EXHIBIT 10.28.1
AMENDMENT #2
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND
PHYSICIANS HEALTH CARE PLANS
THIS AMENDMENT, entered into between the Florida Healthy Kids Corporation,
hereinafter referred to as "FHKC" and PHYSICIANS HEALTH CARE PLANS, hereinafter
referred to as "PHP", amends its Contract dated July 2, 2002.
WHEREAS, Section 4-12(B) of the said Contract between FHKC and PHP, provides
that if there is a change in controlling interest in PHP that FHKC has ten (10)
days to elect to continue or terminate said Contract with PHP; and,
WHEREAS, on November 26, 2002, PHP notified FHKC that the Florida Department of
Insurance had granted regulatory approval for the change in controlling interest
of PHP from PHP Holdings, Inc., to AMERIGROUP Florida Inc., hereinafter referred
to as AMERIGROUP effective January 1, 2003; and,
WHEREAS, the Florida Department of Insurance has also approved a name change
from PHP to AMERIGROUP effective January 1, 2003; and
WHEREAS, FHKC has elected to continue said Contract with AMERIGROUP and will
amend its Contract to reflect the name change; and,
THEREFORE, be it resolved that the Parties agree to the following amendment of
their contract:
I. All references to Physicians Healthcare Plans, Inc. or PHP in
said contract shall now be renamed AMERIGROUP.
II. Section 4-6: Notice is amended to read:
FOR AMERIGROUP:
Contact Name: ▇▇▇▇▇ ▇▇▇▇▇▇
Manager, Regulatory Compliance
Address: AMERIGROUP Corporation
▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇
Phone Number: (▇▇▇) ▇▇▇-▇▇▇▇, ext. 2547
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.
Amerigroup - Pasco and Polk Page 1 of 2
Effective Date: January 1, 2003
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 is hereby
made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this two (2) page amendment
to be executed by their officials thereunto duly authorized.
FLORIDA HEALTHY KIDS CORPORATION
/s/ ▇▇▇▇ ▇. ▇▇▇▇
---------------------------------
▇▇▇▇ ▇. ▇▇▇▇, EXECUTIVE DIRECTOR
DATE:2/10/03
AMERIGROUP FLORIDA, INC.
_________________________________
NAME:
DATE:
Amerigroup - Pasco and Polk Page 2 of 2
Effective Date: January 1, 2003
AMENDMENT #3
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND AMERIGROUP FLORIDA, INC.
THIS INDENTURE, Made and entered into this 23rd day of July, 2003, by and
between THE FLORIDA HEALTHY KIDS CORPORATION, hereinafter referred to "FHKC" and
AMERIGROUP FLORIDA, INC., hereinafter referred to as "AMERIGROUP".
WITNESSETH
WHEREAS, FHKC AND AMERIGROUP executed a contract effective October 1, 2002, and
WHEREAS, said contract allows for revisions to the benefits and coverage offered
under this contract pursuant to statutory or regulatory changes and such changes
have been made by the 2003 Legislature through the 2003-2004 General
Appropriations Act;
WHEREAS, the parties have agreed to amend the contract for such adjustments and
to allow for rate adjustments to reflect such revisions;
WHEREAS, said contract also allows for an annual premium rate adjustment; and,
NOW THEREFORE IN CONSIDERATION of the covenants contained herein and the
agreement of FHKC and AMERIGROUP to amend the above-described contract, it is
agreed by the parties as follows that:
1. Exhibit A will be amended as attached and made a part hereof;
2. Exhibit C will be amended as attached and made a part hereof;
and,
3. The effective date of this Amendment shall be October 1, 2003.
IN WITNESS WHEREOF, the Parties hereto have executed this Agreement on 23rd day
of July, 2003.
AMERIGROUP FLORIDA, INC.
/s/ [ILLEGIBLE] /s/ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇
------------------- ---------------------------
WITNESS NAME:
TITLE:
FLORIDA HEALTHY
KIDS CORPORATION
/s/ [ILLEGIBLE] /s/ ▇▇▇▇ ▇. ▇▇▇▇
------------------- ---------------------------
WITNESS Name:
Title:
Amendment #3 Page 1 of 8
Amerigroup/Pasco & Polk October 1, 2003
EXHIBIT A
HEALTH SERVICES AGREEMENT
THE PREMIUM FOR PARTICIPANTS IN THE FLORIDA HEALTHY KIDS PROGRAM FOR THE
COVERAGE PERIOD OF OCTOBER 1, 2003 THROUGH SEPTEMBER 30, 2004 SHALL BE $71.34
FOR EACH COVERED PARTICIPANT IN PASCO COUNTY.
THE PREMIUM FOR PARTICIPANTS IN THE FLORIDA HEALTHY KIDS PROGRAM FOR THE
COVERAGE PERIOD OF OCTOBER 1,2003 THROUGH SEPTEMBER 30, 2004 SHALL BE $72.45 FOR
EACH COVERED PARTICIPANT IN POLK COUNTY.
Amendment #3 Page 2 of 8
Amerigroup/Pasco & Polk October 1, 2003
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
I. Minimum Benefits; Statutory Requirements
AMERIGROUP agrees to provide, at a minimum, those benefits that are
prescribed by state law under Section 409.815(2)(a-p) and 409.815
(r-t). AMERIGROUP shall pay an enrollees' covered expenses up to a
lifetime maximum of $1 million per covered enrollee.
The following health care benefits are included under this Agreement:
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BENEFIT LIMITATIONS PAYMENTS
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A. Inpatient Services All admissions must be authorized by AMERIGROUP. NONE
All covered services
provided for the medical The length of the patient stay shall be determined based on the
care and treatment of an medical condition of the enrollee in relation to the necessary
enrollee who is admitted and appropriate level of care.
as an inpatient to a
hospital licensed under Room and board may be limited to semi-private accommodations,
part I of Chapter 395. unless a private room is considered medically necessary or
semi-private accommodations are not available.
Covered services include:
physician's services; Private duty nursing limited to circumstances where such care is
room and board; general medically necessary.
nursing care; patient
meals; use of operating Admissions for rehabilitation and physical therapy are limited to
room and related 15 days per contract year.
facilities; use of
intensive care unit and Shall Not Include Experimental or Investigational Procedures as
services; radiological, defined as a drug, biological product, device, medical treatment
laboratory and other or procedure that meets any one of the following criteria, as
diagnostic tests; drugs; determined by AMERIGROUP.
medications; biologicals;
anesthesia and oxygen 1. Reliable Evidence shows the drug, biological product, device,
services; special duty medical treatment, or procedure when applied to the circumstances
nursing; radiation and of a particular patient is the subject of ongoing phase I, II or
chemotherapy; respiratory III clinical trials or
therapy; administration
of whole blood plasma; 2. Reliable Evidence shows the drug, biological product, device,
physical, speech and medical treatment or procedure when applied to the circumstances
occupational therapy; of a particular patient is under study with a written protocol to
medically necessary determine maximum tolerated dose, toxicity, safety, efficacy, or
services of other health efficacy in comparison to conventional alternatives, or
professionals.
3. Reliable Evidence shows the drug, biological product, device,
medical treatment, or procedure is being delivered or should be
delivered subject to the approval and supervision of an
Institutional Review
Board (IRB) as required and defined by federal regulations,
particularly those of the U.S. Food and Drug Administration or
the Department of Health and Human Services.
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Amendment #3 Page 3 of 8
Amerigroup/Pasco & Polk October 1, 2003
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B. Emergency Services Must use an AMERIGROUP designated facility or provider for $10 per visit waived if
Covered Services include emergency care unless the time to reach such facilities or admitted or authorized by
visits to an emergency providers would mean the risk of permanent damage to patient's primary care physician
room or other licensed health.
facility if needed
immediately due to an AMERIGROUP must also comply with the provisions of s. 641.513,
injury or illness and Florida Statutes.
delay means risk of
permanent damage to the
enrollee's health.
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C. Maternity Services and Infant is covered for up to three (3) days following birth or NONE
Newborn Care until the infant is transferred to another medical facility,
Covered services include whichever occurs first.
maternity and newborn
care; prenatal and Coverage may be limited to the fee for vaginal deliveries.
postnatal care; initial
inpatient care of
adolescent participants,
including nursery charges
and initial pediatric or
neonatal examination.
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D. Organ Transplantation Coverage is available for transplants and medically related NONE
Services services if deemed necessary and appropriate within the
Covered services include guidelines set by the Organ Transplant Advisory Council or the
pretransplant, transplant Bone Marrow Transplant Advisory Council.
and postdischarge
services and treatment of
complications after
transplantation.
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E. Outpatient Services Services must be provided directly by AMERIGROUP or through No co-payment for well
Preventive, diagnostic, pre-approved referrals. child care, preventive
therapeutic, palliative care or for routine
care, and other services Routine hearing and screening must be provided by primary care vision and hearing
provided to an enrollee physician. screenings.
in the outpatient portion
of a health facility Family planning limited to one annual visit and one supply visit
licensed under chapter each ninety days.
395.
Covered services include Chiropractic services shall be provided in the same manner as in $5 per office visit
Well-child care, the Florida Medicaid program.
including those services
recommended in the Podiatric services are limited to one visit per day totaling two
Guidelines for Health visits per month for specific foot disorders. Dental services
Supervision of Children must be provided to an oral surgeon for medically necessary
and Youth as developed by reconstructive dental surgery due to injury.
Academy of Pediatrics;
immunizations and Immunizations are to be provided by the primary care
injections as recommended physician.
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Amendment #3 Page 4 of 8
Amerigroup/Pasco & Polk October 1, 2003
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by the Advisory Committee Treatment for temporomandibular joint (TMJ) disease is
on Immunization specifically excluded.
Practices; health
education counseling and Shall Not Include Experimental or Investigational Procedures as
clinical services; family defined as a drug, biological product, device, medical treatment
planning services, vision or procedure that meets any one of the following criteria, as
screening; hearing determined by AMERIGROUP:
screening; clinical
radiological, laboratory 1. Reliable Evidence shows the drug, biological product, device,
and other outpatient medical treatment, or procedure when applied to the circumstances
diagnostic tests; of a particular patient is the subject of ongoing phase I, II or
ambulatory surgical III clinical trials or
procedures; splints and
casts; consultation with 2. Reliable Evidence shows the drug, biological product, device,
and treatment by referral medical treatment or procedure when applied to the circumstances
physicians; radiation and of a particular patient is under study with a written protocol to
chemotherapy; determine maximum tolerated dose, toxicity, safety, efficacy, or
chiropractic services; efficacy in comparison to conventional alternatives, or
podiatric services.
3. Reliable Evidence shows the drug, biological product, device,
medical treatment, or procedure is being delivered or should be
delivered subject to the approval and supervision of an
Institutional Review Board (IRB) as required and defined by
federal regulations, particularly those of the U.S. Food and Drug
Administration or the Department of Health and Human Services.
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E. Behavioral Health All services must be provided directly by AMERIGROUP or upon
Services approved referral.
Covered services include
inpatient and outpatient Inpatient services are limited to not more than thirty inpatient INPATIENT:
care for psychological or days per contract year for psychiatric admissions, or residential NONE
psychiatric evaluation, services in lieu of inpatient psychiatric admissions; however, a
diagnosis and treatment minimum often of the thirty days shall be available only for
by a licensed mental inpatient psychiatric services when authorized by AMERIGROUP
health professional. physician.
Outpatient services are limited to a maximum of forty outpatient OUTPATIENT:
visits per contract year. $5 per visit
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F. Substance Abuse All services must be provided directly by AMERIGROUP or upon INPATIENT:
Services approved referral. NONE
Includes coverage for
inpatient and outpatient Inpatient services are limited to not more than seven inpatient
care for drug and alcohol days per contract year for medical detoxification only and thirty
abuse including days residential services.
counseling and placement
assistance. Outpatient Outpatient visits are limited to a maximum of forty visits per OUTPATIENT:
services include contract year. $5 per visit
evaluation, diagnosis and
treatment by a licensed
practitioner.
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Amendment #3 Page 5 of 8
Amerigroup/Pasco & Polk October 1, 2003
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G. Therapy Services All treatments must be performed directly or as authorized by $5 per visit
Covered services include AMERIGROUP.
physical, occupational,
respiratory and speech Limited to up to twenty-four treatment sessions within a sixty
therapies for short-term day period per episode or injury, with the sixty day period
rehabilitation where beginning with the first treatment.
significant improvement
in the enrollee's
condition will result.
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H. Home Health Services Coverage is limited to skilled nursing services only. Meals, $5 per visit
Includes prescribed home housekeeping and personal comfort items are excluded. Services
visits by both registered must be provided directly by AMERIGROUP. Private duty nursing is
and licensed practical limited to circumstances where such care is medically
nurses to provide skilled appropriate.
nursing services on a
part-time intermittent
basis.
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I. Hospice Services Once a family elects to receive hospice care for an enrollee, $5 per visit
Covered services include other services that treat the terminal condition will not be
reasonable and necessary covered.
services for palliation
or management of an Services required for conditions totally unrelated to the
enrollee's terminal terminal condition are covered to the extent that the services
illness. are covered under this contract.
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J.Nursing Facility All admissions must be authorized by AMERIGROUP and provided by a NONE
Services AMERIGROUP affiliated facility.
Participant must require and receive skilled services on a daily
Covered services include basis as ordered by AMERIGROUP physician.
regular nursing services, The length of the enrollee's stay shall be determined by the
rehabilitation services, medical condition of the enrollee in relation to the necessary
drugs and biologicals, and appropriate level of care, but is no more than 100 days per
medical supplies, and the contract year.
use of appliances and
equipment furnished by Room and board is limited to semi-private accommodations unless a
the facility. private room is considered medically necessary or semi-private
accommodations are not available.
Specialized treatment centers and independent kidney disease
treatment centers are excluded.
Private duty nurses, television, and custodial care are excluded.
Admissions for rehabilitation and physical therapy are limited to
fifteen days per contract year.
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K. Durable Medical Equipment and devices must be provided by authorized AMERIGROUP NONE
Equipment and Prosthetic supplier.
Devices
Equipment and devices Covered prosthetic devices include artificial eyes and limbs,
that are medically braces, and other artificial aids.
indicated to assist in
the treatment of a Low vision and telescopic lenses are not included.
medical
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Amendment #3 Page 6 of 8
Amerigroup/Pasco & Polk October 1, 2003
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condition and Hearing aids are covered only when medically indicated to assist
specifically prescribed in the treatment of a medical condition.
as medically necessary by
enrollee's AMERIGROUP
physician.
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L. Refractions Enrollee must have failed vision screening by primary care $5 per visit
Examination by a physician.
AMERIGROUP optometrist to
determine the need for Corrective lenses and frames are limited to one pair every two
and to prescribe years unless head size or prescription changes. $10 for corrective
corrective lenses as lenses
medically indicated. Coverage is limited to Medicaid frames with plastic or SYL
non-tinted lenses.
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M. Pharmacy Prescribed drugs covered under this Agreement shall include all $5 per
Prescribed drugs for the prescribed drugs covered under the Florida Medicaid program. prescription for
treatment of illness or AMERIGROUP may implement a pharmacy benefit management program if up to a 31-day supply
injury or injury. FHKC so authorizes.
Brand name products are covered if a generic substitution is not
available or where the prescribing physician indicates that a
brand name is medically necessary.
All medications must be dispensed through AMERIGROUP or an
AMERIGROUP designated pharmacy.
All prescriptions must be written by the participant's primary
care physician, AMERIGROUP approved specialist or consultant
physician.
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N. Transportation Must be in response to an emergency situation. $10 per service
Services
Emergency transportation
as determined to be
medically necessary in
response to an emergency
situation.
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II. Cost Sharing Provisions
AMERIGROUP agrees to comply with all cost sharing restrictions imposed on FHKC
participants by federal or state laws and regulations, including the following
specific provisions:
A. Special Populations
Enrollees identified by FHKC to AMERIGROUP as Native Americans
or Alaskan Natives are prohibited from paying any cost sharing
amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's
Income
FHKC may identify to AMERIGROUP other enrollees who have met
federal requirements regarding maximum out of pocket
expenditures. Enrollees identified by FHKC as having met this
threshold are not required to pay any further cost sharing for
covered services for a time specified by FHKC.
Amendment #3 Page 7 of 8
Amerigroup/Pasco & Polk October 1, 2003
C. AMERIGROUP is responsible for informing its providers of these
provisions and ensuring that enrollees under this section
incur no further out of pocket costs for covered services and
are not denied access to services. FHKC will provide these
enrollees with a letter indicating that they may not incur any
cost sharing obligations.
III. Other Benefit Provision
All requirements for prior authorizations must conform with
federal and state regulations and must be completed within
fourteen (14) days of request by the enrollee. Extensions to
this process may be granted in accordance with federal and/or
state regulations.
Amendment #3 Page 8 of 8
Amerigroup/Pasco & Polk October 1, 2003