Financial Statements

EX-10.27.2.1 3 w41089exv10w27w2w1.htm EXHIBIT 10.27.2.1 exv10w27w2w1
 

Exhibit 10.27.2.1

Medicaid HMO Contract
Amerigroup Florida, Inc.  
d/b/a Amerigroup Community Care    
AHCA CONTRACT NO. FA614
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 FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY CARE, hereinafter referred to as the “Vendor” or “Health Plan”, is hereby amended as follows:
1. Attachment I, Scope of Services, is hereby amended to include Exhibit II-D, Fourth Revised Capitation Rates, attached hereto and made a part of the Contract. All references in the Contract to Exhibit II-C, Third Revised Capitation Rates, shall hereinafter also refer to Exhibit II-D, Fourth Revised Capitation Rates, as appropriate.
2. Attachment I, Scope of Services, is hereby amended to include Exhibit III-A, September 1, 2007-August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, attached hereto and made a part of the Contract. All references in the Contract to Exhibit III, September 1, 2006 — August 31, 2007 HMO Rates, shall hereinafter also refer to Exhibit III-A, September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, as appropriate.
3. 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.   Adult basic dental benefits, such as cleanings, simple fillings, and/or extractions.
 
  b.   Up to $25 credit per household each month for selected over-the-counter drugs and/or health supplies.
 
  c.   Respite Care services — Annual maximum of not more than an initial home health visit by an R.N. and eight (8) follow-up visits by an aide. 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.
 
  d.   Circumcisions for newborns (routine newborn circumcision up to twelve (12) weeks of age).
4.   This Amendment shall have an effective date of September 1, 2007, or the date on which both parties execute the Amendment, 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.
This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.
   
AHCA Form 2100-0002 (Rev. NOV03) AHCA Contract No. FA614, Amendment No. 4, Page 1 of 2

 

 

Amerigroup Florida, Inc.
d/b/a Amerigroup Community Care 		  Medicaid HMO Contract
     IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which includes all attachments hereto) to be executed by their officials thereunto duly authorized.
             
AMERIGROUP FLORIDA, INC.   STATE OF FLORIDA, AGENCY FOR
D/B/A/ AMERIGROUP COMMUNITY CARE   HEALTH CARE ADMINISTRATION
 
SIGNED BY:       SIGNED BY:    
 
           
 
            
NAME:
  William McHugh   NAME:   Andrew C. Agwunobi, M.D
 
            
TITLE:
  CEO   TITLE:   Secretary
 
            
DATE:
      DATE:    
 
           
List of attachments included as part of this Amendment:
         
Specify   Letter/    
Type   Number   Description
Exhibit
  II-D   Fourth Revised Capitation Rates (1 Page)
 
Exhibit
  III-A   September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO Capitation Rates (5 Pages)
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
   
AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form 2100-0002 (Rev. NOV03)

 

 

Amerigroup Florida, Inc.
d/b/a Amerigroup Community Care 		  Medicaid HMO Contract
EXHIBIT II-D
FOURTH REVISED CAPITATION RATES
Table 4 — General Capitation Rates plus Mental Health Rates plus Transportation:
         
Area 3 Counties:
        
County:
    Provider Number:
Hernando
    015005350  
Lake
    015005341  
 
        
Area 5 Counties:
        
County:
    Provider Number:
Pasco
    015005304  
Pinellas
    015005305  
 
        
Area 6 Counties:
        
County:
    Provider Number:
Hillsborough
    015005300  
Polk
    015005307  
Manatee
    015005318  
 
        
Area 7 Counties:
        
County:
    Provider Number:
Orange
    015005308  
Seminole
    015005313  
Osceola
    015005314  
Brevard
    015005336  
 
        
Area 8 Counties:
        
County:
    Provider Number:
Lee
    015005302  
Sarasota
    015005306  
 
        
Area 9 Counties:
        
County:
    Provider Number:
Palm Beach
    015005310  
 
        
Area 10 Counties:
        
County:
    Provider Number:
Broward
    015005311  
 
        
Area 11 Counties:
        
County:
    Provider Number:
Miami-Dade
    015005312  
   
AHCA Form 2100-0002 (Rev. NOV03) AHCA Contract No. FA614, Exhibit II-D, Page 1 of 1

 

 

     
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
 ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
TABLE 1
General Rates:
                                                         
                TANF                           SSI-N   SSI-B   SSI-AB
Area   BTHM0+2M0 3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21.54)   AGE (55+)   BTHMO+2M0   3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
              Female   Male   Female   Male                            
**** REDACTED****
TABLE 2
General + Mental Health Rates:
                                                         
                TANF                           SSI-N   SSI-B   SSI-AB
Area   BTHM0+2M0 3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21.54)   AGE (55+)   BTHMO+2M0   3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
              Female   Male   Female   Male                            
**** REDACTED****
AHCA Contract No. FA614, Exhibit III-A, Page 1 of 5
HMO CapRates_200709-200608 08/10/2007

 

 

     
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area, Age and Eligibility Category
 ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
TABLE 3
General + MH + Dental Rates:
                                                         
    TANF                                       SSI-N   SSI-B   SSI-AB
Area   BTHM0+2M0 3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21.54)   AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
              Female   Male   Female   Male                            
**** REDACTED****
TABLE 4
General + MH + Transportation Rates:
                                                         
                TANF                       SSI-N   SSI-B   SSI-AB
Area   BTHM0+2M0 3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
              Female   Male   Female   Male                            
**** REDACTED****
   
AHCA Contract No. FA614, Exhibit III-A, Page 2 of 5 HMO CapRates_200709-200808 08/10/2007

 

 

     
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area, Age and Eligibility Category
 ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
TABLE 5
General + Transportation Rates:
                                                             
 
  TANF                                   SSI-N           SSI-B   SSI-AB
Area
  BTHM0+2M0   3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)       AGE (21.54)       AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
                  Female   Male   Female   Male                            
**** REDACTED****
TABLE 6
General + Dental Rates:
                                                             
 
  TANF                                   SSI-N           SSI-B   SSI-AB    
Area
  BTHM0+2M0   3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)       AGE (21-54)       AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
                  Female   Male   Female   Male                            
**** REDACTED****
   
AHCA Contract No. FA614, Exhibit III-A, Page 3 of 5 HMO CapRates_200709-200808 08/10/2007

 

 

     
EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
 ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
TABLE 7
General + Dental + Transportation Rates:
                                                             
 
  TANF                                   SSI-N           SSI-B   SSI-AB
Area
  BTHM0+2M0   3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)       AGE (21.54)       AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
                  Female   Male   Female   Male                            
**** REDACTED****
TABLE 8
General + Mental Health + Dental + Transportation Rates:
                                                             
 
  TANF                                   SSI-N           SSI-B   SSI-AB
Area
  BTHM0+2M0   3M0.11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)       AGE (21-54)       AGE (55+)   BTHMO+2M0 3M0-11MO   AGE (1-5)   AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)       AGE (65-)   AGE (65+)
 
                  Female   Male   Female   Male                            
**** REDACTED****
   
AHCA Contract No. FA614, Exhibit III-A, Page 4 of 5 HMO CapRates_200709-200808 08/10/2007

 

 

EXHIBIT III-A
September 1, 2007- August 31, 2008
Medicaid Non-Reform HMO Capitation Rates
By Area , Age and Eligibility Category
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
     
Area
  Corresponding Counties
 
    
Area 1
  Escambia, Okaloosa, Santa Rosa, Walton
Area 2
  Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla
Area 3
  Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hemando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union
Area 4
  Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
Area 5
  Pasco, Pinellas
Area 6
  Hardee, Highlands, Hillsborough, Manatee, Polk
Area 7
  Brevard, Orange, Osceola, Seminole
Area 8
  Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota
Area 9
  Indian River, Okeechobee, St. Lucie, Martin, Palm Beach
Area 10
  Broward
Area 11
  Dade, Monroe
Created on August 10, 2007
   
AHCA Contract No. FA614, Exhibit III-A, Page 5 of 5 HMO CapRates_200709-200808 08/10/2007

 

 

Amerigroup Florida, Inc.
d/b/a Amerigroup Community Care 		  Medicaid HMO Contract
     IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which includes all attachments hereto) to be executed by their officials thereunto duly authorized.
                 
AMERIGROUP FLORIDA, INC.   STATE OF FLORIDA, AGENCY FOR
D/B/A/ AMERIGROUP COMMUNITY C   HEALTH CARE ADMINISTRATION
 
              
SIGNED BY:
 /S/ William McHugh       SIGNED BY:    
           
 
              
NAME: William McHugh   NAME: Andrew C. Agwunobi, M.D
     
 
              
TITLE:. CEO   TITLE: Secretary
   
 
              
DATE: 8-31-07   DATE:    
       
 
              
List of attachments included as part of this Amendment:      
 
              
         
Specify
  Letter/    
Type
  Number   Descnption  
 
Exhibit   II-D   Fourth Revised Capitation Rates (1 Page)
 
Exhibit   III-A   September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO Capitation Rates (5 Pages)
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
   
AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2 AHCA Form 2100-0002 (Rev. NOV03)