Benefit Plan

Medicare Advantage Attestation of Benefit Plan WELLCARE OF CONNECTICUT, INC. H0712 Date: 08/29/2012

by WellCare
September 19th, 2012
Exhibit 10.4
Medicare Advantage Attestation of Benefit Plan
 
WELLCARE OF CONNECTICUT, INC.
 
H0712
 
Date: 08/29/2012
 
I attest that I have examined the Plan Benefit Packages (PBPs) identified below and that the benefits identified in the PBPs are those that the above ­stated organization will make available to eligible beneficiaries in the approved service area during program year 2013. I further attest that we have reviewed the bid pricing tools (BPTs) with the certifying actuary and have determined them to be consistent with the PBPs being attested to here.
 
I further attest that these benefits will be offered in accordance with all applicable Medicare program authorizing statutes and regulations and program guidance that CMS has issued to date and will issue during the remainder of 2012 and 2013, including but not limited to, the 2013 Call Letter, the 2013 Solicitations for New Contract Applicants, the Medicare Prescription Drug Benefit Manual, the Medicare Managed Care Manual, and the CMS memoranda issued through the Health Plan Management System (HPMS).
 
Plan
ID
Segment
ID
Version
Plan Name
Plan
Type
Transaction
Type
MA
Premium
Part D Premium
CMS Approval Date
Effective
Date
001
0
8
WellCare Choice
(HMO-POS)
HMOPOS
Renewal
62.60
6.40
08/24/2012
01/01/2013
005
0
6
WellCare Access
(HMO SNP)
HMO
Renewal
0.00
28.50
08/20/2012
01/01/2013
019
0
8
Wellcare Value (HMO)
HMO
Renewal
0.00
0.00
08/24/2012
01/01/2013
 
 

 

  H0712
 

 


 
 THOMAS TRAN    8/29/2012 1:37:16 PM  
        
 Contracting Official Name    Date  
       
       
       
     116 WASHINGTON AVENUE  
 WELLCARE OF CONNECTICUT, INC.    NORTH HAVEN, CT 06437  
       
 Organization    Address  
 
 
 
 
H0712