Amendment number 4 to the Medicaid Managed Care and Family Health Plus Model Contract between the New York State Department of Health and WellCare of New York, Inc
EX-10.1 2 exhibit10-1.htm EXHIBIT 10.1 Exhibit 10.1
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Exhibit 10.1
APPENDIX X
[Amendment #4]
| Agency Code 12000 | Contract No. C020454 |
| Period 10/1/06-9/30/08 | 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 Corning 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." The effective date of these modifications is October 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 their signatures.
| 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 |
| Date: 3/23/2007 | Date: 4/6/2007 |
| | 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 23 day of March 2007, 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 and 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)
APPENDIX L
Approved Capitation Payment Rates
APPENDIX L
October 1, 2006
L-l
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
| MMIS ID#: 01182503 | Effective Date: 10/01/06 |
| Approved by DOB: Yes | Region: Northeast |
| Reinsurance: No | County: ALBANY |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $266.66 |
| TANF/SN 6mo-14 F | $90.84 |
| TANF/SN 15-20 F | $132.88 |
| TANF/SN 6mo-20 M | $88.65 |
| TANF 21+ M/F | $215.57 |
| SN 21-29 M/F | $204.54 |
| SN 30+ M/F | $370.80 |
| SSI 6mo-20 M/F | $179.30 |
| SSI 21-64 M/F | $500.80 |
| SSI 65+ M/F | $445.49 |
| Maternity Kick Payment | $5,097.14 |
| Newborn Kick Payment | $1,734.99 |
Optional Benefits Offered:
| R Emergency Transportation | £Dental |
| R Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Central |
| Reinsurance: No | County: COLUMBIA |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $257.40 |
| TANF/SN 6mo-14 F | $83.44 |
| TANF/SN 15-20 F | $141.87 |
| TANF/SN 6mo-20 M | $83.83 |
| TANF 21+ M/F | $232.72 |
| SN 21-29 M/F | $218.50 |
| SN 30+ M/F | $374.26 |
| SSI 6mo-20 M/F | $181.92 |
| SSI 21-64 M/F | $481.49 |
| SSI 65+ M/F | $398.31 |
| Maternity Kick Payment | $5,466.64 |
| Newborn Kick Payment | $1,980.01 |
Optional Benefits Offered:
| R Emergency Transportation | £Dental |
| R Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region.: Mid-Hudson |
| Reinsurance: No | County: DUTCHESS |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $270.87 |
| TANF/SN 6mo-14 F | $94.94 |
| TANF/SN 15-20 F | $137.72 |
| TANF/SN 6mo-20 M | $104.62 |
| TANF 21+ M/F | $233.20 |
| SN 21-29 M/F | $214.30 |
| SN 30+ M/F | $435.52 |
| SSI 6mo-20 M/F | $179.73 |
| SSI 21-64 M/F | $495.51 |
| SSI 65+ M/F | $431.82 |
| Maternity Kick Payment | $5,651.55 |
| Newborn Kick Payment | $2,276.59 |
| Optional Benefits Offered: | |
| R Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Central |
| Reinsurance: No | County: GREENE |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $255.17 |
| TANF/SN 6mo-14 F | $81.61 |
| TANF/SN 15-20 F | $139.56 |
| TANF/SN 6mo-20 M | $81.96 |
| TANF 21+ M/F | $229.85 |
| SN 21-29 M/F | $215.70 |
| SN 30+ M/F | $371.16 |
| SSI 6mo-20 M/F | $178.82 |
| SSI 21-64 M/F | $477.44 |
| SSI 65+ M/F | $396.59 |
| Maternity Kick Payment | $5,466.64 |
| Newborn Kick Payment | $1,980.01 |
| Optional Benefits Offered: | |
| R Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Mid-Hudson |
| Reinsurance: No | County: ORANGE |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $267.68 |
| TANF/SN 6mo-14 F | $94.17 |
| TANF/SN 15-20 F | $134.59 |
| TANF/SN 6mo-20 M | $103.58 |
| TANF 21+ M/F | $229.78 |
| SN 21-29 M/F | $209.82 |
| SN 30+ M/F | $429.39 |
| SSI 6mo-20 M/F | $175.89 |
| SSI 21-64 M/F | $487.16 |
| SSI 65+ M/F | $426.97 |
| Maternity Kick Payment | $5,651.55 |
| Newborn Kick Payment | $2,276.59 |
| Optional Benefits Offered: | |
| £ Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Northeast |
| Reinsurance: No | County: RENSSELAER |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $264.44 |
| TANF/SN 6mo-14 F | $89.01 |
| TANF/SN 15-20 F | $130.59 |
| TANF/SN 6mo-20 M | $86.79 |
| TANF 21+ M/F | $212.69 |
| SN 21-29 M/F | $201.74 |
| SN 30+ M/F | $367.69 |
| SSI 6mo-20 M/F | $176.21 |
| SSI 21-64 M/F | $496.76 |
| SSI 65+ M/F | $443.78 |
| Maternity Kick Payment | $5,097.14 |
| Newborn Kick Payment | $1,734.99 |
| Optional Benefits Offered: | |
| R Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Northern Metro |
| Reinsurance: No | County: ROCKLAND |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $250.95 |
| TANF/SN 6mo-14 F | $88.86 |
| TANF/SN 15-20 F | $113.17 |
| TANF/SN 6mo-20 M | $99.37 |
| TANF 21+ M/F | $193.00 |
| SN 21-29 M/F | $266.43 |
| SN 30+ M/F | $419.43 |
| SSI 6mo-20 M/F | $178.93 |
| SSI 21-64 M/F | $556.61 |
| SSI 65+ M/F | $419.43 |
| Maternity Kick Payment | $4,812.65 |
| Newborn Kick Payment | $1,569.65 |
| Optional Benefits Offered: | |
| R Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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: 10/01/06 |
| Approved by DOB: Yes | Region: Mid-Hudson |
| Reinsurance: No | County: ULSTER |
| Premium Group | Rate Amount |
| TANF/SN <6mo M/F | $267.68 |
| TANF/SN 6mo-14 F | $94.17 |
| TANF/SN 15-20 F | $134.59 |
| TANF/SN 6mo-20 M | $103.58 |
| TANF 21+ M/F | $229.78 |
| SN 21-29 M/F | $209.82 |
| SN 30+ M/F | $429.39 |
| SSI 6mo-20 M/F | $175.89 |
| SSI 21-64 M/F | $487.16 |
| SSI 65+ M/F | $426.97 |
| Maternity Kick Payment | $5,651.55 |
| Newborn Kick Payment | $2,276.59 |
| Optional Benefits Offered: | |
| £ Emergency Transportation | £Dental |
| £ Non-Emergent Transportation | R 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 CITY | $196.82 | $151.39 | $245.60 | $5,114.41 | Yes | Yes |
