Mr. Mitch Wright Amerigroup Florida, Inc. 4425 Corporation Lane Virginia Beach, FL 23462
Dear Mr. Wright:
Enclosed is an executed copy of Amendment No. 4 to AHCA Contract No. FA523, Health Care Services to Medicaid Beneficiaries (HMO), for your records. Should you have any questions I may be contacted at (850) 414 — 7653.
Sincerely,
/s/ Barbara B. Vaughan
Barbara B. Vaughan, Mgmt. Review Specialist Procurement Office
BBV/bv
Enclosures
cc: Christina Lopez, AHCA Contract Manager, MS #50
2727 Mahan Drive • Mail Stop #15 Tallahassee, FL 32308
Visit AHCA online at ahca.myflorida.com
1
AHCA CONTRACT NO. FA523
AMENDMENT NO. 4
THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and AMERIGROUP OF FLORIDA, INC., hereinafter referred to as the “Vendor”, is hereby amended as follows:
WHEREAS, the Vendor’s name has been referenced as Amerigroup of Florida, Inc. throughout the Contract and its attachments.
WHEREAS, Amerigroup of Florida, Inc. is not the correct name of the Vendor, the correct name being “Amerigroup Florida, Inc.”
NOW, THEREFORE, the Contract and its attachments are hereby amended to reflect the correct Vendor name.
1. The Vendor name is hereby amended from Amerigroup of Florida, Inc. to Amerigroup Florida, Inc.
2. Standard Contract, Section ILA, Contract Amount, the first sentence is hereby amended to now read:
To pay for contracted services according to the conditions ofAttachment Iin an amount not to exceed$663,357,697.00(an increase of $4,531,502.00), subject to the availability of funds.
3.
Effective March 1, 2005,Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 2, Area 07 is hereby amended to read as follows:
Table 2
Area07General Rates plus Mental Health Plan -
015005308(ORANGE) 015005313(SEMINOLE)
015005314(OSCEOLA)
<1 year
1-5
6-13
14-20 Male
14-20 Female
21-54 Male
21-54 Female
55-64
65+
TANF/FC/SOBRA
337.20
76.92
58.07
59.10
114.69
136.45
206.32
287.87
287.87
SSI/No Medicare
3217.90
406.84
260.45
239.73
239.73
628.24
628.24
594.96
594.96
SSI/Part B
266.03
266.03
266.03
266.03
266.03
266.03
266.03
266.03
266.03
SSI/Part A & B
293.59
293.59
293.59
293.59
293.59
293.59
293.59
293.59
208.25
4.
Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table 3, the second paragraph is hereby amended to now read:
Notwithstanding the payment amounts which may be computed with the above rate table, the sum of total capitation payments under this contract shall not exceed the total contract amount of$663,357,697.00(an increase of $4,531,502.00), expressed on page seven of this contract.
5.
This amendment shall begin on March 1, 2005, or the date on which the amendment has been signed by both parties, 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 are hereby made a part of the Contract.AHCA Contract No. FA523, Amendment No. 4, Page 1 of 2
AHCA Form 2100-0002 (Rev. NOV03)
2
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 2 page amendment (including all attachments) to be executed by their officials thereunto duly authorized.
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 2 page amendment (including all attachments) to be executed by their officials thereunto duly authorized.
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