Contract

Ahca Contract No. Far001 Amendment No. 4


Exhibit 10.1
 

AHCA CONTRACT NO. FAR001
AMENDMENT NO. 4


THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency,” and HEALTHEASE HEALTH PLAN OF FLORIDA, INC., hereinafter referred to as the “Vendor,” is hereby amended as follows:

1.  
All references in the Contract to the Vendor’s company name are hereby changed from HealthEase Health Plan of Florida, Inc. to HealthEase of Florida, Inc. d/b/a HealthEase.  The Vendor’s contact information, including names, addresses and telephone numbers and the Vendor’s FEID number remain unchanged.

2.  
Effective September 1, 2007, Standard Contract, Section II., Item A., Contract Amount, the first sentence, is hereby revised to change the total amount of the Contract from $399,853,991.00 to $410,329,182.00 (an increase of $10,475,191.00).

3.  
Effective September 1, 2007, Attachment I, Scope of Services, Section C., Method of Payment, Item 1., General, the first paragraph is hereby revised to now read as follows:

 
Notwithstanding the payment amounts which may be computed with the rate tables specified in Tables 2 thru 8, the sum of total capitation payments under this Contract shall not exceed the total Contract amount of $410,329,182.00.00 (an increase of $10,475,191.00).

 
4.
Effective September 1, 2007, Attachment I, Scope of Services, Exhibits 1-A, 3-A, 4-A, 5-A, 6-A, 7-A, 8-A and 9-A, are hereby included and made a part of the Contract.  All references in the Contract to Exhibits 1, 3, 4, 5, 6, 7, 8 and 9, shall hereinafter refer respectively to Exhibits 1-A, 3-A, 4-A, 5-A, 6-A, 7-A, 8-A and 9-A.

 
5.
Effective September 1, 2007, Attachment II, Medicaid Reform Health Plan Model Contract, Section XIII, Method of Payment, Section B, Capitation Rate Payments, is hereby revised as follows:

--           Sub-item 1.b.(1)(b), is hereby amended to include the following:

Contract Year 2007-2008 Medicaid Reform rates under current Capitation Rate methodology.

--           Sub-item 1.b.(1)(i), the first paragraph is hereby amended to now read as follows:

 
(i)
50% of Risk Adjusted Methodology: The capitation amount based on the percentage of Risk-Adjusted methodology (h) multiplied by the Base Rates column for Risk-Adjusted methodology after budget neutrality factor (g).

--           Sub-item 1.b.(1)(j), the first sentence is hereby amended to now read as follows:

 
(j)
Final Rate (with Enhanced Benefit Adjustment): The current methodology capitation amount (d) added to the 50% of Risk-Adjusted methodology amount (i).

 
6.
This Amendment shall be effective upon execution by both parties or July 1, 2007, whichever is later.


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

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

This Amendment, and all its attachments, is 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 fourteen (14) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.
 

HEALTHEASE OF FLORIDA, INC. D/B/A HEALTHEASE
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION
SIGNED BY: /s/  Todd Farha
SIGNED BY: /s/  Andrew Agwunobi
NAME:   Todd S. Farha
NAME:  Andrew C. Agwunobi, M.D.
TITLE:    President and CEO                                                                
TITLE:   Secretary                                                                
DATE:    6/29/2007                                           
DATE:   6/29/07

List of Attachments/Exhibits included as part of this Amendment:


Specify Type
Letter/ Number
Description
Exhibit
1-A
Benefit Grid Effective September 1, 2007 (4 Pages)
Exhibit
3-A
Comprehensive Component and Catastrophic Component Capitation Rates (2 Pages)
Exhibit
4-A
Comprehensive Component Only (1 Page)
Exhibit
5-A
Capitation Rates SSI Medicare Part B Only and SSI Medicare Parts A and B Enrollees for All Medicaid Reform Counties (1 Page)
Exhibit
6-A
Capitation Rates for HIV/AIDS Populations for Each Medicaid Reform County (1 Page)
Exhibit
7-A
Capitation Rates for Children with Chronic Conditions for All Medicaid Reform Counties (1 Page)
Exhibit
8-A
Kick Payment Amounts for Covered Transplant Services (1 Page)
Exhibit
9-A
Kick Payment Amounts for Covered Obstetrical Delivery Services (1 Page)
 
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EXHIBIT 1-A
Benefit Grid
Effective September 1, 2007

(i)      Area 10 Broward- Children and Families

 
*IF ADDITIONAL SERVICES ARE NEEDED THEY MUST BE PRIOR AUTHORIZED.
 
Enhanced benefits
 (Circumcision, boys up to one year)
($25 OTC, per household per month)
(Adult Dental – Adult Dental – Exams / X-rays / Two Annual Standard Cleanings)
 
 

AHCA Contract No. FAR001, Exhibit 1-A, Page 1 of 4



(ii)                 Area 10 Broward- Aged and Disabled
 
 
*IF ADDITIONAL SERVICES ARE NEEDED THEY MUST BE PRIOR AUTHORIZED.
 
Enhanced benefits
(Circumcision, boys up to one year)
($25 OTC, per household per month)
(Meals on Wheels – Home delivery up to 10 meals post discharge)
(Expanded dental services – Exams/Xrays / Deep Cleaning/ Clear and Silver Fillings/ Crown (limited)
Flouride/Periodontal Scaling and root planing)
(Respite Events - up to 1 per month)

AHCA Contract No. FAR001, Exhibit 1-A, Page 2 of 4    



(i)      Area 4 Duval- Children and Families
 
 
*IF ADDITIONAL SERVICES ARE NEEDED THEY MUST BE PRIOR AUTHORIZED.
 
Enhanced benefits
(Circumcision, boys up to one year)
($25 OTC, per household per month)
(Adult Dental Exams / X-rays / Deep Cleaning / Unlimited Silver Fillings / Two Annual Standard Cleanings)

AHCA Contract No. FAR001, Exhibit 1-A, Page 3 of 4    

(ii)                 Area 4 Duval- Aged and Disabled
 
 
*IF ADDITIONAL SERVICES ARE NEEDED THEY MUST BE PRIOR AUTHORIZED.
 

Enhanced benefits
(Circumcision, boys up to one year)
($25 OTC, per household per month)
(Meals on Wheels)
(Adult Dental – Exams / X-rays / Deep Cleaning / Clear and Silver Fillings / Crown (limited) / Fluoride / Periodontal Scaling and Root Planing)
(Respite Events - up to 1 per month)


AHCA Contract No. FAR001, Exhibit 1-A, Page 4 of 4

 
EXHIBIT 3-A
COMPREHENSIVE COMPONENT AND CATASTROPHIC COMPONENT CAPITATION RATES

TABLE 2
   
Area:                      4
County:                      Duval, Clay, Baker and Nassau
September 1, 2007


ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

Age Range
 
 
FY0708 Discounted Reform rates Under Current Methodology
   
Percentage of Current Methodology
   
50% of Current Methodology
   
Preliminary FY0708 Base rates for Risk Adjusted Methodology
   
Budget Neutrality Factor
   
FY0708 Base rates for Risk Adjusted Methodology after Budget Neutrality
   
Percentage of Risk Adjusted Methodology
   
50% of Risk Adjusted Methodology
   
Final Rates (with Enhanced Benefit Adjustment)
 
 
a
 
 
 
b
     
c
     
d
     
e
     
f
     
g
     
h
   
i
     
j
 
                                                                           
Eligibility Category:
 
 
Children and Family
                                                       
                                                                           
Month 0-2 All
                                                                  $
942.31
 
Month 3-11 All
                                                                  $
218.74
 
1-5 All
    $
113.17
     
50
%   $
56.58
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
118.98
 
6-13 All
    $
82.75
     
50
%   $
41.37
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
104.08
 
14-20 Female
    $
119.81
     
50
%   $
59.91
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
122.24
 
14-20 Male
    $
81.70
     
50
%   $
40.85
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
103.56
 
21-54 Female
    $
218.13
     
50
%   $
109.06
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
170.41
 
21-54 Male
    $
158.54
     
50
%   $
79.27
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
141.22
 
55+ All
    $
350.55
     
50
%   $
175.28
    $
124.53
     
1.04120
    $
129.66
     
50
%   $
64.83
    $
235.30
 
         
 
     
 
                                                         
Composite Based on Total Casemonths
    $
119.40
                                    $
129.66
            $
0.00
    $
122.04
 
         
 
                                                                 
Eligibility Category:
   
Aged and Disabled
                                                         
         
 
                                                                 
Month 0-2 All
     
 
                                                            $
14,803.79
 
Month 3-11 All
     
 
                                                            $
3,019.63
 
1-5 All
    $
537.41
     
50
%
  $
268.70
    $
657.05
     
1.05080
    $
690.42
     
50
%   $
345.21
    $
601.64
 
6-13 All
    $
312.13
     
50
%   $
156.06
    $
657.05
     
1.05080
    $
690.42
     
50
%   $
345.21
    $
491.25
 
14-20 All
    $
296.53
     
50
%   $
148.27
    $
657.05
     
1.05080
    $
690.42
     
50
%   $
345.21
    $
483.61
 
21-54 All
    $
790.16
     
50
%   $
395.08
    $
657.05
     
1.05080
    $
690.42
     
50
%   $
345.21
    $
725.49
 
55+ All
    $
809.32
     
50
%   $
404.66
    $
657.05
     
1.05080
    $
690.42
     
50
%   $
345.21
    $
734.88
 
                                                                             
Composite Based on Total Casemonths
    $
623.67
                                    $
690.42
            $
0.00
    $
643.91
 

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AHCA Contract No. FAR001, Exhibit 3-A, Page 1 of 2    


EXHIBIT 3-A
COMPREHENSIVE COMPONENT AND CATASTROPHIC COMPONENT CAPITATION RATES
 
TABLE 2
   
Area:                      10           
County:                      Broward                      
September 1, 2007


    ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

Age Range
   
FY0708
 Discounted
Reform rates
Under Current Methodology
   
Percentage of Current Methodology
   
50% of Current Methodology
   
Preliminary FY0708 Base rates for Risk Adjusted Methodology
   
Budget Neutrality Factor
   
FY0708 Base rates for Risk Adjusted Methodology after Budget Neutrality
   
Percentage of Risk Adjusted Methodology
   
50% of Risk Adjusted Methodology
   
Final Rates (with Enhanced Benefit Adjustment)
 
 
a
     
b
     
c
     
d
     
e
     
f
     
g
     
h
     
i
     
j
 
                                                                             
Eligibility Category:
   
Children and Family
                                                                 
                                                                             
Month 0-2 All
                                                                    $
907.28
 
Month 3-11 All
                                                                    $
208.49
 
1-5 All
    $
106.14
     
50
%   $
53.07
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
113.98
 
6-13 All
    $
82.94
     
50
%   $
41.47
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
102.61
 
14-20 Female
    $
115.00
     
50
%   $
57.50
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
118.32
 
14-20 Male
    $
79.98
     
50
%   $
39.99
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
101.16
 
21-54 Female
    $
202.08
     
50
%   $
101.04
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
160.99
 
21-54 Male
    $
146.71
     
50
%   $
73.35
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
133.86
 
55+ All
    $
325.58
     
50
%   $
162.79
    $
117.69
     
1.07460
    $
126.47
     
50
%   $
63.23
    $
221.50
 
         
 
             
 
                             
 
             
 
 
Composite Based on Total Casemonths
    $
108.91
                                    $
126.47
     
 
    $
0.00
    $
115.34
 
         
 
                                                                 
Eligibility Category:
   
Aged and Disabled
                                                                 
                                                                             
Month 0-2 All
                                                                    $
17,822.94
 
Month 3-11 All
                                                                    $
3,594.38
 
1-5 All
    $
631.27
     
50
%   $
315.63
    $
813.28
     
1.06682
    $
867.63
     
50
%   $
433.81
    $
734.46
 
6-13 All
    $
355.68
     
50
%   $
177.84
    $
813.28
     
1.06682
    $
867.63
     
50
%   $
433.81
    $
599.42
 
14-20 All
    $
343.79
     
50
%   $
171.90
    $
813.28
     
1.06682
    $
867.63
     
50
%   $
433.81
    $
593.59
 
21-54 All
    $
930.27
     
50
%   $
465.13
    $
813.28
     
1.06682
    $
867.63
     
50
%   $
433.81
    $
880.97
 
55+ All
    $
965.71
     
50
%   $
482.85
    $
813.28
     
1.06682
    $
867.63
     
50
%   $
433.81
    $
898.33
 
                                                                         
 
 
Composite Based on Total Casemonths
    $
758.94
                                    $
867.63
            $
0.00
    $
797.02
 


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AHCA Contract No. FAR001, Exhibit 3-A, Page 2 of 2

 
EXHIBIT 4-A
COMPREHENSIVE COMPONENT ONLY
TABLE 3
 
   
Area: ________________
County: _________________
September 1, 2007
 

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
Area ________
                                         
Age Range
FY0607 Discounted Reform rates Under Current Methodology
Percentage of Current
Methodology
   
75% of Current Methodology
 
FY0607 Base Rates for Risk-Adjusted Methodology
 
Percentage of Risk-Adjusted
Methodology
   
25% of Risk-Adjusted Methodology
 
Budget Neutrality Factor
 
Budget Adjusted of 25% of Risk Adjusted
Methodology
 
Blended Rate (Risk = 1.00)
 
Final Rate (with Enhanced Benefit Adjustment)
 
(a)
(b)
(c)
   
(d)
 
(e)
 
(f)
   
(g)
 
(h)
 
(i)
 
(j)
 
(k)
 
Eligibility Category:
Children and Family
                                       
Month 0-2 All
 $  
75
%   $    $    
25
%   $    $             $    
Month 3-11 All
 $  
75
%   $    $    
25
%   $    $             $    
1-5 All
 $  
75
%   $    $    
25
%   $    $             $    
6-13 All
 $  
75
%   $    $    
25
%   $    $             $    
14-20 Female
 $  
75
%   $    $    
25
%   $    $             $    
14-20 Male
 $  
75
%   $    $    
25
%   $    $             $    
21-54 Female
 $  
75
%   $    $    
25
%   $    $             $    
21-54 Male
 $  
75
%   $    $    
25
%   $    $             $    
55+ All
 $  
75
%   $    $    
25
%   $    $             $    
Composite
   
 
               
 
           $             $    
     
 
               
 
                             
Eligibility Category:
Aged and Disabled
 
 
               
 
                             
Month 0-2 All
 $  
75
%   $    $    
25
%   $    $             $    
Month 3-11 All
 $  
75
%   $    $    
25
%   $    $             $    
1-5 All
 $  
75
%   $    $    
25
%   $    $             $    
6-13 All
 $  
75
%   $    $    
25
%   $    $             $    
14-20 All
 $  
75
%   $    $    
25
%   $    $             $    
21-54 All
 $  
75
%   $    $    
25
%   $    $             $    
55+ All
 $  
75
%   $    $    
25
%   $    $             $    
Composite
                                                $    
                                                       


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AHCA Contract No. FAR001, Exhibit 4-A, Page 1 of 1



EXHIBIT 5-A
CAPITATION RATES
SSI MEDICARE PART B ONLY
AND
SSI MEDICARE PARTS A AND B ENROLLEES
FOR ALL MEDICAID REFORM COUNTIES
 

 
TABLE 4

Area:
4
County:
Duval, Baker, Clay and Nassau
   

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
 
 
Under Age 65
Age 65 & Over
SSI/Parts A & B
$200.51
$135.15
SSI/Part B Only
$369.64
$369.64


Area:                         10           County:                      Broward                      

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
 
 
Under Age 65
Age 65 & Over
SSI/Parts A & B
$192.29
$129.85
SSI/Part B Only
$249.37
$249.37

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        AHCA Contract No. FAR001, Exhibit 5-A, Page 1 of 1      
    



EXHIBIT 6-A
CAPITATION RATES FOR HIV/AIDS POPULATIONS FOR EACH MEDICAID REFORM COUNTY

 
TABLE 5


Area:
4
County:
 
Duval, Baker, Clay and Nassau
 
 
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
 
 
Capitation Rate
   
HIV (no medicare)
$1,216.29
AIDS (no medicare)
$2,394.42
HIV-SSI/Parts A & B, SSI Part B Only
$   294.90
AIDS-SSI/Parts A & B, SSI Part B Only
$   291.91


Area:
   10
County:
Broward
   


ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
 
 
Capitation Rate
   
HIV (no medicare)
$1,966.44
AIDS (no medicare)
$3,690.27
HIV-SSI/Parts A & B, SSI Part B Only
$   331.60
AIDS-SSI/Parts A & B, SSI Part B Only
$   708.10


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EXHIBIT 7-A
CAPITATION RATES FOR CHILDREN WITH CHRONIC CONDITIONS FOR ALL MEDICAID REFORM COUNTIES

 
 
TABLE 6


Area:
 
County: ____________________


ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
 
 
Age < 1 Yr
Age 1 Yr
Age 2 - 20 Yrs
       
Children with Chronic Conditions
$
 
$
$




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        AHCA Contract No. FAR001, Exhibit 7-A, Page 1 of 1      
    


EXHIBIT 8-A
KICK PAYMENT AMOUNTS FOR COVERED
TRANSPLANT SERVICES
 

 
TABLE 7

Area:
4
County:
 
Duval, Baker, Clay and Nassau
 

Area:
10
County:
 
Broward  


CPT Code
Transplant CPT Code Description
Children/Adolescents or Adult
Payment Amount
32851
lung single, without bypass
Children/Adolescents
$320,800.00
32851
lung single, without bypass
Adult
$238,000.00
32852
lung single, with bypass
Children/Adolescents
$320,800.00
32852
lung single, with bypass
Adult
$238,000.00
32853
lung double, without bypass
Children/Adolescents
$320,800.00
32853
lung double, without bypass
Adult
$238,000.00
32854
lung double, with bypass
Children/Adolescents
$320,800.00
32854
lung double, with bypass
Adult
$238,000.00
33945
heart transplant with or without recipient cardiectomy
Children/Adolescents
$162,000.00
33945
heart transplant with or without recipient cardiectomy
Adult
$162,000.00
47135
liver, allotransplation, orthotopic, partial or whole from cadaver or living donor
Children/Adolescents
$122,600.00
47135
liver, allotransplation, orthotopic, partial or whole from cadaver or living donor
Adult
$122,600.00
47136
liver, heterotopic, partial or whole from cadaver or living donor any age
Children/Adolescents
$122,600.00
47136
liver, heterotopic, partial or whole from cadaver or living donor any age
Adult
$122,600.00


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        AHCA Contract No. FAR001, Exhibit 8-A, Page 1 of 1      
    

 
EXHIBIT 9-A
KICK PAYMENT AMOUNTS FOR COVERED
 
OBSTETRICAL DELIVERY SERVICES

 
TABLE 8

Area:                 4                      County:                      Duval, Baker, Clay & Nassau                                                                

CPT Code
Obstetrical Delivery CPT Code Description
Payment Amount
59409
Vaginal delivery only
$3,982.26
59410
Vaginal delivery including postpartum care
59515
Cesarean delivery including postpartum care
59612
Vaginal delivery only, after previous cesarean delivery
59614
Vaginal delivery only, after previous cesarean delivery including postpartum care
59622
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care


Area:
10
County:
Broward
   

CPT Code
Obstetrical Delivery CPT Code Description
Payment Amount
59409
Vaginal delivery only
$3,997.99
59410
Vaginal delivery including postpartum care
59515
Cesarean delivery including postpartum care
59612
Vaginal delivery only, after previous cesarean delivery
59614
Vaginal delivery only, after previous cesarean delivery including postpartum care
59622
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care

 
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AHCA Contract No. FAR001, Exhibit 9-A, Page 1 of 1