Attachment II, Section IX(B)(6) of Amendment No. 2 to Contract No. FP020 between the Agency for Health Care Administration and WellCare of Florida, Inc. (d/b/a Staywell Health Plan of Florida)

General

The entity which comprises the Health Plan or of which the Health Plan is a part and which is required to submit the IRS Form 8963 pursuant to the above mentioned federal regulations (referred to hereinafter as the “Reporting Plan”) shall submit to the Agency a copy of the IRS Form 8963 submitted to the IRS by April 15 after each year it intends to be reimbursed.

The Reporting Plan shall submit to the Agency a copy of the IRS Notice of final fee calculation (as described in 26 CFR s. 57.7) by September 15 after each calendar year it intends to be reimbursed.

The Reporting Plan shall submit its annual statement (which includes information pertinent to the tax impact of the subject fee) once it is issued for the preceding calendar year for which it intends to be reimbursed.

All documents listed above and any additional data or information requested by the Agency shall be submitted with an attestation by the Reporting Plan in accordance with the certification requirements specified in Section XII, Reporting Requirements, of this Contract. Following the determination of the amount to be reimbursed and the federal and state income tax impact related to this health insurance providers fee, the capitated per member per month Fee for the plan will be timely reprocessed. This process is subject to approval by the Centers for Medicare and Medicaid Services and any change in federal or state law.

Health insurance Providers Fee Methodology

Table 1 would show revenue information for the data year related to the fee payment year. For example, Table 1 would include 2013 revenue information for the 2014 Health Insurance Providers fee. This approach is consistent with how the Health Insurance Providers fee amount is calculated by the IRS. Please note that the amounts designated as A through I are net of the exempted premiums amounts. The total premiums taken into account should be allocated proportionately to total premiums by state and line of business.

The information in Table 1 will be used by the Agency to calculate the portion of the Health Insurance Providers Fee related to Medicaid activities for the Reporting Plan using the formula (A / I) * J. The proportion denoted by (A / I) represents the percentage of total premiums taken into account related to Medicaid for the Reporting Plan, and J represents the total Health Insurance Providers Fee amount allocated to the Reporting Plan as documented by the Reporting Plan’s IRS notice. Note that items I and J should be taken directly from the IRS memos received by the Reporting Plan.

Adjustment for federal and state income tax related to the Health Insurance Providers Fee Methodology

An actuarially sound approach will be developed to calculate the amount of income tax related to the Health Insurance Providers Fee.