Attached files
EXHIBIT 10.11
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
AHCA CONTRACT NO. FA904
AMENDMENT NO. 3
THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the "Vendor," or "Health Plan," is hereby amended as follows:
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1.
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Standard Contract, Section III., Item C, Contract Managers, sub-item 1., the Agency's Contract Manager's telephone number is hereby amended to now read as follows:
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(850) 412-4067
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2.
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Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms, Item A., Definitions, the following definitions are hereby amended to now read as follows:
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Catastrophic Component Threshold - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The point at which the cost of covered services, based on Medicaid fee-for-service payment levels, reaches $50,000 for an enrollee in a Contract year. For a Health Plan that accepts the comprehensive capitation rate only, the Agency begins reimbursing the Health Plan for the cost of covered services received by the enrollee for the remainder of the Contract year. This reimbursement is based on a percentage of Medicaid fee-for-service payment levels.
Comprehensive Component - (Capitated Reform Health Plans that are approved to offer comprehensive services only) - The amount of financial risk assumed by a Health Plan to provide covered service up to $50,000 per enrollee based on Medicaid fee-for-service payment levels.
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3.
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Attachment II, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services, sub-item 3.a.(6) is hereby amended to now read as follows:
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(6)
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A request to update the enrollee's name, address (home and mailing), county of residence, and telephone number, and include information on how to update this information with the health plan and through DCF and/or the Social Security Administration;
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4.
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Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item A., Quality Improvement, is hereby amended to include sub-item 3.c.(6) as follows:
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(6)
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The Agency may offer incentives to high-performing Health Plans. The Agency will notify the Health Plan annually on or before December 31 of the incentives that will be offered for the following calendar year. Incentives may be awarded to all high-performing Health Plans or may be offered on a competitive basis. Incentives may include, but are not limited to, quality designations, quality awards, and enhanced auto-assignments. The Agency, at its discretion, may disqualify a Health Plan for any reason the Agency deems appropriate including, but not limited to, Health Plans that received a monetary sanction for performance measures or any other sanctionable offense.
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5.
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Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item B., Utilization Management (UM), sub-item 2., Care Management, is hereby deleted in its entirety and replaced as follows:
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The Health Plan shall be responsible for the management and continuity of medical care for all enrollees. The Health Plan shall maintain written case management and continuity of care protocols that include the following minimum functions:
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a.
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Appropriate referral and scheduling assistance for enrollees needing specialty health care or transportation services, including those identified through CHCUP screenings;
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AHCA Contract No. FA904, Amendment No. 3, Page 1 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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b.
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Determination of the need for non-covered services and referral of the enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) with assistance, as needed, by the area Medicaid office;
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c.
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Case management follow-up services for children/adolescents whom the Health Plan identifies through blood screenings as having abnormal levels of lead;
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d.
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A mechanism for direct access to specialists for enrollees identified as having special health care needs, as appropriate for their conditions and identified needs;
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e.
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An outreach program and other strategies for identifying every pregnant enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating providers to notify the plan of any Medicaid enrollee who is identified as being pregnant;
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f.
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Documentation of referral services in enrollee medical records, including reports resulting from the referral;
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g.
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Monitoring of enrollees with ongoing medical conditions and coordination of services for high utilizers to address the following, as appropriate: acting as a liaison between the enrollee and providers, ensuring the enrollee is receiving routine medical care, ensuring the enrollee has adequate support at home, assisting enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the enrollee in developing community resources to manage a medical condition;
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h.
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Documentation of emergency care encounters in enrollee medical records with appropriate medically indicated follow-up;
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i.
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Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate;
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j.
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Sharing with other Health Plans serving the enrollee the results of its identification and assessment of any enrollee with special health care needs so that those activities need not be duplicated;
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k.
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Ensuring that in the process of coordinating care, each enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.
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6.
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Attachment II, Core Contract Provisions, Section XII, Reporting Requirements, Item A., Health Plan Reporting Requirements, Table 2-A, Summary of Submission Requirements, is hereby deleted in its entirety and replaced with the following Table 2-B, Revised Summary of Submission Requirements. All references in the Contract to Table 2-A shall hereinafter refer to Table 2-B.
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TABLE 2-B
REVISED SUMMARY OF SUBMISSION REQUIREMENTS
2. Other Health Plan submissions (not in Table 1-A) required by the Agency are as follows:
AHCA Contract No. FA904, Amendment No. 3, Page 2 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Attachment I, Section B., Item 3.a.
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Increase in enrollment levels
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Capitated Health Plans; FFS PSNs; CCC
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Before increases occur
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BMHC and HSD
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Attachment I, Section D., Item 3.b.
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Changes to optional or expanded services
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FFS PSNs; CCC
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Annually, by June 15th
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HSD
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Attachment I, Section D., Item 3.c.
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Changes to optional or expanded services
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Capitated Health Plans
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Annually, by June 15th
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HSD
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Subsequent references are to Attachment II and its Exhibits
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Section II, Item D.4.
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Policies, procedures, model provider agreements & amendments, subcontracts, All materials related to Contract for distribution to enrollees, providers,
public
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All
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Before beginning use; whenever changes occur
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BMHC
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Section II, Item D.4.a.
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Written materials
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All
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Forty-five (45) calendar days before effective date
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BMHC
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Section II, Item D.4.b
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Written notice of change to enrollees
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All
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Thirty (30) calendar days before effective date
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Enrollees affected by change
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Section II, Item D.6.
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Enrollee materials, PDL, provider & enrollee handbooks
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All
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Available on Health Plan's web site without log-in
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Plan web site
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Section III, Item B.3.c.(l)
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Enrollee pregnancy
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All
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Upon confirmation
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DCF & MPI
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Section III, Item B.3.c.(3)
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Unborn activation notice
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All
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Presentation for delivery
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DCF & MPI
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Section III, Item B.3.d.
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Birth information if no unborn activation
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All
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Upon delivery
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DCF
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Section III, Item C.4.b.
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Involuntary disenrollment request
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All
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Forty-five (45) calendar days before effective date
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BMHC
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Section III, Item C.4.e.
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Notice that Health Plan is requesting disenrollment in next Contract month
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All
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Before effective date
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Enrollee affected
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AHCA Contract No. FA904, Amendment No. 3, Page 3 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section IV, Item A.1.e.
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Notice of reinstatement of enrollee
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All
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By 1st calendar day of month after learning of reinstatement or within five (5) calendar days from receipt of enrollment file, whichever is later
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Person being reinstated
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Section IV, Item A.2.a. and Item A. 6.a.(17); Section VIII, Item A.4.
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How to get Health Plan information in alternative formats
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All
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Include in cultural competency plan and enrollee handbook, and upon request
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Enrollees &
potential enrollees
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Section IV, Item A.2.c.
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Right to get information about Health Plan
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All
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Annually
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Enrollees
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Section IV, Item A.7.c.
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Provider directory online file
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All
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Update monthly & submit attestation
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BMHC
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Section IV, Item A.9.a.
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Enrollee assessments
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All
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Within thirty (30) calendar days of enrollment notify about pregnancy screening
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Enrollees
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Section IV, Item A.9.c.
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Enrollees more than 2 months behind in periodicity screening
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All
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Contact twice, if needed
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Enrollees who
meet criteria
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Section IV, Item A.11.f.
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Toll-free help line performance standards
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All
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Get approval before beginning operation
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BMHC
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Section IV, Item A.12. and Item A.,6.a.(17); Section VIII, Item A.4.
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How to access translation services
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All
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Include in cultural competence plan and enrollee handbook
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Enrollees
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Section IV, Item A.14.a.
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Incentive program
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All
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Get approval before offering
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BMHC
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Section IV, Item A.14.g.
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Pre-natal care programs
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All
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Before implementation
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BMHC
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Section IV, Item A.17.c
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Notice of change in participation in redetermination notices
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All
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If change in participation, annually, by June 1st
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BMHC
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Section IV, Item A.17.c.(1)
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Redetermination policies & procedures
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All
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When Health Plan agrees to participate
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BMHC
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Section IV, Item A.17.c.(1)(a)
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Notice in writing to discontinue Medicaid redetermination date data use
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All
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Thirty (30) calendar days before stopping
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BMHC
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AHCA Contract No. FA904, Amendment No. 3, Page 4 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section IV, Item B.3.c.
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Member services phone script responding to community outreach calls and outreach materials
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All
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Before use
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BMHC
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Section IV, Item B.4.c.
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In case of force majeure, notice of participation in health fair or other public event
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All
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By day of event
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BMHC
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Section IV, Item B.6.f.
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Report of staff or community outreach rep. violations
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All
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Within fifteen (15) calendar days of knowledge
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BMHC
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Section V, Item C.1.
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Written details of expanded services
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All
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Before implementation
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HSD
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Section V, Item F.
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Decision to not offer a service on moral/religious grounds
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All
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One-hundred and twenty (120) calendar days before implementation
Thirty (30) calendar days before implementation
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BMHC
Enrollees
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Section V, Item H.10.b.2.
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UNOS form & disenrollment request for specified transplants
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All
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When enrollee listed
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BMHC
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Section V, Item H.14.e.
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Attestation that the Health Plan has
advised providers to enroll in VFC program
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All
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Annually, by October 1st
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BMHC
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Section V, Item H.16.a.(4)
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PDL update
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All
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Annually, by October 1st.
Thirty (30) calendar days written notice of change.
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BMHC and Bureau of Medicaid Pharmacy Services
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Section VII, Item A.2.
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Capacity to provide
covered services
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All
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Before taking enrollment
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BMHC
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Section VII, Item C.1.
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Request for initial or expansion review
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All
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When requesting initial enrollment or expansion into a county.
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BMHC and HSD
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AHCA Contract No. FA904, Amendment No. 3, Page 5 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section VII, Item C.2.
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Compliance with access requirements following significant changes in service area or new populations
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All
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Before expansion
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BMHC and HSD
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Section VII, Item C.3.
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Significant network changes
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All
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Within seven (7) business days
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BMHC
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Section VII, Item C.5.
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When PCP leaves network
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All
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Within fifteen (15) calendar days of knowledge. A copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after receipt of the PCP termination notice.
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BMHC & affected enrollees
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Section VII, Item D.2.jj.
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Waiver of provider agreement indemnifying clause
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All
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Approval before use
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BMHC
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Section VII, Item E.3.
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Notice of terminated providers due to imminent danger/impairment
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All
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Immediate
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BMHC and Provider
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Section VII, Item E.4.
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Termination or suspension of providers; for "for cause" terminations, include reasons for termination
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All
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Sixty (60) calendar days before termination effective date
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BMHC, affected enrollees, & provider
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Section VIII, Item A.1.b.
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Written Quality Improvement Plan
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All
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Within thirty (30) calendar days of initial Contract execution; Thereafter, Annually by April 1st
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BMHC
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Section VIII, Item A.3.a.(6)
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Measurement periods and methodologies
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All
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Any new PIPs before initiation
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BMHC
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Section VIII, Item A.3.a.(7)
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Proposal for each planned PIP
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All
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Ninety (90) calendar days after Contract execution; Thereafter, Annually by June 1st
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BMHC
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Section VIII, Item A.3.c.(1)
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Performance measure data and auditor certification
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All
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Annually by July 1st
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BMQM
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AHCA Contract No. FA904, Amendment No. 3, Page 6 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section VIII, Item A.3.c.(4)
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Performance measure action plan
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All
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Within thirty (30) calendar days of determination of unacceptable performance
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BMQM
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Section VIII, Item A.3.e.(7)
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Written strategies for medical record review
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All
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Before use
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BMHC
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Section VIII, Item B.1.a.(4)(a)
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Service authorization protocols & any changes
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All
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Before use
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BMHC
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Section VIII, Item B.4.
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Changes to UM component
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All
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Thirty (30) calendar days before effective date
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BMHC
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Section IX, Item A.8.
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Complaint log
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All
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Upon request
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BMHC
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Section X, Item B.2.
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Changes in staffing
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All
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Five (5) business days of any change
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BMHC & HSD
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Section X Item B.2.b.
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Full-Time Administrator
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All
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Before designating duties of any other position
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BMHC
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Section X, Item D. 3. a.
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Reform and non-Reform historical encounter data for all typical and atypical services
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All
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According to Agency-approved schedules and no later than 10/31/09
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MEDS team & Fiscal Agent
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Section X, Item D.3.b.
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Encounter data for all typical and atypical services
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All
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Within sixty (60) calendar days following end of month in which Health Plan paid claims for services, and as specified in MEDS Companion Guide
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MEDS Team & Agency Fiscal Agent
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Section X, Item E.4.
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Fraud & abuse compliance plan & policies & procedures
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All
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Before implementation
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MPI
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Section XI, Item D.4.a.
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Any problem that threatens system performance
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All
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Within one (1) hour
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Applicable Agency staff
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Section XI, Item D.8.a.
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Business Continuity-Disaster Recovery Plan
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All
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Before beginning operation and certification if plan is unchanged by April 30 annually thereafter;
Changes within ten (10) calendar days of change
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BMHC
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AHCA Contract No. FA904, Amendment No. 3, Page 7 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
|
Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section XI, Item E.1.
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System changes
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All
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Ninety (90) calendar days before change
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HSD
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Section XIV, Item A.1.(a)
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Corrective action plan
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All
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Within ten (10) business days of notice of violation or non-compliance with Contract
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Agency Bureau sending violation notice
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Section XIV, Item A.1.(b)
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Performance measure action plan
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All
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Within thirty (30) calendar days of notice of failure to meet a performance standard
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Agency Bureau sending violation notice
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Section XV, Item C.
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Proof of working capital
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All
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Before enrollment
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BMHC
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Section XV, Item G.2.
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Physician incentive plan
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All
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Written description before use
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BMHC
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Section XV, Item H.
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Third party coverage identified
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All
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As soon as known
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Medicaid Third Party Liability Vendor
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Section XV, Item I.
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Proof of fidelity bond coverage
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All
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Within sixty (60) calendar days of Contract execution & before delivering health care
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HSD Contract manager
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Section XVI, Item C.1.
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Request for assignment or transfer of contract in approved merger/acquisition
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All
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Ninety (90) days before effective date
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HSD
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Section XVI, Item M.
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Use of "Medicaid" or "AHCA"
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All
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Before use
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BMHC
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Section XVI, Item O.
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All subcontracts for Agency approval
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All
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Before effective date
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BMHC
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Section XVI, Item O.1.f.
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Subcontract monitoring schedule
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All
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Annually, by December 1
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BMHC
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Section XVI, Item V.1.
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Ownership & management disclosure forms
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All
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With initial application; and then annually by September 1
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HSD - for initial application; BMHC & HSD for annual
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Section XVI, Item V.1.
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Changes in ownership & control
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All
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Within five (5) calendar days of knowledge & sixty (60) days before effective date
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BMHC & HSD
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Section XVI, Item V.4.
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Fingerprints for principals
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All
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Before Contract execution; Thereafter, Annually by September 1
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HSD
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AHCA Contract No. FA904, Amendment No. 3, Page 8 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
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Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Section XVI, Item V.4.c.
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Fingerprints of newly hired principals
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All
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Within thirty (30) calendar days of hire date
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HSD
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Section XVI, Item V.5.
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Information about offenses listed in 435.03
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All
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Within five (5) business days of
knowledge
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HSD
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Section XVI, Item V.6.
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Corrective action plan related to principals committing offenses under 435.03
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All
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As prescribed by the Agency
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HSD
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Section XVI, Item Y.
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General insurance policy declaration pages
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All except CCC
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Annually upon renewal
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BMHC
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Section XVI, Item Z.
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Workers' compensation insurance declaration page
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All except CCC
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Annually upon renewal
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BMHC
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Section XVI, Item BB.
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Emergency Management Plan
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All
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Before beginning operation and by May 31 annually thereafter
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BMHC
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Exhibit 2, Section II, Item D.4.c.
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Policies & procedures for screening for clinical eligibility & any changes to them
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CCC
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Before implementation
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BMHC
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Exhibit 3, Section III, Item C.5.
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Disenrollment notice
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CCC
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Get template approved before use
At least two (2) months before anticipated effective date of involuntary disenrollment
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BMHC
Enrollee
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Exhibit 5, Section V, Item A.6.
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Letters about exhaustion of benefits under customized benefit package
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Reform capitated Health Plans
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Before use
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BMHC
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Exhibit 5, Section V, Item H.20.g.
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Transportation subcontract
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NR HMO offering transportation; Reform Health Plans
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Before execution
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BMHC
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Exhibit 5, Section V, Item H.20.h.
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Transportation policies & procedures
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NR HMO offering transportation; Reform Health Plans
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Before use
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BMHC
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AHCA Contract No. FA904, Amendment No. 3, Page 9 of 14
| WellCare of Florida, Inc. |
|
Medicaid HMO Non-Reform Contract |
| d/b/a Staywell Health Plan of Florida |
|
Contract Section
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Submission
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Plan Type
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Frequency
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Submit To
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Exhibit 5, Section V, Item H.20.i.
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Transportation adverse incidents
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NR HMO offering transporation; Reform Health Plans
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Within two (2) business days of the occurrence
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BMHC
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Exhibit 5, Section V, Item H.20.i.
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Transportation suspected fraud
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NR HMO offering transportation; Reform Health Plans
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Immediately upon identification
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MPI
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Exhibit 5, Section V, Item H.20.p.
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Performance measures
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NR HMO offering transportation; Reform Health Plans
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Annually report by July 1
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BMQM
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Exhibit 5, Section V, Item H.20.q. & r.
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Attestation that Health Plan complies with transportation policies & procedures & drivers pass background checks & meet qualifications
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NR HMO offering transportation; Reform Health Plans
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Annually by January 1
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BMHC
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Exhibit 6, Item A.3.
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Review & approval of behavioral health services staff & subcontractors for licensure compliance
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Reform Health Plans & NR HMOs
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Before providing services
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BMHC
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Exhibit 6, Item B.9.
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Model agreement with community mental health centers
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Reform Health Plans & NR HMOs
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Before agreement is executed
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BMHC
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Exhibit 6, Item C.3.e.
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Denied appeals from providers for emergency services claims
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Plans covering behavioral health
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Within ten (10) days after Health Plan's final denial
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BMHC
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Exhibit 6, Item C.5.a.(3)
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Medical necessity criteria for community mental health services
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Plans covering behavioral health
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Before use and before changes implemented
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BMHC
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Exhibit 6, Item L.2.
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MBHO staff psychiatrist and model contracts for each specialty type
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Plans covering behavioral health
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Before execution
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BMHC
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Exhibit 6, Item M.
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Optional services
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Plans covering behavioral health
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Before offering
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BMHC
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Exhibit 6, Item R.3.a.
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Schedule for administrative and program monitoring and clinical record review
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Plans covering behavioral health
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Annually by July 1
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BMHC
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Exhibit 8, Section VIII, Item B.5.
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Substitute disease management initiatives
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CCC
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Within sixty (60) calendar days of Contract execution
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BMHC
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AHCA Contract No. FA904, Amendment No. 3, Page 10 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
|
Contract Section
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Submission
|
Plan Type
|
Frequency
|
Submit To
|
|
Exhibit 8, Section VIII, Item A.3.f.
|
Provider satisfaction survey
|
All Reform Health Plans
|
By end of 8th month of Contract
|
BMHC
|
|
Exhibit 8, Section VIII, Item B.5.b.
|
Policies and procedures and program descriptions for each disease management program
|
All Reform Health Plans
|
Annually, by April 1
|
BMHC
|
|
Exhibit 8, Section VIII, Item B. 1. e. (5)
|
Caseload maximums for case managers
|
HIV/AIDS specialty plan
|
Before providing services
|
BMHC
|
|
Exhibit 10, Section X, Item C. 5. a.
|
Discrepancies in ERV
|
FFS Health Plans; CCC
|
Within ten (10) business days of discovery
|
HSD analyst
|
|
Exhibit 15, Section XV, Item A. 1. a.
|
Plan for transition from FFS to prepaid capitated plan
|
FFS PSNs; CCC
|
Last calendar day of 24th month of
Health Plan's initial Reform operation
|
HSD
|
|
Exhibit 15, Section XV, Item A. 1. b.
|
Conversion application to capitated Health
Plan
|
FFS PSNs; CCC
|
By August 1 of 4th year of Reform operation
|
HSD
|
|
Exhibit 15, Section XV, Item I.
|
Proof of coverage for any non-government subcontractor
|
CCC
|
Within sixty (60) calendar days of execution and before delivery of care
|
BMHC
|
NR HMO = Non-Reform health maintenance organization, includes Health Plans covering
Frail/Elderly Program services as specified in Attachment I
Ref HMO = Reform health maintenance organization
Ref Cap PSN = Reform capitated provider service network
Ref FFS PSN = Reform Fee-for-Service Provider Service Network
NR Cap PSN = Non-Reform Capitated Provider Service Network
NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC = Specialty plan for children with chronic conditions
HIV/AIDS = Specialty plan for recipients living with HIV/AIDS
|
7.
|
Attachment II, Core Contract Provisions, Section XIII, Method of Payment, the third line of the title, is hereby amended to now read as follows:
|
See Attachment II, Exhibit 13
|
8.
|
Attachment II, Core Contract Provisions, Section XIV, Sanctions, Item G., is hereby included as follows:
|
|
|
G. Performance Measure Sanctions
|
|
|
The Agency shall sanction the Health Plan for failure to achieve minimum scores on HEDIS performance measures after the first year of poor performance. The Agency may impose monetary sanctions as described below in the event that the PMAP fails to result in performance consistent with the Agency's expected minimum standards, as specified in sub-items 2.a. and 2.b. of this item.
|
AHCA Contract No. FA904, Amendment No. 3, Page 11 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
The Agency shall assign performance measures a point value that correlates to the National Committee for Quality Assurance HEDIS National Means and Percentiles. The scores will be assigned according to the table below. Individual performance measures will be grouped and the scores averaged within each group.
|
PM Ranking
|
Score
|
|
>90th percentile
|
6
|
|
75th-89th percentile
|
5
|
|
60th-74th percentile
|
4
|
|
50th-59th percentile
|
3
|
|
25th- 49th percentile
|
2
|
|
10th,-24th percentile
|
1
|
|
<10th percentile
|
0
|
1. PMAP Sanctions
The Health Plan shall complete a PMAP after the first year of poor performance as described in Attachment II, Section VIII, A.3.c.(5). If the PMAP fails to result in scores above the minimum performance standard, the Health Plan may be assessed monetary sanctions under this section.
2. Monetary sanctions
|
|
a. The Health Plan may receive a monetary sanction of up to $10,000 for each performance measure group where the group score is two (2) or lower but above zero (0). Performance measure groups are as follows:
|
(1) Mental Health and Substance Abuse
(a) Follow-Up Hospitalization After Mental Illness (7 day)
(b) Antidepressant Medication Management
(c) Follow-Up Care for Children Prescribed ADHD Medication
(2) Well-Child
(a) Childhood Immunization Status
(b) Well-Child Visits in the First 15 Months of Life (6 or more)
(c) Well-Child Visits 3rd, 4th, 5th, and 6th Years of Life
(d) Adolescent Well-Care Visits
(e) Lead Screening in Children
(3) Other Preventive Care
(a) Breast Cancer Screening
(b) Cervical Cancer Screening
(c) Adults' Access to Preventive/Ambulatory Health Services
(d) Annual Dental Visits
AHCA Contract No. FA904, Amendment No. 3, Page 12 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
(e) BMI Assessment
(4) Prenatal/Postpartum
(a) Prenatal and Postpartum Care (includes two (2) measures)
(b) Frequency of Ongoing Prenatal Care
(5) Chronic Care
(a) Use of Appropriate Medications for People with Asthma
(b) Controlling High Blood Pressure
(c) Persistence of Beta-Blocker Treatment After a Heart Attack
(6) Diabetes - Comprehensive Diabetes Care (excluding the blood pressure submeasures)
|
b.
|
If the Health Plan receives a score of zero (0) on any of the individual measures in the following performance measure groups: Mental Health and Substance Abuse, Chronic Care, or Diabetes; the Health Plan may be sanctioned for individual performance measures, which will result in a sanction of $500 for each member of the denominator not present in the numerator of the performance measure, as defined in the HEDIS manual. If the Health Plan fails to improve these performance measures in subsequent years, the Agency shall impose a sanction of $1,000 per member.
|
|
c.
|
The Agency may amend the performance measure groups with sixty (60) days' advance notice.
|
|
3.
|
Implementation - Performance measure sanctions will be implemented following the phase-in schedule below.
|
a. 2010 Submission - PMAP assessed for all measures scored at two (2) or below.
b. 2011 Submission - Individual measure sanctions as described in 2.b. above.
|
c.
|
2012 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 40th percentile
|
|
d.
|
2013 Submission - Group sanctions as described in 2.a. above for all group scores that fall below the equivalent of the 50th percentile
|
|
9.
|
Attachment II, Core Contract Provisions, Section XV, Financial Requirements, Item D., Surplus Requirement, the first sentence, is hereby amended to now read as follows:
|
In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at all times in the form of cash, investments that mature in less than 180 calendar days and allowable as admitted assets by the Department of Financial Services, and restricted funds of deposits controlled by the Agency (including the Health Plan's insolvency protection account) or the Department of Financial Services, a surplus amount equal to the greater of $1.5 million, ten percent (10%) of total liabilities, or two percent (2%) of the annualized amount of the Health Plan's prepaid revenues.
AHCA Contract No. FA904, Amendment No. 3, Page 13 of 14
| WellCare of Florida, Inc. | Medicaid HMO Non-Reform Contract | |
| d/b/a Staywell Health Plan of Florida |
| 10. |
|
Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O., Subcontracts, sub-item I.e., is hereby deleted in its entirety and replaced with the following:
|
|
c.
|
The Agency encourages use of minority business enterprise subcontractors. See Attachment II, Section VII, Provider Network, Item D., Provider Contract Requirements, for provisions and requirements specific to provider contracts. See Attachment II, Section XVI, Terms and Conditions, Item W., Minority Recruitment and Retention Plan, for other minority recruitment and retention plan requirements. The Health Plan shall provide a monthly Minority Participation Report (see Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the HSD designated minority participation report contact, summarizing the business it does with minority subcontractors or vendors.
|
|
11.
|
Attachment II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item P., Community Behavioral Health Services Annual 80/20 Expenditure Report (HMOs serving non-Reform populations only), the third sentence is hereby amended to now read as follows:
|
In the event the Health Plan expends less than eighty percent (80%) of the capitation rate, the Health Plan shall return the difference to the Agency no later than April 1st of each Contract year.
|
12.
|
Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral Health Reporting Requirements, sub-item 5., the second sentence is hereby amended to now read as follows:
|
For Health Plans operating less than one (1) year, the Health Plan shall submit this report to BMHC quarterly, forty-five (45) calendar days after the end of the quarter being reported.
Unless otherwise stated, this Amendment is effective upon execution by both parties or May 1, 2010 (whichever is later).
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 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 fourteen (14) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.
|
WELLCARE OF FLORIDA, INC.
D/B/A/ STAYWELL HEALTH PLAN OF
FLORIDA
|
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
|
|||||
|
SIGNED
BY:
|
/s/ Thomas L. Tran
|
SIGNED
BY:
|
/s/ Thomas W. Arnold
|
|||
|
NAME:
|
Thomas Tran
|
NAME:
|
Thomas W. Arnold
|
|||
|
TITLE:
|
Chief Financial Officer
|
TITLE:
|
Secretary
|
|||
|
DATE:
|
April 29, 2010
|
DATE:
|
5/3/10
|
|||
AHCA Contract No. FA904, Amendment No. 3, Page 14 of 14