APPENDIX X Agency Code 12000 Contract No. C-017720Period 4/1/05 9/30/05 Funding Amount for Period Based on approved capitation rates
APPENDIX X
Agency Code 12000 | Contract No. C-017720 | |||||
Period 4/1/05 9/30/05 | 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 C017720 by substituting the attached Appendix L Approved Capitation Payment Rates for the FHPlus Program. The effective date of these modifications is April 1, 2005.
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
Printed Name Printed Name
Title: _President and CEO Title: Deputy Director, OMC
Date: | July 1, 2005 | Date: July 25, 2005 | ||
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 _1st day of July 20 05 , before me personally appeared Todd S. Farha , to me known, who being by me duly sworn, did depose
and say that he resides at Tampa, Florida ,
that he is the _President and CEO of _WellCare of New York, Inc. , the corporation described herein which executed the foregoing instrument; and that he signed his
name thereto by order of the board of directors of said corporation.
(Notary) Kathleen R. Casey
STATE COMPTROLLERS SIGNATURE | Title: | _for the State Comptroller | ||
/s/Maryann Yurbon | Date: | _August 18, 2005 | ||
Appendix L
Family Health Plus
Approved Capitation Payment Rates
for the FHPlus Program
FHPlus
Appendix X
April 1, 2005WELLCARE OF NEW YORK, INC.
Family Health Plus Rates
Effective April 1, 2005
Optional
benefits covered
Family | Dental | |||||||||||||||||||||||
Planning | | |||||||||||||||||||||||
Adults with | Adults without | Adults without | ||||||||||||||||||||||
County | Children 19 - 64 | Children 19 - 29 | Children 30 - 64 | Maternity Kick | ||||||||||||||||||||
ALBANY | $ | 249.08 | $ | 306.31 | $ | 358.88 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
COLUMBIA | $ | 274.42 | $ | 304.61 | $ | 424.11 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
DUTCHESS | $ | 223.77 | $ | 273.11 | $ | 335.15 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
GREENE | $ | 274.42 | $ | 304.61 | $ | 424.11 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
ORANGE | $ | 223.77 | $ | 273.11 | $ | 335.15 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
RENSSELAER | $ | 249.08 | $ | 306.31 | $ | 358.88 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
ROCKLAND | $ | 253.14 | $ | 303.06 | $ | 328.52 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
ULSTER | $ | 223.77 | $ | 273.11 | $ | 335.15 | $ | 4,661.82 | Yes | Yes | ||||||||||||||
NEW YORK CITY | $ | 208.52 | $ | 201.72 | $ | 308.40 | $ | 4,834.20 | Yes | Yes | ||||||||||||||