Amendment No. 3 to Contract No. FP020 between the Agency for Health Care Administration and WellCare of Florida, Inc. (d/b/a Staywell Health Plan of Florida)

EX-10.1 2 ex101fp020am3.htm AMENDMENT NO. 3 TO FP020 Ex101FP020Am3

Back to Form 8-K
Exhibit 10.1




AHCA CONTRACT NO. FP020
AMENDMENT NO. 3
THIS CONTRACT, entered into between the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and WELLCARE OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the “Vendor” or “Managed Care Plan,” is hereby amended as follows:
1.
Effective August 1, 2014, Attachment I, Scope of Services, - Effective Date: July 1, 2014, Statewide Medicaid Managed Care Program, is hereby deleted in its entirety and replaced with Attachment I, Scope of Services, - Effective Date: August 1, 2014, Statewide Medicaid Managed Care Program, attached hereto and made a part of this Contract. All references in this Contract to Attachment I, Scope of Services – Effective Date: July 1, 2014, shall hereinafter refer to Attachment I, Scope of Services – Effective Date: August 1, 2014.
2.
Standard Contract, Section III., Item B., Contract Managers, sub-item 2., is hereby amended to read as follows:
2.
The Vendor’s Contract Manager’s contact information is as follows:
Michelle Bimle
WellCare of Florida, Inc., d/b/a
Staywell Health Plan of Florida, Inc.
3031 N. Rocky Point Drive, West
Suite 600
Tampa, FL 33607
(813) 206-6952
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.
This Amendment, and all its attachments, are hereby made part of this Contract.
This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.
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AHCA Contract No. FP020, Amendment No. 3, Page 1 of 2


IN WITNESS WHEREOF, the Parties hereto have caused this twenty-nine (29) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.
WELLCARE OF FLORIDA, INC.
 
STATE OF FLORIDA, AGENCY FOR
D/B/A STAYWELL HEALTH PLAN
 
HEALTH CARE ADMINISTRATION
OF FLORIDA
 
 
 
 
 
 
 
 
SIGNED
 
SIGNED
BY:
/s/ Gregg Macdonald
 
BY:
/s/ Elizabeth Dudek
NAME:
Gregg Macdonald
 
NAME:
Elizabeth Dudek
TITLE:
State President
 
TITLE:
Secretary
DATE:
9-18-14
 
DATE:
9/19/14

List of Attachments/Exhibits included as part of this Amendment
 
 
 
 
 
Specify
Letter/
 
 
 
Type
Number
Description
 
 
Attachment
I
Scope of Services – Effective Date: August 1, 2014 (27 Pages)

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AHCA Contract No. FP020, Amendment No. 3, Page 2 of 2


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
SCOPE OF SERVICES - Effective Date: August 1, 2014
STATEWIDE MEDICAID MANAGED CARE PROGRAM
I.
Services to be Provided
A.
Overview of Contract Structure
Part IV of Chapter 409, F.S. established Florida Medicaid’s statewide managed care program, referred to as statewide Medicaid managed care (SMMC). Contracted managed care plans participate in one, or both, of two SMMC programs: one for managed medical assistance (MMA) and one for long-term care (LTC). Additionally, some managed care plans participating in the MMA program component serve specialty populations who meet specified criteria based on age, condition or diagnosis.
The Contract consists of distinct parts as follows:
(1)
Attachment I, Scope of Services, includes contract provisions that are unique to the particular managed care plan.
(a)
Exhibit I-A, Approved Expanded Benefits Coverage and Limitations;
(b)
Exhibit I-B, Medicaid Provider Identification Numbers;
(c)
Exhibit I-C, Managed Care Plan Rates.
(2)
Attachment II, Core Contract Provisions, includes contract provisions that apply to all managed care plans unless specifically noted otherwise.
(3)
Exhibits to Attachment II, include contract provisions that are unique to the specific component of SMMC:
(a)
Exhibit II-A, Managed Medical Assistance (MMA) Program, i.e. the MMA Exhibit;
(b)
Exhibit II-B, Long-Term Care (LTC) Managed Care Program, i.e. the LTC Exhibit;
(c)
Exhibit II-C, Specialty Plan (if applicable).
B.
Authorized Regions and Program Enrollment Levels
The Managed Care Plan is authorized to provide services pursuant to this Contract in the region(s), and up to the maximum enrollment levels for such region(s), for the applicable SMMC program as specified in Table 1 below.
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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 1 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida



Table 1: Regions and Program Enrollment Levels
Region
Program Component
MMA
LTC
Specialty
Region 1
 
 
 
Region 2
117,516
 
 
Region 3
130,444
 
 
Region 4
152,143
 
 
Region 5
95,177
 
 
Region 6
118,754
 
 
Region 7
129,577
 
 
Region 8
104,607
 
 
Region 9
   
 
 
Region 10
 
 
 
Region 11
114,124
 
 

The authorized maximum enrollment levels listed are effective upon Contract execution unless otherwise specified. The maximum enrollment levels may be altered during the life of this Contract pursuant to Attachment II and its Exhibits.
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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 2 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


C.
Covered Services
The Managed Care Plan shall ensure the provision of covered services in accordance with the provisions of Attachment II and its Exhibits, summarized in Table 2a (MMA) and/or Table 2b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.
 
Table 2a: Required MMA Services
(1)
Advanced Registered Nurse Practitioner
(2)
Ambulatory Surgical Center Services
(3)
Assistive Care Services
(4)
Behavioral Health Services
(5)
Birth Center and Licensed Midwife Services
(6)
Clinic Services
(7)
Chiropractic Services
(8)
Dental Services
(9)
Child Health Check Up
(10)
Immunizations
(11)
Emergency Services
(12)
Emergency Behavioral Health Services
(13)
Family Planning Services and Supplies
(14)
Healthy Start Services
(15)
Hearing Services
(16)
Home Health Services and Nursing Care
(17)
Hospice Services
(18)
Hospital Services
(19)
Laboratory and Imaging Services
(20)
Medical Supplies, Equipment, Prostheses and Orthoses
(21)
Optometric and Vision Services
(22)
Physician Assistant Services
(23)
Podiatric Services
(24)
Physician Services
(25)
Prescribed Drug Services
(26)
Renal Dialysis Services
(27)
Therapy Services
(28)
Transportation Services

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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 3 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


 
Table 2b: Required LTC Services
(1)
Adult Companion Care
(2)
Adult Day Health Care
(3)
Assistive Care Services
(4)
Assisted Living
(5)
Attendant Care
(6)
Behavioral Management
(7)
Caregiver Training
(8)
Care Coordination/Case Management
(9)
Home Accessibility Adaptation Services
(10)
Home Delivered Meals
(11)
Homemaker Services
(12)
Hospice
(13)
Intermittent and Skilled Nursing
(14)
Medical Equipment and Supplies
(15)
Medication Administration
(16)
Medication Management
(17)
Nutritional Assessment/Risk Reduction Services
(18)
Nursing Facility Services
(19)
Personal Care
(20)
Personal Emergency Response Systems (PERS)
(21)
Respite Care
(22)
Occupational Therapy
(23)
Physical Therapy
(24)
Respiratory Therapy
(25)
Speech Therapy
(26)
Transportation

D.
Approved Expanded Benefits
The Managed Care Plan shall provide the following expanded benefits, in accordance with the provisions of Attachment II and its Exhibits and the coverage and limitations specified in Exhibit I-A of this Attachment, denoted by “X” in Table 3a (MMA) and/or Table 3b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 4 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida



Table 3a: Approved MMA Expanded Benefits
X
Primary Care Visits (Non-Pregnant Adults)
X
Home Health Care (Non-Pregnant Adults)
X
Physician Home Visits
X
Prenatal/Perinatal Visits
X
Outpatient Services
X
Over-The-Counter (OTC) Medication/Supplies
X
Adult Dental Services
X
Waived Copayments
X
Vision Services
X
Hearing Services
X
Newborn Circumcision
X
Adult Pneumonia Vaccine
X
Adult Influenza Vaccine
X
Adult Shingles Vaccine
X
Post Discharge Meals
X
Nutritional Counseling
X
Pet Therapy
X
Art Therapy
X
Equine Therapy
X
Medically Related Lodging and Food


 
Table 3b: Approved LTC Expanded Benefits
 
ALF/AFCH Bed Hold
 
Cellular Phone Services
 
Dental Services
 
Emergency Financial Assistance
 
Hearing Evaluation
 
Mobile Personal Emergency Response System
 
Non-Medical Transportation
 
Over-The-Counter (OTC) Medication/Supplies
 
Support to Transition Out of a Nursing Facility
 
Vision Services
 
Wellness Grocery Discount
Additional LTC Expanded Benefits
These benefits will not appear in Choice Counseling materials
 
Box Fan
 
Caregiver Information/Support
 
Document Keeper
 
Household Set-Up Kit
 
Welcome Home Basket
 
Nurse Helpline Services
 
Pill Organizer

II.
Manner of Service Provision
A.
Plan Qualification
The Managed Care Plan is approved to provide contracted services as a qualified entity under s 409.962(6), F.S., as denoted by “X” in Table 4 below.

AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 5 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


Table 4: Plan Qualification
X
Health Maintenance Organization (HMO)
 
Provider Service Network (PSN)
 
Exclusive Provider Organization (EPO)
 
Accountable Care Organization (ACO)
 
Other Insurer

B.
Plan Type
The Managed Care Plan is approved to provide contracted services as one or more of four plan types, denoted by authorized region(s) in Table 5 below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.
(1)
MMA Managed Care Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1)(a) through (cc), F.S.
(2)
LTC Managed Care Plans are those plans that provide covered services specified in the LTC Exhibit, including those covered under s. 409.98(1) through (19), F.S.
(3)
Comprehensive LTC Plans are those plans that provide services described in s. 409.973, F.S., and also provide the services described in s. 409.98, F.S.
(4)
Specialty Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1 )(a) through (cc), F.S., to only eligible recipients defined as a specialty population in the Attachment II and its Exhibits.
Table 5: SMMC Plan Type
Region
SMMC Program
MMA/LTC
Specialty
Region 1
 
 
Region 2
MMA Plan
 
Region 3
MMA Plan
 
Region 4
MMA Plan
 
Region 5
MMA Plan
 
Region 6
MMA Plan
 
Region 7
MMA Plan
 
Region 8
MMA Plan
 
Region 9
 
 
Region 10
 
 
Region 11
MMA Plan
 

III.
Method of Payment
A.
Total Contract Amount
The Agency shall make payment, in a total dollar amount not to exceed $11,789,499,367.00 to the Managed Care Plan in accordance with Attachment II and its Exhibits. The Agency shall make payments through its fiscal agent using the Medicaid Provider Identification Number(s) specified in Exhibit I-B.
B.
Capitation Rates

AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 6 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


The capitation rate payment shall be in accordance with Attachment II and its Exhibits. The capitation rates are contained in Exhibit I-C of this Attachment. These rates are titled “MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”
IV.
Special Provisions
A.
Order of Precedence
The Managed Care Plan shall perform its contracted duties in accordance with this Contract, the ITN(s), including all addenda and the Vendor’s response to the ITN(s). In the event of conflict among Contract documents, any identified inconsistency in this Contract shall be resolved by giving precedence in the following order:
(1)
This Contract, including all attachments;
(2)
The ITN(s), including all addenda; and
(3)
The Vendor’s response to the ITN(s), including information provided through negotiations.
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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 7 of 7


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-A - Effective Date: August 1, 2014
Approved Expanded Benefit Coverage and Limitations
Managed Medical Assistance (MMA)
Approved Benefit
Approved Limitations
Primary Care Visits
(Non-Pregnant Adults)
Unlimited visits.
Home Health Care
(Non-Pregnant Adults)
One (1) visit per day; subject to medical necessity and prior authorization.
Physician Home Visits
Unlimited visits; limited to homebound enrollees who are frail, have a chronic disability and/or complex medical needs; subject to medical necessity.
Prenatal/Perinatal Visits
Unlimited prenatal visits; unlimited postnatal visits for the first four (4) weeks post-partum.
Outpatient Services
One-thousand dollars ($1,000) for outpatient services per fiscal year (July 1-June 30); subject to prior authorization.
Over-The Counter (OTC)
Medication/Supplies
Twenty-five dollars ($25) per household per month; enrollee purchases limited to an approved list of products.
Adult Dental Services
One (1) exam every six (6) months; one (1) cleaning every six (6) months; one (1) x-ray per year.
Waived Copayments
Enrollees shall not be subject to co-payment charges except: non-emergency emergency room visits and chiropractic services.
Vision Services
One-hundred dollars ($100) with which enrollees may purchase frames, lenses and contact lenses per year.
Hearing Services
One (1) hearing exam every two (2) years; one (1) hearing aid every two (2) years.
Newborn Circumcision
Available upon request up to three (3) months old; subject to prior authorization.
Adult Pneumonia Vaccine
Administered as medically advised; limit one (1) vaccination per lifetime.
Adult Influenza Vaccine
One (1) vaccination per year.
Adult Shingles Vaccine
Limit one (1) vaccination every six (6) years; subject to prior authorization.
Post Discharge Meals
Ten (10) meals within two weeks of an enrollee being discharged from an inpatient facility; limited to SSI and Medicare/Medicaid dual eligible enrollees; subject to prior authorization.
Nutritional Counseling
Unlimited visits; limited to enrollees who receive home health services with a chronic disability or a complex medical need; subject to medical necessity and prior authorization.
Pet Therapy
Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.

AHCA Contract No. FP020, Attachment I, Exhibit I-A, Effective 8/1/14, Page 1 of 2


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


Art Therapy
Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.
Equine Therapy
Ten (10) visits per year; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; enrollee must be more than one (1) year old; subject to prior authorization.
Medically Related Lodging and Food
Unlimited coverage for enrollees and traveling partners; benefit only available if enrollee is required to travel more than fifty (50) miles from their home for non-emergent specialist or hospital treatment; overnight stay required; adult enrollees are limited to one (1) travel partner; child enrollees are limited to two (2) travel partners; subject to prior authorization.

All expanded benefits are in excess of benefits specified in the Medicaid State Plan.
The Managed Care Plan may require enrollees to use an established network of providers, approved by the Agency, to obtain expanded benefits under this Contract.
Unless otherwise specified in this Exhibit, expanded benefits are not subject to prior authorization or co-payment charges.

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AHCA Contract No. FP020, Attachment I, Exhibit I-A, Effective 8/1/14, Page 2 of 2


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida



ATTACHMENT I
EXHIBIT I-B - Effective Date: August 1, 2014

Medicaid Provider Identification Numbers

Region
MMA
LTC
Specialty
1
 
 
 
2
0105630-02
 
 
3
0105630-03
 
 
4
0105630-04
 
 
5
0105630-05
 
 
5
0105630-06
 
 
7
0105630-07
 
 
8
0105630-08
 
 
9
 
 
 
10
 
 
 
11
0105630-11
 
 

The Agency will provide Medicaid Provider Identification Numbers to the Managed Care Plan subsequent to the Agency’s completion of a plan-specific readiness review and prior to enrolling recipient in the Managed Care Plan in each authorized region.









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AHCA Contract No. FP020, Attachment I, Exhibit I-B, Effective 8/1/14, Page 1 of 1


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 2 – Effective May 1, 2014 – June 30, 2014
REGION 2
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,094.16


$19,072.40

 

$1,369.48

 
 
 
 
3-11 Months
183.32

3,735.12

 
565.76

 
 
 
 
1-13 Years
111.00

342.61

 
429.69

 
 
 
 
14-54 Years Female
308.78

 
 
 
 
 
 
 
14-54 Years Male
132.53

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
790.05

 
678.18

 
 
 
 
55+ Years (Male and Female)
360.48

 
 
 
 
 
 
 
Under Age 65
 
 
156.77
 
 
 

$290.81


$2,064.22

Age 65+
 
 
109.02
 
 
 

$159.36


$1,334.05

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
155.48

$
2,697.66

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 1 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 3 – Effective May 1, 2014 – June 30, 2014
REGION 3
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,237.57


$22,454.93

 

$1,394.19

 
 
 
 
3-11 Months
207.35

4,397.55

 
575.97

 
 
 
 
1-13 Years
125.55

403.37

 
437.44

 
 
 
 
14-54 Years Female
349.25

 
 
 
 
 
 
 
14-54 Years Male
149.90

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
930.16

 
690.42

 
 
 
 
55+ Years (Male and Female)
407.73

 
 
 
 
 
 
 
Under Age 65
 
 
153.34
 
 
 

$295.91


$2,237.34

Age 65+
 
 
106.63
 
 
 

$161.91


$1,445.93

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
182.12

$
2,705.71

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 2 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 4 – Effective May 1, 2014 – June 30, 2014
REGION 4
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,146.62


$22,224.26

 

$1,526.83

 
 
 
 
3-11 Months
192.11

4,352.38

 
630.77

 
 
 
 
1-13 Years
116.32

399.23

 
479.06

 
 
 
 
14-54 Years Female
323.58

 
 
 
 
 
 
 
14-54 Years Male
138.88

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
920.61

 
756.11

 
 
 
 
55+ Years (Male and Female)
377.76

 
 
 
 
 
 
 
Under Age 65
 
 
173.69
 
 
 

$289.37


$2,516.16

Age 65+
 
 
120.78
 
 
 

$158.16


$1,626.12

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
155.82

$
2,500.46

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 3 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 5 – Effective May 1, 2014 – June 30, 2014
REGION 5
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,377.91


$24,350.08

 

$1,813.76

 
 
 
 
3-11 Months
230.86

4,768.69

 
749.30

 
 
 
 
1-13 Years
139.79

437.41

 
569.09

 
 
 
 
14-54 Years Female
388.86

 
 
 
 
 
 
 
14-54 Years Male
166.90

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
1,008.67

 
898.20

 
 
 
 
55+ Years (Male and Female)
453.97

 
 
 
 
 
 
 
Under Age 65
 
 
131.76
 
 
 

$276.19


$2,482.33

Age 65+
 
 
91.63
 
 
 

$151.15


$1,604.26

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
154.10

$
2,887.15

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 4 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 6 – Effective May 1, 2014 – June 30, 2014
REGION 6
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,236.35


$22,063.22

 

$1,658.03

 
 
 
 
3-11 Months
207.15

4,320.84

 
684.97

 
 
 
 
1-13 Years
125.42

396.33

 
520.22

 
 
 
 
14-54 Years Female
348.91

 
 
 
 
 
 
 
14-54 Years Male
149.75

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
913.94

 
821.08

 
 
 
 
55+ Years (Male and Female)
407.33

 
 
 
 
 
 
 
Under Age 65
 
 
127.88
 
 
 

$283.44


$2,505.48

Age 65+
 
 
88.93
 
 
 

$154.18


$1,619.23

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
163.88

$
2,902.00

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 5 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 7 – Effective May 1, 2014 – June 30, 2014
REGION 7
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
3-11 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
1-13 Years
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
14-54 Years Female
Not Applicable
 
 
 
 
 
 
 
14-54 Years Male
Not Applicable
 
 
 
 
 
 
 
14+ Years (Male and Female)
 
Not Applicable
 
Not Applicable
 
 
 
 
55+ Years (Male and Female)
Not Applicable
 
 
 
 
 
 
 
Under Age 65
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Age 65+
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Medicare Advantage/D-SNP
 
 
TBD
 
 
 
 
 
HIV-AIDS
 
 
 
 
Not Applicable
Not Applicable
 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 6 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 8 – Effective May 1, 2014 – June 30, 2014
REGION 8
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,272.58


$24,376.24

 

$1,366.19

 
 
 
 
3-11 Months
213.22

4,773.82

 
564.40

 
 
 
 
1-13 Years
129.10

437.88

 
428.66

 
 
 
 
14-54 Years Female
359.13

 
 
 
 
 
 
 
14-54 Years Male
154.14

 
 
 
 
 
 
 
14+ Years (Male and Female)
 
1,009.75

 
676.56

 
 
 
 
55+ Years (Male and Female)
419.26

 
 
 
 
 
 
 
Under Age 65
 
 
137.13
 
 
 

$233.54


$2,446.41

Age 65+
 
 
95.36
 
 
 

$127.84


$1,581.05

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 
$
167.77

$
2,909.87

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 7 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 10 – Effective May 1, 2014 – June 30, 2014
REGION 10
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
3-11 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
1-13 Years
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
14-54 Years Female
Not Applicable
 
 
 
 
 
 
 
14-54 Years Male
Not Applicable
 
 
 
 
 
 
 
14+ Years (Male and Female)
 
Not Applicable
 
Not Applicable
 
 
 
 
55+ Years (Male and Female)
Not Applicable
 
 
 
 
 
 
 
Under Age 65
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Age 65+
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Medicare Advantage/D-SNP
 
 
TBD
 
 
 
 
 
HIV-AIDS
 
 
 
 
Not Applicable
Not Applicable
 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 8 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 11 – Effective May 1, 2014 – June 30, 2014
REGION 11
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
3-11 Months
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
1-13 Years
Not Applicable
Not Applicable
 
Not Applicable
 
 
 
 
14-54 Years Female
Not Applicable
 
 
 
 
 
 
 
14-54 Years Male
Not Applicable
 
 
 
 
 
 
 
14+ Years (Male and Female)
 
Not Applicable
 
Not Applicable
 
 
 
 
55+ Years (Male and Female)
Not Applicable
 
 
 
 
 
 
 
Under Age 65
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Age 65+
 
 
Not Applicable
 
 
 
Not Applicable
Not Applicable
Medicare Advantage/D-SNP
 
 
TBD
 
 
 
 
 
HIV-AIDS
 
 
 
 
Not Applicable
Not Applicable
 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 9 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 2 – Effective July 1, 2014 – August 31, 2015
REGION 2
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,068.84


$17,812.93

 

$1,309.21

 
 
 
 
3-11 Months

$187.39


$3,575.66

 

$553.28

 
 
 
 
1-13 Years

$115.99


$352.10

 

$429.54

 
 
 
 
14-54 Years Female

$312.46

 
 
 
 
 
 
 
14-54 Years Male

$136.40

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$802.08

 

$671.86

 
 
 
 
55+ Years (Male and Female)

$374.00

 
 
 
 
 
 
 
Under Age 65
 
 

$159.47

 
 
 

$297.45


$2,051.61

Age 65+
 
 

$110.85

 
 
 

$163.17


$1,331.90

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$159.13


$2,795.08

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 10 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 3 – Effective July 1, 2014 – August 31, 2015
REGION 3
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,118.07


$19,551.78

 

$1,299.83

 
 
 
 
3-11 Months

$196.02


$3,924.71

 

$549.31

 
 
 
 
1-13 Years

$121.33


$386.47

 

$426.46

 
 
 
 
14-54 Years Female

$326.85

 
 
 
 
 
 
 
14-54 Years Male

$142.68

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$880.37

 

$667.04

 
 
 
 
55+ Years (Male and Female)

$391.23

 
 
 
 
 
 
 
Under Age 65
 
 

$155.75

 
 
 

$306.36


$2,046.46

Age 65+
 
 

$108.27

 
 
 

$167.80


$1,328.56

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$182.70


$2,642.48

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 11 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 4 – Effective July 1, 2014 – August 31, 2015
REGION 4
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,057.16


$19,538.35

 

$1,454.69

 
 
 
 
3-11 Months

$185.34


$3,922.01

 

$614.76

 
 
 
 
1-13 Years

$114.72


$386.20

 

$477.27

 
 
 
 
14-54 Years Female

$309.04

 
 
 
 
 
 
 
14-54 Years Male

$134.91

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$879.77

 

$746.51

 
 
 
 
55+ Years (Male and Female)

$369.91

 
 
 
 
 
 
 
Under Age 65
 
 

$176.91

 
 
 

$296.28


$2,177.66

Age 65+
 
 

$122.97

 
 
 

$162.11


$1,413.73

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$159.24


$2,461.15

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 12 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 5 – Effective July 1, 2014 – August 31, 2015
REGION 5
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,302.22


$22,081.30

 

$1,766.09

 
 
 
 
3-11 Months

$228.31


$4,432.47

 

$746.36

 
 
 
 
1-13 Years

$141.31


$436.47

 

$579.44

 
 
 
 
14-54 Years Female

$380.68

 
 
 
 
 
 
 
14-54 Years Male

$166.18

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$994.27

 

$906.32

 
 
 
 
55+ Years (Male and Female)

$455.67

 
 
 
 
 
 
 
Under Age 65
 
 

$134.56

 
 
 

$282.51


$2,354.78

Age 65+
 
 

$93.54

 
 
 

$154.78


$1,528.72

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$157.32


$2,958.89

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 13 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 6 – Effective July 1, 2014 – August 31, 2015
REGION 6
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,123.47


$19,086.27

 

$1,572.23

 
 
 
 
3-11 Months

$196.97


$3,831.26

 

$664.43

 
 
 
 
1-13 Years

$121.91


$377.27

 

$515.83

 
 
 
 
14-54 Years Female

$328.43

 
 
 
 
 
 
 
14-54 Years Male

$143.37

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$859.41

 

$806.83

 
 
 
 
55+ Years (Male and Female)

$393.12

 
 
 
 
 
 
 
Under Age 65
 
 

$129.84

 
 
 

$291.09


$2,226.74

Age 65+
 
 

$90.26

 
 
 

$158.54


$1,445.60

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$167.13


$2,868.52

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 14 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 7 – Effective July 1, 2014 – August 31, 2015
REGION 7
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,143.19


$19,730.90

 

$1,582.04

 
 
 
 
3-11 Months

$200.42


$3,960.66

 

$668.57

 
 
 
 
1-13 Years

$124.06


$390.01

 

$519.05

 
 
 
 
14-54 Years Female

$334.19

 
 
 
 
 
 
 
14-54 Years Male

$145.88

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$888.44

 

$811.87

 
 
 
 
55+ Years (Male and Female)

$400.02

 
 
 
 
 
 
 
Under Age 65
 
 

$131.26

 
 
 

$292.40


$2,479.20

Age 65+
 
 

$91.24

 
 
 

$158.49


$1,609.49

Medicare Advantage/D-SNP
 
 
TBD

 
 
 
 
 
HIV-AIDS
 
 
 
 

$167.43


$2,862.24

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK


AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 15 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 8 – Effective July 1, 2014 – August 31, 2015
REGION 8
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,133.57


$20,548.31

 

$1,278.24

 
 
 
 
3-11 Months

$198.74


$4,124.74

 

$540.19

 
 
 
 
1-13 Years

$123.01


$406.17

 

$419.38

 
 
 
 
14-54 Years Female

$331.38

 
 
 
 
 
 
 
14-54 Years Male

$144.66

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$925.24

 

$655.96

 
 
 
 
55+ Years (Male and Female)

$396.65

 
 
 
 
 
 
 
Under Age 65
 
 

$137.78

 
 
 

$238.39


$2,076.58

Age 65+
 
 

$95.78

 
 
 

$130.64


$1,348.11

Medicare Advantage/D-SNP
 
 
 
 
 
 
 
 
HIV-AIDS
 
 
 
 

$171.11


$2,890.62

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 16 of 17


WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida


ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 11 – Effective July 1, 2014 – August 31, 2015
REGION 11
 
HIV/AIDS
Long-Term Care Enrollees1
Age Band
TANF
SSI No Medicare
Dual Eligible
Child Welfare
Dual Eligible
Medicaid Only
Dual Eligible
Medicaid Only
0-2 Months

$1,237.30


$24,338.77

 

$1,902.10

 
 
 
 
3-11 Months

$216.92


$4,885.62

 

$803.84

 
 
 
 
1-13 Years

$134.27


$481.09

 

$624.06

 
 
 
 
14-54 Years Female

$361.70

 
 
 
 
 
 
 
14-54 Years Male

$157.89

 
 
 
 
 
 
 
14+ Years (Male and Female)
 

$1,095.92

 

$976.12

 
 
 
 
55+ Years (Male and Female)

$432.95

 
 
 
 
 
 
 
Under Age 65
 
 

$175.91

 
 
 

$293.29


$2,511.25

Age 65+
 
 

$122.28

 
 
 

$158.71


$1,630.30

Medicare Advantage/D-SNP
 
 
TBD

 
 
 
 
 
HIV-AIDS
 
 
 
 

$162.86


$3,361.00

 
 

1. Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2. Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 17 of 17