WELL CARE HMO, INC., Medicaid HMO Contractd/b/a STAY WELL HEALTH PLAN OF FLORIDA AHCA CONTRACT NO. FA522 AMENDMENT NO. 1

Exhibit 10.2

AHCA CONTRACT NO. FA522
AMENDMENT NO. 1

     THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and WELL CARE HMO, INC., d/b/a STAY WELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the “Vendor”, is hereby amended as follows:

The plan shall ensure the provision of services is sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished and shall ensure the provision of the following covered services as defined and specified in sections 10.1, General and 10.8, Manner of Service Provision:

The plan shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. The plan may place appropriate limits on a service on the basis of criteria such as medical necessity or for utilization control, consistent with this contract, provided the services furnished can reasonably be expected to achieve their purpose.

     The plan may only provide for abortions in the following situations:

The plan shall have administrative and management arrangements or procedures and a mandatory compliance plan and shall comply with program integrity requirement as required in 42 CFR 438.608 to develop and maintain written policies and procedures for fraud and abuse prevention. In addition, the policies shall contain the following:

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In addition, the plan may not deny payment for treatment obtained when a representative of the plan instructs the enrollee to seek emergency services.

If the member’s primary care physician responds to the notification, the hospital physician and the primary care physician may discuss the appropriate care and treatment of the member. The plan may have a member of the hospital staff with whom it has a contract participate in the treatment of the member within the scope of the physician’s hospital staff privileges. The member may be transferred, in accordance with state and federal law, to a hospital that has a contract with the plan and has the service capability to treat the member’s emergency medical condition. The attending emergency physician, or the provider actually treating the enrollee, is responsible for determining when the enrollee is sufficiently stabilized for transfer or discharge, and that determination is binding on the entities identified in 42 CFR 438.114(b) as responsible for coverage and payment. Notwithstanding any other state law, a hospital may request and collect insurance or financial information from a patient in accordance with federal law, which is necessary to determine if the patient is a member of the plan, if emergency services and care are not delayed.

In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the plan must also cover poststabilization services without authorization, regardless of whether the beneficiary obtains the service within or outside the plan’s network for the following situations:

The grievance process must be completed in time to permit the disenrollment to be effective in accordance with the timeframe specified in 42 CFR 438.56(e)(1).

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The beneficiary or provider may request a Medicaid fair hearing by contacting DCF at the Office of Appeal Hearings, 1317 Winewood Boulevard, Building 5, Room 203 Tallahassee, Florida ###-###-####.

.... both in and out of the plan’s service area; to include the enrollee has a right to use any hospital or other setting for emergency use; the extent to which...

Owns, indirectly or directly 5 percent or more of the plan’s capital or stock, has ownership of 5% or more in a plan’s provider or subcontractor, or receives 5 percent or more of its profits;

Table 2.

Area wide Age-banded Capitation Rates for all agency areas
of the state other than Area 6 and Area 1.

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Table 3.

Area 6 or Area 1 Age-banded Capitation Rates, Including Community Mental
Health and Mental Health Targeted Case Management.

Post-stabilization Care Services – as defined in 42 CFR 438.114, means covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in paragraph (e) of 42 CFR 438.114, to improve or resolve the enrollee’s condition.

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.

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     IN WITNESS WHEREOF, the parties hereto have caused this 5 page amendment (including all attachments) to be executed by their officials thereunto duly authorized.

THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY

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