EXHIBIT 10.25.1
PHYSICIANS HEALTHCARE PLANS, INC. MEDICAID HMO CONTRACT
OCTOBER ▇▇▇▇ ▇▇▇▇▇▇▇▇ # ▇▇▇▇▇
AMENDMENT # 001
THIS AMENDMENT, entered into between the State of Florida, Agency for
Health Care Administration, hereinafter referred to as the "Agency" and
Physicians Healthcare Plans, Inc., hereinafter referred to as the "provider,"
amends contract # FA309.
1. Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table
1 is amended as shown below.
TABLE 1 PROJECTED ENROLLMENT
COUNTY INITIAL AUTHORIZED ENROLLMENT LEVEL MAXIMUM ENROLLMENT LEVEL
BROWARD 10,429 10,438
[ILLEGIBLE] 17,138 21,685
[ILLEGIBLE] 28,089 31,423
[ILLEGIBLE] 10,889 12,672
[ILLEGIBLE] 20,975 21,000
[ILLEGIBLE] 4,126 4,551
[ILLEGIBLE] 6,785 6,829
PASCO 6,313 7,196
PINELLAS 14,376 15,677
POLK 11,157 19,000
SARASOTA 4,186 4,310
SEMINOLE 4,025 4,577
2. Attachment I, Section 90.0,2nd paragraph is amended to read:
Notwithstanding the payment amounts which may be computed with the above
rate table, the sum of total capitation payments under this contract shall
not exceed the total contract amount of $376,898,400.00 expressed on page
three of this contract.
3. Section II.A. of the Standard Contract is amended to read:
A. CONTRACT AMOUNT
To pay for contract services according to the conditions of Attachment I in
an amount not to exceed $376,898,400.00, subject to the availability of
funds. The State of Florida's performance and obligation to pay under this
contract is contingent upon an annual appropriation by the Legislature.
4. This amendment shall become effective November 1,2002, or the date on which
the amendment has been signed by both parties, whichever is later.
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 are hereby made a part of the
contract.
1
PHYSICIANS HEALTHCARE PLANS, INC. MEDICAID HMO CONTRACT
OCTOBER 2002 AMENDMENT # 001
IN WITNESS WHEREOF, the parties hereto have caused this -2- page amendment
to be executed by their officials thereunto duly authorized.
STATE OF FLORIDA
AGENCY FOR HEALTH CARE
PROVIDER: Physicians Healthcare Plans, Inc. ADMINISTRATION
SIGNED SIGNED
BY: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ BY: /s/ [ILLEGIBLE]
--------------------------- ---------------------------
NAME: ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ NAME: ▇▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D.
FAAFP
TITLE: CEO and Chairman TITLE: Secretary
DATE: 11-26-02 DATE: 11/27/02
FEDERAL ID NUMBER:
650318864
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA Form 2100-0002 APR96
2
PHYSICIANS HEALTHCARE PLANS, INC. MEDICAID HMO CONTRACT
OCTOBER 2002 FA309
AMENDMENT # 002
THIS AMENDMENT, entered into between the State of Florida, Agency for
Health Care Administration, hereinafter referred to as the "Agency" and
Physicians Healthcare Plans, Inc., hereinafter referred to as the "provider,
amends contract # FA309.
Section III.C.1., Standard Contract, is amended to read
C. NOTICE AND CONTACT
1. The name, address and telephone number of the contract manager for the
agency for this contract is:
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇, AHC ADMINISTRATOR
DIVISION OF MEDICAID
▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇ ▇▇▇▇ #▇
▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇
(▇▇▇)▇▇▇-▇▇▇▇
2. This amendment shall become effective November 1, 2002, or the date on which
the amendment has been signed by both parties, whichever is later.
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 are hereby made a part of the
contract.
IN WITNESS WHEREOF, the parties hereto have caused this -1- page
amendment to be executed by their officials thereunto duly authorized.
STATE OF FLORIDA
AGENCY FOR HEALTH CARE
PROVIDER: Physicians Healthcare Plans, Inc. ADMINISTRATION
SIGNED SIGNED
BY: /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ BY: /s/ ▇▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇
--------------------------- ---------------------
NAME: ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ NAME: ▇▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D.
FAAFP
TITLE: Chairman and CEO TITLE: Secretary
DATE: 12/5/02 DATE: 12/18/02
FEDERAL ID NUMBER:
650318864
AHCA Form 2100-0002 APR96
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
AHCA CONTRACT NO. FA309
AMENDMENT NO. 003
THIS AMENDMENT, entered into between the STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and
Physicians Healthcare Plans, INC., hereinafter referred to as the "Provider," is
hereby amended as follows:
WHEREAS, as a result of a corporate merger and subsequent name
change, effective January 1, 2003, the Provider is changing
its name to AMERIGROUP Florida; Inc. and,
WHEREAS, the Provider remains intact as a legal entity under
its new name and its current ▇▇▇▇ number; and,
WHEREAS, the Contract needs to be revised to change the
Provider's name.
NOW, THEREFORE, both parties hereby agree as follows:
1. The name of the Provider for AHCA Contract No. FA309 is hereby changed
to AMERIGROUP Florida Inc. and AMERIGROUP Florida shall have all the
rights, duties, liabilities and responsibilities, past, present and
future, of Physicians Healthcare Plans, Inc. under the Contract.
2. The Standard Contract, Section I, Item N is hereby revised to change
the Provider name to AMERIGROUP Florida, Inc.
3. Section II.A. of the Standard Contract is amended to read:
A. CONTRACT AMOUNT
To pay for contract services according to the conditions of Attachment
I in an amount not to exceed $383,927,000.00, subject to the
availability of funds. The State of Florida's performance and
obligation to pay under this contract is contingent upon an annual
appropriation by the Legislature.
4. The Standard Contract, Section III, Item C, Paragraph 2 is hereby
revised to now read:
2. The name, address and telephone number of the representative
of the Provider responsible for administration of the program
under this contract is:
▇▇▇▇▇ ▇▇▇▇▇
AMERIGROUP Florida, Inc.
▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇
▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇
(800) 830-6937 ext. 6902
5. The Standard Contract, Section III, Item E, Paragraphs 1 and 2 are
hereby revised to now read:
E. Name, Mailing and Street Address of Payee
1. The name (Provider name as shown on page 1 of this contract)
and mailing address of the official payee to whom the payment
shall be made:
AMERIGROUP Florida, Inc.
▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇
▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇
2. The name of the contact person and street address where
financial and administrative records are maintained:
▇▇▇▇▇ ▇▇▇▇▇▇▇
AMERIGROUP Corporation
▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇
(▇▇▇) ▇▇▇-▇▇▇▇
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 1 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
6. Attachment I, Section 10.8.1 f., Florida Statutory Reference is changed
to: 409.912(26) F.S.
7. Attachment I, Section 10.8.4 f., Florida Statutory Reference is changed
to: 409.912(33)(e) and (f) F.S.
8. Attachment I, Section 10.8.9 a., Florida Statutory Reference is changed
to: 409.912(33) F.S.
9. Attachment I, Section 20.12.2 a., Florida Statutory Reference is
changed to: 409.912(29)(e)F.S.
10. Attachment I, Section 30.2.1 a., Florida Statutory Reference is changed
to: 409.912(19)(a) F.S.
11. Attachment I, Section 30.2.1 b., Florida Statutory Reference is changed
to: 409.912(19)(b) F.S.
13. Attachment I, Section 30.2.1 d., Florida Statutory Reference is changed
to: 409.912(19)(c) F.S.
12. Attachment I, Section 30.2.1 e., Florida Statutory Reference is changed
to: 409.912(19)(d) F.S.
14. Attachment I, Section 30.2.1 h., Florida Statutory Reference is changed
to: 409.912(19)(b)2. F.S.
15. Attachment I, Section 30.2.1 i., Florida Statutory Reference is changed
to: 409.912(19)(b)(4) F.S.
16. Attachment I, Section 30.2.1 j., Florida Statutory Reference is changed
to: 409.912(19)(b)2. F.S.
17. Attachment I, Section 30.2.1 k., Florida Statutory Reference is changed
to: 409.912(19)(b)1. F.S.
18. Attachment I, Section 30.2.1 o., Florida Statutory Reference is changed
to: 409.912(19)(e) F.S.
19. Attachment I, Section 30.5 first paragraph, Florida Statutory
Reference is changed to: 409.912(27) F.S.
20. Attachment I, Section 30.5 second paragraph, Florida Statutory
Reference is changed to: 409.912(27) F.S.
21. Attachment I, Section 30.7 a. 3., Florida Statutory Reference is
changed to: 409.912(24) F.S.
22. Attachment I, Section 30.7.2, Florida Statutory Reference is changed
to: 409.912(28) F.S.
23. Attachment I, Section 30.12.2 c., Florida Statutory Reference is
changed to: 409.912(31) F.S.
24. Attachment I, Section 40.7 d., Florida Statutory Reference is changed
to: 409.912(30) F.S.
25. Attachment I, Section 50.1, Florida Statutory Reference is changed to:
409.912(16)(a) F.S.
26. Attachment I, Section 50.2, Florida Statutory Reference is changed to:
409.912(16)(b) F.S.
27. Attachment I, Section 50.4, Florida Statutory Reference is changed to:
409.912(15) F.S.
28. Attachment I, Section 60.2.11, Table 13, Florida Statutory Reference is
changed to: 409.912(26) F.S.
29. Attachment I, Section 70.3 a., Florida Statutory Reference is changed
to: 409.912(18) F.S.
30. Attachment I, Section 70.17, first paragraph, Florida Statutory
Reference is changed to: 409.912(20) F.S.
31. Attachment I, Section 70.17 d., Florida Statutory Reference is changed
to: 409.912(20) F.S.
32. Attachment I, Section 70.17 f., Florida Statutory Reference is changed
to: 409.912(26) F.S.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 2 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
33. Attachment I, Section 10.3 b. is amended to read:
b. Medicaid eligible recipients who are receiving services
through a hospice program, the Medicaid AIDS waiver (Project
AIDS Care) program, the assisted living waiver program, or a
prescribed pediatric extended care center, or are enrolled in
Children's Medical Services Network.
34. Attachment I, Section 10.8.8.1 a. is amended to read:
a. Medically necessary and appropriate transplants: bone marrow,
all ages; cornea, all ages; and kidney, all ages. For other
transplants not covered by Medicaid, the evaluations,
pre-transplant care and post-transplant follow-up care are
covered by Medicaid and, therefore, must be covered by the
plan even though the transplant procedure is not covered.
Transplant service components are also covered under
outpatient services, physician services and prescribed drug
services per the applicable Medicaid coverage and limitations
handbooks.
The plan is not responsible for the cost of pre-transplant
care and post transplant follow-up care when a member has been
listed with UNOS as a status 1A, IB, or 2 as a candidate for
an adult or pediatric heart transplant or pediatric heart/lung
transplant. If at the end of the evaluation the recipient is
listed with the above UNOS parameters the recipient will be
disenrolled from the plan.
The plan is not responsible for the cost of pre-transplant
care and post transplant follow up care when a member has been
listed with UNOS with a MELD score of 11-25 for an adult or
pediatric liver transplant. If at the end of the evaluation
the recipient is listed with the above UNOS parameter the
recipient will be disenrolled from the plan.
The plan is not responsible for the cost of pre-transplant
care and post transplant follow up care when a member has been
listed with UNOS as a status 0 for an adult or pediatric lung
transplant. If at the end of the of the evaluation the
recipient is listed with the above UNOS parameters the
recipient will be disenrolled from the plan.
The recipient will have the option to re-enroll at one year
post transplant. The plan is responsible for the cost of the
above transplant evaluations, except adult heart (21 and
over).
35. Attachment I, Section 10.11.1, Service Requirements (Behavioral
Health), is amended to read:
The plan, in addition to the provisions set forth in this
contract and elsewhere in this section, shall provide to Areas
1 and 6, (also, upon implementation of behavioral health
services in Areas 5 and 8) enrolled members a full range of
behavioral health care service categories authorized under the
State Medicaid Plan. The plan shall comply with the specific
service requirements as described in the general service
requirements of the PMHP RFP specific to the Medicaid Area
except as provided below:
The plan shall continue to provide Prescribed Drug Services in
accordance with Section 10.8.12 of this contract.
The plan shall continue to provide outpatient medical
services in accordance with Section 10.8.8.2 of this
contract.
In addition to the above requirements, the plan shall
also adhere to the requirements specified below.
36. Attachment I, Section 20.5, Licensure of Staff, Florida Statutory
Reference is changed to: 456.047(4) F.S.
37. Attachment I, Section 20.12.2 b. is amended to read:
b. The plan shall use the results of the annual member
satisfaction survey to develop and implement plan-wide
activities designed to improve member satisfaction. These
activities shall include, but not be limited to, analyses of
the following: formal and informal member complaints, claims
timely payment, disenrollment reasons, policies and
procedures, and any pertinent internal improvement plan
implemented to improve member satisfaction. Activities
pertaining to improving member satisfaction resulting from the
annual member
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 3 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
satisfaction survey must be reported to the agency on a
quarterly basis within 30 days after the end of a reporting
quarter.
38. Attachment 1, Section 30.5 Pre-enrollment Activities, 8th paragraph is
amended to read:
If the voluntary applicant is recognized to be in ▇▇▇▇▇▇ care
by the plan, and is dependent, prior to enrollment the plan
must receive written authorization from (1) a parent if the
parental rights have not been terminated or (2) the DCF if the
parental rights have been terminated. If a parent is
unavailable, the plan shall obtain authorization from the DCF.
39. Attachment I, Section 30.7.1, Member Services Handbook, is amended to
read:
The member services handbook shall include the following
information: terms and conditions of enrollment including the
reinstatement process; a description of the open enrollment
process; description of services provided, including
limitations and general restrictions on provider access,
exclusions and out-of-plan use; procedures for obtaining
required services, including second opinions; the toll-free
telephone number of the statewide Consumer Call Center;
emergency services and procedures for obtaining services both
in and out of the plan's service area; procedures for
enrollment, including member rights and responsibilities;
grievance procedures; and procedures for disenrollment;
procedures for filing a "good cause change" request, including
the agency's toll-free telephone number for the enrollment and
disenrollment services contractor; information regarding
newborn enrollment, including the mother's responsibility to
notify the plan and the mother's DCF caseworker of the
newborn's birth and assignment of pediatricians and other
appropriate physicians; member rights and responsibilities;
information on emergency transportation and non-emergency
transportation available under the plan; and information
regarding the health care advance directives pursuant to
Chapter 765, F.S.
40. Attachment I, Section 30.7.4.b. is amended to read:
b. A notice that members who lose eligibility and are
disenrolled shall be automatically reenrolled in the
plan if eligibility is regained within 60 days.
41. Attachment I, Section 30.8, Enrollment Reinstatements, first paragraph
is amended to read:
Pre-enrollment applications and new member materials are not
required for a former member who was disenrolled because of
the loss of Medicaid eligibility and who regains his/her
eligibility within 60 days and is automatically reinstated as
a plan member. In addition, pre-enrollment and new member
materials are not required for a former member subject to open
enrollment who was disenrolled because of the loss of Medicaid
eligibility, who regains his/her eligibility within 10 months
of his/her managed care enrollment, and is reinstated as a
plan member by the agency's enrollment and disenrollment
services contractor. The plan is responsible for assigning
all reinstated recipients to the primary care physician who
was treating them prior to loss of eligibility, unless the
recipient specifically requests another primary care
physician, the primary care physician no longer participates
in the plan or is at capacity, or the member has changed
geographic areas. A notation of the effective date of the
reinstatement is to be made on the most recent application or
conspicuously identified in the member's administrative file.
42. Attachment I, Section 40.16, Certification Regarding HIPAA Compliance,
is replaced as follows:
CERTIFICATION
REGARDING HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
COMPLIANCE
This certification is required for compliance with the requirements of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The undersigned Provider certifies and agrees as to abide by the following:
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 4 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
1. Protected Health Information. For purposes of this
Certification, Protected Health Information shall have the
same meaning as the term "protected health information" in 45
C.F.R. Section 164.501, limited to the information created or
received by the Provider from or on behalf of the Agency.
2. Limits on Use and Disclosure of Protected Health Information.
The Provider shall not use or disclose Protected Health
Information other than as permitted by this Contract or by
federal and state law. The Provider will use appropriate
safeguards to prevent the use or disclosure of Protected
Health Information for any purpose not in conformity with
this Contract and federal and state law. The Provider will not
divulge, disclose, or communicate Protected Health Information
to any third party for any purpose not in conformity with
this contract without prior written approval from the Agency.
The Provider will report to the Agency, within ten (10)
business days of discovery, any use or disclosure of Protected
Health Information not provided for in this Contract of which
the Provider is aware. A violation of this paragraph shall be
a material violation of this Contract.
3. Use and Disclosure of Information for Management,
Administration, and Legal Responsibilities. The Provider is
permitted to use and disclose Protected Health Information
received from the Agency for the proper management and
administration of the Provider or to carry out the legal
responsibilities of the Provider, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where
required by law, or where the Provider obtains reasonable
assurances from the person to whom the Protected Health
Information is disclosed that: (1) the Protected Health
Information will be held confidentially, (2) the Protected
Health Information will be used or further disclosed only as
required by law or for the purposes for which it was disclosed
to the person, and (3) the person notifies the Provider of any
instance of which it is aware in which the confidentiality of
the Protected Health Information has been breached.
4. Disclosure to Agents. The Provider agrees to enter into an
agreement with any agent, including a subcontractor, to whom
it provides Protected Health Information received from, or
created or received by the Provider on behalf of, the Agency.
Such agreement shall contain the same terms, conditions, and
restrictions that apply to the Provider with respect to
Protected Health Information.
5. Access to Information. The Provider shall make Protected
Health Information available in accordance with federal and
state law, including providing a right of access to persons
who are the subjects of the Protected Health Information.
6. Amendment and Incorporation of Amendments. The Provider shall
make Protected Health Information available for amendment and
to incorporate any amendments to the Protected Health
Information in accordance with 45 C.F.R. Section 164.526.
7. Accounting for Disclosures. The Provider shall make Protected
Health Information available as required to provide an
accounting of disclosures in accordance with 45 C.F.R. Section
164.528. The Provider shall document all disclosures of
Protected Health Information as needed for the Agency to
respond to a request for an accounting of disclosures in
accordance with 45 C.F.R. Section 164.528.
8. Access to Books and Records. The Provider shall make its
internal practices, books, and records relating to the use and
disclosure of Protected Health Information received from, or
created or received by the Provider on behalf of, the Agency
available to the Secretary of the Department of Health and
Human Services or the Secretary's designee for purposes of
determining compliance with the Department of Health and Human
Services Privacy Regulations.
9. Termination. At the termination of this contract, the Provider
shall return all Protected Health Information that the
Provider still maintains in any form, including any copies or
hybrid or merged databases made by the Provider; or with prior
written approval of the Agency, the Protected Health
Information may be destroyed by the Provider after its use. If
the Protected Health Information is destroyed pursuant to the
Agency's prior written approval, the Provider must provide a
written confirmation of such destruction to the Agency. If
return or destruction of the Protected Health Information is
determined not feasible by the Agency, the Provider agrees to
protect the Protected Health Information and treat it as
strictly confidential.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 5 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
CERTIFICATION
The Provider has caused this Certification to be signed and delivered
by its duly authorized representative, as of the date set forth below.
Provider Name:
/s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ 6/9/03
--------------------- ------
Signature Date
▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, President & CEO, AMERIGROUP Florida
------------------------------------------------------
Name and Title of Authorized Signer
43. Attachment I, Section 60.1,9 is amended to read:
9. HMO Reinstatement Report(FLMR 8200-R009)-Lists those persons who
were disenrolled for loss of eligibility but who regained their
Medicaid eligibility within 60 days of the previous plan.
44. Attachment I, Section 60.2. Table 1. Summary of Reporting Requirements for
medicaid Contracted Health Maintenance Organizations is amended to
read:
TABLE 1. SUMMARY OF REPORTING REQUIREMENTS FOR MEDICAID CONTRACTED
HEALTH MAINTENANCE ORGANIZATIONS
Medicaid HMO Reports Required by AHCA
------------------------------------------------------------------------------------------------------------------------------------
LEVEL OF
REPORT NAME ANALYSIS FREQUENCY SUBMISSION MEDIA
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Enrollment, Disenrollment, and Location Level Monthly Asynchronous Transfer to
Cancellation Report for Payments fiscal agent
Table 2
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Madicaid HMO/PHP Disenrollment Location Level Monthly, within 15 days from the Electronic mail of discloser
Summary begining of the reporting month submission
Table 3
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Frail Eiderly Disenrollment Location Level Annually, day by June 1 Electronic mail of discloser
Summary submission
------------------------------------------------------------------------------------------------------------------------------------
Newborn Payment Report Individual Level Monthly Electronic mail of discloser
Table 4 submission
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Services Utilization Summary Plan Level Quarterly, within 45 days of end of Electronic mail of discloser
Table 5 and 6 reporting quarter submission
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Grievance Reporting Individual Level Quarterly, within 45 days from the end of Electronic mail of discloser
Table 7 the reporting quarter submission
------------------------------------------------------------------------------------------------------------------------------------
Inpatient Discharge Report Individual Level Quarterly, within 30 days from the end of Electronic mail of discloser
Table 8 the reporting quarter submission
------------------------------------------------------------------------------------------------------------------------------------
Pharmacy Encounter Data Individual Level Quarterly, within one month from the end Electronic mail or CD
Table 9 of the quarter Submission
------------------------------------------------------------------------------------------------------------------------------------
Claims Inventory Summary Report Plan Level Quarterly, within 45 days of the end of Electronic mail of diskette
submission
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AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 6 OF 13
AHCA Form 2100-0002(Rev. OCT02)
AMERIGROUP FLORIDA, INC.
FEBRUARY 2003 MEDICAID HMO CONTRACT
--------------------------------------------------------------------------------------------------------------------------------
Table 13 contract completed spreadsheet file
--------------------------------------------------------------------------------------------------------------------------------
AHCA Quality Plan Level Annually, for previous calendar Electronic mail, CD ROM or diskette
Indicators year, due October 1. submission
--------------------------------------------------------------------------------------------------------------------------------
Frail/Elderly Care Individual Level Quarterly, within 45 days of Electronic mail, CD ROM or diskette
Service Utilization end of reporting quarter submission
Report
--------------------------------------------------------------------------------------------------------------------------------
Financial Reporting Plan Level Quarterly, within 45 days of AHCA supplied spreadsheet template on
end of reporting quarter diskette
--------------------------------------------------------------------------------------------------------------------------------
Audited Financial Report Plan Level Annually, within 90 days of end Electronic mail or diskette submission
of plan Fiscal Year
--------------------------------------------------------------------------------------------------------------------------------
Minority Business Individual Level Monthly by the fifteenth Electronic mail
Enterprise Contract
Reporting
--------------------------------------------------------------------------------------------------------------------------------
Suspected Fraud Reporting Plan Level As required by Section 60.2.16 As required by Section 60.2.16
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Behavioral Health: ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇ and Monthly, within 15 days of Electronic mail or diskette
of Recipients, Targeted Case Area I the beginning of the submission of completed
Management, Grievance, and Location reporting month agency-supplied template
Critical Incident Reporting Level
--------------------------------------------------------------------------------------------------------------------------------
Behavioral Health: Service Area 6 and Area Quarterly, within 45 days of Electronic mail or diskette
Utilization Detail and 1 Location the end of the quarter submission of completed
Summary Level and agency-supplied template
Individual
Level
--------------------------------------------------------------------------------------------------------------------------------
Behavioral Health: Area 6 and Annually, due no later than Electronic mail or diskette
Annual Expenditure Area 1 Plan April 1. submission of completed
Report Level agency-supplied template
--------------------------------------------------------------------------------------------------------------------------------
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 7 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
45. Attachment I, Section 60.2.13, Frail/Elderly Care Service Utilization
Reporting (F***YYQ*.dbf) is deleted and replaced as follows:
The plan shall provide recipient-specific service utilization data in
the electronic format specified below,. The services reported represent
the comprehensive array of services that might be necessary to maintain
a member at home while avoiding nursing home placement, including acute
and long-term care services.
These reports must be provided as ASCII, fixed length text files, with
two files, per recipient, per month. There will be one file for
long-term care services and one file for acute care services. For
example, if a recipient were enrolled for an entire quarter, you would
lave three separate records in each of two separate files that are
submitted once for the entire quarter. These two files, the LTC
services file and the Acute Care Services file, must be submitted once
every quarter to your DOEA/AHCA contract manager. You will have up to
three months after the last month in a specific quarter to submit the
quarterly report.
If no units of service are provided in a category or if the category is
not applicable to yon, fill that field with the specified number of
spaces (using the spacebar) that match that particular field length.
Right Justify all fields unless noted otherwise. For amount paid,
include the sum of Medicaid and Medicare crossover claims (deductibles
and co-pays for Medicare claims). If you have questions about the
definitions of these services please reference the appropriate Medicaid
coverage and limitations handbook for Medicaid state plan services.
Note: Please do not use commas between fields. Round currency to the
nearest dollar amount.
FILE 1: LONG-TERM CARE SERVICES
---------------------------------------------------------------------------------------------------------------------------
FIELD START
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
---------------------------------------------------------------------------------------------------------------------------
SSN Social Security Number (left justify) 000000000 9 1 9 Numeric
---------------------------------------------------------------------------------------------------------------------------
MEDICAID Medicaid ID Number 0000000000 10 10 19 Numeric
---------------------------------------------------------------------------------------------------------------------------
ENROLL Initial Date of Program Enrollment MMYYYY 6 20 25 Numeric
---------------------------------------------------------------------------------------------------------------------------
DISENROL Date of Disenrollment, if Applicable MMYYYY 6 26 31 Numeric
---------------------------------------------------------------------------------------------------------------------------
REINST Reinstate date MMYYYY 6 32 37 Numeric
---------------------------------------------------------------------------------------------------------------------------
ALF ALF Resident Indicator 1=Yes;2=No 1 38 38 Numeric
---------------------------------------------------------------------------------------------------------------------------
MONTH Report Month MMYYYY 6 39 44 Numeric
---------------------------------------------------------------------------------------------------------------------------
LTC UNIT OF SERVICE
SERVICES DESCRIPTION /COST
---------------------------------------------------------------------------------------------------------------------------
ADCOMP Adult Companion Services 15 Minute Unit 4 45 48 Numeric
---------------------------------------------------------------------------------------------------------------------------
ADAYHLTH Adult Day Health Services 15 Minute Unit 4 49 52 Numeric
---------------------------------------------------------------------------------------------------------------------------
ALESYS Assisted Living Services Days 2 53 54 Numeric
---------------------------------------------------------------------------------------------------------------------------
ALESVSSS Assisted Living Services Amount Paid 6 55 60 Numeric
---------------------------------------------------------------------------------------------------------------------------
ATTCARE Attendant Care Services 15 Minute Unit 4 61 64 Numeric
---------------------------------------------------------------------------------------------------------------------------
CASEAID Case Aide 15 Minute Unit 4 65 68 Numeric
---------------------------------------------------------------------------------------------------------------------------
CASEMGMT Case Management (Internal) 15 Minute Unit 4 69 72 Numeric
---------------------------------------------------------------------------------------------------------------------------
CHORE Chore Services 15 Minute Unit 2 73 74 Numeric
---------------------------------------------------------------------------------------------------------------------------
COM_MH Community Mental Health Visit 2 75 76 Numeric
---------------------------------------------------------------------------------------------------------------------------
CNMS_$$ Consumable Medical Supplies Amount Paid 6 77 82 Numeric
---------------------------------------------------------------------------------------------------------------------------
COUNSEL Counseling 15 Minute Unit 4 83 86 Numeric
---------------------------------------------------------------------------------------------------------------------------
DME_$$ Durable Medical Equipment Amount Paid 6 87 92 Numeric
---------------------------------------------------------------------------------------------------------------------------
ENVIRAA Environmental Accessibility Adaptations Job 2 93 94 Numeric
---------------------------------------------------------------------------------------------------------------------------
-------------------------
* Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
clients who are also eligible for Medicare.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 8 OF 12
AHCA Form 2100-0002(Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
----------------------------------------------------------------------------------------------------------------------------
FIELD START
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
----------------------------------------------------------------------------------------------------------------------------
ESCORT Escort Services 15 Minute Unit 4 95 98 Numeric
----------------------------------------------------------------------------------------------------------------------------
FAMT_I Family Training Services (Individual) 15 Minute Unit 2 99 100 Numeric
----------------------------------------------------------------------------------------------------------------------------
FAMT_G Family Training Services (Group) 15 Minute Unit 2 101 102 Numeric
----------------------------------------------------------------------------------------------------------------------------
FINARRS Financial Assessment/Risk Reduction Services 15 Minute Unit 4 103 106 Numeric
----------------------------------------------------------------------------------------------------------------------------
FINM_RRS Financial Maintenance/Risk Reduction Services 15 Minute Unit 4 107 110 Numeric
----------------------------------------------------------------------------------------------------------------------------
HDMEAL Home Delivered Meals Meal 2 111 112 Numeric
----------------------------------------------------------------------------------------------------------------------------
HOMESRVS Homemaker Services 15 Minute Unit 4 113 116 Numeric
----------------------------------------------------------------------------------------------------------------------------
MH_CM Mental Health Case Management 15 Minute Unit 4 117 120 Numeric
----------------------------------------------------------------------------------------------------------------------------
SNF Nursing Facility Services- Long-term Days 2 121 122 Numeric
----------------------------------------------------------------------------------------------------------------------------
NUTR_RRS Nutritional Assessment/Risk Reduction Services 15 Minute Unit 4 123 126 Numeric
----------------------------------------------------------------------------------------------------------------------------
OT Occupational Therapy 15 Minute Unit 4 127 130 Numeric
----------------------------------------------------------------------------------------------------------------------------
PCS Personal Care Services 15 Minute Unit 4 131 134 Numeric
----------------------------------------------------------------------------------------------------------------------------
PERS_I Personal Emergency Response
System Installation Job 2 135 136 Numeric
----------------------------------------------------------------------------------------------------------------------------
PERS_M Personal Emergency Response System-
Maintenance Day 2 137 138 Numeric
----------------------------------------------------------------------------------------------------------------------------
PEST_I Pest Control - Initial Visit Job 2 139 140 Numeric
----------------------------------------------------------------------------------------------------------------------------
PEST_M Pest Control - Maintenance Month 1 141 141 Numeric
----------------------------------------------------------------------------------------------------------------------------
PT Physical Therapy 15 Minute Unit 4 142 145 Numeric
----------------------------------------------------------------------------------------------------------------------------
RISKREDU Physical Risk Assessment and Reduction 15 Minute Unit 4 146 149 Numeric
----------------------------------------------------------------------------------------------------------------------------
PRIVNURS Private Duty Nursing Services 15 Minute Unit 4 150 153 Numeric
----------------------------------------------------------------------------------------------------------------------------
PT_R Registered Physical Therapist Visit 2 154 155 Numeric
----------------------------------------------------------------------------------------------------------------------------
RSPTH Respiratory Therapy 15 Minute Unit 4 156 159 Numeric
----------------------------------------------------------------------------------------------------------------------------
RESP_HM Respite Care- In Home 15 Minute Unit 4 160 163 Numeric
----------------------------------------------------------------------------------------------------------------------------
RESP_FAC Respite Care- Facility-Based Days 2 164 165 Numeric
----------------------------------------------------------------------------------------------------------------------------
NURSE Skilled Nursing Visit 4 166 169 Numeric
----------------------------------------------------------------------------------------------------------------------------
SPTH Speech Therapy 15 Minute Unit 4 170 173 Numeric
----------------------------------------------------------------------------------------------------------------------------
TRANSPOR Transportation Services (not included
in Escort or Adult Day Health services) Trips 3 174 176 Numeric
----------------------------------------------------------------------------------------------------------------------------
OTH_UNIT Other LTC Service not listed (unit) Unit/ Visit 6 177 182 Numeric
----------------------------------------------------------------------------------------------------------------------------
DESCR_1 Description of other LTC service 35 183 217 Text
----------------------------------------------------------------------------------------------------------------------------
OTH_$$ Other LTC service not listed (amount) Amount Paid 6 218 223 Numeric
----------------------------------------------------------------------------------------------------------------------------
DESCR_2 Description of other LTC service 35 224 258 Text
----------------------------------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 9 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
FILE 2: ACUTE CARE SERVICES
------------------------------------------------------------------------------------------------------------------------------------
FIELD START
CODE FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
------------------------------------------------------------------------------------------------------------------------------------
ACUTE UNITS OF SERVICE/
SERVICES DESCRIPTION COST
------------------------------------------------------------------------------------------------------------------------------------
SSN Social Security Number (left justify) 000000000 9 1 9 Numeric
------------------------------------------------------------------------------------------------------------------------------------
MEDICAID Medicaid ID Number 0000000000 10 10 19 Numeric
------------------------------------------------------------------------------------------------------------------------------------
MONTH Report Month MMYYYY 6 20 25 Numeric
------------------------------------------------------------------------------------------------------------------------------------
CLINIC Clinic Services Visit 2 26 27 Numeric
------------------------------------------------------------------------------------------------------------------------------------
CLINIC$$ Clinic Services Costs Visit 2 28 29 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DENTAL Dental Services Visit 6 30 35 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DENTAL$$ Dental Services Costs Amount Paid 6 36 41 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DIALYSIS Dialysis Center Visit 2 42 43 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DIALYS$$ Dialysis Center Costs Amount Paid 6 44 49 Numeric
------------------------------------------------------------------------------------------------------------------------------------
ER Emergency Room Services Visit 2 50 51 Numeric
------------------------------------------------------------------------------------------------------------------------------------
ER_$$ Emergency Room Services Costs Amount Paid 6 52 57 Numeric
------------------------------------------------------------------------------------------------------------------------------------
FQHC FQHC Services Visit 2 58 59 Numeric
------------------------------------------------------------------------------------------------------------------------------------
FQHC_$$ FQHC Services Costs Amount Paid 6 60 65 Numeric
------------------------------------------------------------------------------------------------------------------------------------
HEAR Hearing Services Including Hearing aids Amount Paid 6 66 71 Numeric
------------------------------------------------------------------------------------------------------------------------------------
INPTSVS Inpatient Hospital Services Day 3 72 74 Numeric
------------------------------------------------------------------------------------------------------------------------------------
INPTSVS$ Inpatient Hospital Services Costs Amount Paid 6 75 80 Numeric
------------------------------------------------------------------------------------------------------------------------------------
LAB Independent Laboratory or Portable Amount Paid 6 81 86 Numeric
X-ray Services
------------------------------------------------------------------------------------------------------------------------------------
ARNP Nurse Practitioner Services Visit 2 87 88 Numeric
------------------------------------------------------------------------------------------------------------------------------------
ARNP_$$ Nurse Practitioner Services Costs Amount Paid 6 89 94 Numeric
------------------------------------------------------------------------------------------------------------------------------------
RX_$$ Pharmaceuticals Amount Paid 6 95 100 Numeric
------------------------------------------------------------------------------------------------------------------------------------
PA Physical Assistant Visit 2 101 102 Numeric
------------------------------------------------------------------------------------------------------------------------------------
PA_$$ Physical Assistant Costs Amount Paid 6 103 108 Numeric
------------------------------------------------------------------------------------------------------------------------------------
MD Physician Services Visit 2 109 110 Numeric
------------------------------------------------------------------------------------------------------------------------------------
MD_$$ Physician Services Costs Amount Paid 6 111 116 Numeric
------------------------------------------------------------------------------------------------------------------------------------
OUTPT Outpatient Hospital Services Encounter 3 117 119 Numeric
------------------------------------------------------------------------------------------------------------------------------------
OUTPT_$$ Outpatient Hospital Services Costs Amount Paid 6 120 125 Numeric
------------------------------------------------------------------------------------------------------------------------------------
PODIATRY Podiatry Visit 2 126 127 Numeric
------------------------------------------------------------------------------------------------------------------------------------
PODIAT$$ Podiatry Costs Amount Paid 6 128 133 Numeric
------------------------------------------------------------------------------------------------------------------------------------
RURAL Rural Health Services Visit 2 134 135 Numeric
------------------------------------------------------------------------------------------------------------------------------------
RURAL$$ Rural Health Services Costs Amount Paid 6 136 141 Numeric
------------------------------------------------------------------------------------------------------------------------------------
SNFREHAS Skilled nursing facility Amount Paid 6 142 147 Numeric
services - rehabilitation**
------------------------------------------------------------------------------------------------------------------------------------
EYE_$$ Visual Services including eyeglasses Amount Paid 6 148 153 Numeric
------------------------------------------------------------------------------------------------------------------------------------
OTH UNIT Other Acute Service not listed (unit) Unit/Visit 6 154 159 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DESCR_1 Description of other Acute service 35 160 194 Text
------------------------------------------------------------------------------------------------------------------------------------
OTH_$$ Other Acute service not listed (amount) Amount Paid 6 195 200 Numeric
------------------------------------------------------------------------------------------------------------------------------------
DESCR_2 Description of other Acute service 35 201 235 Text
------------------------------------------------------------------------------------------------------------------------------------
**Medicare Crossovers
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 10 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
46. Attachment 1, Section 70.1, Agency Contract Management is amended to read:
The Division of Medicaid within the agency shall be responsible for
management of the contract. All statewide policy decision making or
contract interpretation shall be made by the Division of Medicaid. In
addition, the Division of Medicaid shall be responsible for the
interpretation of all federal and state laws, rules and regulations
governing or in any way affecting this contract. Management shall be
conducted in good faith with the best interest of the state and the
recipients it serves being the prime consideration. The agency shall
provide final interpretation of general Medicaid policy. When
interpretations are required, the plan shall submit written requests to
the agency.
The terms of this contract do not limit or waive the ability, authority
or obligation of the Office of Inspector General, Bureau of Medicaid
Program Integrity, its contractors, or other duly constituted
government units (state or federal) to audit or investigate matters
related to, or arising out of this contract.
47. Attachment I, Section 70.10, Disputes, is amended to read:
Any disputes which arise out of or relate to this contract shall be
decided by the agency's Division of Medicaid which shall reduce the
decision to writing and serve a copy on the plan. The written decision
of the agency's Division of Medicaid shall be final and conclusive. The
Division will render its final decision based upon the written
submission of the plan and the agency, unless, at the sole discretion
of the Division director, the Division allows an oral presentation by
the plan, and the agency. If such a presentation is allowed, the
information presented will be considered in rendering the Division's
decision. Should the plan challenge an agency decision through
arbitration as provided below, the action shall not be stayed except by
order of on arbitrator. Thereafter, a plan shall resolve any
controversy or claim arising out of or relating to the contract, or the
breach thereof, by arbitration. Said arbitration shall be held in the
City of Tallahassee, Florida, and administered by the American
Arbitration Association in accordance with its applicable rules and the
Florida Arbitration Code (Chapter 682, F.S.). Judgment upon any award
rendered by the arbitrator may be entered by the Circuit Court in and
for the Second Judicial Circuit, ▇▇▇▇ County, Florida. The chosen
arbitrator must be a member of the Florida Bar actively engaged in the
practice of law with expertise in the process of deciding disputes and
interpreting contracts in the health care field. Any arbitration award
shall be in writing and shall specify the factual and legal bases for
the award. Either party may appeal a judgment entered pursuant to an
arbitration award to the First District Court of Appeal. The parties
shall bear their own costs and expenses relating to the preparation and
presentation of a case in arbitration. The arbitrator shall award to
the prevailing party all administrative fees and expenses of the
arbitration, including the arbitrator's fee. This contract with
numbered attachments represents the entire agreement between the plan
and the agency with respect to the subject matter in it and supersedes
all other contracts between the parties when it is duly signed and
authorized by the plan and the agency. Correspondence and memoranda of
understanding do not constitute part of this contract In the event of a
conflict of language between the contract and the attachments, the
provisions of the contract shall govern. However, the agency reserves
the right to clarify any contractual relationship in writing with the
concurrence of the plan and such clarification shall govern. Pending
final determination of any dispute over an agency decision, the plan
shall proceed diligently with the performance of the contract and in
accordance with the agency's Division of Medicaid direction.
48. Attachment I, Section 70.17 d. is amended to read:
Imposition of a fine for violation of the contract with the agency,
pursuant to Section 409.912(20), F.S. With respect to any nonwillful
violation, such fine shall not exceed $2,500 per violation. In no event
shall such fine exceed an aggregate amount of $10,000 for all
nonwillful violations arising out of the same action. With respect to
any knowing and willful violation of Section 409.912, F.S. or the
contract with the agency, the agency may impose a fine upon the entity
in an amount not to exceed $20,000 for each such violation. In no event
shall such fine exceed an aggregate amount of $100,000 for all knowing
and willful violations arising out of the same action.
49. Attachment I, Section 80.7, Overpayments, is deleted.
50. Attachment I, Section 110.4, paragraph 6.B. is amended to read:
B. Forward any unresolved concerns involving the HMO and the CHD to the
Division of Medicaid.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 11 OF 12
AHCA Form 2100-0002 (Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
FEBRUARY 2003
51. Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table
1 is hereby deleted and replaced as follows:
TABLE 1 ENROLLMENT LEVELS
------------------------------------------------------
COUNTY MAXIMUM ENROLLMENT LEVEL
------------------------------------------------------
BROWARD 10,438
------------------------------------------------------
DADE 21,685
------------------------------------------------------
HILLSBOROUGH 31,423
------------------------------------------------------
▇▇▇ 14,000
------------------------------------------------------
ORANGE 21,000
------------------------------------------------------
OSCEOLA 8,000
------------------------------------------------------
PALM BEACH 10,000
------------------------------------------------------
PASCO 9,000
------------------------------------------------------
PINELLAS 18,000
------------------------------------------------------
POLK 19,000
------------------------------------------------------
SARASOTA 8,000
------------------------------------------------------
SEMINOLE 7,500
------------------------------------------------------
52. Attachment I, Section 90.0,2nd paragraph is amended to read:
Notwithstanding the payment amounts which may be computed with the above
rate table, the sum of total capitation payments under this contract
shall not exceed the total contract amount of $ 383,927.000.00 expressed
on page three of this contract.
53. This amendment shall begin on April 1,2003 or the date on which the
amendment has been signed by both parties, whichever is later.
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 are hereby made a 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 12 page
amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
AMERIGROUP FLORIDA, Inc. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED SIGNED
BY: /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ BY: /s/ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇
---------------------- ------------------
NAME: ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ for NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D.,
FAAFP
TITLE: President & CEO TITLE: Secretary
DATE: 6/4/03 DATE: 6/09/03
AHCA CONTRACT NO. FA309, AMENDMENT NO. 003, PAGE 12 OF 12
AHCA Form 2100-0002(Rev. OCT 02)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
AHCA CONTRACT NO. FA309
AMENDMENT NO. 004
THIS AMENDMENT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH
CARE ADMINISTRATION, hereinafter referred to as the "Agency" and AMERIGROUP
Florida, Inc., hereinafter referred to as the "plan", is hereby amended as
follows:
1. Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table
1 is amended to read:
TABLE 1 ENROLLMENT LEVELS
-----------------------------------------------------------------
COUNTY MAXIMUM ENROLLMENT LEVEL
-----------------------------------------------------------------
BROWARD 14,000
-----------------------------------------------------------------
DADE 24,000
-----------------------------------------------------------------
HILLSBOROUGH 37,500
-----------------------------------------------------------------
▇▇▇ 15,500
-----------------------------------------------------------------
MANATEE 1,600
-----------------------------------------------------------------
ORANGE 27,000
-----------------------------------------------------------------
OSCEOLA 8,000
-----------------------------------------------------------------
PALM BEACH 10,000
-----------------------------------------------------------------
PASCO 12,000
-----------------------------------------------------------------
PINELLAS 23,000
-----------------------------------------------------------------
POLK 21,133
-----------------------------------------------------------------
SARASOTA 8,000
-----------------------------------------------------------------
SEMINOLE 7,500
-----------------------------------------------------------------
2. Attachment I, Section 90.0, Payment and Authorized Enrollment Levels,
Paragraph 2 is hereby amended to read:
Notwithstanding the payment amounts which may be computed with the above
rate table, the sum of total capitation payments under this contract shall
not exceed the total contract amount of $458,000,000.00 expressed on page
three of this contract.
3. Standard Contract Section II.A., Contract Amount, is amended to read:
To pay for contract services according to the conditions of Attachment I in
an amount not to exceed $458,000,000.00, subject to the availability of
funds. The State of Florida's performance and obligation to pay under this
contract is contingent upon an annual appropriation by the Legislature.
4. This amendment shall begin on July 1, 2003 or the date on which the
amendment has been signed by both parties, whichever is later.
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.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 004, PAGE 1 OF 2
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
This amendment and all its attachments are hereby made a 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 2 page
amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
AMERIGROUP Florida, Inc. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED BY: /s/ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ SIGNED BY: ______________________
----------------------
NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D., FAAFP
TITLE: President and CEO TITLE: Secretary
DATE: June 27, 2003 DATE: ___________________________
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA CONTRACT NO. FA309, AMENDMENT NO. 004, PAGE 2 OF 2
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
AHCA CONTRACT NO. FA309
AMENDMENT NO. 005
THIS AMENDMENT, entered into between the STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and
AMERIGROUP Florida, Inc., hereinafter referred to as the "Provider," is hereby
amended as follows:
1. Attachment I, Section 10.3, Ineligible Recipients, subsection f. is
amended to read:
f. Medicaid eligible beneficiaries who have other creditable
health care coverage like CHAMPUS or a private HMO.
2. Attachment I, Section 10.8.6, Hearing Services, is amended to read:
10.8.6 HEARING SERVICES
These services include a hearing evaluation, diagnostic testing and
selective amplification procedures necessary to certify an individual
for a hearing aid device, and fitting and dispensing of hearing aids
and repair services as specified in the Medicaid Hearing Coverage and
Limitations Handbook. Medical and surgical treatment for hearing
disorders is part of physician services.
3. Attachment I, Section 10.10, Incentive Programs, is amended to include
a new subsection d.
d. The plan may offer an Agency-approved program for pregnant
women in order to encourage the commencement of prenatal care
visits in the first trimester of pregnancy and successful
completion of prenatal and post-partum care to promote early
intervention and prenatal care to decrease infant mortality
and low birth weight and to enhance healthy birth outcomes.
The program may include the provision of maternity and
health-related items and education as an incentive. The
request for approval must contain a detailed description of
the program and its mission.
4. Attachment I, Section 20.1, Availability/Accessibility of Services, is
amended to include a third and fourth paragraph to read:
If the plan is unable to provide medically necessary services covered
under the contract to a particular beneficiary, the plan must
adequately and timely cover these services outside of the network for
the beneficiary for as long as the plan is unable to provide them.
The plan must require out-of-network providers to coordinate with
respect to payment and must ensure that cost to the beneficiary is no
greater than it would be if the covered services were furnished within
the network.
5. Attachment I, Section 20.2, Minimum Standards, is amended to include a
new subsection h. Former subsections h., i., and j. remain unchanged
and are renamed consecutively as i., j., and k.
h. By October 1, 2003, at least one pediatrician or one county
health department, a federally qualified health center, or a
rural health clinic within 30 minutes of typical travel time,
providing care or coverage on a 24 hours a day, 7 days a week
basis. The Agency may waive this requirement in writing for
rural areas and where there are no pediatricians, county
health departments, federal qualified health centers, or rural
health clinics within 30 minutes of typical travel time.
6. Attachment I, 20.8, Case Management/Continuity of Care, is amended to
include new subsection f. Former subsection f. becomes subsection g.
f. Coordination of services the plan furnishes to the beneficiary
with services the beneficiary receives from any other managed
care entity during the same period of enrollment.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 1 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
7. Attachment I, is amended to include new Section 20.8.13, Individuals
with Special Health Care Needs, as follows:
20.8.13 INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS
The plan shall implement mechanisms for identifying, assessing and
ensuring the existence of a treatment plan for individuals with special
health care needs, as specified in Section 20.12, Quality Improvement.
The plan shall implement procedures to deliver primary care to and
coordinate health care service for all beneficiaries. These procedures
must meet the following requirements:
a. Ensure that each beneficiary has an ongoing source of primary
care appropriate to his/her needs and a person or entity
formally designated as primarily responsible for coordinating
the health care services furnished to the beneficiary.
b. Coordinate the services the plan furnishes to the beneficiary
with the services the beneficiary receives from any other
managed care entity during the same period of enrollment.
c. Share with other managed care organizations serving the
beneficiary with special health care needs the results of its
identification and assessment of that beneficiary's needs to
prevent duplication of those activities.
d. Ensure that in the process of coordinating care, each
beneficiary's privacy is protected in accordance with the
privacy requirements in 45 CFR Part 160 and 164 Subparts A and
E, to the extent that they are applicable.
8. Attachment I, Section 20.11, Grievance System Requirements,
introduction and subsection a. are amended to read:
The plan shall refer all members and providers who are dissatisfied
with the plan to the grievance coordinator for the appropriate
follow-up and documentation in accordance with approved grievance
procedures. The plan shall develop and implement grievance procedures,
subject to Agency written approval, prior to implementation. The
grievance procedures shall meet the requirements of Section 641.511,
F.S., and the following policies and guidelines:
a. Ensure that the individuals who make decisions on grievances
and appeals are individuals who were not involved in any
previous level of review or decision-making and who are health
care professionals having the appropriate clinical expertise,
as determined by the Agency, in treating the beneficiary's
condition or disease if deciding any of the following:
An appeal of a denial that is based on lack of medical
necessity.
A grievance regarding denial of expedited resolution of an
appeal.
A grievance or appeal that involves clinical issues.
9. Attachment I, Section 20.11, Grievance System Requirements, subsection
f. is amended to read:
f. The plan shall offer to meet with the complainant during the
formal grievance process. The location of the meeting shall be
at the administrative offices of the plan within the service
area or at a location within the service area which is
convenient to the complainant. The plan shall give reasonable
assistance in completing forms and taking other procedural
steps. This includes but is not limited to providing
interpreter services and toll-free numbers that have adequate
TTY/TTD and interpreter capability.
10. Attachment I, Section 20.11, Grievance System Requirements, subsection
i. 1. is amended to read:
1. A notice of the right to appeal upon completion of the full
grievance procedure and supply the Agency with a copy of the
final decision letter. In addition, for expedited grievances,
the plan shall provide the complainant notice of the right to
appeal immediately upon request.
The process for appeals must:
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 2 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
Acknowledge receipt of a grievance or appeal. Provide that a record of
oral inquiries seeking to appeal an action shall be maintained and
include date of inquiry, name, and nature of appeal. Upon receipt of a
written and signed appeal, the plan shall process the appeal for
resolution using the date of the oral inquiry as the date of receipt.
The terms "appeal" and "action" are defined in 42 CFR 438.400.
Provide the beneficiary a reasonable opportunity to present evidence
and allegations of fact or law in person as well as in writing. The
plan must inform the beneficiary of the limited time available for this
in the case of expedited resolution.
Provide the beneficiary and his or her representative opportunity
before and during the appeals process to examine the beneficiary's case
file, including medical records and any other documents and records
considered during the appeals process.
Include as parties to the appeal the beneficiary and his or her
representative, or the legal representative of a deceased beneficiary's
estate.
11. Attachment I, Section 20.12, Quality Improvement, subsection c. is
amended to read:
c. At least three Agency-approved quality-of-care studies must be
performed by the plan. The plan shall provide notification to
the agency prior to implementation of any quality-of-care
study to be performed. The notification shall include the
general description, justification, and methodology for each
study. The plan shall report quarterly to the agency the
results and corrective action to be implemented to improve
outcomes for three of these studies within 30 days of the
reporting quarter. Each study shall have been through the
plan's quality process, including reporting and assessments by
the quality committee and reporting to the board of directors.
Pursuant to 42 CFR 438.240, the projects shall focus on
clinical and nonclinical areas. These projects must be
designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in
clinical care and nonclinical care areas that are expected to
have a favorable effect on health outcomes and enrollee
satisfaction. Each performance improvement project must be
completed in a reasonable time period so as to generally allow
information on the success of performance improvement projects
in the aggregate to produce new information on quality of care
every year. The Centers for Medicare and Medicaid Services, in
consultation with states and other stakeholders, may specify
performance measures and topics for performance improvement
projects. The quality-of-care studies shall:
1. Target specific conditions and specific health
service delivery issues for focused individual
practitioner and system-wide monitoring and
evaluation.
2. Use clinical care standards or practice guidelines to
objectively evaluate the care the entity delivers or
fails to deliver for the targeted clinical
conditions.
3. Use quality indicators derived from the clinical care
standards or practice guidelines to screen and
monitor care and services delivered.
4. Implement system interventions to achieve improvement
in quality.
5. Evaluate the effectiveness of the interventions.
6. Plan and initiate activities for increasing or
sustaining improvement.
7. Monitor the quality, appropriateness and
effectiveness of enrollee home and community based
services for those plans containing a frail/elderly
component. The studies must include quarterly reviews
of long-term care records of enrollees who have
received services during the previous quarter. Review
elements include management of diagnosis,
appropriateness and timeliness of care,
comprehensiveness of compliance with the plan of care
and evidence of special screening for, and monitoring
of, high-risk persons and conditions. The plan's
selection of a condition and issues to study should
be based on member profile data.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 3 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
The plan's quality improvement information shall be used in such
processes as recredentialing, recontracting, and annual performance
ratings of individuals. It shall also be coordinated with other
performance monitoring activities, including utilization management,
risk management, and resolution and monitoring of member grievances.
There shall also be a link between other management activities such as
network changes, benefits redesign, medical management systems (e.g.,
precertification), practice feedback to physicians, patient education,
and member services.
The plan's quality improvement program shall have a peer review
component with the authority to review practice methods and patterns of
individual physicians and other health care professionals,
morbidity/mortality, and all grievances related to medical treatment;
evaluate the appropriateness of care rendered by professionals;
implement corrective action when deemed necessary; develop policy
recommendations to maintain or enhance the quality of care provided to
Medicaid enrollees; conduct a review process which includes the
appropriateness of diagnosis and subsequent treatment, maintenance of
medical records requirements, adherence to standards generally accepted
by professional group peers, and the process and outcome of care;
maintain written minutes of the meetings; receive all written and oral
allegations of inappropriate or aberrant service; and educate
beneficiaries and staff on the role of the peer review authority and
the process to advise the authority of situations or problems.
12. Attachment I, Section 20.12, Quality Improvement, is amended to include
subsection d. as follows:
d. Pursuant to 42 CFR 438.208(c)(1), the plan shall implement
mechanisms to identify persons with special health care needs,
as those persons are defined by the Agency.
13. Attachment I, Section 20.15, Quality and Performance Measures Review,
first and second paragraph is amended to read:
20.15 QUALITY AND PERFORMANCE MEASURES REVIEW
Quality and performance measures reviews shall be performed at least
once annually, at dates to be determined by the agency or as otherwise
specified by this contract. During state fiscal year 2003-2004, the
Agency, in conjunction with Medicaid managed care plans, will design
and implement an enhanced quality assurance system to provide for the
delivery of quality care with the primary goal of improving the health
status of enrollees. The design could include but may not be limited to
reviewing CHCUP rates, a selection of the required reporting measures,
and the results of each plan's performance improvement projects. This
collaborative initiative may involve meetings and conference calls.
If CAHPS, the AHCA quality indicators, the annual medical record audit
or the external quality review indicate that the plan's performance is
not acceptable, then the agency may restrict the plan's enrollment
activities including but not limited to termination of mandatory
assignments.
14. Attachment I, Section 30.2.1, Prohibited Activities, subsection d. is
amended to read:
d. In accordance with Section 409.912(19), F.S., granting or
offering of any monetary or other valuable consideration for
enrollment, except as authorized by Section 409.912(22), F.S.
15. Attachment I, Section 30.6, Enrollment, subsection b. last paragraph:
b. New eligibles and existing beneficiaries subject to open
enrollment who change from their current Medicaid managed
health care plan shall remain enrolled in their plan for 12
months. Additionally, beneficiaries who are reinstated or
regain eligibility within 60 days of their 12 month enrollment
period shall remain "locked-in" until the date for the next
open enrollment period. Members that move to a new county
shall remain a member of their current plan if the plan
operates in the new county. Beneficiaries will only be allowed
to disenroll from plans outside of the annual open enrollment
period if they meet a "good cause change" reason. The agency
shall forward to the plan the open enrollment status of the
plan's current enrollees monthly.
16. Attachment I, Section 30.7, Member Notification, introductory paragraph
is amended to read:
The plan shall develop and implement written enrollment procedures
which shall be used to notify all new plan members of enrollment with
the plan. The plan must give each beneficiary written notice of any
change in the
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 4 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
information required by this section, 42 CFR 438.10(f)(6), and 42 CFR
438.10(g) and (h), at least 30 days before the intended effective date
of the change.
17. Attachment I, Section 30.7.1, Member Services Handbook, is amended to
read:
The member services handbook shall include the following information:
Terms and conditions of enrollment including the reinstatement process;
a description of the open enrollment process; description of services
provided, including limitations and general restrictions on provider
access, exclusions and out-of-plan use; procedures for obtaining
required services, including second opinions; the toll-free telephone
number of the statewide Consumer Call Center; emergency services and
procedures for obtaining services both in and out of the plan's service
area; procedures for enrollment, including member rights and
procedures; grievance procedures; member rights and procedures for
disenrollment; procedures for filing a "good cause change" request,
including the Agency's toll-free telephone number for the enrollment
and disenrollment services contractor; information regarding newborn
enrollment, including the mother's responsibility to notify the plan
and the mother's DCF caseworker of the newborn's birth and assignment
of pediatricians and other appropriate physicians; member rights and
responsibilities; information on emergency transportation and
non-emergency transportation, counseling and referral services
available under the plan and how to access these; information that
interpretation services and alternative communication systems are
available, free of charge, for all foreign languages, and how to access
these services; information that post-stabilization services are
provided without prior authorization; information that services will
continue upon appeal of a suspended authorization and that the
beneficiary may have to pay in case of an adverse ruling; information
regarding the health care advance directives pursuant to ▇▇▇▇▇▇▇ ▇▇▇,
▇.▇., ▇▇ ▇▇▇ 422.128; and information that beneficiaries may obtain
from the plan information regarding quality performance indicators,
including aggregate beneficiary satisfaction data.
18. Attachment I, Section 30.8, Enrollment Reinstatements, first paragraph,
is amended to read:
Pre-enrollment applications and new member materials are not required
for a former member who was disenrolled because of the loss of Medicaid
eligibility and who regains his/her eligibility within 60 days and is
automatically reinstated as a plan member. In addition, unless
requested by the beneficiary, pre-enrollment and new member materials
are not required for a former member subject to open enrollment who was
disenrolled because of the loss of Medicaid eligibility, who regains
his/her eligibility within 6 months of his/her managed care enrollment,
and is reinstated as a plan member by the agency's enrollment and
disenrollment services contractor. The plan is responsible for
assigning all reinstated beneficiaries to the primary care physician
who was treating them prior to loss of eligibility, unless the
beneficiary specifically requests another primary care physician, the
primary care physician no longer participates in the plan or is at
capacity, or the member has changed geographic areas. A notation of the
effective date of the reinstatement is to be made on the most recent
application or conspicuously identified in the member's administrative
file. Beneficiaries who were previously enrolled in a managed care plan
and lose eligibility and regain eligibility after 60 days will be
treated as new eligibles.
19. Attachment I, Section 30.12.1, Voluntary Disenrollments, is amended to
include subsections f. and g. as follows:
f. A beneficiary may request disenrollment as follows:
1. For good cause, at any time.
2. Without cause, at the following times:
(a) During the 90 days following the
beneficiary's initial enrollment or the date
the Agency sends the beneficiary notice of
the enrollment, whichever is later.
(b) At least every 12 months thereafter.
(c) Upon enrollment reinstatement according to
Section 30.8, Enrollment Reinstatements, of
this contract, if the temporary loss of
Medicaid eligibility has caused the
beneficiary to miss the annual disenrollment
opportunity.
(d) When the Agency grants the beneficiary the
right to terminate enrollment without cause
as an intermediate sanction specified in 42
CFR 438.702(a)(3).
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 5 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
g. If a disenrollment request is not reviewed by the Agency
within the time frames specified in this section, the
disenrollment is considered approved.
20. Attachment I, Section 30.12.2, Involuntary Disenrollments, subsection
g. is amended to read:
g. The following are unacceptable reasons for the plan, on its
own initiative, to request disenrollment of a member:
pre-existing medical condition, changes in health status,
volume of utilization, and periodically missed appointments.
21. Attachment I is amended to include a new Section 40.14, Certification
of Reported Data. Subsequent sections are renumbered.
40.14 CERTIFICATION OF REPORTED DATA
Data reported as provided in Section 60.0, Reporting Requirements, and
data specified in 42 CFR 438.604, must be certified by one of the
following: the plan's chief executive officer, the chief financial
officer, or an individual who has delegated authority to sign for and
who reports directly to the plan's chief executive officer or chief
financial officer.
Based on best knowledge, information, and belief, the certification
must attest to the accuracy, completeness, and truthfulness of the data
and of the documents specified by the Agency. The plan must submit the
certification concurrently with the certified data.
22. Attachment I, Section 60.2, HMO Reporting Requirements, first paragraph
is amended to read:
The plan is responsible for complying with all the reporting
requirements established by the Agency. All reports identified in Table
1 of Section 60.0 that are subject to the federal HIPAA regulations
must be in compliance as of October 16, 2003. The plan is responsible
for assuming the accuracy and completeness of the reports as well as
the timely submission of each report. Before October 1 of each contract
year, the plans shall deliver to the Agency a certification by an
Agency approved independent auditor that the CHCUP screening rate
report in Table 1 has been fairly and accurately presented. In
addition, the plans shall deliver to the Agency a certification by an
Agency approved independent auditor that the quality indicator data
reported for the previous calendar year have been fairly and accurately
presented before October 1. If a reporting due date falls on a weekend,
the report will be due to the Agency on the following Monday. The
Agency will furnish the plan with the appropriate reporting formats,
instructions, submission timetables and technical assistance as
required. When Agency payments to a plan are based on data submitted by
the plan, the Agency requires certification of the data as provided in
42 CFR 438.606.
The data that must be certified include but are not limited to
enrollment information, encounter data, and other information required
by the Agency and contained in contracts, proposals, and related
documents. Certification is required, as provided in Section 42 CFR
438.606, for all documents specified by the Agency.
23. Attachment I, Section 60.2, HMO Reporting Requirements, third paragraph
is deleted and replaced by the following:
Beginning July 1, 2003, the reporting of pharmacy data (as defined in
Section 60.2.8) will be discontinued for the remainder of the contract
term. As of October 16, 2003, inpatient data can no longer be
transmitted directly to the Bureau of Managed Health Care, as defined
in Section 60.2.7. Instead, these data records must be submitted to the
fiscal agent's State Healthcare Clearinghouse. The inpatient data
records must conform to the HIPAA X12N837I (inpatient) encounter
transaction requirements. The Agency is currently preparing model HIPAA
encounter transactions for inpatient data. These model examples along
with Medicaid compliance guidelines will be made available to the
plans.
The Agency will establish a Medicaid comprehensive managed care
encounter information system in fiscal year 2004/05. Fiscal year
2003/04 will be used for needs assessment, design/testing, and other
related tasks towards the creation of this information system. This
effort will be performed in collaboration with the Agency, the plans,
and other relevant parties. The plan must be able to submit all data,
meet all the requirements, and be certified by the Agency by June 30,
2004, in order to be considered as 2004-2006 contractor.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 6 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
24. Attachment I, Section 60.2.7, Inpatient Discharge Report
(H***YYQ*.dbf), second paragraph, is amended to read:
Until October 15, 2003, a DBF file with the following record layout
will be submitted to the Agency for Health Care Administration via
Internet e-mail to ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇ or on a high density 3.5"
diskette (IBM compatible, 1.44 Mb) quarterly within 30 calendar days
following the end of the reported quarter. Beginning October 16, 2003,
these data records must be submitted to the fiscal agent's State
Healthcare Clearinghouse. Additionally, the plan must submit to the
fiscal agent monthly the number of inpatient days used by an enrollee
and paid by the plan as described in Section 60.2.1, Enrollment,
Disenrollment, and Cancellation Report for Payment.
25. Attachment I, Section 70.18, Subcontracts, first paragraph is amended
to read:
The plan is responsible for all work performed under this contract, but
may, with the written approval of the Agency, enter into subcontracts
for the performance of work required under this contract. All
subcontracts must comply with 42 CFR 438.230. All subcontracts and
amendments executed by the plan must meet the following requirements
and all model provider subcontracts must be approved, in writing, by
the Agency in advance of implementation. All subcontractors must be
eligible for participation in the Medicaid program; however, the
subcontractor is not required to participate in the Medicaid program as
a provider. The Agency encourages use of minority business enterprise
subcontractors. Subcontracts are required with all major providers of
services including all primary care sites.
26. Attachment I, Section 70.18, Subcontracts, subsection a. 5. is amended
to read:
5. Physician incentive plans must comply with 42 CFR 417.479, 42
CFR 438.6(h), 42 CFR 422.208 and 42 CFR 422.210. Plans shall
make no specific payment directly or indirectly under a
physician incentive plan to a physician or physician group as
an inducement to reduce or limit medically necessary services
furnished to an individual enrollee. Incentive plans must not
contain provisions which provide incentives, monetary or
otherwise, for the withholding of medically necessary care.
27. Attachment I, Section 70.18, Subcontracts, is amended to include new
subsection d.13. as follows:
13. Provide for revoking delegation or imposing other sanctions if
the subcontractor's performance is inadequate.
28. Attachment I, Section 80.1, Payment to Plan by Agency, subsection a. is
amended to read:
a. Until December 31, 2003, the plan may submit one
fee-for-service claim for each member who receives an adult
health screening or a Child Health Check-Up from a Medicaid
enrolled provider within three (3) months of the member's
enrollment.
29. Attachment I, Section 80.1, Payment to Plan by Agency, subsection c. is
amended to read:
c. The capitation rates to be paid are developed using historical
rates paid by Medicaid fee-for-service for similar services in
the same geographic area, adjusted for inflation, where
applicable and in accordance with 42 CFR 438.6(c).
30. Attachment I, Section 90.0, Payment and Authorized Enrollment Levels,
Tables 1, 2, and 3 are amended as shown below:
Table 1 Enrollment Levels
----------------------------------------------------------------
COUNTY MAXIMUM ENROLLMENT LEVEL
----------------------------------------------------------------
BROWARD 14,000
----------------------------------------------------------------
DADE 25,000
----------------------------------------------------------------
HILLSBOROUGH 40,000
----------------------------------------------------------------
▇▇▇ 18,000
----------------------------------------------------------------
MANATEE 2,500
----------------------------------------------------------------
ORANGE 30,000
----------------------------------------------------------------
OSCEOLA 8,500
----------------------------------------------------------------
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 7 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
----------------------------------------------------------------
PALM BEACH 12,000
----------------------------------------------------------------
PASCO 15,000
----------------------------------------------------------------
PINELLAS 25,000
----------------------------------------------------------------
POLK 30,000
----------------------------------------------------------------
SARASOTA 8,000
----------------------------------------------------------------
SEMINOLE 8,000
----------------------------------------------------------------
Table 2
Area Wide Age-Banded Capitation Rates for all Agency areas of the State other
than Agency areas 1 and 6.
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 284.82 69.97 44.29 50.06 108.08 124.17 191.63 291.66 291.66
SSI/No Medicare 1625.98 299.92 159.96 167.94 167.94 507.79 507.79 521.21 521.21
SSI/Part B 214.75 214.75 214.75 214.75 214.75 214.75 214.75 214.75 214.75
SSI/Part A & B 272.08 272.08 272.08 272.08 272.08 272.08 272.08 272.08 192.15
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 279.09 68.63 43.55 49.34 106.06 122.13 188.27 286.92 286.92
SSI/No Medicare 1583.14 292.43 157.12 164.73 164.73 497.77 497.77 510.22 510.22
SSI/Part B 264.13 264.13 264.13 264.13 264.13 264.13 264.13 264.13 264.13
SSI/Part A & B 256.66 256.66 256.66 256.66 256.66 256.66 256.66 256.66 181.25
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 260.49 64.06 40.70 46.02 99.10 114.14 175.80 267.92 267.92
SSI/No Medicare 1609.24 297.43 159.65 167.50 167.50 505.94 505.94 519.02 519.02
SSI/Part B 250.18 250.18 250.18 250.18 250.18 250.18 250.18 250.18 250.18
SSI/Part A & B 250.37 250.37 250.37 250.37 250.37 250.37 250.37 250.37 176.99
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 278.38 68.45 43.40 49.11 105.75 121.61 187.61 285.60 285.60
SSI/No Medicare 1794.62 331.89 178.53 187.44 187.44 565.53 565.53 580.02 580.02
SSI/Part B 249.82 249.82 249.82 249.82 249.82 249.82 249.82 249.82 249.82
SSI/Part A & B 286.54 286.54 286.54 286.54 286.54 286.54 286.54 286.54 202.32
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 292.18 71.92 45.80 51.82 111.20 128.26 197.51 301.16 301.16
SSI/No Medicare 2164.51 399.92 214.82 225.57 225.57 680.72 680.72 697.90 697.90
SSI/Part B 265.58 265.58 265.58 265.58 265.58 265.58 265.58 265.58 265.58
SSI/Part A & B 315.61 315.61 315.61 315.61 315.61 315.61 315.61 315.61 223.03
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 347.27 85.05 53.71 60.63 131.25 150.48 232.46 353.22 353.22
SSI/No Medicare 2341.86 432.37 231.38 242.79 242.79 734.39 734.39 753.11 753.11
SSI/Part B 419.88 419.88 419.88 419.88 419.88 419.88 419.88 419.88 419.88
SSI/Part A & B 354.14 354.14 354.14 354.14 354.14 354.14 354.14 354.14 250.17
Table 3
Areas 1 and 6 Age Banded Capitation Rates, Including Community Mental Health and
Mental Health Targeted case Management.
▇▇▇▇ ▇▇
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 280.20 71.58 60.20 66.25 123.28 125.59 192.18 291.84 291.84
SSI/No Medicare 1487.89 291.26 242.50 195.74 195.74 524.32 524.32 508.73 508.73
SSI/Part B 240.14 240.14 240.14 240.14 240.14 240.14 240.14 240.14 240.14
SSI/Part A & B 259.32 259.32 259.32 259.32 259.32 259.32 259.32 259.32 184.52
31. Attachment I, Section 100.0, Glossary, is amended to include additional
definitions as follows:
ACTION - 42 CFR 438.400 - 1. The denial or limited authorization of a
requested service, including the type or level of service. 2. The
reduction, suspension, or termination of a previously authorized
service. 3. The denial, in whole or in part, of payment for a service.
4. The failure to provide services in a timely manner, as defined by
the state. 5. The failure of the plan to act within the timeframes
provided in Sec. 438.408(b). 6. For a resident of a rural area with
only one managed care entity, the denial of a Medicaid enrollee's
request to exercise his or her right, under Sec. 438.52(b)(2)(ii), to
obtain services outside the network.
APPEAL - 42 CFR 438.400 - A request for review of action.
INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS - November 6, 2000 Report to
Congress - Individuals with special health care needs are adults and
children who daily face physical, mental, or environmental challenges
that place at risk their health and ability to fully function in
society. They include, for example, individuals with mental
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 8 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
retardation or related conditions; individuals with serious chronic
illnesses such as Human Immunodeficiency Virus (HIV), schizophrenia, or
degenerative neurological disorders; individuals with disabilities
resulting from many years of chronic illness such as arthritis,
individuals with disabilities from many years of chronic illness such
as arthritis, emphysema or diabetes; and children and adults with
certain environmental risk factors such as homelessness or family
problems that lead to the need for placement in ▇▇▇▇▇▇ care.
32. This amendment shall begin on July 1, 2003, or the date on which the
amendment has been signed by both parties, whichever is later.
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 are hereby made a 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 9 page
amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
AMERIGROUP FLORIDA, INC. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED BY: /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ SIGNED BY: ______________________
------------------------
NAME: ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D., FAAFP
TITLE: President and CEO TITLE: Secretary
DATE: July 1, 2003 DATE: ___________________________
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA CONTRACT NO. FA309, AMENDMENT NO. 005, PAGE 9 OF 9
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
AHCA CONTRACT NO. FA309
AMENDMENT NO. 006
THIS AMENDMENT, entered into between the STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and
AMERIGROUP Florida, Inc., hereinafter referred to as the "Provider," is hereby
amended as follows:
1. Attachment I, Section 10.1, General, third paragraph is amended to
read:
The plan shall comply with all Agency handbooks noticed in or
incorporated by reference in rules relating to the provision of
services set forth in Sections 10.4, Covered Services, and 10.5,
Optional Services, except where the provisions of the contract alter
the requirements set forth in the handbooks. In addition, the plan
shall comply with the limitations and exclusions in the Agency
handbooks unless otherwise specified by this contract. In no instance
may the limitations or exclusions imposed by the plan be more stringent
than those specified in the handbooks. Pursuant to 42 CFR 438.210(a),
the plan must furnish services up to the limits specified by the
Medicaid program. The plan may exceed these limits. However, service
limitations shall not be more restrictive than the Florida
fee-for-service program, pursuant to 42 CFR 438.210(a).
2. Attachment I, Section 10.10, Incentive Programs, first paragraph is
amended to read:
The plan may offer incentives for members to receive preventive care
services. The plan shall receive written approval from the Agency prior
to the use of any special incentive items for members. Any incentive
program offered must be provided to all eligible individuals and will
not be used to direct individuals to select providers. Additionally,
any limitations and requirements below apply to all incentive programs.
3. Attachment I, Section 20.1, Availability/Accessibility of Services,
first paragraph, is amended to include the following:
The plan must allow each enrollee to choose his or her health care
professional, as defined in Section 100.0, Glossary, to the extent
possible and appropriate.
Each plan shall provide the Agency with documentation of compliance
with access requirements no less frequently than the following:
a. At the time it enters into a contract with the Agency.
b. At any time there has been a significant change in the plan's
operations that would affect adequate capacity and services,
including but not limited to:
1. Changes in plan services, benefits, geographic
service area, or payments.
2. Enrollment of a new population in the plan.
4. Attachment I, Section 20.3, Administration and Management, first
paragraph is amended to read:
The plan's governing body shall set policy and has overall
responsibility for the organization. The plan shall be responsible for
the administration and management of all aspects of this contract.
Pursuant to 42 CFR 438.210(b)(2), the plan is responsible for ensuring
consistent application of review criteria for authorization decisions
and consulting with the requesting provider when appropriate. Any
delegation of activities does not relieve the plan of this
responsibility. This includes all subcontracts, employees, agents and
anyone acting for or on behalf of the plan. The plan must have written
policies and procedures for selection and retention of providers. These
policies and procedures must not discriminate against particular
providers that serve high-risk populations or specialize in conditions
that require costly treatments.
5. Attachment I, Section 20.3, Administration and Management, is amended
to include new paragraph f.
f. Pursuant to 42 CFR 438.236(b), the plan shall adopt practice
guidelines that meet the following requirements:
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 1 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
Are based on valid and reliable clinical evidence or
a consensus of health care professionals in the
particular field;
Consider the needs of the enrollees.
Are adopted in consultation with contracting health
care professionals.
Are reviewed and updated periodically as appropriate.
The plan shall disseminate the guidelines to all affected
providers and, upon request, to enrollees and potential
enrollees. The decisions for utilization management, enrollee
education, coverage of services, and other areas to which the
guidelines apply shall be consistent with the guidelines.
6. Attachment I, 20.4.1, Fraud Prevention Policies and Procedures, last
paragraph is amended to read:
The policies and procedures for fraud prevention shall provide for use
of the List of Excluded Individuals and Entities (LEIE), or its
equivalent, to identify excluded parties during the process of
enrolling providers to ensure the plan providers are not in a
non-payment status or excluded from participation in federal health
care programs under section 1128 or section 1128A of the Social
Security Act. The plan must not employ or contract with excluded
providers and must terminate providers if they become excluded.
7. Attachment I, 20.8, Case Management/Continuity of Care, is amended to
include:
Pursuant to 42 CFR 438.208(b), the plan must implement procedures to
deliver primary care to and coordinate health care service for all
enrollees that:
a. Ensure that each enrollee has an ongoing source of primary
care appropriate to his/her needs and a person or entity
formally designated as primarily responsible for coordinating
the health care services furnished to the enrollee.
b. Coordinate the services the plan furnishes to the enrollee
with the services the enrollee receives from any other managed
care entity during the same period of enrollment.
c. Share with other managed care organizations serving the
enrollee with special health care needs the results of its
identification and assessment of the enrollee's needs to
prevent duplication of those activities.
d. Ensure that in the process of coordinating care, each
enrollee's privacy is protected in accordance with the privacy
requirements in 45 CFR Part 160 and 164 Subparts A and E, to
the extent that they are applicable.
8. Attachment I, Section 20.8.13, Individuals with Special Health Care
Needs, all but the first paragraph is moved to Section 20.8, Case
Management/Continuity of Care, as indicated above. Also, the first
paragraph is amended as follows and the two paragraphs below it are
added:
The plan shall implement mechanisms for identifying, assessing and
ensuring the existence of a treatment plan for individuals with special
health care needs, as specified in Section 20.12, Quality Improvement.
Mechanisms shall include evaluation of health risk assessments, claims
data, and, if available, CPT/ICD-9 codes. Additionally, the plan shall
implement a process for receiving and considering provider and enrollee
input.
Pursuant to 42 CFR 438.208(c)(4), for enrollees with special health
care needs determined through an assessment by appropriate health care
professionals (consistent with 42 CFR 438.208(c)(2)) to need a course
of treatment or regular care monitoring, each plan must have a
mechanism in place to allow enrollees to directly access a specialist
(for example, through a standing referral or an approved number of
visits) as appropriate for the enrollee's condition and identified
needs.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 2 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
9. Attachment I, Section 20.10, Emergency Care Requirements, subsection f.
is amended to read:
f. In accordance with 42 CFR 438.114, the plan must also cover
post-stabilization services without authorization, regardless
of whether the enrollee obtains the service within or outside
the plan's network, for the following situations:
1. Post-stabilization care services that were
pre-approved by the plan; or were not
pre-approved by the plan because the plan
did not respond to the treating provider's
request for pre-approval within one hour
after being requested to approve such care,
or could not be contacted for pre-approval.
2. Post stabilization services are services
subsequent to an emergency that a treating
physician views as medically necessary after
an emergency medical condition has been
stabilized. These are not emergency
services, but are non-emergency services
that the plan could choose not to cover
out-of-plan except in the circumstances
described above.
10. Attachment I, Section 20.11, Grievance System Requirements, is deleted
and replaced by the following:
20.11 GRIEVANCE SYSTEM REQUIREMENTS
The plan must have a grievance system in place for enrollees that
includes a grievance process, an appeal process, and access to the
Medicaid fair hearing system. The plan must develop, implement and
maintain a grievance system that complies with the requirements in s.
641.511, F.S., and with federal laws and regulations, including 42 CFR
431.200 and 438, Subpart F, "Grievance System." The system must include
written policies and procedures that are approved by the Agency. The
plan shall refer all enrollees and providers who are dissatisfied with
the plan or its action to the grievance/appeal coordinator for
processing and documentation in accordance with this contract and the
approved policies and procedures. The nature of the complaint, using
the definitions in this contract, determines which of the two processes
the plan must follow. The grievance process is the procedure for
addressing enrollee grievances, which are expressions of
dissatisfaction about any matter other than an action, as "action" is
defined in 100.0, Glossary. The appeal process is the procedure for
addressing enrollee appeals, which are requests for review of an
action, as "action" is defined in 100.0, Glossary.
The plan must give enrollees reasonable assistance in completing forms
and other procedural steps, including but not limited to providing
interpreter services and toll-free numbers with TTY/TDD and interpreter
capability. The plan must acknowledge receipt of each grievance and
appeal in writing. The plan must ensure that decision makers on
grievances and appeals were not involved in previous levels of review
or decision-making and are health care professionals with clinical
expertise hi treating the enrollee's condition or disease when deciding
any of the following:
a. An appeal of a denial based on lack of medical
necessity.
b. A grievance regarding denial of expedited resolution
of an appeal.
c. A grievance or appeal involving clinical issues.
The plan must provide information on grievance, appeal, and fair
hearing, and their respective policies, procedures, and time frames, to
all providers and subcontractors at the time they enter into a
contract. Procedural steps must be clearly specified in the member
handbook for members and the provider manual for providers, including
the address, telephone number, and office hours of the grievance
coordinator. The information must include:
a. Enrollee rights to Medicaid fair hearing, the method
for obtaining a hearing, the rules that govern
representation at the hearing, and the DCF address
for pursuing a fair hearing, which is Office of
Public Assistance Appeals Hearings, ▇▇▇▇ ▇▇▇▇▇▇▇▇
▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇-▇▇▇▇.
b. Enrollee rights to file grievances and appeals and
requirements and time frames for filing.
c. The availability of assistance in the filing process.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 3 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
d. The toll-free numbers to file oral grievances and
appeals.
e. Enrollee rights to request continuation of benefits
during an appeal or Medicaid fair hearing process
and, if the plan's action is upheld in a hearing, the
fact that the enrollee may be liable for the cost of
any continued benefits.
f. Enrollee rights to appeal to the Agency and the
Statewide Provider and Subscriber Assistance Panel
(Panel) after exhausting the plan's appeal or
grievance process in accordance with s. 408.7056 and
641.511, F.S., with the following exception: a
grievance taken to Medicaid fair hearing will not be
considered by the Panel. The information must explain
that a request for Panel review must be made by the
enrollee within one year of receipt of the final
decision letter from the plan, must explain how to
initiate such a review, must include the Panel's
address and telephone number as follows: Agency for
Health Care Administration, Bureau of Managed Health
Care, ▇▇▇▇▇▇▇▇ ▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇,
▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇, (▇▇▇) ▇▇▇-▇▇▇▇.
g. Notice that the plan must continue enrollee benefits
if:
1. The appeal is filed timely, meaning on or
before the later of the following:
(a) Within 10 days of the date on the
notice of action (Add 5 days if the
notice is sent via U.S. mail).
(b) The intended effective date of the
plan's proposed action.
2. The appeal involves the termination,
suspension, or reduction of a previously
authorized course of treatment;
3. The services were ordered by an authorized
provider;
4. The authorization period has not expired;
and
5. The enrollee requests extension of benefits.
The plan must maintain records of grievances and appeals in accordance
with the terms of this contract.
20.11.1 APPEAL PROCESS
An appeal is a request for review of an "action" as defined in 100.0,
Glossary. An enrollee may file an appeal, and a provider, acting on
behalf of the enrollee and with the enrollee's written consent, may
file an appeal. The appeal procedure must be the same for all
enrollees.
a. Filing Requirements
The enrollee or provider may file an appeal within 30 days of
the date of the notice of action. If the plan does not issue a
written notice of action, the enrollee or provider may file an
appeal within one year of the action.
The enrollee or provider may file an appeal either orally or
in writing and must follow an oral filing with a written,
signed appeal. For oral filings, time frames for resolution
begin on the date the plan receives the oral filing.
b. General Plan Duties
The plan must:
1. Ensure that oral inquiries seeking to appeal
an action are treated as appeals and confirm
those inquiries in writing, unless the
enrollee or the provider requests expedited
resolution.
2. Provide a reasonable opportunity to present
evidence, and allegations of fact or law, in
person as well as in writing.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 4 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
3. Allow the enrollee and representative
opportunity, before and during the appeals
process, to examine the enrollee's case
file, including medical records, and any
other documents and records.
4. Consider the enrollee, representative, or
estate representative of a deceased enrollee
as parties to the appeal.
5. Resolve each appeal, and provide notice, as
expeditiously as the enrollee's health
condition requires, within State-established
time frames not to exceed 45 days from the
day the plan receives the appeal.
6. Continue the enrollee's benefits if:
(a) The appeal is filed timely, meaning
on or before the later of the
following:
Within 10 days of the date on the
notice of action (Add 5 days if the
notice is sent via U.S. mail).
The intended effective date of the
plan's proposed action.
(b) The appeal involves the
termination, suspension, or
reduction of a previously
authorized course of treatment;
(c) The services were ordered by an
authorized provider;
(d) The authorization period has not
expired; and
(e) The enrollee requests extension of
benefits.
7. Provide written notice of disposition that
includes the results and date of appeal
resolution, and for decisions not wholly in
the enrollee's favor, that includes:
(a) Notice of the right to request a
Medicaid fair hearing.
(b) Information about how to request a
Medicaid fair hearing, including
the DCF address for pursuing a fair
hearing, which is Office of Public
Assistance Appeals Hearings, ▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇,
▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇-▇▇▇▇.
(c) Notice of the right to continue to
receive benefits pending a hearing.
(d) Information about how to request
the continuation of benefits.
(e) Notice that if the plan's action is
upheld in a hearing, the enrollee
may be liable for the cost of any
continued benefits.
(f) Notice that if the appeal is not
resolved to the satisfaction of the
enrollee, the enrollee has one year
in which to request review of the
plan's decision concerning the
appeal by the Statewide Provider
and Subscriber Assistance Program,
as provided in section 408.7056,
F.S. The notice must explain how to
initiate such a review and must
include the addresses and toll-free
telephone numbers of the Agency and
the Statewide Provider and
Subscriber Assistance Program.
8. Provide the Agency with a copy of the
written notice of disposition upon request.
9. Ensure that punitive action is not taken
against a provider who files an appeal on an
enrollee's behalf or supports an enrollee's
appeal.
The plan may extend the resolution time frames by up to 14
calendar days if the enrollee requests the extension or the
plan documents that there is need for additional information
and that the delay is in the enrollee's interest. If the
extension is not requested by the enrollee, the plan must give
the enrollee written notice of the reason for the delay.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 5 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
If the plan continues or reinstates enrollee benefits while
the appeal is pending, the benefits must be continued until
one of following occurs:
1. The enrollee withdraws the appeal.
2. 10 days pass from the date of the plan's
adverse plan decision and the enrollee has
not requested a Medicaid fair hearing with
continuation of benefits until a Medicaid
fair hearing decision is reached. (Add 5
days if the notice is sent via U.S. mail.)
3. A Medicaid fair hearing decision adverse to
the enrollee is made.
4. The authorization expires or authorized
service limits are met.
If the final resolution of the appeal is adverse to the
enrollee, the plan may recover the cost of the services
furnished while the appeal was pending, to the extent that
they were furnished solely because of the requirements of this
section.
The plan must authorize or provide the disputed services
promptly, and as expeditiously as the enrollee's health
condition requires, if the services were not furnished while
the appeal was pending and the disposition reverses a decision
to deny, limit, or delay services.
The plan must pay for disputed services, in accordance with
State policy and regulations, if the services were furnished
while the appeal was pending and the disposition reverses a
decision to deny, limit, or delay services.
c. Expedited Process
Each plan must establish and maintain an expedited review
process for appeals when the plan determines (if requested by
the enrollee) or the provider indicates (in making the request
on the enrollee's behalf or supporting the enrollee's request)
that taking the time for a standard resolution could seriously
jeopardize the enrollee's life or health or ability to attain,
maintain, or regain maximum function.
The enrollee or provider may file an expedited appeal either
orally or writing. No additional enrollee follow-up is
required.
The plan must:
1. Inform the enrollee of the limited time
available for the enrollee to present
evidence and allegations of fact or law, in
person and in writing.
2. Resolve each expedited appeal and provide
notice, as expeditiously as the enrollee's
health condition requires, within
State-established time frames not to exceed
72 hours after the plan receives the appeal.
3. Provide written notice of disposition.
4. Make reasonable efforts to also provide oral
notice of disposition.
5. Ensure that punitive action is not taken
against a provider who requests an expedited
resolution on the enrollee's behalf or
supports an enrollee's request for expedited
resolution.
The plan may extend the resolution time frames by up to 14
calendar days if the enrollee requests the extension or the
plan documents that there is need for additional information
and that the delay is in the enrollee's interest. If the
extension is not requested by the enrollee, the plan must give
the enrollee written notice of the reason for the delay.
If the plan denies a request for expedited resolution of an
appeal, the plan must:
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 6 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
1. Transfer the appeal to the standard time
frame of no longer than 45 days from the day
the plan receives the appeal with a possible
14-day extension.
2. Make reasonable efforts to provide prompt
oral notice of the denial
3. Provide written notice of the denial within
two calendar days.
4. Fulfill all general plan duties listed
above.
20.11.2 GRIEVANCE PROCESS
A grievance is an expression of dissatisfaction about any matter other
than an action, as "action" is defined in 100.0, Glossary. An enrollee
may file a grievance, and a provider, acting on behalf of the enrollee
and with the enrollee's written consent, may file a grievance.
a. Filing Requirements
The enrollee or provider may file a grievance within one year
after the date of occurrence that initiated the grievance.
The enrollee or provider may file a grievance either orally or
in writing. An oral request may be followed up with a written
request, but the time frame for resolution begins the date the
plan receives the oral filing.
b. General Plan Duties
The plan must:
1. Resolve each grievance, and provide notice,
as expeditiously as the enrollee's health
condition requires, within State-established
time frames not to exceed 90 days from the
day the plan receives the grievance.
2. Provide written notice of disposition that
includes the results and date of grievance
resolution, and for decisions not wholly in
the enrollee's favor, that includes:
(a) Notice of the right to request a
Medicaid fair hearing.
(b) Information about how to request a
Medicaid fair hearing, including
the DCF address for pursuing a fair
hearing, which is Office of Public
Assistance Appeals Hearings, ▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇,
▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇-▇▇▇▇.
(c) Notice of the right to continue to
receive benefits pending a hearing.
(d) Information about how to request
the continuation of benefits.
(e) Notice that if the plan's action is
upheld in a hearing, the enrollee
may be liable for the cost of any
continued benefits.
3. Provide the Agency with a copy of the
written notice of disposition upon request.
4. Ensure that punitive action is not taken
against a provider who files a grievance on
an enrollee's behalf or supports an
enrollee's grievance.
The plan may extend the resolution time frames by up to 14
calendar days if the enrollee requests the extension or the
plan documents that there is need for additional information
and that the delay is in the enrollee's interest. If the
extension is not requested by the enrollee, the plan must give
the enrollee written notice of the reason for the delay.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 7 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
20.11.3 MEDICAID FAIR HEARING SYSTEM
The Medicaid fair hearing policy and process is detailed in Rule
65-2.042, F.A.C. The plan's grievance system policy and appeal and
grievance processes shall state that the enrollee has the right to
request a Medicaid fair hearing in addition to pursuing the plan's
grievance process. A provider acting on behalf of the enrollee and with
the enrollee's written consent may request a Medicaid fair hearing.
Parties to the Medicaid fair hearing include the plan, as well as the
enrollee and his or her representative or the representative of a
deceased enrollee's estate.
a. Request Requirements
The enrollee or provider may request a Medicaid fair hearing
within 90 days of the date of the notice of action.
The enrollee or provider may request a Medicaid fair hearing
by contacting DCF at the Office of Public Assistance Appeals
Hearings, ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇, ▇▇▇▇ ▇▇▇,
▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇.
b. General Plan Duties
The plan must:
1. Continue the enrollee's benefits while
Medicaid fair hearing is pending if:
(a) The Medicaid fair hearing is filed
timely, meaning on or before the
later of the following:
Within 10 days of the date on the
notice of action (Add 5 days if the
notice is sent via U.S. mail).
The intended effective date of the
plan's proposed action.
(b) The Medicaid fair hearing involves
the termination, suspension, or
reduction of a previously
authorized course of treatment;
(c) The services were ordered by an
authorized provider;
(d) The authorization period has not
expired; and
(e) The enrollee requests extension of
benefits.
2. Ensure that punitive action is not taken
against a provider who requests a Medicaid
fair hearing on the enrollee's behalf or
supports an enrollee's request for a
Medicaid fair hearing.
If the plan continues or reinstates enrollee benefits while
the Medicaid fair hearing is pending, the benefits must be
continued until one of following occurs:
1. The enrollee withdraws the request for
Medicaid fair hearing.
2. 10 days pass from the date of the plan's
adverse plan decision and the enrollee has
not requested a Medicaid fair hearing with
continuation of benefits until a Medicaid
fair hearing decision is reached. (Add 5
days if the notice is sent via U.S. mail.)
3. A Medicaid fair hearing decision adverse to
the enrollee is made.
4. The authorization expires or authorized
service limits are met.
The plan must authorize or provide the disputed services
promptly, and as expeditiously as the enrollee's health
condition requires, if the services were not furnished while
the Medicaid fair hearing was pending and the Medicaid fair
hearing officer reverses a decision to deny, limit, or delay
services.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 8 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
The plan must pay for disputed services, in accordance with
State policy and regulations, if the services were furnished
while the Medicaid fair hearing was pending and the Medicaid
fair hearing officer reverses a decision to deny, limit, or
delay services.
11. Attachment I, 20.12, Quality Improvement, subsection c. is amended to
include:
8. Monitor the quality and appropriateness of care furnished to
enrollees with special health care needs.
12. Attachment I, Section 20.12.1, Utilization Management, subsection f. is
amended to read:
f. The plan's service authorization systems shall provide
authorization numbers, effective dates for the authorization,
and written confirmation to the provider of denials, as
appropriate. Pursuant to 42 CFR 438.210(b)(3), any decision to
deny a service authorization request or to authorize a service
in an amount, duration, or scope that is less than requested,
must be made by a health care professional who has appropriate
clinical expertise in treating the enrollee's condition or
disease. Pursuant to 42 CFR 438.210(c), the plan must notify
the requesting provider of any decision to deny a service
authorization request or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to
the provider need not be in writing. The plan must notify the
enrollee in writing of any decision to deny a service
authorization request or to authorize a service in an amount,
duration, or scope that is less than requested.
Pursuant to 42 CFR 438.404(a), 42CFR 438.404(c) and 42 CFR
438.210(b) and (c), the plan must give the enrollee written
notice of any "action" as defined in Section 100.0, Glossary,
within the time frames for each type of action. Pursuant to 42
CFR 438.404(b) and 42 CFR 438.210(c), the notice must explain:
1. The action the plan has taken or intends to
take.
2. The reasons for the action.
3. The enrollee's or the provider's right to
file a grievance/appeal.
4. The enrollee's right to request a Medicaid
Fair Hearing.
5. Procedures for exercising enrollee rights to
appeal or grieve.
6. Circumstances under which expedited
resolution is available and how to request
it.
7. Enrollee rights to request that benefits
continue pending the resolution of the
appeal, how to request that benefits be
continued, and the circumstances under which
the enrollee may be required to pay the
costs of these services.
Pursuant to 42 CFR 438.404 (a) and (c), the notice must be in
writing and must meet the language and format requirements of
42 CFR. 438.10(c) and (d) to ensure ease of understanding.
The plan must mail the notice within the following time
frames:
1. For termination, suspension, or reduction of
previously authorized Medicaid-covered
services, within the time frames specified
in 42 CFR. 431.211,431.213, and 42 CFR
431.214.
2. For denial of payment, at the time of any
action affecting the claim.
3. For standard service authorization decisions
that deny or limit services, within the time
frame specified in 42 CFR 438.210(d)(l).
4. If the plan extends the time frame in
accordance with 42 CFR 438.210(d)(l), it
must:
Give the enrollee written notice of the
reason for the decision to extend the time
frame and inform the enrollee of the right
to file a grievance if he or she disagrees
with that decision.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 9 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
Issue and carry out its determination as
expeditiously as the enrollee's health
condition requires and no later than the
date the extension expires.
5. For service authorization decisions not
reached within the time frames specified in
42 CFR 438.210(d) (which constitutes a
denial and is thus an adverse action), on
the date that the time frames expire.
6. For expedited service authorization
decisions, within the time frames specified
in 42 CFR 438.210(d).
13. Attachment I, Section 20.13, Medical Records Requirements, subsection
a. 15. is amended to read:
15. All records must contain documentation that the member was
provided written information concerning the member's rights
regarding advanced directives (written instructions for living
will or power of attorney), and whether or not the member has
executed an advance directive. The provider shall not, as a
condition of treatment, require the member to execute or waive
an advance directive in accordance with Section 765.110, F.S.
The plan must comply with the requirements of 42 CFR 422.128
for maintaining written policies and procedures for advance
directives.
14. Attachment I, Section 20.17, Independent Medical Review (External
Quality Review) is amended to read:
20.17 INDEPENDENT MEDICAL REVIEW (EXTERNAL QUALITY REVIEW)
The Agency shall provide for an independent review of Medicaid services
provided or arranged by the provider. The plan shall provide
information necessary for the review based upon the requirements of the
Agency or the Agency's independent peer review contractor. The
information shall include quality outcomes concerning timeliness of and
access to services covered under the contract. The review shall be
performed at least once annually by an entity outside state government.
If the medical audit indicates that quality of care is not acceptable
pursuant to contractual requirements, the Agency may restrict the
plan's enrollment activities pending attainment of acceptable quality
of care.
15. Attachment I, Section 30.1, Marketing and Pre-enrollment Materials. The
title is changed to "Marketing, Pre-enrollment and Post-enrollment
Materials."
16. Attachment I, Section 30.2.1, Prohibited Activities, is amended to
include a new subsection j. Subsequent subsections are renamed
accordingly. Subsection j. becomes k. and is amended to read:
j. In accordance with 42 CFR 438.104(b)(2)(i), any assertion or
statement (whether written or oral) that the beneficiary must
enroll in the plan in order to obtain benefits or in order to
not lose benefits.
k. In accordance with Section 409.912(18), F.S., and 42 CFR
438.104(b)(2)(ii), false or misleading claims that the entity
is recommended or endorsed by any federal, state or county
government, the Agency, CMS, or any other organization which
has not certified its endorsement in writing to the plan.
17. Attachment I, Section 30.5, Pre-enrollment Activities, ninth paragraph
is amended to read:
The plan must provide a reasonable written explanation of the plan to
the beneficiary prior to accepting the pre-enrollment application. The
information must comply with CFR 438.10, to ensure that, before
enrolling, the beneficiary receives, from the plan or the enrollment
and disenrollment services contractor, accurate oral and written
information he or she needs to make an informed decision on whether to
enroll.
18. Attachment I, Section 30.6, Enrollment, is amended to include
additional paragraphs to read:
Pursuant to 1932(a)(4)(A) and (B) of the Social Security Act, the
enrollment and disenrollment services contractor shall permit an
individual eligible for medical assistance under the State plan who is
enrolled with the plan to terminate (or change) such enrollment for
good cause at any time (consistent with section 1903(m)(2)(A)(vi)), and
without cause during the 90-day period beginning on the date the
individual first receives notice of such enrollment, and at least every
12 months thereafter. The plan shall provide for notice to each
enrollee of opportunity to terminate (or change) enrollment under such
conditions. Such notice shall be provided at least 60 days before each
annual enrollment opportunity.
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 10 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
The plan accepts individuals eligible for enrollment in the order in
which they apply without restriction (unless authorized by the CMS
Regional Administrator), up to the limits set under the contract. The
plan will not discriminate against individuals eligible to enroll on
the basis of race, color, or national origin, and will not use any
policy or practice that has the effect of discriminating on any basis
including but not limited to race, color, or national origin.
Enrollment is voluntary, except in the case of mandatory enrollment
programs that comply with 42 CFR 438.50(a).
19. Attachment I, Section 30.7, Member Notification, subsection b. 2. and
3. are deleted and replaced as follows, subsequent numbers are changed
accordingly:
2. Termination of a contracted provider, within 15 days after
receipt or issuance of the termination notice, to each
enrollee who received his or her primary care from, or was
seen on a regular basis, by the terminated provider. The plan
must make a good faith effort to give written notice of such
termination to the enrollee.
20. Attachment I, Section 30.7, Member Notification, subsection c. is
amended to read:
c. Pursuant to 42 CFR 438.10(g)(3), the plan shall provide
information on the plan's physician incentive plans or on the
plan's structure and operation to any Medicaid recipient, upon
request.
21. Attachment I, Section 30.7.1, Member Services Handbook, is amended to
read:
The member services handbook shall include the following information:
Terms and conditions of enrollment including the reinstatement process;
a description of the open enrollment process; description of services
provided, including limitations and general restrictions on provider
access, exclusions and out-of-plan use; procedures for obtaining
required services, including second opinions; the toll-free telephone
number of the statewide Consumer Call Center; emergency services and
procedures for obtaining services both in and out of the plan's service
area; procedures for enrollment, including member rights and
procedures; grievance system components and procedures; member rights
and procedures for disenrollment; procedures for filing a "good cause
change" request, including the Agency's toll-free telephone number for
the enrollment and disenrollment services contractor; information
regarding newborn enrollment, including the mother's responsibility to
notify the plan and the mother's DCF caseworker of the newborn's birth
and assignment of pediatricians and other appropriate physicians;
member rights and responsibilities, including the right obtain family
planning services from any participating Medicaid provider without
prior authorization for such services; information on emergency
transportation and non-emergency transportation, counseling and
referral services available under the plan and how to access these;
information that interpretation services and alternative communication
systems are available, free of charge, for all foreign languages, and
how to access these services; information that post-stabilization
services are provided without prior authorization; information that
services will continue upon appeal of a suspended authorization and
that the enrollee may have to pay in case of an adverse ruling;
information regarding the health care advance directives pursuant to
▇▇▇▇▇▇▇ ▇▇▇, ▇.▇., ▇▇ ▇▇▇ 422.128; and information that enrollees may
obtain from the plan information regarding quality performance
indicators, including aggregate enrollee satisfaction data. Written
information regarding advance directives provided by the plan must
reflect changes in state law as soon as possible, but no later than 90
days after the effective date of the change.
In addition, per 42 CFR 438.10(f)(6), if the following topics are not
covered in the handbook, information must be available upon request:
a. The extent to which, and how, enrollees may obtain benefits,
including family planning services, from out-of-network
providers.
b. The extent to which, and how, after-hours and emergency
coverage are provided.
c. The post-stabilization care services rules set forth in 42 CFR
422.113(c).
d. Cost sharing, if any.
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AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
e. How and where to access any benefits that are available under
the State plan but are not covered under the contract,
including any cost sharing, and how transportation is
provided. For a counseling or referral service that the plan
does not cover because of moral or religious objections, the
plan need not furnish information on how and where to obtain
the service.
22. Attachment I is amended to include new Section 50.9, Inspection and
Audit of Financial Records.
50.9 INSPECTION AND AUDIT OF FINANCIAL RECORDS
The state and DHHS may inspect and audit any financial records of the
plan or its subcontractors. Pursuant to section 1903(m)(4)(A) of the
Social Security Act and State Medicaid Manual 2087.6(A-B),
non-federally qualified plans must report to the state, upon request,
and to the Secretary and the Inspector General of DHHS, a description
of certain transactions with parties of interest as defined in section
1318(b) of the Social Security Act.
23. Attachment I, Section 70.2, Applicable Laws and Regulations, is amended
to read:
70.2 APPLICABLE LAWS AND REGULATIONS
The plan agrees to comply with all applicable federal and state laws,
rules and regulations including but not limited to: Title 42 Code of
Federal Regulations (CFR) Chapter IV, Subchapter C; Title 45 CFR, Part
74, General Grants Administration Requirements; Chapters 409 and 641,
Florida Statutes; all applicable standards, orders, or regulations
issued pursuant to the Clean Air Act of 1970 as amended (42 USC 1857,
et seq.); Title VI of the Civil Rights Act of 1964 (42 USC 2000d) in
regard to persons served; Title IX of the Education Amendments of 1972
(regarding education programs and activities); 42 CFR 431, Subpart F,
Section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C. in
regard to the contractor safeguarding information about beneficiaries;
Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to
employees or applicants for employment; Rule 59G-8.100, F.A.C.; Section
504 of the Rehabilitation Act of 1973, as amended, 29 USC. 794, which
prohibits discrimination on the basis of handicap in programs and
activities receiving or benefiting from federal financial assistance;
Chapter 641, parts I and III, F.S., in regard to managed care; the Age
Discrimination Act of 1975, as amended, 42 USC. 6101 et. seq., which
prohibits discrimination on the basis of age in programs or activities
receiving or benefiting from federal financial assistance; the Omnibus
Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits
discrimination on the basis of sex and religion hi programs and
activities receiving or benefiting from federal financial assistance;
Medicare - Medicaid Fraud and Abuse Act of 1978; the federal omnibus
budget reconciliation acts; Americans with Disabilities Act (42 USC
12101, et seq.); the Newborns' and Mothers' Health Protection Act of
1996; the Balanced Budget Act of 1997, and the Health Insurance
Portability and Accountability Act of 1996. The plan is subject to any
changes in federal and state law, rules, or regulations.
24. Attachment I, Section 70.17, Sanctions, subsection e. is amended to
read:
e. Termination pursuant to paragraph III.B.(3) of the Agency core
contract and Section 70.19, Termination Procedures, if the
plan fails to carry out substantive terms of its contract or
fails to meet applicable requirements in sections 1932,
1903(m) and 1905(t) of the Social Security Act. After the
Agency notifies the plan that it intends to terminate the
contract, the Agency may give the plan's enrollees written
notice of the state's intent to terminate the contract and
allow the enrollees to disenroll immediately without cause.
25. Attachment I, Section 70.17, Sanctions, is amended to include a new
subsection f. Former subsection f. becomes subsection g.
f. The Agency may impose intermediate sanctions in accordance
with 42 CFR 438.702, including:
1. Civil monetary penalties in the amounts specified in
Section 409.912(20), F.S.
2. Appointment of temporary management for the plan.
Rules for temporary management pursuant to 42 CFR
438.706 are as follows:
(a) The State may impose temporary management
only if it finds (through onsite survey,
enrollee complaints, financial audits, or
any other means) that--
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 12 OF 15
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AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
(1) There is continued egregious
behavior by the plan, including but
not limited to behavior that is
described in 42 CFR 438.700, or
that is contrary to any
requirements of sections 1903(m)
and 1932 of the Social Security
Act; or
(2) There is substantial risk to
enrollees, health; or
(3) The sanction is necessary to ensure
the health of the plan's
enrollees--
(i) While improvements are
made to remedy violations
under 42 CFR 438.700; or
(ii) Until there is an orderly
termination or
reorganization of the
plan.
(b) The State must impose temporary management
(regardless of any other sanction that may
be imposed) if it finds that an plan has
repeatedly failed to meet substantive
requirements in section 1903(m) or section
1932 of the Social Security Act or 42 CFR
438.706. The State must also grant enrollees
the right to terminate enrollment without
cause, as described in 42 CFR 438.702(a)(3),
and must notify the affected enrollees of
their right to terminate enrollment.
(c) The State may not delay imposition of
temporary management to provide a hearing
before imposing this sanction.
(d) The State may not terminate temporary
management until it determines that the plan
can ensure that the sanctioned behavior will
not recur.
3. Granting enrollees the right to terminate enrollment
without cause and notifying affected enrollees of
their right to disenroll.
4. Suspension or limitation of all new enrollment,
including default enrollment, after the effective
date of the sanction.
5. Suspension of payment for beneficiaries enrolled
after the effective date of the sanction and until
CMS or the Agency is satisfied that the reason for
imposition of the sanction no longer exists and is
not likely to recur.
6. Denial of payments provided for under the contract
for new enrollees when, and for so long as, payment
for those enrollees is denied by CMS in accordance
with 42 CFR 438.730.
Before imposing any intermediate sanctions, the state must
give the plan timely notice according to 42 CFR 438.710.
26. Attachment I, Section 70.18, Subcontracts, second paragraph of the
introduction is amended to read:
The plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license, or certification under
applicable state law, solely on the basis of such license, or
certification, in accordance with Section 4704 of the Balanced Budget
Act of 1997. This paragraph shall not be construed to prohibit a plan
from including providers only to the extent necessary to meet the needs
of the plan's enrollees or from establishing any measure designed to
maintain quality and control costs consistent with the responsibilities
of the organization. If the plan declines to include individual
providers or groups of providers in its network, it must give the
affected providers written notice of the reason for its decision.
In all contracts with health care professionals, the plan must comply
with the requirements specified in 42 CFR 438.214 which includes but is
not limited to selection and retention of providers, credentialing and
recredentialing requirements, and nondiscrimination.
27. Attachment I, Section 70.18, Subcontracts, subsection a. 1. is amended
to read:
1. The plan agrees to make payment to all subcontractors pursuant
to Section 641.3155, F.S., 42 CFR 447.46,42 CFR 447.45(d)(2),
42 CFR 447.45 (d)(3), 42 CFR 447.45 (d)(5) and 42 CFR 447.45
(d)(6) If third party
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 13 OF 15
AHCA Form 2100-0002 (Rev. MAR03)
AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
liability exists, payment of claims shall be determined in
accordance with Section 70.20, Third Party Resources.
28. Attachment I, Section 70.18, Subcontracts, subsection c.3. is amended
to read:
3. Provide for timely access to physician appointments to comply
with the following availability schedule: urgent care - within
one day; routine sick care - within one week; well care -
within one month. Require that the network providers offer
hours of operation that are no less than the hours of
operation offered to commercial beneficiaries or comparable to
Medicaid fee-for-service if the provider serves only Medicaid
beneficiaries.
29. Attachment I, Section 70.18, Subcontracts, subsection d. 1. is amended
to read:
1. Require safeguarding of information about enrollees according
to 42 CFR, 438.224.
30. Attachment I, Section 80.1, Payment to plan by Agency, subsection a. is
amended to read:
a. Until December 31, 2003, as an incentive to increase
the Child Health Check-Up and adult health screenings
rates, if the statewide HMO Child Health Check-Up
screening ratio for FY 2001-2002 increases by a
minimum often percent over FY 2000-2001, the plan may
submit one fee-for-service claim for each enrollee
who receives an adult health screening or a Child
Health Check-Up from a Medicaid enrolled provider
within three (3) months of the member's enrollment.
31. Attachment I, Section 80.5, Member Payment Liability Protection,
subsection c. is amended to read:
c. For payments to the health care provider, including referral
providers, that furnished covered services under a contract,
or other arrangement with the plan, that are in excess of the
amount that normally would be paid by the member if the
service had been received directly from the plan.
32. Attachment I, Section 100.0, Glossary, definition of Enrollee is
amended to read:
ENROLLEE - according to 42 CFR 438.10(a) means a Medicaid recipient who
is currently enrolled in an HMO as defined in 42 CFR 438.10(a). See
"Member."
33. Attachment I, Section 100.00 Glossary, definition of Good Cause is
amended to read:
GOOD CAUSE - special reasons that allow beneficiaries to change their
managed care option outside their open enrollment period such as:
The enrollee moves out of the plan's service area.
The plan does not, because of moral or religious
objections, cover the service the enrollee seeks.
The enrollee needs related services (for example a
cesarean section and a tubal ligation) to be
performed at the same time; not all related services
are available within the network; and the enrollee's
primary care provider or another provider determines
that receiving the services separately would subject
the enrollee to unnecessary risk.
Other reasons, including but not limited to, poor
quality of care, lack of access to services covered
under the contract, or lack of access to providers
experienced in dealing with the enrollee's health
care needs.
Note: Federal law uses the term "cause" rather than
"good cause." In the context with beneficiary
disenrollment, this contract uses the term "good
cause."
34. Attachment I, Section 100.0, Glossary, definition of Grievance is
deleted and replaced as follows:
GRIEVANCE - means an expression of dissatisfaction about any matter
other than an action, as "action" is defined in this section. The term
is also used to refer to the overall system that includes grievances
and appeals handled at the plan level and access to the Medicaid fair
hearing process. (Possible subjects for grievances include, but are not
limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee,
or failure to respect the enrollee's rights.) (42 CFR 438.2)
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 14 OF 15
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AMERIGROUP FLORIDA, INC. MEDICAID HMO CONTRACT
35. Attachment I, Section 100.0, Glossary, definition of Grievance
Procedure is deleted and replaced as follows:
GRIEVANCE PROCEDURE - the procedure for addressing enrollees'
grievances. A grievance is an enrollee's expression of dissatisfaction
with any aspect of their care other than the appeal of actions (which
is an appeal).
36. Attachment I, Section 100.0, Glossary, definition of Health Care
Professional is added.
HEALTH CARE PROFESSIONAL - means a physician or any of the following: a
podiatrist, optometrist, chiropractor, psychologist, dentist, physician
assistant, physical or occupational therapist, therapist assistant,
speech-language pathologist, audiologist, registered or practical nurse
(including nurse practitioner, clinical nurse specialist, certified
registered nurse anesthetist, and certified nurse midwife), licensed
certified social worker, registered respiratory therapist, and
certified respiratory therapy technician.
37. Attachment I, Section 100.0, Glossary, definition of Medically
Necessary is amended to read:
MEDICALLY NECESSARY OR MEDICAL NECESSITY - services provided in
accordance with 42 CFR Section 438.210(a)(4) and as defined in Section
59G-1.010(166), F.A.C., to include that medical or allied care, good,
or services furnished or ordered must:
38. Attachment I, Section 100.0, Glossary, definition of Potential Enrollee
is added to read:
POTENTIAL ENROLLEE - according to 42 CFR 438.10(a) means a Medicaid
recipient who is subject to mandatory enrollment or may voluntarily
elect to enroll in a given managed care program, but is not yet an
enrollee of a specific managed care program.
39. This amendment shall begin on August 13, 2003, or the date on which the
amendment has been signed by both parties, whichever is later.
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 specific 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 are hereby made a 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
15-page amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
AMERIGROUP FLORIDA, INC. STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED SIGNED
BY: /s/ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ BY: _____________________________
--------------------------
NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ NAME: ▇▇▇▇▇▇ ▇▇▇▇▇▇, M.D., FAAFP
TITLE: President & CEO TITLE: Secretary
DATE: 8/13/03 DATE:____________________________
AHCA CONTRACT NO. FA309, AMENDMENT NO. 006, PAGE 15 OF 15
AHCA Form 2100-0002 (Rev. MAR03)