EXHIBIT3-C
EX-10.1 2 far001amend9.htm AHCA REFORM CONTRACT AMENDMENT 9, HEALTHEASE far001amend9.htm
Addendum to Exhibit 3-C
Exhibit 1-B
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
Back to Form 8-K
Exhibit 10.1
Addendum to Exhibit 3-C
The Agency and the Vendor acknowledge and agree that the rates reflected in this AHCA Contract No. FAR 001 Amendment No. 9 do not reflect the parties' prior understanding. Accordingly, the Agency agrees to increase the Children and Families and Aged and Disabled (No Medicare, Medicare Parts A and B and Medicare Part B Only) by approximately 2% to be effective September 1, 2008.
WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida
Signed
By: /s/ Heath Schiesser
Name: Heath Schiesser
Title: President and CEO
Date: August 29, 2008
State of Florida, Agency for Health Care Administration
By: /s/ William H. Roberts
Name: William H. Roberts for Holly Benson
Title: Deputy General Counsel
Date: 8/29/08
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age, and Eligibility Category)
September 1, 2008 - August 31, 2009
TABLE 2
| Area: 10 | County: Broward | September 1, 2008 |
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| Eligibility Category/ Population | Total Rates for Comprehensive and Catastrophic Components | Total Rate for Comprehensive Component Only |
| Children and Families: | ||
| Newborns aged 0-2 months | $ 868.52 | $ 750.55 |
| Newborns aged 3-11 months | $ 191.05 | $ 181.72 |
| Age 1 and Up - Base Rate for Risk adjustment | $ 107.11 | $ 105.39 |
| Aged and Disabled: | ||
| No Medicare | ||
| Newborns aged 0-2 months | $ 17,572.21 | $ 9,173.75 |
| Newborns aged 3-11 months | $ 3,896.35 | $ 2,187.93 |
| Age 1 and Up - Base Rate for Risk Adjustment | $ 789.84 | $ 725.69 |
| Medicare Parts A and B | ||
| Under Age 65 | $ 139.11 | N/A |
| Age 65 and over | $ 99.49 | N/A |
| Medicare Part B Only | ||
| All ages | $ 265.17 | N/A |
| HIV/AIDS Specialty Population | ||
| No Medicare HIV | $ 1,823.74 | N/A |
| No Medicare AIDS | $ 3,422.47 | N/A |
| Medicare HIV | $ 256.03 | N/A |
| Medicare AIDS | $ 546.61 | N/A |
| Kick Payments Amounts for Covered Obstetrical Delivery Services: | ||
| CPT Code | Obstetrical Delivery CPT Code Description | Payment Amount |
| 59409 | Vaginal delivery only | $3,941.45 |
| 59410 | Vaginal delivery including postpartum care | |
| 59515 | Cesarean delivery including postpartum care | |
| 59612 | Vaginal delivery only, after previous cesarean delivery | |
| 59614 | Vaginal delivery only, after previous cesarean delivery including postpartum care | |
| 59622 | Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery inc postpartum care | |
AHCA Contract No. FAR001, Exhibit 3-C, Page 1 of 3
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age, and Eligibility Category)
September 1, 2008 - August 31, 2009
September 1, 2008
Area: 4 County: Duval. Bakar, Clay and Nassau
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| Eligibility Category/ Population | Total Rates for Comprehensive and Catastrophic Component | Total Rate for Comprehensive Component Only |
| Children and Families: | ||
| Newborns aged 0-2 months | $ 895.21 | $ 773.61 |
| Newborns aged 3-11 months | $ 196.74 | $ 187.13 |
| Age 1 and Up - Base Rate for Risk Adjustment | $ 110.24 | $ 108.46 |
| Aged and Disabled: | ||
| No Medicare | ||
| Newborns aged 0-2 months | $ 14,234.51 | $ 7,431.27 |
| Newborns aged 3-11 months | $ 3,172.94 | $ 1,765.42 |
| Age1 and Up-Base Rate for Risk Adjustment | $ 610.65 | $ 561.06 |
| Medicare Parts A and B | ||
| Under Age 65 | $ 158.06 | N/A |
| Age 65 and over | $ 112.96 | N/A |
| | ||
| Medicare Part B Only | ||
| All ages | $ 326.42 | N/A |
| HIV/AIDS Specialty Population | ||
| No Medicare HIV | $ 1,161.19 | N/A |
| No Medicare AIDS | $ 2,285.96 | N/A |
| Medicare HIV | $ 157.41 | N/A |
| Medicare AIDS | $ 336.05 | N/A |
| Kick Payments Amounts for Covered Obstetrical Delivery Services: | ||
| CPT Code | Obstetrical Delivery CPT Code Description | Payment Amount |
| 59409 | Vaginal delivery only | $3,977.49 |
| 59410 | Vaginal delivery including postpartum care | |
| 59515 | Cesarean delivery including postpartum care | |
| 59612 | Vaginal delivery only, after previous cesarean delivery | |
| 59614 | Vaginal delivery only, after previous cesarean delivery including postpartum care | |
| 59622 | Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery inc postpartum care | |
AHCA Contract No. FAR001, Exhibit 3-C, Page 2 of 3
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age. and Eligibility Category)
September 1, 2008 - August 31, 2009
| Area: 10 | County: Broward | September 1, 2008 |
| Area: 4 | County: Duval, Baker, Clay and Nassau |
| CPT Code | Transplant CPT Code Description | Children/Adolescents or Adult | Payment Amount |
| 32851 | lung single, without bypass | Children/Adolescents | $320,800.00 |
| 32851 | lung single, without bypass | Adult | $238,000.00 |
| 32852 | lung single, with bypass | Children/Adolescents | $320,800.00 |
| 32852 | lung single, with bypass | Adult | $238,000.00 |
| 32853 | lung double, without bypass | Children/Adolescents | $320,800.00 |
| 32853 | lung double, without bypass | Adult | $238,000.00 |
| 32854 | lung double, with bypass | Children/Adolescents | $320,800.00 |
| 32854 | lung double, with bypass | Adult | $238,000.00 |
| 33945 | heart transplant with or without recipient cardiectomy | All Age Groups | $162,000.00 |
| 47135 | liver, allotransplation, orthotopic, partial or whole from cadaver or living donor | All Age Groups | $122,600.00 |
| 47136 | liver, heterotopic, partial or whole from cadaver or living donor any age | All Age Groups | $122,600.00 |
AHCA Contract No. FAR001, Exhibit 3-C, Page 3 of 3
| HealthEase of Florida, Inc. | Medicaid Reform HMO Contract |
AHCA CONTRACT NO. FAR001
AMENDMENT NO. 9
THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency,” and HEALTHEASE OF FLORIDA, INC., hereinafter referred to as the “Vendor,” is hereby amended as follows:
| 1. | Effective September 1, 2008, Standard Contract, Section III, Item C, Contract Managers, sub-item 1, is hereby amended to now read as follows: |
| | 1. | The Agency’s Contract Manager’s name, address and telephone number for this Contract is as follows: |
| Suzanne Stacknik Agency for Health Care Administration 2727 Mahan Drive, MS #50 Tallahassee, FL 32308 (850) 487-2355 |
| 2. | Attachment I, Scope of Services, Exhibit 1-B, effective January 1, 2009, is hereby included and made a part of the Contract. Exhibit 1-A will remain in effect until December 31, 2008. After January 1, 2009, all references in the Contract to Exhibit 1-A, shall hereinafter refer to Exhibit 1-B. |
| 3. | Effective September 1, 2008, Attachment I, Scope of Services, Exhibit 2-B is hereby included and made a part of the Contract. All references in the Contract to Exhibit 2-A, shall hereinafter refer to Exhibit 2-B. |
| 4. | Effective September 1, 2008, Attachment I, Scope of Services, Exhibit 3-C is hereby included and made a part of the Contract. All references in the Contract to Exhibits 3-B, shall hereinafter refer respectively to Exhibit 3-C. |
| 5. | Effective September 1, 2008, Attachment II, Medicaid Reform Health Plan Model Contract, Section XIII, Method of Payment, Section B, Capitation Rate Payments, is hereby revised as follows: |
-- Sub-item 1.b.(1)(b), is hereby amended to include the following:
Contract Year 2008-2009 Medicaid Reform rates under current Capitation Rate methodology.
-- Sub-item 1.b.(1)(i), the first paragraph is hereby amended to now read as follows:
| | (i) 100% of Risk Adjusted Methodology: The capitation amount based on the percentage of Risk-Adjusted methodology (h) multiplied by the Base Rates column for Risk-Adjusted methodology after budget neutrality factor (g). |
-- Sub-item 1.b.(1)(j), the first sentence is hereby amended to now read as follows:
| | (j) Final Rate (with Enhanced Benefit Adjustment): The current methodology capitation amount (d) added to the 100% of Risk-Adjusted methodology amount (i). |
AHCA Contract No. FAR001, Amendment No. 9, Page 1 of 2
AHCA Form 2100-0002 (Rev. NOV03)
| HealthEase of Florida, Inc. | Medicaid Reform HMO Contract |
| | All provisions in the Contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to conform with this Amendment. |
| | All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the Contract. |
| | This Amendment, and all its attachments, is hereby made part of the Contract. |
| | This Amendment cannot be executed unless all previous Amendments to this Contract have been fully executed. |
| | IN WITNESS WHEREOF, the parties hereto have caused this ten (10) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized. |
| HEALTHEASE OF FLORIDA, INC. | STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION |
| SIGNED | SIGNED |
| BY: /s/ Heath Schiesser | BY: /s/ William H. Roberts |
| NAME: Heath Schiesser | NAME: William H. Roberts for Holly Benson |
| TITLE: President and CEO | TITLE: Secretary |
| DATE: | DATE: |
List of Attachments/Exhibits included as part of this Amendment:
| Specify Type | Letter/ Number | Description |
| Exhibit | 1-B | Benefit Grid (4 Pages) |
| Exhibit | 2-B | Second Revised Enrollment Levels (1 Page) |
| Exhibit | 3-C | Medicaid Reform HMO Capitation Rates (3 pages) |
REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK
AHCA Contract No. FAR001, Amendment No. 9, Page 2 of 2
AHCA Form 2100-0002 (Rev. NOV03)
| HealthEase of Florida, Inc. | 2008-2009 |
Exhibit 1-B
Benefit Grid
(i) Area 10 Broward- Children and Families
| COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
| Hospital Inpatient | ||||||
| Behavioral Health | $ | admit | ||||
| Physical Health | $ | admit | ||||
| Transplant Services | ||||||
| Outpatient Services | ||||||
| Emergency Room | ||||||
| Medical/Drug Therapies (Chemo, Dialysis) | ||||||
| Ambulatory Surgery - ASC | ||||||
| Hospital Outpatient Surgery | $ | visit | ||||
| Lab / X-ray | $ | day | ||||
| Hospital Outpatient Services NOS | Annual | $ | visit | |||
| Outpatient Therapy (PT/RT) | Annual | | ||||
| Outpatient Therapy (OT/ST) | ||||||
| Maternity and Family Planning Services | ||||||
| Inpatient Hospital | ||||||
| Birthing Centers | ||||||
| Physician Care | ||||||
| Family Planning | ||||||
| Pharmacy | ||||||
| Physician and Phys Extender Services (non maternity) | ||||||
| EPSDT | ||||||
| Primary Care Physician | $ - | visit | ||||
| Specialty Physician | $ | visit | ||||
| ARNP / Physician Assistant | $ - | visit | ||||
| Clinic (FQHC, RHC) | $ | visit | ||||
| Clinic (CHD) | ||||||
| Other | ||||||
| Other Outpatient Professional Services | ||||||
| Home Health Services | Annual | Annual | $ | visit | ||
| Chiropractor | Annual | Annual | $ | visit | ||
| Podiatrist | Annual | Annual | $ | visit | ||
| Dental Services | | Annual | - | coinsurance | ||
| Vision Services | Annual | $ - | visit | |||
| Hearing Services | Annual | | ||||
| Outpatient Mental Health | $ | visit | ||||
| Outpatient Pharmacy | 10 | Monthly | Annual | |||
| | ||||||
| Other Services | ||||||
| Ambulance | ||||||
| Non-emergent Transportation | $ | trip | ||||
| Durable Medical Equipment | Annual | |||||
| Enhanced benefits | ||||||
AHCA Contract No. FAR001, Exhibit 1-B, Page 1 of 4
| HealthEase of Florida, Inc. | 2008-2009 |
Exhibit 1-B
Benefit Grid
(ii) Area 10 Broward- Aged and Disabled
| COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
| Hospital Inpatient | | | ||||
| Behavioral Health | $ | admit | ||||
| Physical Health | admit | |||||
| Transplant Services | ||||||
| Outpatient Services | ||||||
| Emergency Room | ||||||
| Medical/Drug Therapies (Chemo, Dialysis) | ||||||
| Ambulatory Surgery - ASC | ||||||
| Hospital Outpatient Surgery | $ | visit | ||||
| Lab / X-ray | $ | day | ||||
| Hospital Outpatient Services NOS | Annual | $ | visit | |||
| Outpatient Therapy (PT/RT) | Annual | |||||
| Outpatient Therapy (OT/ST) | ||||||
| Maternity and Family Planning Services | ||||||
| Inpatient Hospital | ||||||
| Birthing Centers | ||||||
| Physician Care | ||||||
| Family Planning | ||||||
| Pharmacy | ||||||
| Physician and Phys Extender Services (non maternity) | ||||||
| EPSDT | ||||||
| Primary Care Physician | $ - | visit | ||||
| Specialty Physician | $ | visit | ||||
| ARNP / Physician Assistant | $ - | visit | ||||
| Clinic (FQHC, RHC) | $ | visit | ||||
| Clinic (CHD) | | |||||
| Other | ||||||
| Other Outpatient Professional Services | ||||||
| Home Health Services | Annual | Annual | $ | visit | ||
| Chiropractor | Annual | Annual | $ | visit | ||
| Podiatrist | Annual | Annual | $ | visit | ||
| Dental Services | $ | Annual | - | coinsurance | ||
| Vision Services | Annual | $ - | visit | |||
| Hearing Services | Annual | |||||
| Outpatient Mental Health | $ | visit | ||||
| Outpatient Pharmacy | 17 | Monthly | Annual | |||
| Other Services | ||||||
| Ambulance | ||||||
| Non-emergent Transportation | $ | trip | ||||
| Durable Medical Equipment | Annual | |||||
| Enhanced benefits |
| (Circumcision, boys up to one year) |
| ($25 OTC, per household per month) |
| (Expanded dental services – Exams / X-rays / Deep Cleaning / Clear and Silver Fillings / Crown (limited) |
| Flouride / Periodontal Scaling and root planning) |
| (Respite Events – up to 1 per month) |
AHCA Contract No. FAR001, Exhibit 1-B, Page 2 of 4
| HealthEase of Florida, Inc. | 2008-2009 |
Exhibit 1-B
Benefit Grid
(i) Area 4 Duval- Children and Families
| COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
| Hospital Inpatient | ||||||
| Behavioral Health | $ | admit | ||||
| Physical Health | $ | admit | ||||
| Transplant Services | ||||||
| Outpatient Services | ||||||
| Emergency Room | ||||||
| Medical/Drug Therapies (Chemo, Dialysis) | ||||||
| Ambulatory Surgery - ASC | ||||||
| Hospital Outpatient Surgery | $ | visit | ||||
| Lab / X-ray | $ | day | ||||
| Hospital Outpatient Services NOS | Annual | $ | visit | |||
| Outpatient Therapy (PT/RT) | Annual | |||||
| Outpatient Therapy (OT/ST) | ||||||
| Maternity and Family Planning Services | ||||||
| Inpatient Hospital | ||||||
| Birthing Centers | ||||||
| Physician Care | ||||||
| Family Planning | ||||||
| Pharmacy | ||||||
| Physician and Phys Extender Services (non maternity) | ||||||
| EPSDT | ||||||
| Primary Care Physician | $ - | visit | ||||
| Specialty Physician | $ | visit | ||||
| ARNP / Physician Assistant | $ - | visit | ||||
| Clinic (FQHC, RHC) | $ | visit | ||||
| Clinic (CHD) | ||||||
| Other | ||||||
| Other Outpatient Professional Services | ||||||
| Home Health Services | Annual | Annual | $ | visit | ||
| Chiropractor | Annual | Annual | $ | visit | ||
| Podiatrist | Annual | Annual | $ | visit | ||
| Dental Services | Annual | - | coinsurance | |||
| Vision Services | Annual | $ - | visit | |||
| Hearing Services | Annual | |||||
| Outpatient Mental Health | $ | visit | ||||
| Outpatient Pharmacy | 9 | Monthly | Annual | |||
| Other Services | ||||||
| Ambulance | ||||||
| Non-emergent Transportation | $ | trip | ||||
| Durable Medical Equipment | Annual | |||||
| Enhanced benefits | ||||||
AHCA Contract No. FAR001, Exhibit 1-B, Page 3 of 4
| HealthEase of Florida, Inc. | 2008-2009 |
Exhibit 1-B
Benefit Grid
(ii) Area 4 Duval- Aged and Disabled
| COVERED SERVICE CATEGORY | Visit/Script Limit | Limit Period (Annual/Monthly) | Dollar Limit | Limit Period (Annual) | Copay Amount | Copay Application |
| Hospital Inpatient | ||||||
| Behavioral Health | $ | admit | ||||
| Physical Health | $ | admit | ||||
| Transplant Services | ||||||
| Outpatient Services | ||||||
| Emergency Room | ||||||
| Medical/Drug Therapies (Chemo, Dialysis) | ||||||
| Ambulatory Surgery - ASC | ||||||
| Hospital Outpatient Surgery | $ | visit | ||||
| Lab / X-ray | $ | day | ||||
| Hospital Outpatient Services NOS | Annual | $ | visit | |||
| Outpatient Therapy (PT/RT) | Annual | |||||
| Outpatient Therapy (OT/ST) | ||||||
| Maternity and Family Planning Services | ||||||
| Inpatient Hospital | ||||||
| Birthing Centers | ||||||
| Physician Care | ||||||
| Family Planning | ||||||
| Pharmacy | ||||||
| Physician and Phys Extender Services (non maternity) | ||||||
| EPSDT | ||||||
| Primary Care Physician | $ - | visit | ||||
| Specialty Physician | $ | visit | ||||
| ARNP / Physician Assistant | $ - | visit | ||||
| Clinic (FQHC, RHC) | $ | visit | ||||
| Clinic (CHD) | ||||||
| Other | ||||||
| Other Outpatient Professional Services | ||||||
| Home Health Services | Annual | Annual | $ | visit | ||
| Chiropractor | Annual | Annual | $ | visit | ||
| Podiatrist | Annual | Annual | $ | visit | ||
| Dental Services | $ | Annua | - | coinsurance | ||
| Vision Services | Annual | $ - | visit | |||
| Hearing Services | Annual | | ||||
| | ||||||
| Outpatient Mental Health | $ | visit | ||||
| Outpatient Pharmacy | 17 | Monthly | Annual | |||
| Other Services | ||||||
| Ambulance | ||||||
| Non-emergent Transportation | $ | trip | ||||
| Durable Medical Equipment | Annual | |||||
| Enhanced benefits |
AHCA Contract No. FAR001, Exhibit 1-B, Page 4 of 4
HEALTHEASE OF FLORIDA, INC.
EXHIBIT 2-B
SECOND REVISED ENROLLMENT LEVELS
TABLE 1 (Duval – Area 4, Broward – Area 10)
| Agency Area 04 |
| Eligibility Category/ Population | County | Health Plan Provider Number | Plan Type (Comp or Comp & Catastrophic) | Maximum Enrollment Level |
| TANF | Duval | Comprehensive & Catastrophic | 35,500 | |
| SSI | Duval | Comprehensive & Catastrophic | ||
| HIV/AIDS | ||||
| Children with Chronic Conditions |
| Agency Area 10 |
| Eligibility Category/ Population | County | Health Plan Provider Number | Plan Type (Comp or Comp & Catastrophic) | Maximum Enrollment Level |
| TANF | Broward | Comprehensive & Catastrophic | 15,500 | |
| SSI | Broward | Comprehensive & Catastrophic | ||
| HIV/AIDS | ||||
| Children with Chronic Conditions |
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Contract No. FAR001, Exhibit 2-B, Page 1 of 1
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age, and Eligibility Category)
September 1, 2008 – August 31, 2009
TABLE 2
| Area: 10 | County: Broward | September 1, 2008 |
ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
| Eligibility Category/ Population | Total Rates for Comprehensive and Catastrophic Components | Total Rate for Comprehensive Component Only |
| Children and Families: | ||
| Newborns aged 0-2 months | $ 868.52 | $ 750.55 |
| Newborns aged 3-11 months | $ 191.05 | $ 181.72 |
| Age 1 and Up - Base Rate for Risk adjustment | $ 107.11 | $ 105.39 |
| Aged and Disabled: | |||
| No Medicare | |||
| Newborns aged 0-2 months | $ 17,572.21 | $ 9,173.75 | |
| Newborns aged 3-11 months | $ 3,896.35 | $ 2,167.93 | |
| Age 1 and Up - Base Rate for Risk Adjustment | $ 789.84 | $ 725.69 | |
| Medicare Parts A and B | ||
| Under Age 65 | $ 139.11 | N/A |
| Age 65 and over | $ 99.49 | N/A |
| Medicare Part B Only | ||
| All ages | $ 265.17 | N/A |
| HIV/AIDS Specialty Population | ||
| No Medicare HIV | $ 1,823.74 | N/A |
| No Medicare AIDS | $ 3,422.47 | N/A |
| Medicare HIV | $ 256.03 | N/A |
| Medicare AIDS | $ 546.61 | N/A |
| Kick Payments Amounts for Covered Obstetrical Delivery Services: | ||
| CPT Code | Obstetrical Delivery CPT Code Description | Payment Amount |
| 59409 | Vaginal delivery only | $3,941.45 |
| 59410 | Vaginal delivery including postpartum care | |
| 59515 | Cesarean delivery including postpartum care | |
| 59612 | Vaginal delivery only, after previous cesarean delivery | |
| 59614 | Vaginal delivery only, after previous cesarean delivery including postpartum care | |
| 59622 | Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery inc postpartum care | |
AHCA Contract No. FAR001, Exhibit 3-C, Page 1 of 3
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age, and Eligibility Category)
September 1, 2008 – August 31, 2009
| Area: 4 | County: Duval, Baker, Clay and Nassau | September 1, 2008 |
(ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)`
| Eligibility Category/ Population | Total Rates for Comprehensive and Catastrophic Component | Total Rate for Comprehensive Component Only |
| Children and Families: | ||
| Newborns aged 0-2 months | $ 895.21 | $ 773.61 |
| Newborns aged 3-11 months | $ 196.74 | $ 187.13 |
| Age 1 and Up - Base Rate for Risk Adjustment | $ 110.24 | $ 108.46 |
| Aged and Disabled: | ||
| No Medicare | ||
| Newborns aged 0-2 months | $ 14,234.51 | $ 7,431.27 |
| Newborns aged 3-11 months | $ 3,172.94 | $ 1,765.42 |
| Age 1 and Up - Base Rate for Risk Adjustment | $ 610.65 | $ 561.06 |
| Medicare Parts A and B | ||
| Under Age 65 | $ 158.06 | N/A |
| Age 65 and over | $ 112.96 | N/A |
| Medicare Part B Only | ||
| All ages | $ 326.42 | N/A |
| HIV/AIDS Specialty Population | ||
| No Medicare HIV | $ 1,161.19 | N/A |
| No Medicare AIDS | $ 2,285.96 | N/A |
| Medicare HIV | $ 157.41 | N/A |
| Medicare AIDS | $ 336.05 | N/A |
| Kick Payments Amounts for Covered Obstetrical Delivery Services: | ||
| CPT Code | Obstetrical Delivery CPT Code Description | Payment Amount |
| 59409 | Vaginal delivery only | $3,977.49 |
| 59410 | Vaginal delivery including postpartum care | |
| 59515 | Cesarean delivery including postpartum care | |
| 59612 | Vaginal delivery only, after previous cesarean delivery | |
| 59614 | Vaginal delivery only, after previous cesarean delivery including postpartum care | |
| 59622 | Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery inc postpartum care | |
AHCA Contract No. FAR001, Exhibit 3-C, Page 2 of 3
EXHIBIT 3-C
MEDICAID REFORM HMO CAPITATION RATES
(By Area, Age, and Eligibility Category)
September 1, 2008 – August 31, 2009
| Area: 4 | County: Duval, Baker, Clay, Nassau | September 1, 2008 |
| CPT Code | Transplant CPT Code Description | Children/Adolescents or Adult | Payment Amount |
| 32851 | lung single, without bypass | Children/Adolescents | $320,800.00 |
| 32851 | lung single, without bypass | Adult | $238,000.00 |
| 32852 | lung single, with bypass | Children/Adolescents | $320,800.00 |
| 32852 | lung single, with bypass | Adult | $238,000.00 |
| 32853 | lung double, without bypass | Children/Adolescents | $320,800.00 |
| 32853 | lung double, without bypass | Adult | $238,000.00 |
| 32854 | lung double, with bypass | Children/Adolescents | $320,800.00 |
| 32854 | lung double, with bypass | Adult | $238,000.00 |
| 33945 | heart transplant with or without recipient cardiectomy | All Age Groups | $162,000.00 |
| 47135 | liver, allotransplation, orthotopic, partial or whole from cadaver or living donor | All Age Groups | $122,600.00 |
| 47136 | liver, heterotopic, partial or whole from cadaver or living donor any age | All Age Groups | $122,600.00 |
AHCA Contract No. FAR001, Exhibit 3-C, Page 3 of 3
