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					                                                                      REVISED DRAFT 12/31/09


                                   ATTACHMENT I
                                SCOPE OF SERVICES
                    FEE-FOR-SERVICE PROVIDER SERVICE NETWORKS


A. Plan Type

     The Vendor (Health Plan) is approved to provide contracted services as the following health
     plan type as denoted by “X”

                                              TABLE 1
        Health        Fee- for-Service       Capitated PSN    Specialty Health       Specialty
     Maintenance       (FFS) Provider                         Plan for Children       Plan for
     Organization     Service Network                           with Chronic        Recipients
        (HMO)              (PSN)                                 Conditions         Living with
                                                                                     HIV/AIDS




B. Population(s) to be Served

     1. Population Groups

        The Health Plan shall deliver covered services as defined in Attachment II to the specific
        population(s) approved below with “X” and as listed in Attachment II, Section III,
        Eligibility and Enrollment:

                                               TABLE 2
     Non-     Non-      Non-       Non-       Reform     Reform   Reform        Reform      Reform
    Reform   Reform    Reform     Reform       TANF       SSI     Dually       Children      HIV/
     TANF     SSI      Dually      Frail/                         Eligible   with Chronic   AIDS***
                       Eligible   Elderly*                                   Conditions**




*   Enrollees, who have been determined to be at risk for nursing home institutionalization by
    the Comprehensive Assessment and Review for Long Term Care (CARES) Unit, and are
    enrolled in an Agency-authorized plan which participates in the Frail/Elderly Program.
** Enrolled in an Agency-authorized specialty plan for children with chronic conditions and
    screened by the Florida Department of Health as clinically eligible for Children’s Medical
    Services using an Agency-approved screening tool as specified in Attachment II, Section III,
    Eligibility and Enrollment, Exhibit 3.
*** Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS.


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          AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 1 of 11
REVISED DRAFT 12/31/09

   2. Age Restrictions
      The Health Plan’s enrollment is restricted as indicated by “X” below in regard to the age
      range for the population groups referenced in Item 1 above that the Health Plan is
      authorized by the Agency to serve:

                                            TABLE 3
                   Age Restriction                          Non-Reform             Reform
                                                             Restricted           Restricted
   None
   Only ages 0 up to 21
   Only ages 21 and over

   3. Enrollment Levels and Authorized Counties of Operation

      The Agency assigns the Health Plan an authorized maximum enrollment level for each
      operational county indicated in Exhibit 1 of this attachment for Reform and non-Reform
      populations if those populations are covered in this Contract as specified in Section B.
      above. The authorized maximum enrollment level listed is effective on September 1,
      2009, or upon Contract execution, whichever is later.

      a. The Agency must approve in writing any increase or decrease in the Health Plan’s
          maximum enrollment level for each operational county to be served.

      b. Such approval shall be based upon the Health Plan’s satisfactory performance of
          terms of this Contract and upon the Agency’s approval of the Health Plan’s
          administrative and service resources, as specified in this Contract, in support of each
          enrollment level.

C. Service Level Required

   The Health Plan shall deliver Medicaid covered services at the service level(s) listed below
   in Table 4 with “X.” In addition, if the Health Plan is listed as approved to provide both
   Reform comprehensive component only and Reform comprehensive and catastrophic
   components, then the Health Plan is approved to provide services at the “Reform
   comprehensive component only” service level only for the county populations listed below:

                                          TABLE 4

     Non-Reform              Reform Comprehensive            Reform Comprehensive and
  Medicaid State Plan           Component Only                Catastrophic Components




D. Service(s) to be Provided

   1. Covered Medicaid Services

      a. The Health Plan shall ensure the provision of the Medicaid services listed below in
         Table 5 with “X” and as specified in applicable exhibits to this Attachment and as


        AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 2 of 11
REVISED DRAFT 12/31/09

        defined in Attachment II, Section I, Definitions; Section V, Covered Services; and
        Section VI, Behavioral Health Care, and as specified in applicable exhibits to
        Attachment II.

     b. For non-Reform PSN populations, Medicaid State Plan dental services (notated in
        the table with an asterisk and in bold-type font) is considered an optional service,
        and the Health Plan may request that the Agency allow the Health Plan to provide
        this service under this Contract. The denotation of “X” in Table 5 below indicates the
        Agency has approved the Health Plan to cover this service. See Attachment II,
        Exhibit 5, for more information regarding the provision of optional benefits. See Item
        3., Other Service Requirements, of this subsection for more information regarding
        optional services.

        For optional dental services for the non-Reform population, the Health Plan is further
        limited as follows:

        (1) Dental services include the arrangement and provision of Medicaid State Plan
            dental services to the adult and child populations. The Health Plan shall comply
            with the limitations and exclusions in the Medicaid Dental Services Coverageand
            Limitations & Reimbursement Handbooks.

        (2) In no instance may the limitations or exclusions imposed by the Health Plan be
            more stringent than those specified in the Medicaid Dental Services Coverage
            and Limitation Reimbursement Handbook.

                                        TABLE 5
              Health Plan Covered Services Chart                Non-       Reform
                                                               Reform      Covered
                                                               Covered
       Advanced Registered Nurse Practitioner Services             X           X
       Ambulatory Surgical Center Services                         X           X
       Birth Center Services                                       X           X
       Child Health Check-Up Services                              X           X
       Chiropractic Services                                       X           X
       Community Behavioral Health Services                                    X
       County Health Department Services                           X           X
       Dental Services*                                                        X
       Durable Medical Equipment and Medical Supplies              X           X
       Dialysis Services                                           X           X
       Emergency Room Services                                     X           X
       Family Planning Services                                    X           X
       Federally Qualified Health Center Services                  X           X
       Frail/Elderly Program Services*
       Freestanding Dialysis Centers                               X           X
       Hearing Services                                            X           X
       Home Health Care Services                                   X           X


      AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 3 of 11
REVISED DRAFT 12/31/09


                                        TABLE 5
             Health Plan Covered Services Chart                 Non-      Reform
                                                               Reform     Covered
                                                               Covered
       Hospital Services – Inpatient                              X          X
       Hospital Services – Outpatient                             X          X
       Immunizations                                              X          X
       Independent Laboratory Services                            X          X
       Licensed Midwife Services                                  X          X
       Optometric Services                                        X          X
       Physician Services                                         X          X
       Physician Assistant Services                               X          X
       Podiatry Services                                          X          X
       Portable X-ray Services                                    X          X
       Prescribed Drugs                                           X          X
       Prescribed Pediatric Extended Care Services
       Primary Care Case Management Services                      X          X
       Private Duty Nursing (for Specialty Plan for Children
       with Chronic Conditions ONLY)
       Rural Health Clinic Services                               X          X
       Targeted Case Management                                              X
       Therapy Services: Occupational                             X          X
       Therapy Services: Physical                                 X          X
       Therapy Services: Respiratory                              X          X
       Therapy Services: Speech                                   X          X
       Transplant Services                                        X          X
       Transportation Services                                               X
       Vision Services                                            X          X

  2. Approved Expanded Benefits

     The Health Plan agrees to provide the following expanded benefits to enrollees, as
     specified below in accordance with Contract provisions including Attachment I, Section
     B., Population(s) to be Served, and Attachment II, Section V, Covered Services, of this
     Contract.

                                       TABLE 6
      Expanded Services for Reform Populations
      List approved services here




      AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 4 of 11
REVISED DRAFT 12/31/09

                                       TABLE 7
      Expanded Services for Non-Reform Populations
      List approved services here




  3. Other Service Requirements

     a. The Health Plan shall meet the minimum service requirements as outlined and
        defined in Attachments I and II of this Contract.

     b. The Health Plan shall submit for approval any changes to the optional services listed
        in Table 5 and those expanded benefits in Tables 6 and 7 of this attachment, if
        applicable, to the Agency’s Bureau of Health Systems Development (HSD) by June
        15 of each contract year. These services may be changed on a contract year basis
        and only if approved by the Agency in writing.

     c. The Health Plan shall use the following service provisions for prescribed drug
        services as allowed in Attachment II, Section V, Covered Services of this Contract,
        and as listed by “X” below.

                                               TABLE 8
                         Pharmacy Authorizations                           Authorized
        The Health Plan shall use a pharmacy benefits manager
        as specified in Attachment II, Section V.

     d. The Health Plan has agreed to and is authorized by the Agency to use the Medicaid
        redetermination date data provided in its enrollment files as specified in Attachment
        II, Section IV, Enrollee Services, Community Outreach and Marketing, only if listed
        by “X” below.

                                            TABLE 9
                  Medicaid redetermination date data                       Authorized
        The Health Plan shall use Medicaid redetermination date
        data as specified in Attachment II, Section IV, Enrollee
        Services, Community Outreach and Marketing.

     e. For FFS PSNs serving Reform populations, the Health Plan is approved to provide
        transportation as a capitated service if designated by “X” below.

                                            TABLE 10
                        Reform Transportation Capitation                   Authorized
        The Health Plan is authorized to provide transportation as
        a capitated service.




      AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 5 of 11
REVISED DRAFT 12/31/09

E.   Method of Payment

     1. General

        This is a fixed price (unit cost) Contract. The Agency will manage this fixed price
        Contract for the delivery of services to enrollees (service units). The Health Plan will
        be paid through the Agency’s Medicaid fiscal agent, in accordance with the terms of
        this Contract, a total dollar amount not to exceed $ ______________, subject to the
        availability of funds and the amount of shared cost-savings experienced through this
        Contract. Payments made to the Health Plan resulting from this Contract will include
        monthly administrative allocation payments and share of cost-savings payments, if
        any, as specified in Attachment II, Section XIII, Method of Payment. Administrative
        and share of cost-savings payments are in addition to a monthly $_______ per
        member per month fee paid to the Health Plan for the provision of primary care case
        management for enrollees. This primary care case management fee is subject to
        change as legislatively mandated.

     2. Capitation Rate and Reform Kick Payment Rate Tables

        Attachment I Exhibit 2-FFS-NR and 2-FFS-R tables provide the capitation rates for
        both non-Reform and Reform respectively, and for Reform populations, the Reform
        kick payment rates, used by the Agency for the establishment of the per capita
        capitation benchmark (PCCB) respective to the authorized areas of operation and for
        the specific populations identified.

     3. Special Provision(s) – Reform Only

        Capitation Payments for FFS PSNs with Capitation Subcontracts or Provider
        Agreements for Transportation Services for Reform Populations

        Each month the Agency shall pay the Health Plan the applicable capitation rate in
        Table 11 for transportation services for each enrollee who appears on the Health
        Plan’s HIPAA-compliant X12 820 file, in accordance with Attachment II, Exhibit 13.



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      AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 6 of 11
REVISED DRAFT 12/31/09


                          Table 11: Area 10 (Broward) Transportation Rates
                                     Effective September 1, 2008

            TANF                                  SSI no Medicare
                 Age          Gender     Rate           Age             Rate
            Month 0-2                   $3.72
            Month 3-11                  $1.02     Month 0-2           $45.32
             1–5                        $0.80     Month 3-11          $28.83
             6 – 13                     $0.80      1–5                $13.09
            14 – 20          Female     $0.80      6 – 13             $13.09
            14 – 20          Male       $0.80     14 – 20             $13.09
            21 – 54          Female     $0.80     21 – 54             $13.09
            21 – 54          Male       $0.80     55+                 $13.09
            55+                         $0.80

            HIV/AIDS                              Dual Eligible
            HIV                        $24.51     Any Age             $15.88
            AIDS                       $18.06
            HIV - Dual                 $20.72
            AIDS - Dual                $17.24




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      AHCA Contract No. _, FINAL DRAFT FFS Attachment I, 12/31/09, Page 7 of 11
                                                                                                 REVISED DRAFT 12/31/09


F. Applicable Exhibits
   Any additions or variations from Contract requirements specified in Attachments I and II are
   provided in the exhibits to those attachments. Exhibits required are noted by “X” below
   depending on health plan type and population served. There are no additional requirements
   or changes to the Health Plan’s Contract in those exhibits marked N/A.
                                                Table 12-A – Revised Applicable Exhibits
  Attachment/          HMO      HMO         Specialty       Fee-       Capitated      Fee-       Capitated       Specialty          HMO
    Exhibit*          Reform    Non-        Plan for         for-        PSN           for-        PSN           Plan for           Non-
                               Reform      Recipients      Service       Non-        Service      Reform       Children with       Reform
                                           Living with      PSN         Reform        PSN                        Chronic          with Frail/
                                            HIV/AIDS        Non-                     Reform                     Conditions         Elderly
                                             Reform        Reform                                                 Reform          Program
  Att. I, Exh. 1        X          X            X            N/A           X           N/A           X               N/A               X
  Att. I, Exh. 1-
                        N/A       N/A          N/A            X           N/A           X           N/A               X                N/A
        FFS
   Att. I, Exh.
                        N/A        X           N/A           N/A           X           N/A          N/A              N/A               X
      2-NR
 Att. I, Exh. 2-R       X         N/A           X            N/A          N/A          N/A           X               N/A               N/A
   Att. I, Exh.
                        N/A       N/A          N/A            X           N/A          N/A          N/A              N/A               N/A
   2-FFS-NR
    Att.I, Exh.
                        N/A       N/A          N/A           N/A          N/A           X           N/A               X                N/A
     2-FFS-R
  Att. II, Exh. 1       N/A       N/A           X            N/A          N/A          N/A          N/A               X                N/A

  Att. II, Exh. 2       X          X            X             X            X            X            X                X                X

  Att. 2, Exh. 3        X         N/A           X             X           N/A           X            X                X                X

  Att. II, Exh. 4       X         N/A           X            N/A          N/A           X            X                X                X

  Att. II, Exh. 5       X          X            X             X            X            X            X                X                X
  Att. II, Exh. 6-
                        X          X            X            N/A          N/A           X            X                X                X
     HMO&R
  Att. II, Exh. 6-
                        N/A       N/A          N/A            X            X           N/A          N/A              N/A               N/A
     PSN-NR
  Att. II, Exh. 7       X         N/A           X             X           N/A           X            X                X                N/A

  Att. II, Exh. 8       X          X            X             X            X            X            X                X                X

  Att. II, Exh. 9       N/A       N/A          N/A           N/A          N/A          N/A          N/A              N/A               N/A

 Att. II, Exh. 10       X          X            X             X            X            X            X                X                X

 Att. II, Exh. 11       X          X            X            N/A          N/A          N/A          N/A              N/A               N/A

 Att. II, Exh. 12       N/A       N/A          N/A           N/A          N/A          N/A          N/A              N/A               N/A
   Att. II, Exh.
                        X         N/A           X            N/A          N/A           X            X               N/A               N/A
   13-CAP-R
   Att. II, Exh.
                        N/A        X           N/A           N/A           X           N/A          N/A              N/A               X
   13-CAP-NR
   Att. II, Exh.
                        N/A       N/A          N/A            X           N/A           X           N/A               X                N/A
    13-FFS
 Att. II, Exh. 14       N/A       N/A          N/A           N/A          N/A          N/A          N/A              N/A               N/A
 Att. II, Exh. 15       X          X            X             X            X            X            X                X                X
 Att. II, Exh. 16       X          X            X             X            X            X            X                X                X

Plans offering certain optional coverage also will have additional language in the exhibits as follows: Exhibits 3, 4, 5, 8 and 13 –
Frail/Elderly Program; Exhibit 5 – dental and transportation. Safety net hospital-based PSNs will have additional language in the
exhibits as follows: – Exhibit 13 – Method of Payment.



                     AHCA Contract No. _, DRAFT FFS Attachment I, 12/31/09, Page 8 of 11
REVISED DRAFT 12/31/09          SAMPLE EXHIBIT 1




                        MAXIMUM ENROLLMENT LEVELS
Maximum enrollment levels and Health Plan provider numbers associated with the counties and
populations served. Exhibits 2-FFS-NR and 2-FFS-R provide the capitation rate tables
respective to the areas of operation listed below for the applicable population(s) to be served.

A. Non-Reform


       Area __ Counties: ______________________

                                         Effective Date: _______/______/______
                County                Enrollment Level          Provider Number
                                                                 To Be Assigned
                                                                 To Be Assigned



       Area __ Counties: ______________________

                                         Effective Date: _______/______/______
                County                Enrollment Level          Provider Number
                                                                 To Be Assigned
                                                                 To Be Assigned



B. Reform

     TABLE 1 (Broward County)

     Agency Area 10


                                         Effective Date: _______/______/______
                County                 Enrollment Level          Provider Number
                                                                 To Be Assigned




         AHCA Contract No. _, Attachment I, DRAFT Exhibit 1, 12/31/09, Page 9 of 11
REVISED DRAFT 12/31/09 SAMPLE EXHIBIT 2-FFS-NR

  “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”


                        EXHIBIT 2-FFS-NR
      SEPTEMBER 1, 2009 - August 31, 2012 BENCHMARK RATES
                    (MEDICAID Non-Reform CAPITATION RATES)
                       By Area, Age and Eligibility Category
                                  Revised on February 16, 2009




Insert Capitation Rate Tables here




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AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-FFS-NR, 12/31/09, Page 10 of 11
REVISED DRAFT 12/31/09 SAMPLE EXHIBIT 2-FFS-R

  “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”


                           EXHIBIT 2-FFS-R
       September 1, 2009 - August 31, 2012 BENCHMARK RATES
                      (MEDICAID Reform CAPITATION RATES)
                        By Area, Age and Eligibility Category
                                  Revised on February 16, 2009



Insert Capitation Rate Tables here




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AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-FFS-R, 12/31/09, Page 11 of 11

				
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