THIS CONTRACT,entered into between theSTATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” andAMERIGROUP FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY CARE,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:
Margaret Cavendish Agency for Health Care Administration 2727 Mahan Drive, MS #50
Tallahassee, FL 32308
(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.
3. Effective, December 1, 2008, Attachment II, Medicaid Prepaid Health Plan Model Contract, Section V,
Covered Services, Item C, Expanded Services, sub-item 2 is hereby deleted in its entirety and replaced with the following:
2. The following is a list of the Health Plan’s Expanded Services:
a.
OTC Medications — Up to ten ($10.00) credit per household each month for selected over- the-counter drugs and/or health supplies.
b.
Respite Care Services — Annual maximum of not more than an initial homehealth visit by RN @ $65.00 and eight (8) follow-up visits by an aide at $23.00 per visit. Follow-up visits are four (4) hours in length. Maximum of sixteen (16) hours in a given month and thirty- two (32) hours per year.
c.
Enhanced Hearing Aid Benefit — Upgrade from standard medically necessary, behind-theear hearing aid benefit to digital canal hearing aid up to $500.
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.
1
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 seven (7) page Amendment (which includes all attachments hereto) to be executed by their officials thereunto duly authorized.
AMERIGROUP FLORIDA, INC. STATE OF FLORIDA, AGENCY D/B/A AMERIGROUP COMMUNITY CARE FOR HEALTH CARE ADMISTRATIONSIGNED SIGNED
BY: /S/ William L. McHugh
BY:
NAME: William L. McHugh
NAME: Holly Benson
TITLE: CEO
TITLE: Secretary
DATE: 8/29/08
DATE:
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)
2
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
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:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,113.37
1,113.37
1,217.57
1,067.51
1,214.96
1,056.56
1,092.94
1,033.51
1,067.78
1,083.46
1,372.19
TANF 3M0-11MO
187.38
187.38
206.51
181.92
206.53
181.19
186.84
177.08
181.58
186.46
232.59
TANF AGE (1-5)
101.38
101.38
112.28
99.04
112.30
98.87
101.87
96.67
98.82
101.73
126.24
TANF AGE (6-13)
61.45
61.45
69.11
61.51
69.38
61.99
63.49
60.37
61.05
63.88
77.54
TANF AGE (14-20)Female
129.49
129.49
143.30
126.30
143.25
126.18
129.77
123.15
126.06
129.70
161.30
TANF AGE (14-20) Male
69.52
69.52
77.85
69.23
78.21
69.68
71.35
68.03
68.67
71.87
87.46
TANF AGE (21-54)Female
255.23
255.23
283.53
250.83
284.08
251.35
258.27
245.23
249.80
258.53
319.10
TANF AGE (21-54) Male
153.37
153.37
171.42
152.26
172.12
153.20
157.02
149.29
151.41
157.78
192.88
TANF AGE (55+) 318.51
318.51
359.72
321.21
361.87
325.45
332.09
316.91
318.38
335.92
404.23
SSI-N BTHMO+2M0
10,428.92
10,428.92
11,442.82
10,972.58
12,248.94
11,162.18
11,810.40
10,525.98
11,078.29
14,344.29
14,488.14
SSI-N 3M0-11MO
1,517.58
1,517.58
1,680.06
1,615.28
1,796.88
1,645.44
1,744.81
1,550.30
1,635.46
2,132.34
2,131.88
SSI-N AGE (1-5)
445.88
445.88
495.07
476.38
528.79
485.06
514.41
457.03
482.13
629.36
628.05
SSI-N AGE (6-13)
198.88
198.88
226.05
218.79
240.95
223.95
238.57
210.03
223.68
297.17
289.19
SSI-N AGE (14-20) 213.14
213.14
241.47
233.36
256.93
237.92
254.24
224.35
237.34
314.18
307.93
SSI-N AGE (21-54)
696.73
696.73
787.51
761.37
840.31
777.94
828.77
731.36
775.59
1,027.07
1,004.54
SSI-N AGE (55+)
700.31
700.31
795.55
770.55
849.11
788.05
840.70
740.14
785.85
1,044.85
1,015.98
SSI-B
305.88
305.88
340.56
297.82
225.19
274.94
373.98
256.24
219.29
322.21
370.49
SSI-AB AGE (65-)
94.80
94.80
90.01
90.35
81.19
79.31
84.56
78.77
84.42
94.02
140.27
SSI-AB AGE (65+)
85.77
85.77
81.98
82.40
75.29
72.63
77.61
72.23
77.20
86.21
126.63
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
TABLE 2 General + Mental Health Rates:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,113.39
1,113.40
1,217.58
1,067.52
1,214.97
1,056.58
1,092.96
1,033.52
1,067.80
1,083.48
1,372.21
TANF 3M0-11MO
187.40
187.41
206.52
181.93
206.54
181.21
186.86
177.09
181.60
186.11
232.61
TANF AGE (1-5)
103.02
104.29
113.60
100.42
113.51
100.72
103.65
97.93
100.37
103.65
127.86
TANF AGE (6-13)
73.14
81.71
78.29
71.07
78.06
75.24
76.18
69.16
71.86
77.24
88.83
TANF AGE (14-20)Female
140.42
142.91
149.38
132.64
151.36
138.56
141.63
128.97
133.22
138.55
168.79
TANF AGE (14-20) Male
80.45
82.94
83.93
75.57
86.32
82.06
83.21
73.85
75.83
80.72
94.95
TANF AGE (21-54)Female
259.67
258.64
285.07
252.44
287.37
256.38
263.09
246.72
251.62
260.78
321.01
TANF AGE (21-54) Male
157.81
156.78
172.96
153.87
175.41
158.23
161.84
150.78
153.23
160.03
194.79
TANF AGE (55+)
322.25
321.46
361.06
322.61
364.65
329.70
336.16
318.20
319.95
337.87
405.88
SSI-N BTHMO+2M0
10,429.00
10,429.08
11,442.89
10,972.69
12,248.99
11,162.25
11,810.46
10,526.05
11,078.36
14,344.39
14,488.22
SSI-N 3M0-11MO
1,517.66
1,517.74
1,680.13
1,615.39
1,796.93
1,645.51
1,744.87
1,550.37
1,635.53
2,132.44
2,131.96
SSI-N AGE (1-5)
453.32
459.67
501.33
486.14
533.81
491.58
520.53
463.03
488.46
637.71
635.02
SSI-N AGE (6-13)
246.93
277.70
261.81
274.53
273.37
266.06
278.08
244.31
259.82
344.88
328.99
SSI-N AGE (14-20)
257.13
258.36
261.99
265.34
286.61
276.46
290.41
244.03
248.08
341.56
330.76
SSI-N AGE (21-54)
778.13
749.41
811.41
798.63
895.23
849.27
895.70
754.27
799.75
1,058.95
1,031.14
SSI-N AGE (55+)
731.29
725.19
806.83
788.14
870.01
815.20
866.18
750.96
797.26
1,059.91
1,028.54
SSI-B
306.09
326.08
347.41
322.37
227.92
276.25
376.57
263.09
226.14
329.06
377.72
SSI-AB AGE (65-)
106.45
109.81
98.99
107.12
94.01
83.20
95.08
91.99
94.01
102.08
148.33
SSI-AB AGE (65+)
97.42
100.78
90.96
99.17
88.11
76.52
88.13
85.45
86.79
94.27
134.69
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
TABLE 3
General + Mental Health + Dental Rates:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,113.39
1,113.40
1,217.59
1,067.53
1,214.98
1,056.59
1,092.97
1,033.53
1,067.81
1,083.49
1,372.22
TANF 3M0-11MO
187.41
187.42
206.54
181.94
206.56
181.22
186.87
177.11
181.62
186.12
232.62
TANF AGE (1-5)
104.70
105.97
116.65
102.26
116.92
103.39
106.05
101.57
103.30
106.08
131.59
TANF AGE (6-13)
76.25
84.82
83.95
74.49
84.39
80.20
80.63
75.90
77.30
81.75
96.51
TANF AGE (14-20)Female
143.60
146.09
155.15
136.14
157.83
143.62
146.17
135.86
138.78
143.16
176.76
TANF AGE (14-20)Male
83.14
85.63
88.81
78.52
91.79
86.34
87.05
79.68
80.53
84.62
101.67
TANF AGE (21-54)Female
260.89
259.86
286.81
254.11
290.78
258.26
264.42
248.74
252.58
261.51
321.87
TANF AGE (21-54) Male
159.07
158.04
174.74
155.59
178.92
160.17
163.20
152.85
154.21
160.78
195.67
TANF AGE (55+) 325.04
324.25
365.03
326.43
372.44
334.00
339.20
322.80
322.14
339.53
407.84
SSI-N BTHMO+2M0
10,429.00
10,429.08
11,442.89
10,972.69
12,249.00
11,162.25
11,810.46
10,526.05
11,078.36
14,344.39
14,488.23
SSI-N 3M0-11MO
1,517.66
1,517.74
1,680.14
1,615.39
1,796.94
1,645.52
1,744.88
1,550.38
1,635.54
2,132.45
2,131.98
SSI-N AGE (1-5)
454.94
461.29
504.46
487.92
538.03
494.62
523.53
466.45
491.05
640.50
639.29
SSI-N AGE (6-13)
249.33
280.10
266.45
277.17
279.64
270.56
282.52
249.39
263.67
349.02
336.38
SSI-N AGE (14-20)
259.19
260.42
265.98
267.61
291.99
280.33
294.23
248.39
261.39
345.12
337.23
SSI-N AGE (21-54)
779.46
750.74
813.29
800.51
898.93
851.77
897.25
756.55
800.93
1,059.90
1,032.92
SSI-N AGE (55+)
733.15
727.05
809.48
790.78
875.21
818.71
868.36
754.16
798.91
1,061.24
1,031.04
SSI-B
306.54
326.53
348.44
324.55
231.58
278.01
377.05
264.63
227.97
329.88
381.06
SSI-AB AGE (65-)
107.57
110.93
100.64
108.71
97.80
85.45
96.60
93.66
95.08
103.38
150.49
SSI-AB AGE (65+)
98.28
101.64
92.22
100.38
91.00
78.23
89.29
86.72
87.60
95.25
136.34
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
TABLE 4 General + Mental Health + Transportation Rates:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,118.74
1,118.75
1,224.01
1,072.09
1,218.84
1,060.38
1,096.99
1,038.81
1,072.91
1,086.47
1,375.30
TANF 3M0-11MO
188.77
188.78
208.18
183.11
207.54
182.19
187.89
178.45
182.92
186.89
233.40
TANF AGE (1-5)
103.85
105.12
114.60
101.13
114.11
101.31
104.28
98.76
101.17
104.12
128.34
TANF AGE (6-13)
73.64
82.21
78.89
71.50
78.42
75.60
76.56
69.66
72.34
77.52
89.12
TANF AGE (14-20)Female
142.45
144.94
151.82
134.38
152.83
140.00
143.16
130.99
135.16
139.69
169.97
TANF AGE (14-20) Male
81.79
84.28
85.54
76.72
87.29
83.01
84.23
75.18
77.11
81.47
95.73
TANF AGE (21-54)Female
262.97
261.94
289.04
255.26
289.75
258.73
265.58
249.98
254.77
262.62
322.92
TANF AGE (21-54) Male
160.32
159.29
175.98
156.01
177.22
160.02
163.74
153.26
155.63
161.43
196.24
TANF AGE (55+) 325.76
324.97
365.28
325.61
367.18
332.19
338.80
321.67
323.30
339.83
407.91
SSI-N BTHMO+2M0
10,468.09
10,468.17
11,492.20
11,011.02
12,280.81
11,193.75
11,845.21
10,564.27
11,117.70
14,370.64
14,515.60
SSI-N 3M0-11MO
1,543.33
1,543.41
1,712.51
1,640.55
1,817.81
1,666.20
1,767.68
1,575.46
1,661.37
2,149.68
2,149.93
SSI-N AGE (1-5)
458.61
464.96
508.01
491.32
538.12
495.85
525.23
468.20
493.79
641.26
638.72
SSI-N AGE (6-13)
249.36
280.13
264.88
276.91
275.35
268.01
280.23
246.69
262.27
346.51
330.69
SSI-N AGE (14-20)
263.26
264.49
269.71
271.34
291.59
281.39
295.85
250.01
264.24
345.67
335.05
SSI-N AGE (21-54)
798.19
769.47
836.72
818.29
911.55
865.43
913.53
773.87
819.93
1,072.41
1,045.18
SSI-N AGE (55+)
748.22
742.12
828.19
804.74
883.79
828.84
881.23
767.52
814.30
1,071.28
1,040.40
SSI-B
313.56
333.55
356.12
329.55
234.47
281.96
381.95
269.02
232.70
334.36
382.84
SSI-AB AGE (65-)
120.17
125.53
118.76
122.97
108.09
94.76
107.21
106.78
109.81
114.42
160.77
SSI-AB AGE (65+)
106.26
109.62
103.70
109.39
97.18
83.97
95.94
94.97
96.97
102.22
142.70
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:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,118.72
1,118.72
1,224.00
1,072.08
1,218.83
1,060.36
1,096.97
1,038.80
1,072.89
1,086.45
1,375.28
TANF 3M0-11MO
188.75
188.75
208.17
183.10
207.53
182.17
187.87
178.44
182.90
186.87
233.38
TANF AGE (1-5)
102.21
102.21
113.28
99.75
112.90
99.46
102.50
97.50
99.62
102.20
126.72
TANF AGE (6-13)
61.95
61.95
69.71
61.94
69.74
62.35
63.87
60.87
61.53
64.16
77.83
TANF AGE (14-20)Female
131.52
131.52
145.74
128.04
144.72
127.62
131.30
125.17
128.00
130.84
162.48
TANF AGE (14-20) Male
70.86
70.86
79.46
70.38
79.18
70.63
72.37
69.36
69.95
72.62
88.24
TANF AGE (21-54)Female
258.53
258.53
287.50
253.65
286.46
253.70
260.76
248.49
252.95
260.37
321.01
TANF AGE (21-54) Male
155.88
155.88
174.44
154.40
173.93
154.99
158.92
151.77
153.81
159.18
194.33
TANF AGE (55+) 322.02
322.02
363.94
324.21
364.40
327.94
334.73
320.38
321.73
337.88
406.25
SSI-N BTHMO+2M0
10,468.01
10,468.01
11,492.13
11,010.91
12,280.76
11,193.68
11,845.15
10,564.20
11,117.63
14,370.54
14,515.52
SSI-N 3M0-11MO
1,543.25
1,543.25
1,712.44
1,640.44
1,817.76
1,666.13
1,767.62
1,575.39
1,661.30
2,149.58
2,149.85
SSI-N AGE (1-5)
451.17
451.17
501.75
481.56
533.10
489.33
519.11
462.20
487.46
632.91
631.75
SSI-N AGE (6-13)
201.31
201.31
229.12
221.17
242.93
225.90
240.72
212.41
226.13
298.80
290.89
SSI-N AGE (14-20)
219.27
219.27
249.19
239.36
261.91
242.85
259.68
230.33
243.50
318.29
312.22
SSI-N AGE (21-54)
716.79
716.79
812.82
781.03
856.63
794.10
846.60
750.96
795.77
1,040.53
1,018.58
SSI-N AGE (55+)
717.24
717.24
816.91
787.15
862.89
801.69
855.75
756.70
802.89
1,056.22
1,027.84
SSI-B
313.35
313.35
349.27
305.00
231.74
280.65
379.36
262.17
225.85
327.51
375.61
SSI_AB AGE (65-)
108.52
108.52
109.78
106.20
95.27
90.87
96.69
93.56
100.22
106.36
152.71
SSI_AB AGE (65+)
94.61
94.61
94.72
92.62
84.36
80.08
85.42
81.75
87.38
94.16
134.64
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
TABLE 6
General + Dental Rates:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,113.37
1,113.37
1,217.58
1,067.52
1,214.97
1,056.57
1,092.95
1,033.52
1,067.79
1,083.47
1,372.20
TANF 3M0-11MO
187.39
187.39
206.53
181.93
206.55
181.20
186.85
177.10
181.60
186.10
232.60
TANF AGE (1-5)
103.06
103.06
115.33
100.88
115.71
101.54
104.27
100.31
101.75
104.16
129.97
TANF AGE (6-13)
64.56
64.56
74.77
64.93
75.71
66.95
67.94
67.11
66.49
68.39
85.22
TANF AGE (14-20)Female
132.67
132.67
149.07
129.80
149.72
131.24
134.31
130.04
131.62
134.31
169.27
TANF AGE (14-20) Male
72.21
72.21
82.73
72.18
83.68
73.96
75.19
73.86
73.37
75.77
94.18
TANF AGE (21-54)Female
256.45
256.45
285.27
252.50
287.49
253.23
259.60
247.25
250.76
259.26
319.96
TANF AGE (21-54) Male
154.63
154.63
173.20
153.96
175.63
155.14
158.38
151.36
152.39
158.53
193.76
TANF AGE (55+)
321.30
321.30
363.69
325.03
369.66
329.75
335.13
321.51
320.57
337.58
406.19
SSI-N BTHMO+2M0
10,428.92
10,428.92
11,442.82
10,972.58
12,248.95
11,162.18
11,810.40
10,525.98
11,078.29
14,344.29
14,488.15
SSI-N 3M0-11MO
1,517.58
1,517.58
1,680.07
1,615.28
1,796.89
1,645.45
1,744.82
1,550.31
1,635.47
2,132.35
2,131.90
SSI-N AGE (1-5)
447.50
447.50
498.20
478.16
533.01
488.10
517.41
460.45
484.72
632.15
632.32
SSI-N AGE (6-13)
201.28
201.28
230.69
221.43
247.22
228.45
243.01
215.11
227.53
301.31
296.58
SSI-N AGE (14-20)
215.20
215.20
245.46
235.63
262.31
241.79
258.06
228.71
240.65
317.74
314.40
SSI-N AGE (21-54)
698.06
698.06
789.39
763.25
844.01
780.44
830.32
733.64
776.77
1,028.02
1,006.32
SSI-N AGE (55+)
702.17
702.17
798.20
773.19
854.31
791.56
842.88
743.34
787.50
1,046.18
1,018.48
SSI-B
306.33
306.33
341.59
300.00
228.85
276.70
374.46
257.78
221.12
323.03
373.83
SSI-AB AGE (65-)
95.92
95.92
91.66
91.94
84.98
81.56
86.08
80.44
85.49
95.32
142.43
SSI-AB AGE (65+)
86.63
86.63
83.24
83.61
78.18
74.34
78.77
73.50
78.01
87.19
128.28
EXHIBIT III-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:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,118.72
1,118.72
1,224.01
1,072.09
1,218.84
1,060.37
1,096.98
1,038.81
1,072.90
1,086.46
1,375.29
TANF 3M0-11MO
188.76
188.76
208.19
183.11
207.55
182.18
187.88
178.46
182.92
186.88
233.39
TANF AGE (1-5)
103.89
103.89
116.33
101.59
116.31
102.13
104.90
101.14
102.55
104.63
130.45
TANF AGE (6-13)
65.06
65.06
75.37
65.36
76.07
67.31
68.32
67.61
66.97
68.67
85.51
TANF AGE (14-20) Female
134.70
134.70
151.51
131.54
151.19
132.68
135.84
132.06
133.56
135.45
170.45
TANF AGE (14-20) Male
73.55
73.55
84.34
73.33
84.65
74.91
76.21
75.19
74.65
76.52
94.96
TANF AGE (21-54) Female
259.75
259.75
289.24
255.32
289.87
255.58
262.09
250.51
253.91
261.10
321.87
TANF AGE (21-54) Male
157.14
157.14
176.22
156.12
177.44
156.93
160.28
153.84
154.79
159.93
195.21
TANF AGE (55+) 324.81
324.81
367.91
328.03
372.19
332.24
337.77
324.98
323.92
339.54
408.22
SSI-N BTHMO+2M0
10,468.01
10,468.01
11,492.13
11,010.91
12,280.77
11,193.68
11,845.15
10,564.20
11,117.63
14,370.54
14,515.53
SSI-N 3M0-11MO
1,543.25
1,543.25
1,712.45
1,640.44
1,817.77
1,666.14
1,767.63
1,575.40
1,661.31
2,149.59
2,149.87
SSI-N AGE (1-5)
452.79
452.79
504.88
483.34
537.32
492.37
522.11
465.62
490.05
635.70
636.02
SSI-N AGE (6-13)
203.71
203.71
233.76
223.81
249.20
230.40
245.16
217.49
229.98
302.94
298.28
SSI-N AGE (14-20)
221.33
221.33
253.18
241.63
267.29
246.72
263.50
234.69
246.81
321.85
318.69
SSI-N AGE (21-54)
718.12
718.12
814.70
782.91
860.33
796.60
848.15
753.24
796.95
1,041.48
1,020.36
SSI-N AGE (55+)
719.10
719.10
819.56
789.79
868.09
805.20
857.93
759.90
804.54
1,057.55
1,030.34
SSI-B
313.80
313.80
350.30
307.18
235.40
282.41
379.84
263.71
227.68
328.33
378.95
SSI-AB AGE (65-)
109.64
109.64
111.43
107.79
99.06
93.12
98.21
95.23
101.29
107.66
154.87
SSI-AB AGE (65+)
95.47
95.47
95.98
93.83
87.25
81.79
86.58
83.02
88.19
95.14
136.29
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
TABLE 8 General + Mental Health + Dental + Transportation Rates:
Area
1
2
3
4
5
6
7
8
9
10
11
TANF BTHM0+2M0
1,118.74
1,118.75
1,224.02
1,072.10
1,218.85
1,060.39
1,097.00
1,038.82
1,072.92
1,086.48
1,375.31
TANF 3M0-11MO
188.78
188.79
208.20
183.12
207.56
182.20
187.90
178.47
182.94
186.90
233.41
TANF AGE (1-5)
105.53
106.80
117.65
102.97
117.52
103.98
106.68
102.40
104.10
106.55
132.07
TANF AGE (6-13)
76.75
85.32
84.55
74.92
84.75
80.56
81.01
76.40
77.78
82.03
96.80
TANF AGE (14-20)Female
145.63
148.12
157.59
137.88
159.30
145.06
147.70
137.88
140.72
144.30
177.94
TANF AGE (14-20) Male
84.48
86.97
90.42
79.67
92.76
87.29
88.07
81.01
81.81
85.37
102.45
TANF AGE (21-54)Female
264.19
263.16
290.78
256.93
293.16
260.61
266.91
252.00
255.73
263.35
323.78
TANF AGE (21-54) Male
161.58
160.55
177.76
157.73
180.73
161.96
165.10
155.33
156.61
162.18
197.12
TANF AGE (55+) 328.55
327.76
369.25
329.43
374.97
336.49
341.84
326.27
325.49
341.49
409.87
SSI-N BTHMO+2M0
10,468.09
10,468.17
11,492.20
11,011.02
12,280.82
11,193.75
11,845.21
10,564.27
11,117.70
14,370.64
14,515.61
SSI-N 3M0-11MO
1,543.33
1,543.41
1,712.52
1,640.55
1,817.82
1,666.21
1,767.69
1,575.47
1,661.38
2,149.69
2,149.95
SSI-N AGE (1-5)
460.23
466.58
511.14
493.10
542.34
498.89
528.23
471.62
496.38
644.05
642.99
SSI-N AGE (6-13)
251.76
282.53
269.52
279.55
281.62
272.51
284.67
251.77
266.12
350.65
338.08
SSI-N AGE (14-20)
265.32
266.55
273.70
273.61
296.97
285.26
299.67
254.37
267.55
349.23
341.52
SSI-N AGE (21-54)
799.52
770.80
838.60
820.17
915.25
867.93
915.08
776.15
821.11
1,073.36
1,046.96
SSI-N AGE (55+)
750.08
743.98
830.84
807.38
888.99
832.35
883.41
770.72
815.95
1,072.61
1,042.90
SSI-B
314.01
334.00
357.15
331.73
238.13
283.72
382.43
270.56
234.53
335.18
386.18
SSI-AB AGE (65-)
121.29
124.65
120.41
124.56
111.88
97.01
108.73
108.45
110.88
115.72
162.93
SSI-AB AGE (65+)
107.12
110.48
104.96
110.60
100.07
85.68
97.10
96.24
97.78
103.20
144.35
EXHIBIT III-D September 1, 2008 – August 31, 2009 Medicaid Non-Reform HMO Capitation Rates By Area, Age and Eligibility Category
Area
Corresponding Counties
Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 10 Area 11
Escambia, Okaloosa, Santa Rosa, Walton Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marlon, Putnam, Sumter, Suwannee, Union Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia Pasco, Pinellas Hardee, Highlands, Hillsborough, Manatee, Polk Brevard, Orange, Osceola, Seminole Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota Indian River, Okeechobee, St. Lucie, Martin, Palm Beach Broward Dade, Monroe
3
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