendar year;
 
Unaudited - Quarterly,
forty-five (45) calendar
days after end of reporting
quarter
BMHC
Section XVI, 0.
and Section XVI,
  W.
Minority Participation Report
All Plans
Monthly, fifteen (15)
calendar days after month
being reported
BMHC and HSD
 
NR HMO = Non-Reform health maintenance organization, includes Health Plans covering
Frail/Elderly Program services as specified in Attachment I
Ref HMO = Reform health maintenance organization
Ref Cap PSN = Reform capitated provider service network
Ref FFS PSN = Reform Fee-for-Service Provider Service Network
NR Cap PSN = Non-Reform Capitated Provider Service Network
NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC = Specialty plan for children with chronic conditions
HIV/AIDS = Specialty plan for recipients living with HIV/AIDS

 
AHCA Contract No. FA905, Amendment No. 2, Page 10 of 22

 
 

 

 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
22. 
Attachment II, Core Contract Provisions, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, Table 2, Summary of Submission Requirements, is hereby deleted in its entirety and replaced with the following Table 2-A, Revised Summary of Submission Requirements. All references in the Contract to Table 2 shall hereinafter refer to Table 2-A.

TABLE 2-A
 
REVISED SUMMARY OF SUBMISSION REQUIREMENTS
 
2.  Other Health Plan submissions (not in Table 1-A) required by the Agency are as follows:
 
Contract Section
Submission
Plan Type
Frequency
Submit To
Attachment I, Section B., Item 3.a.
Increase in enrollment levels
Capitated Health Plans;
FFS PSNs;
CCC
Before increases occur
BMHC and HSD
Attachment I, Section D., Item 3.b.
Changes to optional or expanded services
FFS PSNs;
CCC
Annually, by June
15th
HSD
Attachment I, Section D., Item 3.c.
Changes to optional or expanded services
Capitated Health Plans
Annually, by June
15th
HSD
Subsequent references are to Attachment II and its Exhibits
Section II,
Item D.4.
Policies, procedures, model provider agreements &
amendments, subcontracts,
All materials related to
Contract for distribution to
enrollees, providers, public
All
Before beginning use; whenever changes occur
BMHC
Section II,
Item D.4.a.
Written materials
All
Forty-five (45) calendar days before effective date
BMHC
Section II,
Item D.4.b
Written notice of change to enrollees
All
Thirty (30) calendar days before effective date
Enrollees affected by change
Section II, Item D.6.
Enrollee materials, PDL, provider & enrollee handbooks
All
Available on Health Plan's web site without log-in
Plan web site
Section III,
Item
B.3.c.(l)
Enrollee pregnancy
All
Upon confirmation
DCF & MPI
Section III,
Item
B.3.c.(3)
Unborn activation notice
All
Presentation for delivery
DCF & MPI

 
AHCA Contract No. FA905, Amendment No. 2, Page 11 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
Contract
Section
Submission
Plan Type
Frequency
Submit To
Section III,
Item B.3.d.
Birth information if no unborn activation
All
Upon delivery
DCF
Section III,
Item C.4.b.
Involuntary disenrollment request
All
Forty-five (45) calendar days before effective date
BMHC
Section III,
Item C.4.e.
Notice that Health Plan is requesting disenrollment in next Contract month
All
Before effective date
Enrollee affected
Section IV,
Item A.l.e.
Notice of reinstatement of enrollee
All
By 1st calendar day
of month after learning of reinstatement or within five (5) calendar days from receipt of enrollment file, whichever is later
Person being
reinstated
Section IV,
Item A.2.a.
and Item A.
6.a.(17);
Section VIII,
Item A.4.
How to get Health
Plan information in
alternative formats
All
Include in cultural
competency plan and enrollee
handbook, and upon request
Enrollees &
potential enrollees
Section IV,
Item A.2.c.
Right to get
information about Health Plan
All
Annually
Enrollees
Section IV,
Item A.7.c.
Provider directory
online file
All
Update monthly &
submit attestation
BMHC
Section IV,
Item A.9.a.
Enrollee assessments
All
Within thirty (30)
days of enrollment notify about pregnancy screening
Enrollees
 
Section IV,
Item A.9.c.
Enrollees more than 2
months behind in periodicity screening
All
Contact twice, if
needed
Enrollees who
meet criteria
Section IV,
Item A.ll.f.
Toll-free help line
performance standards
All
Get approval
before beginning operation
BMHC
Section IV,
Item A.12.
and Item
A.,6.a.(17);
Section VIII,
Item A.4.
How to access
translation services
All
Include in cultural
competence plan
and enrollee
handbook
Enrollees
Section IV,
Item A.14.a.
Incentive program
All
Get approval
before offering
BMHC
Section IV,
Item A.14.g.
Pre-natal care
programs
All
Before
implementation
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 12 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section IV,
Item A.17.c.
Notice of change in
participation in
redetermination
notices
All
If change in
participation, annually, by June 1st
BMHC
Section IV,
Item
A.17.c.(1)
Redetermination
policies & procedures
All
When Health Plan
agrees to
participate
BMHC
Section IV,
Item
A.17.c.(l)(a)
Notice in writing to
discontinue Medicaid
redetermination date data use
All
Thirty (30)
calendar days
before stopping
BMHC
Section IV,
Item B.3.c.
Member services
phone script responding to community outreach calls and outreach materials
All
Before use
BMHC
Section IV,
Item B.4.c.
In case of force
majeure, notice of participation in health fair or other public event
All
By day of event
BMHC
Section IV,
Item B.6.f.
Report of staff or
community outreach rep. violations
All
Within fifteen (15)
calendar days of knowledge
BMHC
Section V,
Item C.l.
Written details of
expanded services
All
Before
implementation
HSD
Section V,
Item F.
Decision to not offer a
service on
moral/religious
grounds
All
One-hundred and
twenty (120) calendar days before implementation
 
Thirty (30) calendar days before implementation
BMHC
 
 
Enrollees
Section V,
Item
H.10.b.2.
UNOS form &
disenrollment request
for specified transplants
All
When enrollee
listed
BMHC
Section V,
Item H.14.e.
Attestation that the
Health Plan has advised providers to enroll in VFC program
 
All
Annually, by
October 1st
BMHC
Section V,
Item
H.16.a.(4)
PDL update
All
Annually, by
October 1st.
 
Thirty (30) calendar days written notice of change.
BMHC and Bureau
of Medicaid
Pharmacy Services

 
AHCA Contract No. FA905, Amendment No. 2, Page 13 of 22

 
 

 
 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section VII,
Item A.2.
Capacity to provide
covered services
All
Before taking
enrollment
BMHC
Section VII,
Item C.l.
Request for initial or
expansion review
All
When requesting
initial enrollment or expansion into a county.
BMHC and HSD
Section VII,
Item C.2.
Compliance with
access requirements following significant changes in service area or new populations
All
Before expansion
BMHC and HSD
Section VII,
Item C.3.
Significant network
changes
All
Within seven (7)
business days
BMHC
Section VII,
Item C.5.
When PCP leaves
network
All
Within fifteen (15)
calendar days of knowledge.
A copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after receipt of the PCP termination notice.
BMHC & affected
enrollees
Section VII,
Item D.2.jj.
Waiver of provider
agreement indemnifying clause
All
Approval before
use
BMHC
Section VII,
Item E.3.
Notice of terminated
providers due to
imminent
danger/impairment
All
Immediate
BMHC and Provider
Section VII,
Item E.4.
Termination or
suspension of
providers; for "for
cause" terminations,
include reasons for
termination
All
Sixty (60) calendar
days before
termination
effective date
BMHC, affected
enrollees, &
provider
Section VIII,
Item A.l.b.
Written Quality
Improvement Plan
All
Within thirty (30)
calendar days of initial Contract execution; Thereafter, Annually by April 1st
BMHC
Section VIII,
Item
A.3.a.(6)
Measurement periods
and methodologies
All
Any new PIPs
before initiation
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 14 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
Contract
Section
Submission
Plan Type
Frequency
Submit To
Section VIII,
Item
A.3.a.(7)
Proposal for each
planned PIP
All
Ninety (90)
calendar days after
Contract execution; Thereafter, Annually by June 1st
BMHC
Section VIII,
Item
A.3.c.(l)
Performance measure
data and auditor
certification
All
Annually by July 1st
BMQM
Section VIII,
Item
A.3.c.(4)
Performance measure
action plan
All
Within thirty (30)
calendar days of
determination of
unacceptable
performance
BMQM
Section VIII,
Item
A.3.e.(7)
Written strategies for
medical record review
All
Before use
BMHC
Section VIII,
Item
B.l.a.(4)(a)
Service authorization
protocols & any
changes
All
Before use
BMHC
Section VIII,
Item B.4.
Changes to UM
component
All
Thirty (30)
calendar days before
effective date
BMHC
Section IX,
Item A.8.
Complaint log
All
Upon request
BMHC
Section X,
Item B.2.
Changes in staffing
All
Five (5) business
days of any change
BMHC & HSD
Section X,
Item B.2.b.
Full-Time
Administrator
All
Before designating
duties of any other position
BMHC
Section X,
Item D. 3. a.
Reform and non-
Reform historical encounter data for all typical and atypical services
All
According to
Agency-approved schedules and no later than 10/31/09
MEDS team &
Fiscal Agent
Section X,
Item D.3.b.
Encounter data for all
typical and atypical
services
All
Within sixty (60)
calendar days
following end of month in which Health Plan paid claims for services, and as specified in MEDS Companion Guide
MEDS Team &
Agency Fiscal
Agent
Section X,
Item E.4.
Fraud & abuse
compliance plan & policies & procedures
All
Before
implementation
MPI
Section XI,
Item D.4.a.
Any problem that
threatens system performance
All
Within one (1)
hour
Applicable Agency
staff

 
AHCA Contract No. FA905, Amendment No. 2, Page 15 of 22

 
 

 

 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
                                                                                                                               
Contract Section
Submission
Plan Type
Frequency
Submit To
Section XI, Item D.8.a.
Business Continuity-Disaster Recovery Plan
All
Before beginning operation and certification if plan is unchanged by April 30 annually thereafter;
 
Changes within ten (10) business days of change
BMHC
Section XI, Item E.l.
System changes
All
Ninety (90) calendar days before change
HSD
Section XIV, Item A.l.(a.)
Corrective action plan
All
Within ten (10) business days of notice of violation or non-compliance with Contract
Agency Bureau sending violation notice
Section XIV, Item A.l.(b)
Performance measure action plan
All
Within thirty (30) calendar days of notice of failure to meet a performance standard
Agency Bureau sending violation notice
Section XV, Item C.
Proof of working capital
All
Before enrollment
BMHC
Section XV, Item G.2.
Physician incentive plan
All
Written description before use
BMHC
Section XV, Item H.
Third party coverage identified
All
As soon as known
Medicaid Third Party Liability Vendor
Section XV, Item I.
Proof of fidelity bond coverage
All
Within sixty (60) calendar days of Contract execution & before delivering health care
HSD Contract manager
Section XVI, Item C.l.
Request for Assignment or Transfer of Contract in approved merger/acquisition
All
Ninety (90) days before effective date
HSD
Section XVI, Item M.
Use of "Medicaid" or "AHCA"
All
Before use
BMHC
Section XVI, Item O.
All subcontracts for Agency approval
All
Before effective date
BMHC
Section XVI, Item O.l.f.
Subcontract monitoring schedule
All
Annually, by December 1
BMHC
Section XVI, Item V.l.
Ownership & management disclosure forms
All
With initial application; and then annually by
September 1
HSD - for initial application; BMHC & HSD for annual

 
AHCA Contract No. FA905, Amendment No. 2, Page 16 of 22

 
 

 
 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 

Contract Section
Submission
Plan Type
Frequency
Submit To
Section XVI, Item V.I.
Changes in ownership & control
All
Within five (5) calendar days of knowledge & sixty (60) days before effective date
BMHC & HSD
Section XVI, Item V.4.
Fingerprints for principals
All
Before Contract execution; Thereafter, annually by September 1
HSD
Section XVI, Item V.4.c.
Fingerprints of newly hired principals
All
Within thirty (30) calendar days of hire date
HSD
Section XVI, Item V.5.
Information about offenses listed in 435.03
All
Within five (5) business days of knowledge
HSD
Section XVI, Item V.6.
Corrective action plan related to principals committing offenses under 435.03
All
As prescribed by the Agency
HSD
Section XVI, Item Y.
General insurance policy declaration pages
All
Annually upon renewal
BMHC
Section XVI, Item Z.
Workers' compensation insurance declaration page
All
Annually upon renewal
BMHC
Section XVI, Item BB.
Emergency Management Plan
All
Before beginning operation and by May 31 annually thereafter
BMHC
Exhibit 2, Section II, Item D.4.c.
Policies & procedures for screening for clinical eligibility & any changes to them
CCC
Before implementation
BMHC
Exhibit 3, Section III, Item C.5.
Disenrollment notice
CCC
Get template approved before use
 
At least two (2) months before anticipated effective date of involuntary disenrollment
BMHC
 
Enrollee
Exhibit 5, Section V, Item A.6.
Letters about exhaustion of benefits under customized benefit package
Reform
capitated Health Plans
Before use
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 17 of 22

 
 

 
 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 

 
|      Contract Section
Submission
Plan Type
Frequency                  Submit To
Exhibit 5, Section V, Item H.20.g.
Transportation subcontract
NR HMO offering transportation; Reform Health Plans
Before execution
BMHC
Exhibit 5, Section V, Item H.20.h.
Transportation policies & procedures
NR HMO offering transportation; Reform Health Plans
Before use
BMHC
Exhibit 5, Section V, Item H.20.i.
Transportation adverse incidents
NR HMO offering transportation; Reform Health Plans
Within two (2) business days of the occurrence
BMHC
Exhibit 5, Section V, Item H.20.i
Transportation suspected fraud
NR HMO offering transportation; Reform Health Plans
Immediately upon identification
MPI
Exhibit 5, Section V, Item H.20.p.
Performance measures
NR HMO offering transportation; Reform Health Plans
Annually report by July l
BMQM
Exhibit 5, Section V, Item H.20.q. &r.
Attestation that Health Plan complies with transportation policies & procedures & drivers pass background checks & meet qualifications
NR HMO offering transportation; Reform Health Plans
Annually by January 1
BMHC
Exhibit 6, Item A.3.
Review & approval of behavioral health services staff & subcontractors for licensure compliance
Reform Health Plans & NR HMOs
Before providing services
BMHC
Exhibit 6, Item B.9.
Model agreement with community mental health centers
Reform Health Plans & NR HMOs
Before agreement is executed
BMHC
Exhibit 6, Item C.3.e.
Denied appeals from providers for emergency services claims
Plans covering
behavioral
health
Within ten (10) calendar days after Health Plan's final denial
BMHC
Exhibit 6,
Item
C.5.a.(3)
Medical necessity criteria for community mental health services
Plans covering
behavioral
health
Before use and before changes implemented
BMHC
Exhibit 6, Item L.2.
MBHO staff psychiatrist and model contracts for each specialty type
Plans covering
behavioral
health
Before execution
BMHC

 
AHCA Contract No. FA905, Amendment No. 2, Page 18 of 22

 
 

 
 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Exhibit 6, Item M.
Optional services
Plans covering
behavioral
health
Before offering
BMHC
Exhibit 6, Item R.3.a.
Schedule for administrative and program monitoring and clinical record review
Plans covering
behavioral
health
Annually by July 1
BMHC
Exhibit 8, Section VIII, Item B. 5.
Substitute disease
management
initiatives
CCC
Within sixty (60) calendar days of Contract execution
BMHC
Exhibit 8, Section VIII, Item A.3.f.
Provider satisfaction survey
All Reform Health Plans
By end of 8th month of Contract
BMHC
Exhibit 8, Section VIII, Item B.5.b.
Policies and procedures and program descriptions for each disease management program
All Reform Health Plans
Annually, by April
1
BMHC
Exhibit 8, Section VIII, Item B. 1. e. (5)
Caseload maximums for case managers
HIV/AIDS specialty plan
Before providing services
BMHC
Exhibit 10, Section X, Item C. 5. a.
Discrepancies in ERV
FFS Health
Plans;
CCC
Within ten (10) business days of discovery
HSD analyst
Exhibit 15, Section XV, Item A. 1. a.
Plan for transition from FFS to prepaid capitated plan
FFS PSNs; CCC
Last calendar day of 24th month of Health Plan's initial Reform operation
HSD
Exhibit 15, Section XV, Item A. 1. b.
Conversion application to capitated Health Plan
FFS PSNs; CCC
By August 1 of 4th year of Reform operation
HSD
Exhibit 15, Section XV, Item I.
Proof of coverage for any non-government subcontractor
CCC
Within sixty (60) calendar days of execution and before delivery of care
BMHC

 
NR HMO = Non-Reform health maintenance organization, includes Health Plans covering
Frail/Elderly Program services as specified in Attachment I
Ref HMO = Reform health maintenance organization
Ref Cap PSN = Reform capitated provider service network
Ref FFS PSN = Reform Fee-for-Service Provider Service Network
NR Cap PSN = Non-Reform Capitated Provider Service Network
NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC = Specialty plan for children with chronic conditions
HIV/AIDS = Specialty plan for recipients living with HIV/AIDS
 
23.
Attachment II, Core Contract Provisions, Section XIV, Sanctions, Item F., Notice of Sanction, sub-item 4. is hereby amended to now read as follows:

 
AHCA Contract No. FA905, Amendment No. 2, Page 19 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
   4.
For FFS PSNs and the Specialty Plan for Children with Chronic Conditions, the Agency reserves the right to withhold all or a portion of the Health Plan's monthly administrative allocation for any amount owed pursuant to this section.
 
24.
Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item C, Assignment, sub-item 1., the second sentence is hereby amended to now read as follows:
 
 The entity requesting the assignment or transfer shall notify HSD of the request ninety (90) calendar days before the anticipated effective date.
 
25.
Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O., Subcontracts, sub-item 1.e., the third sentence is hereby amended to now read as follows:
 
The Health Plan shall provide a monthly Minority Participation Report (see Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the HSD designated minority participation report contact, summarizing the business it does with minority subcontractors or vendors.
 
26.
Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item V., Ownership and Management Disclosure, sub-item 4.c. is hereby amended to now read as follows:
 
   c.
The Health Plan shall submit to the Agency Contract Manager complete sets of fingerprints of newly hired principals (officers, directors, agents, and managing employees) within thirty (30) calendar days of the hire date.
 
27.
Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item BB., Emergency Management Plan, the first sentence is hereby amended to now read as follows:
 
Before beginning operations and annually by May 31 of each Contract year, the Health Plan shall submit to BMHC for approval an emergency management plan specifying what actions the Health Plan shall conduct to ensure the ongoing provision of health services in a disaster or man-made emergency including, but not limited to, localized acts of nature, accidents, and technological and/or attack-related emergencies.
 
28.
Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, Item 3, Non-Reform HMOs covering transportation as an optional service and Reform Health Plans, Section V, Covered Services, Item H., Coverage Provisions, sub-item 20.i. is hereby amended to now read as follows:
 
  i.
The Health Plan shall report within two (2) business days of the occurrence, in writing to BMHC, any transportation-related adverse or untoward incident (see s. 641.55, F.S.). The Health Plan shall also report, immediately upon identification, in writing to MPI, all instances of suspected enrollee or transportation services provider fraud or abuse. (As defined in s. 409.913, F.S. See also Attachment II, Section X, Administration and Management, on fraud and abuse.)
 
29.
Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, Item 6, Non-Reform HMOs covering transportation as an optional service and Reform Health Plans, Section V, Covered Services, Item H., Coverage Provisions, sub-item 20.p. is hereby amended to now read as follows:
 
   p.
The Health Plan shall submit data on transportation performance measures as defined by the Agency and as specified in the Agency's Performance Measures Specifications Manual. The Health Plan shall report on those measures to the Agency as specified in Attachment II, Section VIII, Quality Management, Item A., Quality Improvement, sub-item 3.c. and Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.
 
30.
Attachment II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item K.4. is hereby amended to now read as follows:
 
AHCA Contract No. FA905, Amendment No. 2, Page 20 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
        4.      The Health Plan shall submit the FARS/CFARS reports to BMHC semi-annually August 15th and February 15th, as required in Attachment II, Section XII, Reporting
                 Requirements, and the Health Plan Report Guide.
 
31.
Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral Health Reporting Requirements is hereby amended to now read as follows:
 
        S.     Behavioral Health Reporting Requirements
 
Additional behavioral health reporting requirements are listed below. Behavioral health reporting requirements are also listed in Attachment II, Section XII, Reporting Requirements, and must be submitted as required in Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.
 
1.  
Behavioral Health Critical Incident Report - Individual - The Health Plan shall report the following events immediately, no later than twenty-four (24) hours after occurrence or knowledge of incident, to the BMHC behavioral health analyst and in accordance with Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.

 
2.  
Behavioral Health Critical Incident Report - Summary - The Health Plan shall submit to BMHC a summary of the previous calendar month's incidents regarding behavioral health critical incidents, involving Health Plan enrollees, by the 15th calendar day of every month, in accordance with Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.

 
3.  
Behavioral Health Encounter Data Report - The Health Plan shall submit to BMHC, quarterly within forty-five (45) calendar days of the end of the quarter being reported, an electronic representation of the Health Plan's complete listing of behavioral health services provided during the report period and in accordance with Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.

 
4.  
Behavioral Health Pharmacy Encounter Data Report - The Health Plan shall submit to BMHC quarterly, within forty-five (45) calendar days after the end of the quarter being reported, an accurate electronic representation of the Health Plan's complete listing of behavioral health prescription services administered during the quarter being reported and in accordance with Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.

 
5.  
Behavioral Health Required Staff/Providers Report - The Health Plan shall submit to BMHC the Behavioral Health Required Staff/Providers Report annually, by August 15. For Health Plans operating less than one (1) year, the Health Plan shall submit this report to BMHC quarterly, forty-five (45) days after the end of the quarter being reported. Submissions shall be submitted in accordance with Attachment II, Section XII, Reporting Requirements, and the Health Plan Report Guide.
 
32.
Attachment II, Core Contract Provisions, Exhibit 10, Administration and Management, Item 1., All Capitated Health Plans, Section X, Administration and Management, Item C, Claims Payment, is hereby amended to include sub-item 7. as follows:
 
    7.
The Health Plan shall reimburse providers for Medicare deductibles and co-insurance payments for Medicare dually eligible members according to the lesser of the following:
 
 a.  The rate negotiated with the provider; or
 
 b.  The reimbursement amount as stipulated in s. 409.908 F.S.

 
AHCA Contract No. FA905, Amendment No. 2, Page 21 of 22

 
 

 
 
HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
   
 
 Unless otherwise stated, this Amendment is effective upon execution by both parties or January 1, 2010, (whichever is later).
 
 All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the 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 twenty-seven (27) 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:
 
 
   
SIGNED
BY: 
 
 
[Illegible] for
 
           
NAME: Thomas Tran   NAME: Thomas W. Arnold  
           
TITLE: Chief Financial Officer   TITLE: Secretary  
           
DATE: January 13, 2010   DATE: 1-14-10  
 
                                                                
List of Attachments/Exhibits included as part of this Amendment:
 
 Specify 
Type    
 
 Letter/
Number
   Description  
Attachment I       Exhibit 2-NR-A  
Medicaid Non-Reform HMO Capitation Rates, Effective
November 1, 2009 - August 31, 2012 (5 Pages)
 
                                                                    
                                                      
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

 
AHCA Contract No. FA905, Amendment No. 2, Page 22 of 22

 
 

 

ATTACHMENT I
EXHIBIT 2-NR-A
MEDICAID NON-REFORM HMO CAPITATION RATES
By Area , Age and Eligibility Category
Effective November 1, 2009 - August 31, 2012
AGE (65+)

 
TABLE 1
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
1,130.45
171.80
102.22
61.92
136.81
72.25
266.35
158.36
341.82
12,166.98
1,661.31
450.32
195.11
211.04
684.60
713.62
345.23
81.01
75.25
02
1,130.45
171.80
102.22
61.92
136.81
72.25
266.35
158.36
341.82
12,166.98
1,661.31
450.32
195.11
211.04
684.60
713.62
345.23
81.01
75.25
03
1,204.98
184.85
110.04
67.83
147.39
78.95
288.08
172.19
374.81
12,984.80
1,788.35
485.21
215.10
232.17
751.31
786.48
219.92
78.09
72.84
04
1,050.61
162.46
96.93
60.59
129.54
70.25
254.54
152.86
335.21
12,420.29
1,720.68
467.26
210.34
226.43
732.37
768.88
158.79
76.07
71.40
05
1,184.66
182.33
108.66
67.27
145.40
78.31
284.72
170.59
372.41
14,030.18
1,934.34
524.96
233.58
251.40
814.40
853.04
257.97
63.54
59.91
06
1,065.08
165.73
99.12
62.65
132.43
72.63
260.83
157.38
347.13
12,740.87
1,765.91
479.44
216.29
232.64
751.93
789.61
332.29
65.62
61.55
07
1,094.60
170.03
101.66
64.09
135.85
74.27
267.33
161.18
354.76
13,685.78
1,905.44
518.10
236.50
253.97
819.80
862.97
278.88
68.32
64.02
08
1,037.09
161.01
96.20
60.62
128.67
70.25
253.12
152.46
335.67
12,799.17
1,774.58
482.11
218.12
234.44
756.47
794.55
315.60
66.83
62.63
09
1,052.10
161.97
96.51
59.97
129.16
69.61
253.28
151.74
331.35
12,607.35
1,749.19
475.00
215.23
231.33
746.37
783.86
278.68
73.65
68.75
10
1,097.08
171.38
102.63
65.26
137.12
75.61
270.62
163.74
362.13
16,173.96
2,267.27
616.85
286.58
306.25
989.86
1,043.17
351.29
80.41
75.32
11
1,387.45
213.12
126.92
78.43
169.76
91.10
332.48
199.01
433.39
16,510.81
2,276.81
618.22
275.31
296.69
960.17
1,005.22
380.51
117.49
109.41
6B*
1,064.96
165.71
99.11
62.64
132.41
72.62
260.80
157.36
347.08
12,740.29
1,765.81
479.42
216.27
232.63
751.89
789.57
332.29
65.62
61.55
  
  
TABLE 2
General + Mental Health Rates:
                                 
         
TANF
             
SSI-N
   
SSI-B
SSkAB
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
1,130.48
171.83
104.08
74.27
148.20
83.64
270.41
162.42
345.39
12,167.05
1,661.38
458.53
246.95
257.82
765.70
745.22
353.34
93.55
87.79
02
1,130.47
171.82
103.70
73.65
148.12
83.56
271.15
163.16
346.04
12,167.09
1,661.42
462.52
271.63
281.47
815.81
764.75
353.34
93.55
87.79
03
1,205.00
184.87
111.59
80.12
159.24
90.80
293.11
177.22
379.23
12,984.86
1,788.41
491.82
256.56
270.33
822.40
814.18
228.03
90.63
85.38
04
1,050.63
162.48
98.39
72.22
140.75
81.46
259.29
157.61
339.39
12,420.35
1,720.74
474.10
253.25
265.92
805.95
797.55
166.90
88.61
83.94
05
1,184.68
182.35
110.60
82.70
160.27
93.18
291.03
176.90
377.96
14,030.25
1,934.41
532.58
281.37
295.39
896.35
884.97
266.08
76.08
72.45
06
1,065.10
165.75
100.09
69.11
138.39
78.59
262.96
159.51
349.00
12,740.90
1,765.94
483.54
242.20
256.02
792.46
805.41
340.40
78.16
74.09
07
1,094.63
170.06
104.05
83.04
154.12
92.54
275.08
168.93
361.57
13,685.85
1,905.51
525.43
282.49
296.30
898.66
893.70
286.99
80.86
76.56
08
1,037.10
161.02
97.18
66.36
136.14
77.72
256.29
155.63
338.45
12,799.21
1,774.62
486.19
243.72
258.00
800.37
811.65
323.71
79.37
75.17
09
1,052.12
161.99
98.40
74.97
143.62
84.07
259.41
157.87
336.74
12,607.42
1,749.26
482.36
261.41
273.83
825.55
814.71
286.79
86.19
81.29
10
1,097.10
171.40
104.57
80.68
151.99
90.48
276.93
170.05
367.67
16,174.08
2,267.39
629.65
366.88
380.16
1,127.55
1,096.82
359.40
92.95
87.86
11
1,387.47
213.14
128.49
90.88
181.77
103.11
337.57
204.10
437.87
16,510.92
2,276.92
630.84
354.52
369.60
1,096.00
1,058.15
388.62
130.03
121.95
6B*
1,064.97
165.72
99.83
66.35
137.92
78.13
263.14
159.70
349.13
12,740.32
1,765.84
483.29
240.54
254.97
793.50
805.79
340.40
78.16
74.09

 
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 1 of 5

 
 

 

ATTACHMENT I
EXHIBIT 2-NR-A
MEDICAID NON-REFORM HMO CAPITATION RATES
By Area , Age and Eligibility Category
Effective November 1, 2009 -August 31, 2012
 
 
TABLE 3
General
 + MH + Dental Rates:
 
             
SSI-N
         
SSI-B
SSI-AB
 
                    TANF                          
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
1,130.49
171.84
105.46
76.79
150.71
85.83
271.81
163.93
348.70
12,167.05
1,661.38
459.71
248.69
259.34
767.10
747.24
353.34
94.73
88.76
02
1,130.48
171.83
105.08
76.17
150.63
85.75
272.55
164.67
349.35
12,167.09
1,661.42
463.70
273.37
282.99
817.21
766.77
353.34
94.73
88.76
03
1,205.01
184.89
114.60
85.61
164.70
95.58
295.67
179.97
385.26
12,984.86
1,788.42
494.65
260.76
273.98
824.81
817.66
229.28
92.63
87.02
04
1,050.64
162.49
100.16
75.45
143.97
84.27
261.36
159.84
344.27
12,420.35
1,720.74
475.76
255.71
268.06
808.10
800.67
168.79
90.28
85.30
05
1,184.69
182.37
114.20
89.29
166.83
98.92
294.84
181.00
386.95
14,030.26
1,934.42
536.45
287.10
300.37
899.47
889.49
266.16
79.19
75.00
06
1,065.11
165.77
102.78
74.04
143.29
82.87
265.06
161.76
353.94
12,740.90
1,765.95
486.45
246.51
259.76
795.04
809.15
343.25
80.33
75.87
07
1,094.64
170.08
106.68
87.86
158.91
96.73
276.71
170.68
365.40
13,685.85
1,905.52
528.40
286.88
300.12
900.23
895.97
287.74
82.30
77.75
08
1,037.12
161.05
101.81
76.83
144.58
85.09
258.91
158.45
344.63
12,799.22
1,774.63
489.94
249.27
262.83
802.91
815.32
326.18
81.28
76.74
09
1,052.13