Exhibit 10.4
APPENDIX X
[Amendment Number 2]
Agency Code 12000 Contract No. C020454
Period 5/1/06-9/30/08 Funding Amount for Period Based on approved capitation rates
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York State Department of Health, having its principal office at Coming Tower, Room 2001, Empire State Plaza, Albany, NY 12237, (hereinafter referred to as the STATE), and WellCare of New York, Inc., (hereinafter referred to as the CONTRACTOR), to modify Contract Number C020454 by substituting the attached Appendix L "Approved Capitation Payment Rates," Schedule 1 of Appendix M "Service Area, Program Participation and Prepaid Benefit Package Optional Covered Services," and Schedule 2 of Appendix M "LDSS Election of Enrollment in Medicaid Managed Care for Foster Care Children and Homeless Persons." The effective date of these modifications is May 1, 2006.
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under
CONTRACTOR SIGNATURE | | STATE AGENCY SIGNATURE |
By: /s/ Todd S. Farha | | By: /s/ Donna Frescatore |
TODD S. FARHA | | DONNA FRESCATORE |
| | | |
Title: PRESIDENT & CEO | | Title: DEPUTY DIRECTOR, OMC |
Date: June 19, 2006 | | Date: 7/7/06 |
| | | State Agency Certification: In addition to the acceptance of this contract, I also certify that original copies of this signature page will be attached to all other exact copies of this contract |
STATE OF FLORIDA
SS.:
County of HILLSBOROUGH
On the 19th day of June 2006, before me personally appeared Todd S. Farha to me known, who being by me duly sworn, did depose and say that he/she resides at Tampa, Florida, , that he/she is the President & CEO of WellCare of New York, Inc., the corporation described herein which executed the foregoing instrument; and that he/she signed his/her name thereto by order of the board of directors of said corporation.
(Notary)
/s/ Sara Gallo
Sara Gallo
STATE COMPTROLLER’S SIGNATURE | Title: State Comptroller |
/s/ Illegible | Date: 7/31/06 |
APPENDIX L
Approved Capitation Payment Rates
APPENDIX L
May 1, 2006
L-l
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
Approved by DOB: Yes | Region: Northeast |
| | County: ALBANY |
Reinsurance: No | Status: Mandatory |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $262.72 |
| TANF/SN 6mo-14 F | $89.50 |
| TANF/SN 15-20 F | $130.92 |
| TANF/SN 6m-20 M | $87.34 |
| TANF21+ M/F | $212.38 |
| SN 21-29 M/F | $201.52 |
| SN 30+ M/F | $365.32 |
| SSI 6mo-20 M/F | $176.65 |
| SSI 21-64 M/F | $493.40 |
| SSI 65+ M/F | $438.91 |
| Maternity Kick Payment | $5,097.14 |
| Newborn Kick Payment | $1,734.99 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
þ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
| Approved by DOB: Yes | Region: Central |
| | County: COLUMBIA |
| Reinsurance: No | Status: Mandatory |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $253.60 |
| TANF/SN 6mo-14 F | $82.21 |
| TANF/SN 15-20 F | $139.77 |
| TANF/SN 6m-20 M | $82.59 |
| TANF21+ M/F | $229.28 |
| SN 21-29 M/F | $215.27 |
| SN 30+ M/F | $368.73 |
| SSI 6mo-20 M/F | $179.23 |
| SSI 21-64 M/F | $474.37 |
| SSI 65+ M/F | $392.42 |
| Maternity Kick Payment | $5,466.64 |
| Newborn Kick Payment | $1,980.01 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
þ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
| Approved by DOB: Yes | Region: Mid-Hudson |
| | County: DUTCHESS |
Reinsurance: No | Status: Voluntary |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $266.87 |
| TANF/SN 6mo-14 F | $93.54 |
| TANF/SN 15-20 F | $135.68 |
| TANF/SN 6m-20 M | $103.07 |
| TANF21+ M/F | $229.75 |
| SN 21-29 M/F | $211.13 |
| SN 30+ M/F | $429.08 |
| SSI 6mo-20 M/F | $177.07 |
| SSI 21-64 M/F | $488.19 |
| SSI 65+ M/F | $425.44 |
| Maternity Kick Payment | $5,651.55 |
| Newborn Kick Payment | $2,276.59 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
| Approved by DOB: Yes | Region: Central |
| | County: GREENE |
Reinsurance: No | Status: Mandatory |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $251.40 |
| TANF/SN 6mo-14 F | $80.40 |
| TANF/SN 15-20 F | $137.50 |
| TANF/SN 6m-20 M | $80.75 |
| TANF21+ M/F | $226.45 |
| SN 21-29 M/F | $212.51 |
| SN 30+ M/F | $365.67 |
| SSI 6mo-20 M/F | $176.18 |
| SSI 21-64 M/F | $470.38 |
| SSI 65+ M/F | $390.73 |
| Maternity Kick Payment | $5,466.64 |
| Newborn Kick Payment | $1,980.01 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
Approved by DOB: Yes | Region: Mid-Hudson |
| | County: ORANGE |
| Reinsurance: No | Status: Voluntary |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $263.72 |
| TANF/SN 6mo-14 F | $92.78 |
| TANF/SN 15-20 F | $132.60 |
| TANF/SN 6m-20 M | $102.05 |
| TANF21+ M/F | $226.38 |
| SN 21-29 M/F | $206.72 |
| SN 30+ M/F | $423.04 |
| SSI 6mo-20 M/F | $173.29 |
| SSI 21-64 M/F | $479.96 |
| SSI 65+ M/F | $420.66 |
| Maternity Kick Payment | $5,651.55 |
| Newborn Kick Payment | $2,276.59 |
Optional Benefits Offered:
¨ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
| Approved by DOB: Yes | Region: Northeast |
| | County: RENSSELAER |
| Reinsurance: No | Status: Mandatory |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $260.53 |
| TANF/SN 6mo-14 F | $87.69 |
| TANF/SN 15-20 F | $128.66 |
| TANF/SN 6m-20 M | $85.51 |
| TANF21+ M/F | $209.55 |
| SN 21-29 M/F | $198.76 |
| SN 30+ M/F | $362.26 |
| SSI 6mo-20 M/F | $173.61 |
| SSI 21-64 M/F | $489.42 |
| SSI 65+ M/F | $437.22 |
| Maternity Kick Payment | $5,097.14 |
| Newborn Kick Payment | $1,734.99 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
| MMIS ID #: 01182503 | Effective Date: 04/01/06 |
Approved by DOB: Yes | Region: Northern Metro |
| | County: ROCKLAND |
Reinsurance: No | Status: Mandatory |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $247.24 |
| TANF/SN 6mo-14 F | $87.55 |
| TANF/SN 15-20 F | $111.50 |
| TANF/SN 6m-20 M | $97.90 |
| TANF21+ M/F | $190.15 |
| SN 21-29 M/F | $262.49 |
| SN 30+ M/F | $413.23 |
| SSI 6mo-20 M/F | $176.29 |
| SSI 21-64 M/F | $548.38 |
| SSI 65+ M/F | $413.23 |
| Maternity Kick Payment | $4,812.65 |
| Newborn Kick Payment | $1,569.65 |
Optional Benefits Offered:
þ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID #: 01182503 | Effective Date: 04/01/06 |
| Approved by DOB: Yes | Region: Mid-Hudson |
| | County: ULSTER |
Reinsurance: No | Status: Voluntary |
Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $263.72 |
| TANF/SN 6mo-14 F | $92.78 |
| TANF/SN 15-20 F | $132.60 |
| TANF/SN 6m-20 M | $102.05 |
| TANF21+ M/F | $226.38 |
| SN 21-29 M/F | $206.72 |
| SN 30+ M/F | $423.04 |
| SSI 6mo-20 M/F | $173.29 |
| SSI 21-64 M/F | $479.96 |
| SSI 65+ M/F | $420.66 |
| Maternity Kick Payment | $5,615.55 |
| Newborn Kick Payment | $2,276.59 |
Optional Benefits Offered:
¨ Emergency Transportation | ¨ Dental |
¨ Non-Emergent Transportation | þ Family Planning |
Box will be checked if the optional benefit is covered by the plan
WELLCARE OF NEW YORK, INC.
Family Health Plus Rates
Effective April 1, 2006
| | | | | | Optional Benefits covered |
County | Adults with Children 19 - 64 | Adults without Children 19 - 29 | Adults without Children 30 - 64 | Maternity Kick | Family Planning | Dental |
| ALBANY | $253.35 | $250.47 | $510.54 | $5,097.14 | Yes | Yes |
| COLUMBIA | $270.53 | $258.71 | $498.03 | $5,466.64 | Yes | Yes |
| DUTCHESS | $260.42 | $291.38 | $528.18 | $5,651.55 | Yes | Yes |
| GREENE | $270.53 | $258.71 | $498.03 | $5,466.64 | Yes | Yes |
| ORANGE | $260.42 | $291.38 | $528.18 | $5,651.55 | Yes | Yes |
| RENSSELAER | $253.35 | $250.47 | $510.54 | $5,097.14 | Yes | Yes |
| ROCKLAND | $256.16 | $208.81 | $471.77 | $4,812.65 | Yes | Yes |
| ULSTER | $260.42 | $291.38 | $528.18 | $5,651.55 | Yes | Yes |
| NEW YORK | $196.82 | $151.39 | $245.60 | $5,114.41 | Yes | Yes |
APPENDIX M
Service Area, Benefit Options, and Enrollment Elections
APPENDIX M
May 1, 2006
M-l
Schedule 1 of Appendix M
Service Area, Program Participation and
Prepaid Benefit Package Optional Covered Services
1. Service Area
The Contractor's service area is comprised of the counties listed in Column A of this schedule in their entirety.
2. Program Participation and Optional Benefit Package Covered Services
a) For each county listed in Column A below, an entry of "yes" in the subsections of Columns B and C means the Contractor offers the MMC and/or FHPlus product and/or includes the optional service indicated in its Benefit Package.
b) For each county listed in Column A below, an entry of "no" in the subsections of Columns B and C means the Contractor does not offer the MMC and/or FHPlus product and/or does not include the optional service indicated in its Benefit Package.
c) In the schedule below, an entry of "N/A" means not applicable for the purposes of this Agreement.
3. Effective Date
The effective date of this Schedule is May 1, 2006.
Contractor: WellCare of New York, Inc. |
Column A County | Column B Medicaid Managed Care | Column C FHPlus |
Contractor Participates | Dental | Family Planning | Non-Emergency Transportation | Emergency Transportation | Contractor Participates | Dental | Family Planning |
| Albany | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Columbia | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Dutchess | Yes | No | Yes | No | Yes | Yes | Yes | Yes |
| Greene | Yes | No | Yes | No | Yes | Yes | Yes | Yes |
| New York City - Bronx | N/A | N/A | N/A | N/A | N/A | Yes | Yes | Yes |
| New York City - Kings | N/A | N/A | N/A | N/A | N/A | Yes | Yes | Yes |
| New York City - New York | N/A | N/A | N/A | N/A | N/A | Yes | Yes | Yes |
| New York City - Queens | N/A | N/A | N/A | N/A | N/A | Yes | Yes | Yes |
APPENDIX M
May 1, 2006
M-2
Contractor: WellCare of New York, Inc. |
Column A County | Column B Medicaid Managed Care | Column C FHPlus |
Contractor Participates | Dental | Family Planning | Non-Emergency Transportation | Emergency Transportation | Contractor Participates | Dental | Family Planning |
| Orange | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Rensselaer | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Rockland | Yes | No | Yes | No | Yes | Yes | Yes | Yes |
| Ulster | Yes | No | Yes | No | No | Yes | Yes | Yes |
APPENDIX M
May 1, 2006
M-3
Schedule 2 of Appendix M
LDSS Election of Enrollment in Medicaid Managed Care For Foster Care Children and Homeless Persons
| | 1. | Effective May 1, 2006, in the Contractor's service area, Medicaid Eligible Persons in the following categories will be eligible for Enrollment in the Contractor's Medicaid Managed Care product at LDSS's option as described in (a) and (b) as follows, and indicated by an "X" in the chart below: |
a) Options for foster care children in the direct care of LDSS:
i) Children in LDSS direct care are mandatorily enrolled in MMC (mandatory counties only);
ii) Children in LDSS direct care are enrolled in on a case by case basis in MMC (mandatory or voluntary counties);
iii) All foster care children are Excluded from Enrollment in MMC (mandatory or voluntary counties).
b) Options for homeless persons living in shelters outside of New York City:
i) Homeless persons are mandatorily enrolled in MMC (mandatory counties only);
ii) Homeless persons are enrolled in on a case by case basis in MMC (mandatory or voluntary counties);
iii) All homeless persons are Excluded from Enrollment in MMC (mandatory or voluntary counties).
c) In the schedule below, an entry of "N/A" means not applicable for the purposes of this Agreement.
Contractor: WellCare of New York, Inc. |
County | Foster Care Children | Homeless Persons |
| Mandatorily Enrolled | Enrolled on Case by Case Basis | Excluded from Enrollment | Mandatorily Enrolled | Enrolled on Case by Case Basis | Excluded from Enrollment |
| Albany | | X | | | X | |
| Columbia | | X | | | X | |
| Dutchess | | X | | | X | |
| Greene | X | | | X | | |
| Orange | | X | | | X | |
| Rensselaer | | X | | | X | |
| Rockland | | X | | | X | |
| Ulster | | | X | | X | |
APPENDIX M
May 1, 2006
M-4
