THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and HEALTHEASE OF FLORIDA, INC., hereinafter referred to as the “Vendor”, is hereby amended as follows:
1.
Standard Contract, Section II.A, 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 $833,550,430.00, (an increase of $12,618,094.00), subject to the availability of funds.
2. Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 1, is hereby
4. Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 3 is hereby amended to
now read as follows:
Table 3 Age-banded Capitation Rates for all Agency Areas of the State.
Area 01 General Rates plus Mental Health
Plan — O15019314 (ESCAMBIA) 015019331(SANTA ROSA)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
856.86
169.64
84.58
64.23
128.66
71.38
227.66
148.26
303.38
303.38
SSI/No Medicare
8379.21
1456.20
384.40
263.28
284.40
284.40
732.06
732.06
631.82
631.82
SSI/Part B
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
SSI/Part A & B
331.54
331.54
331.54
331.64
331.54
331.54
331.54
331.54
331.54
236.11
Area 02 General Rates plus Mental Health Plan — 015Ol9315 (GADSDEN) 015019318(JEFFERSON) 015019320(LEON) 015019322(MADISON) 015019336(WAKULLA) 015019340 (CALHOUN) 015019342 (LIBERTY)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
856.87
169.66
85.36
69.25
128.93
71.65
226.56
147.16
302.78
302.78
SSI/No Medicare
8379.20
1456.19
388.93
278.27
264.36
264.36
690.25
690.25
621.15
621.15
SSI/Part B
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
SSI/Part A & B
328.39
328.39
328.39
328.99
328.39
328.39
328.39
328.39
328.39
232.96
Area 03 General Rates plus Mental Health
Plan - 015019309(CITRUS) 015019319(LAKE) 015019323 (MARION) 015019329(PUTNAM)
BTHMO+2MO
3MO-11MO
1-8
6-13
14-20
(F)
14-20
(M)
21-84
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
956.51
190.37
94.52
67.12
136.49
72.38
254.10
164.92
342.33
342.33
SSI/No Medicare
8796.56
1536.63
401.17
243.67
248.87
248.87
702.91
702.91
649.30
649.30
SSI/Part B
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
SSI/Part A & B
299.65
299.65
299.65
299.65
299.65
299.65
299.65
299.65
299.65
211.35
Area 04 General Rates plus Mental Health
Plan - 015019313(DUVAL)
BTHM0+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
877.99
175.55
87.56
63.92
127.39
68.47
235.93
153.75
318.93
318.93
SSI/NO Medicare
8571.86
1495.59
394.00
254.46
252.62
252.62
694.02
694.02
635.24
635.24
SSI/Part B
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
SSI/Part A & B
311.96
311.96
311.96
311.96
311.96
311.96
311.96
311.96
311.96
223.04
Area 05 General Rates plus Mental Health
Plan - 015019302(PASCO)
015019303(PINELLAS)
BTHM0+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
919.98
183.43
91.15
64.87
131.62
69.93
245.33
159.49
331.03
331.03
SSI/No Medicare
9248.02
1615.41
420.86
252.27
258.55
258.55
735.80
735.80
681.19
681.19
SSI/Part B
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
SSI/Part A & B
321.24
321.24
321.24
321.24
321.24
321.24
321.24
321.24
321.24
227.10
Area 06 General Rates plus Mental Health Plan — 015019300(HILLSBOROUGH) 015019301(MANATEE) 015019304(POLK) 015019317 (HIGHLANDS)
September 1, 2005 through December 31, 2005 — Estimated HMO rates; not for use unless approved by CMS.
Area 01 General Rates plus Mental Health Plan — 015019314(ESCAMBIA) 015019331(SANTA ROSA)
BTHM0+2MO
3MO-11MO
1-5
6-13
14-20
(P)
14-20
(M)
21-54
(P)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
856.86
169.64
84.58
64.23
128.66
71.38
227.66
148.26
303.38
303.38
SSI/NO Medicare
8379.21
1456.20
384.40
263.28
284.40
284.40
732.06
732.06
631.82
631.82
SSI/Part B
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
367.49
SSI/Part A & B
331.54
331.54
331.54
331.54
331.54
331.54
331.54
331.54
331.54
236.11
Area 02 General Rates plus Mental Health Plan — 015019315(GADSDEN) 015019318(JEFFERSON) 015019320(LEON) 015019322(MADISON) 015019336(WAKULLA) 015019340(CALHOUN) 015019342(LIBERTY)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
856.87
169.65
85.36
69.25
128.93
71.65
226.56
147.16
302.78
302.78
SSI/No Medicare
8379.20
1456.19
388.93
278.27
264.36
264.36
690.25
690.25
621.15
621.15
SSI/Part B
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
380.79
SSI/Part A & B
328.39
328.39
328.39
328.39
328.39
328.39
328.39
328.39
328.39
232.96
Area 03 General Rates plus Mental Health Plan — 015019309(CITRUS) 015019319(LAKE) 015019323(MARION) O15019329 (PUTNAM)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(P)
21-54
(M)
55-64
65+
TANF/PC/SOBRA
956.51
190.37
94.52
67.12
136.49
72.38
254,10
164.92
342.33
342.33
SSI/NO Medicare
8796.56
1536.63
401.17
243.67
248.87
248.87
702.91
702.91
649.30
649.30
SSI/Part B
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
356.54
SSI/Part A & B
299.65
299.65
299.65
299.65
299.65
299.65
299.65
299.65
299.65
211.35
Area 04 General Rates plus Mental Health Plan — 015019313(DUVAL)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
877.99
175.55
87.56
63.92
127.39
68.47
235.93
153.75
318.93
318.93
SSI/NO Medicare
8571.86
1495.59
394.00
254.46
252.62
252.62
694.02
694.02
635.24
635.24
SSI/Part B
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
342.17
SSI/Part A & B
311.96
311.96
311.96
311.96
311.96
311.96
311.96
311.96
311.96
223.04
Area 05 General Rates plus Mental Health Plan — 015019302(PASCO) 015019303(PINELLAS)
BTHM0+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
919.98
183.43
91.15
64.87
131.62
69.93
245.33
159.49
331.03
331.03
SSI/NO Medicare
9248.02
1615.41
420.86
252.27
258.55
258.55
735.80
735.80
681.19
681.19
SSI/Part B
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
332.63
SSI/Part A & B
321.24
321.24
321.24
321.24
321.24
321.24
321,24
321.24
321.24
227.10
Area 06 General Rates plus Mental Health Plan — 015019300(HILLSBOROUGH) 015019301(MANATEE) 015019304(POLK) 015019317(HIGHLANDS)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
839.91
168.14
84.80
67.94
131.59
75.16
230.12
151.25
309.66
309.66
SSI/No Medicare
8536.50
1494.29
393.28
262.75
284.04
284.04
746.59
746.59
653.76
653.76
SSI/Part B
319.38
319.38
319.38
319.38
319.38
319.38
319.38
319.38
319.38
319.38
SSI/Part A & B
288.23
288.23
288.23
288.23
288.23
288.23
288.23
288.23
288.23
202.46
Area 07 General Rates plus Mental Health Plan — 015019308(BREVARD) 015019327(ORANGE) 015019328(OSCEOLA) 015019333(SEMINOLE)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
894.05
178.57
89.54
68.64
132.32
72.39
240.41
156.74
324.62
324.62
SSI/NO Medicare
8976.52
1573.98
414.04
264.97
264.82
264.82
733.66
733.66
674.72
674.72
SSI/Part B
312.78
312.78
312.78
312.78
312.78
312.78
312.78
312.78
312.78
312.78
SSI/Part A & B
296.22
296.22
296.22
296.22
296.22
296.22
296.22
296.22
296.22
210.25
Area 08 General Rates plus Mental Health Plan — 015019332(SARASOTA)
Area 11General Rates plus Mental Health plus Transportation Plan - 015019338(DADE)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
1112.09
221.48
110.76
82.14
162.18
87.53
296.62
192.80
398.87
398.87
SSI/No Medicare
12145.45
2131.39
560.13
336.09
345.82
345.82
983.20
983.20
907.03
907.03
SSI/Part B
462.31
462.31
462.31
462.31
462.31
462.31
462.31
462.31
462.31
462.31
SSI/Part A & B
439.76
439.76
439.76
439.76
439.76
439.76
439.76
439.76
439.76
305.52
January 1, 2006 through June 30, 2006 — Estimated HMO rates; not for use unless approved by CMS.
Area 01 General Rates plus Mental Health Plan - 015019314(ESCAMBIA) 015019331(SANTA ROSA)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54(F) 21-54
(M)
55-64 65+
TANF/FC/SOBRA
856.86
169.64
84.58
64.23
128.66
71.38
227.66
148.26
303.38
303.38
SSI/NO Medicare
8379.21
1456.20
384.40
263.28
284.40
284.40
732.06
732.06
631.82
631.82
SSI/Part B
221.62
221.62
221.62
221.62
221.62
221.62
221.62
221.62
221.62
221.62
SSI/Part A & B
94.39
94.39
94.39
94.39
94.39
94.39
94.39
94.39
94.39
84.53
Area 02 General Rates plus Mental Health Plan — 015019315(GADSDEN) 015019318 (JEFFERSON) 015019320 (LEON) 015019322(MADISON) 015019336(WAKULLA) 015019340(CALHOUN) 015019342(LIBERTY)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
856.87
169.65
85.36
69.25
128.93
71.65
226.56
147.16
302.78
302.78
SSI/No Medicare
8379.20
1456.19
388.93
278.27
264.38
264.36
690.25
690.25
621.15
621.15
SSI/Part B
234.92
234.92
234.92
234.92
234.92
234.92
234.92
234.92
234.92
234.92
SSI/Part A & B
91.24
91.24
91.24
91.24
91.24
91.24
91.24
91.24
91.24
81.38
Area 03 General Rates plus Mental Health
Plan - 015019309(CITRUS) 015019319(LAKE) 015019323 (MARION) 015019329(PUTNAM)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
956.51
190.37
94.52
67.12
136.49
72.38
254.10
164.92
342.33
342.33
SSI/No Medicare
8796.56
1536.63
401.17
243.67
248.87
248.87
702.91
702.91
649.30
649.30
SSI/Part B
237.65
237.65
237.65
237.65
237.65
237.65
237.65
237.65
237.65
237.65
SSI/Part A & B
83.24
83.24
83.24
83.24
83.24
83.24
83.24
83.24
83.24
73.70
Area 04 General Rates plus Mental Health
Plan - 015019313 (DUVAL)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
877.99
175.55
87.56
63.92
127.39
68.47
235.93
153.75
318.93
318.93
SSI/No Medicare
8571.86
1495.59
394.00
254.46
252.62
252.62
694.02
694.02
635.24
635.24
SSI/Part B
215.68
215.68
215.68
215.68
215.68
215.68
215.68
215.68
215.68
215.68
SSI/Part A & B
94.67
94.67
94.67
94.67
94.67
94.67
94.67
94.67
94.67
84.86
Area 05 General Rates plus Mental Health
Plan - 015019302(PASCO)
015019303(PINELLAS)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
919.98
183.43
91.15
64.87
131.62
69.93
245.33
159.49
331.03
331.03
SSI/No Medicare
9248.02
1615.41
420.86
252.27
258.55
258.55
735.80
735.80
681.19
681.19
SSI/Part B
214.59
214.59
214.59
214.59
214.59
214.59
214.59
214.59
214.59
214.59
SSI/Part A & B
83.91
83.91
83.91
83.91
83.91
83.91
83.91
83.91
83.91
74.53
Area 06 General Rates plus Mental Health
Plan - 015019300(HILLSBOROUGH) 015019301(MANATEE) 015019304(POLK) 015019317(HIGHLANDS)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
839.91
168.14
84.80
67.94
131.59
75.16
230.12
151.25
309.66
309.66
SSI/No Medicare
8536.50
1494.29
393.28
282.75
284.04
284.04
746.59
746.59
653.76
653.76
SSI/Part B
201.26
201,26
201.26
201.26
201.26
201.26
201.26
201.26
201.26
201.26
SSI/Part A & B
73.23
73.23
73.23
73.23
73.23
73.23
73.23
73.23
73.23
64.45
Area 07 General Rates plus Mental Health
Plan - 015019308 (BREVA—D) O15019327 (ORANGE) 015019328(OSCEOLA) 015019333 (SEMINOLE)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
894.05
178.57
89.54
68.64
132.32
72.39
240.41
156.74
324.62
324.62
SSI/No Medicare
8976.52
1573.98
414.04
264.97
264.82
264.82
733.66
733.66
674.72
674.72
SSI/Part B
203.20
203.20
203.20
203.20
203.20
203.20
203.20
203.20
203.20
203.20
SSI/Part A & B
84.13
84.13
84.13
84.13
84.13
84.13
84.13
84.13
84.13
74.97
Area 08 General Rates plus Mental Health
Plan - 015019332(SARASOTA)
BTHMO+2MO
3MO-11MO
1-5
6-13
14-20
(F)
14-20
(M)
21-54
(F)
21-54
(M)
55-64
65+
TANF/FC/SOBRA
785.53
156.86
78.13
56.61
113.39
60.74
210.44
136.92
284.23
284.23
SSI/No Medicare
8247.94
1440.21
376.25
229.28
234.06
234.06
659.32
659.32
608.59
608.59
SSI/Part B
191.91
191.91
191.91
191.91
191.91
191.91
191.91
191.91
191.91
191.91
SSI/Part A & B
77.95
77.95
77.95
77.95
77.95
77.95
77.95
77.95
77.95
69.13
Area 11 General Rates plus Mental Health plus Transportation Plan — 015019338(DADE)
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 $833,550,430.00 (an increase of $12,618,094.00) expressed on page seven of this contract.
6.
This amendment shall begin on September 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 atthelevel specified in the Contract.
This amendment and all its attachments are hereby made a 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 6 page amendment (including all attachments) to be executed by their officials thereunto duly authorized.
HEALTHEASE OF FLORIDA, INC. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED BY:/s/ Todd S. Farha
SIGNED BY:[Illegible]
NAME:Todd S. Farha NAME:Alan Levine
TITLE: President & CEO
TITLE: Secretary
DATE: 8/31/05
DATE:
9/1/05
THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY
AHCA Contract No.FA521, Amendment No. 8, Page 6 of 6
AHCA Form 2100-0002 (Rev. NOV03)
2
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