Amendment No. 7 to Contract FA904

EX-10.9 2 fa904amendment7.htm FA904 AMENDMENT 7 fa904amendment7.htm
Return to Form 8-k
 
 
  
 WellCare of Florida, Inc.  Medicaid HMO Non-Reform Contract
 d/b/a Staywell Health Plan of Florida  
 
 AHCA CONTRACT NO. FA904
 AMENDMENT NO. 7
 
     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 “Health Plan”, is hereby amended as follows:
 
 
1.
Effective January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a. is hereby amended to include Table 6-B, Revised Expanded Services, as follows.  All references in the Contract to Table 6, Expanded Services and Table 6-A, Revised Expanded Services, shall hereinafter also refer to Table 6-B, as appropriate.

TABLE 6-B
Revised Expanded Services
Effective January 1, 2012
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies.

 
 
 
2.
Effective September 1, 2011, Attachment I, Scope of Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non- Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract.  All references in the Contract to Exhibit 2-NR-B, shall hereinafter also refer to Exhibit 2-NR-C, as appropriate.
 
 
3.
Attachment II, Core Contract Provisions, Section XVI., Terms and Conditions, is hereby amended to include Item HH. as follows:
 
 
HH.
  
Scrutinized Companies Lists
 
 
   
The Vendor shall complete Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, attached hereto and made a part of the Contract, certifying that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to section 215.473, Florida Statutes (F.S.). Pursuant to section 287.135(5), F.S., the Vendor agrees the Agency may immediately terminate this Contract for cause if the Vendor is found to have submitted a false certification or if the Vendor is placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities  in  the  Iran  Petroleum  Energy  Sector  List  during  the  term  of  the Contract
 
 
4.
Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, is hereby attached and made a part of the Contract.
 
 
 
Unless otherwise stated, this amendment is effective upon execution by both Parties.
 
 
 
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the Contract.
 
AHCA Contract No. FA904, Amendment No. 7, Page 1 of 2

 
 
 
 
 
 

 
WellCare of Florida, Inc.  Medicaid HMO Non-Reform Contract
 d/b/a Staywell Health Plan of Florida  
 
 
 
This amendment and all its attachments are hereby made a part of the Contract.
 
 
 
This amendment cannot be executed unles all previous amendments to this Contract have been fully executed.
 
 
 
IN WITNESS WHEREOF, the Parties hereto have caused this eight (8) page amendment (including all attachments) to be executed by their officials thereunto duly authorized.
 

WELLCARE OF FLORIDA, INC., D/B/A
STAYWELL HEALTH PLAN OF FLORIDA
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

SIGNED
BY:
 /s/ Christina Cooper  
SIGNED
BY:
/s/Tonya Kidd for
 NAME:  
 
Christina Cooper
   NAME: 
 
Elizabeth Dudek
 TITLE: 
 
President, FL & HI Division­­
   TITLE:
 
Secretary
 
DATE:
12/27/11
   DATE:
12/29/11



List of Attachments/Exhibits included as part of this amendment:
 
Specify
Type
Letter/
Number
 
Description
 
Attachment I
Exhibit 2-NR-C
 Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011 (5 pages)
 
 
Attachment
 VI Vendor Certification Regarding Scrutinized Companies Lists (1Page)
 
       
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

 
 
 
 
 ATTACHMENT I
 EXHIBIT 2-NR-C
 MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
 By Area, Age and Eligibility Category
 Effective September 1, 2011
 
General Rates:
                                    
                                       
         
TANF
            
SSI-N
    
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE(1-5)
AGE(6-13)
AGE(14-20)
AGE(21-54)
AGE(55+)
BTHMO+2MO
3MO-11MO
AGE(1-5)
AGE(6-13)
AGE(14-20)
AGE(21-54)
AGE(55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
944.58
184.93
99.14
62.81
127.84
67.50
271.85
155.86
430.03
12,534.08
1,853.67
459.10
183.60
219.90
719.01
846.95
304.31
95.72
75.16
02
809.74
158.54
85.26
55.17
110.84
59.12
234.16
134.73
369.40
10,634.20
1,571.89
378.61
129.11
165.06
567.50
702.50
304.31
85.34
66.80
03
977.48
191.38
102.88
66.37
133.57
71.13
282.47
162.44
445.78
13,033.48
1,927.78
480.73
199.09
235.25
760.70
885.63
304.31
86.58
67.80
04
982.26
192.25
101.91
59.51
127.52
64.77
277.81
157.18
443.92
13,413.62
1,983.70
490.64
194.84
234.00
766.84
905.39
304.31
79.94
62.45
05
1,109.71
217.27
116.92
75.94
152.20
81.32
321.19
184.92
506.42
14,476.72
2,141.09
531.81
215.85
257.04
836.50
980.51
304.31
74.93
58.42
06
1,021.04
199.94
108.39
73.89
143.78
78.57
298.90
173.52
468.21
13,062.91
1,932.30
484.19
205.34
240.45
771.66
891.12
304.31
73.50
57.26
07
966.83
189.24
100.39
58.99
125.91
64.15
273.80
155.07
437.19
13,593.51
2,010.10
494.41
190.58
231.59
766.17
913.39
304.31
72.84
56.74
08
952.04
186.41
100.57
66.44
131.76
70.95
276.63
159.73
435.19
12,412.16
1,835.77
456.44
186.23
221.31
719.07
841.38
304.31
80.42
62.84
09
1,032.49
202.14
108.41
68.86
139.93
73.98
297.32
170.54
470.17
14,347.56
2,121.42
519.54
195.54
239.92
799.72
960.67
304.31
82.17
64.25
10
1,028.53
201.37
108.26
69.90
140.62
74.92
297.28
170.98
469.11
17,915.36
2,649.60
657.40
265.37
316.67
1,032.39
1,212.35
304.31
92.58
72.64
11
1,187.84
232.59
125.70
84.02
165.46
89.59
346.10
200.24
543.62
15,014.29
2,220.47
549.99
220.03
263.49
861.45
1,014.60
304.31
120.99
95.51
6B *
1,020.54
199.85
108.39
74.07
143.91
78.73
298.94
173.63
468.11
13,061.73
1,932.14
484.22
205.49
240.58
771.87
891.14
304.31
73.50
57.26
 
TABLE 2
General + Mental Health Rates:
                                  
                                       
         
TANF
            
SSI-N
    
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE(1-5)
AGE(6-13)
AGE(14-20)
AGE(21-54)
AGE(55+)
BTHMO+2MO
3MO-11MO
AGE(1-5)
AGE(6-13)
AGE(14-20)
AGE(21-54)
AGE(55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
944.69
185.04
101.42
73.90
138.20
77.86
281.21
165.22
436.32
12,535.85
1,855.44
479.56
233.51
260.16
798.67
877.14
321.65
105.67
85.11
02
809.82
158.62
86.94
63.35
118.47
66.75
241.06
141.63
374.03
10,636.65
1,574.34
406.90
198.14
220.74
677.67
744.25
321.65
95.29
76.75
03
977.58
191.48
104.95
76.48
143.01
80.57
291.00
170.97
451.51
13,035.03
1,929.33
498.65
242.81
270.52
830.48
912.07
321.65
96.53
77.75
04
982.44
192.43
105.47
76.86
143.72
80.97
292.45
171.82
453.76
13,415.57
1,985.65
513.21
249.90
278.41
854.72
938.69
321.65
89.89
72.40
05
1,109.82
217.38
119.15
86.82
162.35
91.47
330.37
194.10
512.59
14,478.63
2,143.00
553.88
269.70
300.48
922.45
1,013.08
321.65
84.88
68.37
06
1,021.10
200.00
109.62
79.88
149.37
84.16
303.96
178.58
471.61
13,064.26
1,933.65
499.77
243.36
271.12
832.34
914.11
321.65
83.45
67.21
07
967.00
189.41
103.81
75.65
141.46
79.70
287.85
169.12
446.63
13,595.73
2,012.32
520.10
253.26
282.15
866.20
951.30
321.65
82.79
66.69
08
952.12
186.49
102.22
74.49
139.28
78.47
283.42
166.52
439.76
12,413.76
1,837.37
474.89
231.24
257.62
790.90
868.60
321.65
90.37
72.79
09
1,032.61
202.26
110.86
80.78
151.06
85.11
307.38
180.60
476.93
14,350.11
2,123.97
548.96
267.31
297.81
914.26
1,004.08
321.65
92.12
74.20
10
1,028.64
201.48
110.43
80.47
150.48
84.78
306.20
179.90
475.10
17,917.79
2,652.03
685.44
333.77
371.85
1,141.56
1,253.72
321.65
102.53
82.59
11
1,187.93
232.68
127.53
92.93
173.78
97.91
353.62
207.76
548.67
15,016.41
2,222.59
574.45
279.72
311.64
956.71
1,050.70
321.65
130.94
105.46
6B *
1,020.60
199.91
109.57
79.84
149.30
84.12
303.81
178.50
471.38
13,063.07
1,933.48
499.73
243.33
271.10
832.26
914.03
321.65
83.45
67.21
 
 
 
  AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 1 of 5
 
 
ATTACHMENT I
EXHIBIT 2-NR-C
MEDICAID NON-REFORM HMO CAPITATION RATES
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
By Area, Age and Eligibility Category
 Effective September 1, 2011
 
TABLE 3
General + MH + Dental Rates:
                                  
                                       
 
TANF
                  
SSI-N
          
SSI-B
SSI-AB
  
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
944.69
185.06
103.23
76.91
140.85
80.79
282.97
166.83
439.41
12,535.91
1,855.47
481.31
235.72
262.09
800.18
879.25
323.95
106.76
86.03
02
809.83
158.64
89.86
68.21
122.74
71.49
243.79
144.12
378.82
10,636.74
1,574.39
409.58
201.51
223.69
679.30
746.53
323.95
96.63
77.87
03
977.59
191.53
110.77
86.18
151.54
90.02
294.80
174.45
458.19
13,035.24
1,929.45
504.95
250.74
277.45
832.71
915.19
323.95
98.64
79.52
04
982.45
192.46
108.89
82.56
148.73
86.53
296.76
175.76
461.32
13,415.69
1,985.72
516.72
254.31
282.27
857.39
942.42
323.95
92.21
74.35
05
1,109.84
217.44
125.83
97.95
172.14
102.32
334.38
197.77
519.63
14,478.85
2,143.13
560.70
278.28
307.98
924.69
1,016.22
323.95
87.28
70.38
06
1,021.11
200.04
114.54
88.08
156.58
92.15
306.21
180.64
475.56
13,064.42
1,933.74
504.77
249.66
276.62
833.92
916.32
323.95
85.20
68.68
07
967.01
189.46
109.65
85.37
150.01
89.18
290.76
171.78
451.74
13,595.93
2,012.43
526.15
260.87
288.80
868.02
953.84
323.95
84.50
68.13
08
952.14
186.58
112.21
91.13
153.91
94.69
286.81
169.62
445.71
12,414.04
1,837.53
483.35
241.89
266.93
792.93
871.43
323.95
92.29
74.40
09
1,032.63
202.32
118.34
93.24
162.01
97.26
310.56
183.50
482.50
14,350.33
2,124.09
555.67
275.75
305.19
916.18
1,006.76
323.95
93.99
75.77
10
1,028.65
201.51
114.40
87.08
156.30
91.23
307.29
180.90
477.01
17,917.96
2,652.12
690.55
340.20
377.47
1,142.86
1,255.53
323.95
103.74
83.61
11
1,188.00
232.75
137.40
108.70
186.71
110.84
355.80
209.75
552.50
15,016.42
2,222.60
586.08
291.88
320.59
959.38
1,054.43
323.95
134.01
108.03
6B *
1,020.61
199.95
114.49
88.04
156.51
92.11
306.06
180.56
475.33
13,063.23
1,933.57
504.73
249.63
276.60
833.84
916.24
323.95
85.20
68.68
 
TABLE 4
General + MH + Transportation Rates:
                                  
                                       
         
TANF
            
SSI-N
    
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
951.62
187.12
102.70
74.71
140.05
80.81
284.50
169.78
440.86
12,591.13
1,898.82
487.69
238.50
269.54
826.05
900.84
324.43
109.55
88.28
02
816.21
160.54
88.12
64.09
120.17
69.47
244.09
145.84
378.22
10,685.88
1,612.98
414.14
202.58
229.10
702.06
765.36
324.43
98.51
79.37
03
984.48
193.55
106.22
77.28
144.85
83.50
294.27
175.51
456.03
13,083.83
1,967.63
505.83
247.21
278.80
854.65
932.99
324.43
100.56
81.04
04
988.24
194.17
106.54
77.53
145.26
83.43
295.20
175.63
457.56
13,465.86
2,025.12
520.61
254.44
286.95
879.63
960.26
324.43
94.30
75.99
05
1,114.99
218.93
120.10
87.42
163.73
93.67
332.82
197.50
515.98
14,525.16
2,179.52
560.72
273.90
308.38
945.50
1,033.03
324.43
88.93
71.67
06
1,026.36
201.58
110.59
80.49
150.77
86.40
306.46
182.04
475.06
13,112.00
1,971.11
506.79
247.67
279.22
855.98
934.58
324.43
87.18
70.25
07
972.68
191.11
104.86
76.31
142.97
82.11
290.54
172.85
450.35
13,646.03
2,051.80
527.50
257.80
290.69
891.11
972.87
324.43
85.88
69.21
08
958.75
188.48
103.44
75.26
141.04
81.29
286.56
170.88
444.10
12,462.04
1,875.26
481.99
235.60
265.82
814.81
889.30
324.43
93.02
74.95
09
1,039.33
204.28
112.10
81.56
152.85
87.97
310.57
185.02
481.33
14,399.99
2,163.12
556.29
271.81
306.28
938.96
1,025.47
324.43
96.06
77.41
10
1,034.50
203.24
111.51
81.15
152.04
87.27
308.98
183.75
478.93
17,971.60
2,694.26
693.35
338.63
380.98
1,168.21
1,276.79
324.43
106.30
85.66
11
1,192.81
234.14
128.43
93.50
175.08
99.98
355.93
210.97
551.86
15,061.69
2,258.13
581.11
283.81
319.33
979.14
1,070.12
324.43
134.22
108.13
6B *
1,025.86
201.49
110.54
80.45
150.70
86.36
306.31
181.96
474.83
13,110.81
1,970.94
506.75
247.64
279.20
855.90
934.50
324.43
87.18
70.25
 
 
 
ACHAContract No. FA904, Attachment I, Exhibit 2-NR, Page 2 of 5 
 
 
ATTACHMENT I
EXHIBIT 2-NR-C
MEDICAID NON-REFORM HMO CAPITATION RATES
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
By Area, Age and Eligibility Category
Effective September 1, 2011
 
TABLE 5
                                    
General + Transportation Rates:
                                  
                                       
 
TANF
                  
SSI-N
          
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE( 55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
951.51
187.01
100.42
63.62
129.69
70.45
275.14
160.42
434.57
12,589.36
1,897.05
467.23
188.59
229.28
746.39
870.65
307.09
99.60
78.33
02
816.13
160.46
86.44
55.91
112.54
61.84
237.19
138.94
373.59
10,683.43
1,610.53
385.85
133.55
173.42
591.89
723.61
307.09
88.56
69.42
03
984.38
193.45
104.15
67.17
135.41
74.06
285.74
166.98
450.30
13,082.28
1,966.08
487.91
203.49
243.53
784.87
906.55
307.09
90.61
71.09
04
988.06
193.99
102.98
60.18
129.06
67.23
280.56
160.99
447.72
13,463.91
2,023.17
498.04
199.38
242.54
791.75
926.96
307.09
84.35
66.04
05
1,114.88
218.82
117.87
76.54
153.58
83.52
323.64
188.32
509.81
14,523.25
2,177.61
538.65
220.05
264.94
859.55
1,000.46
307.09
78.98
61.72
06
1,026.30
201.52
109.36
74.50
145.18
80.81
301.40
176.98
471.66
13,110.65
1,969.76
491.21
209.65
248.55
795.30
911.59
307.09
77.23
60.30
07
972.51
190.94
101.44
59.65
127.42
66.56
276.49
158.80
440.91
13,643.81
2,049.58
501.81
195.12
240.13
791.08
934.96
307.09
75.93
59.26
08
958.67
188.40
101.79
67.21
133.52
73.77
279.77
164.09
439.53
12,460.44
1,873.66
463.54
190.59
229.51
742.98
862.08
307.09
83.07
65.00
09
1,039.21
204.16
109.65
69.64
141.72
76.84
300.51
174.96
474.57
14,397.44
2,160.57
526.87
200.04
248.39
824.42
982.06
307.09
86.11
67.46
10
1,034.39
203.13
109.34
70.58
142.18
77.41
300.06
174.83
472.94
17,969.17
2,691.83
665.31
270.23
325.80
1,059.04
1,235.42
307.09
96.35
75.71
11
1,192.72
234.05
126.60
84.59
166.76
91.66
348.41
203.45
546.81
15,059.57
2,256.01
556.65
224.12
271.18
883.88
1,034.02
307.09
124.27
98.18
6B *
1,025.80
201.43
109.36
74.68
145.31
80.97
301.44
177.09
471.56
13,109.47
1,969.60
491.24
209.80
248.68
795.51
911.61
307.09
77.23
60.30
 
 
TABLE 6
General + Dental Rates:
                                    
                                       
 
TANF
                  
SSI-N
          
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
  
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      
                                       
01
944.58
184.95
100.95
65.82
130.49
70.43
273.61
157.47
433.12
12,534.14
1,853.70
460.85
185.81
221.83
720.52
849.06
306.61
96.81
76.08
02
809.75
158.56
88.18
60.03
115.11
63.86
236.89
137.22
374.19
10,634.29
1,571.94
381.29
132.48
168.01
569.13
704.78
306.61
86.68
67.92
03
977.49
191.43
108.70
76.07
142.10
80.58
286.27
165.92
452.46
13,033.69
1,927.90
487.03
207.02
242.18
762.93
888.75
306.61
88.69
69.57
04
982.27
192.28
105.33
65.21
132.53
70.33
282.12
161.12
451.48
13,413.74
1,983.77
494.15
199.25
237.86
769.51
909.12
306.61
82.26
64.40
05
1,109.73
217.33
123.60
87.07
161.99
92.17
325.20
188.59
513.46
14,476.94
2,141.22
538.63
224.43
264.54
838.74
983.65
306.61
77.33
60.43
06
1,021.05
199.98
113.31
82.09
150.99
86.56
301.15
175.58
472.16
13,063.07
1,932.39
489.19
211.64
245.95
773.24
893.33
306.61
75.25
58.73
07
966.84
189.29
106.23
68.71
134.46
73.63
276.71
157.73
442.30
13,593.71
2,010.21
500.46
198.19
238.24
767.99
915.93
306.61
74.55
58.18
08
952.06
186.50
110.56
83.08
146.39
87.17
280.02
162.83
441.14
12,412.44
1,835.93
464.90
196.88
230.62
721.10
844.21
306.61
82.34
64.45
09
1,032.51
202.20
115.89
81.32
150.88
86.13
300.50
173.44
475.74
14,347.78
2,121.54
526.25
203.98
247.30
801.64
963.35
306.61
84.04
65.82
10
1,028.54
201.40
112.23
76.51
146.44
81.37
298.37
171.98
471.02
17,915.53
2,649.69
662.51
271.80
322.29
1,033.69
1,214.16
306.61
93.79
73.66
11
1,187.91
232.66
135.57
99.79
178.39
102.52
348.28
202.23
547.45
15,014.30
2,220.48
561.62
232.19
272.44
864.12
1,018.33
306.61
124.06
98.08
6B *
1,020.55
199.89
113.31
82.27
151.12
86.72
301.19
175.69
472.06
13,061.89
1,932.23
489.22
211.79
246.08
773.45
893.35
306.61
75.25
58.73

 
  AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 3 of 5
 
 
 ATTACHMENT I
 EXHIBIT 2-NR-C
 MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
 By Area, Age and Eligibility Category
 Effective September 1, 2011
 
TABLE 7
                                    
General + Dental + Transportation Rates:
                                
                                       
 
TANF
                  
SSI-N
          
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
  
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                      
                                       
01
951.51
187.03
102.23
66.63
132.34
73.38
276.90
162.03
437.66
12,589.42
1,897.08
468.98
190.80
231.21
747.90
872.76
309.39
100.69
79.25
02
816.14
160.48
89.36
60.77
116.81
66.58
239.92
141.43
378.38
10,683.52
1,610.58
388.53
136.92
176.37
593.52
725.89
309.39
89.90
70.54
03
984.39
193.50
109.97
76.87
143.94
83.51
289.54
170.46
456.98
13,082.49
1,966.20
494.21
211.42
250.46
787.10
909.67
309.39
92.72
72.86
04
988.07
194.02
106.40
65.88
134.07
72.79
284.87
164.93
455.28
13,464.03
2,023.24
501.55
203.79
246.40
794.42
930.69
309.39
86.67
67.99
05
1,114.90
218.88
124.55
87.67
163.37
94.37
327.65
191.99
516.85
14,523.47
2,177.74
545.47
228.63
272.44
861.79
1,003.60
309.39
81.38
63.73
06
1,026.31
201.56
114.28
82.70
152.39
88.80
303.65
179.04
475.61
13,110.81
1,969.85
496.21
215.95
254.05
796.88
913.80
309.39
78.98
61.77
07
972.52
190.99
107.28
69.37
135.97
76.04
279.40
161.46
446.02
13,644.01
2,049.69
507.86
202.73
246.78
792.90
937.50
309.39
77.64
60.70
08
958.69
188.49
111.78
83.85
148.15
89.99
283.16
167.19
445.48
12,460.72
1,873.82
472.00
201.24
238.82
745.01
864.91
309.39
84.99
66.61
09
1,039.23
204.22
117.13
82.10
152.67
88.99
303.69
177.86
480.14
14,397.66
2,160.69
533.58
208.48
255.77
826.34
984.74
309.39
87.98
69.03
10
1,034.40
203.16
113.31
77.19
148.00
83.86
301.15
175.83
474.85
17,969.34
2,691.92
670.42
276.66
331.42
1,060.34
1,237.23
309.39
97.56
76.73
11
1,192.79
234.12
136.47
100.36
179.69
104.59
350.59
205.44
550.64
15,059.58
2,256.02
568.28
236.28
280.13
886.55
1,037.75
309.39
127.34
100.75
6B *
1,025.81
201.47
114.28
82.88
152.52
88.96
303.69
179.15
475.51
13,109.63
1,969.69
496.24
216.10
254.18
797.09
913.82
309.39
78.98
61.77
 
 
TABLE 8
General + Mental Health + Dental + Transportation Rates:
                            
                                       
 
TANF
                  
SSI-N
          
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
  
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                      
                                       
01
951.62
187.14
104.51
77.72
142.70
83.74
286.26
171.39
443.95
12,591.19
1,898.85
489.44
240.71
271.47
827.56
902.95
326.73
110.64
89.20
02
816.22
160.56
91.04
68.95
124.44
74.21
246.82
148.33
383.01
10,685.97
1,613.03
416.82
205.95
232.05
703.69
767.64
326.73
99.85
80.49
03
984.49
193.60
112.04
86.98
153.38
92.95
298.07
178.99
462.71
13,084.04
1,967.75
512.13
255.14
285.73
856.88
936.11
326.73
102.67
82.81
04
988.25
194.20
109.96
83.23
150.27
88.99
299.51
179.57
465.12
13,465.98
2,025.19
524.12
258.85
290.81
882.30
963.99
326.73
96.62
77.94
05
1,115.01
218.99
126.78
98.55
173.52
104.52
336.83
201.17
523.02
14,525.38
2,179.65
567.54
282.48
315.88
947.74
1,036.17
326.73
91.33
73.68
06
1,026.37
201.62
115.51
88.69
157.98
94.39
308.71
184.10
479.01
13,112.16
1,971.20
511.79
253.97
284.72
857.56
936.79
326.73
88.93
71.72
07
972.69
191.16
110.70
86.03
151.52
91.59
293.45
175.51
455.46
13,646.23
2,051.91
533.55
265.41
297.34
892.93
975.41
326.73
87.59
70.65
08
958.77
188.57
113.43
91.90
155.67
97.51
289.95
173.98
450.05
12,462.32
1,875.42
490.45
246.25
275.13
816.84
892.13
326.73
94.94
76.50
09
1,039.35
204.34
119.58
94.02
163.80
100.12
313.75
187.92
486.90
14,400.21
2,163.24
563.00
280.25
313.66
940.88
1,028.15
326.73
97.93
78.98
10
1,034.51
203.27
115.48
87.76
157.86
93.72
310.07
184.75
480.84
17,971.77
2,694.35
698.46
345.06
386.60
1,169.51
1,278.60
326.73
107.51
86.68
11
1,192.88
234.21
138.30
109.27
188.01
112.91
358.11
212.96
555.69
15,061.70
2,258.14
592.74
295.97
328.28
981.81
1,073.85
326.73
137.29
110.70
6B *
1,025.87
201.53
115.46
88.65
157.91
94.35
308.56
184.02
478.78
13,110.97
1,971.03
511.75
253.94
284.70
857.48
936.71
326.73
88.93
71.72

 
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 4 of 5
 
 
ATTACHMENT I 
 EXHIBIT 2-NR-C
 MEDICAID NON-REFORM HMO CAPITATION RATES
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
 By Area, Age and Eligibility Category
 Effective September 1, 2011
 
Area
Corresponding  Counties
   
Area 1
Escambia, Okaloosa, Santa Rosa, Walton
Area 2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla
Area 3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union
Area 4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
Area 5
Pasco, Pinellas
Area 6
Hardee, Highlands, Manatee, Polk
Area 6B *
Hillsborough
Area 7
Brevard, Orange, Osceola, Seminole
Area 8
Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota
Area 9
Indian River, Okeechobee, St. Lucie, Martin, Palm Beach
Area 10
Broward
Area 11
Dade, Monroe

 
AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 5 of 5
 
 
 ATTACHMENT VI
 VENDOR CERTIFICATION REGARDING
 SCRUTINIZED COMPANIES LIST
 
 
       
Vendor Name:  WellCare of Florida Inc.    
 
Vendor FEIN:   ###-###-####    
 
Vendor's Authorized Representative Name and Title: Christina Cooper, President    
 
Address:  8735 Henderson Road  
     
City: Tampa  State: FL  Zip: 33634  
     
Telephone Number: 813 ###-###-####    
     
Email Address: ***@***  
     
     
 
 
Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  Both lists are created pursuant to section 215.473, Florida Statutes.
 
As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified above in the section entitled "Vendor Name" is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney's fees, and/or costs.
 
 
       
       
Certified By: /s/Christina Cooper  ,  
       
who is authorized to sign on behalf of the above referenced company.    
       
Authorized Signature Print Name and Title: Christina Cooper, President    
       
       
       
       
       
       
       
       
 
 
AHCA Contract No. FA904, Attachment VI, Page 1of 1