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

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1 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 TABLE 1 Health Maintenance Organization (HMO) Fee- for-service (FFS) Provider Service Network (PSN) Capitated PSN Specialty Health Plan for Children with Chronic Conditions Specialty Plan for Recipients 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 and as listed in Attachment II, Section III, Eligibility and Enrollment: TABLE 2 TANF SSI Dually Eligible Frail/ Elderly* TANF SSI Dually Eligible Children with Chronic Conditions** HIV/ AIDS*** * 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 III. *** Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 1 of 11

2 2. Age Restrictions The Health Plan s enrollment is restricted as indicated by 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: None Only ages 0 up to 21 Only ages 21 and over Age Restriction TABLE 3 Restricted Restricted 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 and non- 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. In addition, if the Health Plan is listed as approved to provide both comprehensive component only and comprehensive and catastrophic components, then the Health Plan is approved to provide services at the comprehensive component only service level only for the county populations listed below: TABLE 4 Medicaid State Plan Comprehensive Component Only Comprehensive and 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 and as specified in applicable exhibits to this Attachment and as AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 2 of 11

3 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- 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 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- 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 Covered Covered Advanced Registered Nurse Practitioner Services Ambulatory Surgical Center Services Birth Center Services Child Health Check-Up Services Chiropractic Services Community Behavioral Health Services County Health Department Services Dental Services* Durable Medical Equipment and Medical Supplies Dialysis Services Emergency Room Services Family Planning Services Federally Qualified Health Center Services Frail/Elderly Program Services* Freestanding Dialysis Centers Hearing Services Home Health Care Services AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 3 of 11

4 TABLE 5 Health Plan Covered Services Chart Covered Covered Hospital Services Inpatient Hospital Services Outpatient Immunizations Independent Laboratory Services Licensed Midwife Services Optometric Services Physician Services Physician Assistant Services Podiatry Services Portable -ray Services Prescribed Drugs Prescribed Pediatric Extended Care Services Primary Care Case Management Services Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY) Rural Health Clinic Services Targeted Case Management Therapy Services: Occupational Therapy Services: Physical Therapy Services: Respiratory Therapy Services: Speech Transplant Services Transportation Services Vision Services 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 Populations List approved services here AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 4 of 11

5 TABLE 7 Expanded Services for 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 below. TABLE 8 Pharmacy Authorizations The Health Plan shall use a pharmacy benefits manager as specified in Attachment II, Section V. Authorized 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 below. TABLE 9 Medicaid redetermination date data The Health Plan shall use Medicaid redetermination date data as specified in Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing. Authorized e. For FFS PSNs serving populations, the Health Plan is approved to provide transportation as a capitated service if designated by below. TABLE 10 Transportation Capitation The Health Plan is authorized to provide transportation as a capitated service. Authorized AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 5 of 11

6 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 III, 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 Kick Payment Rate Tables Attachment I Exhibit 2-FFS-NR and 2-FFS-R tables provide the capitation rates for both non- and respectively, and for populations, the 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) Only Capitation Payments for FFS PSNs with Capitation Subcontracts or Provider Agreements for Transportation Services for 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 file, in accordance with Attachment II, Exhibit 13. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 6 of 11

7 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 $ $0.80 Month 3-11 $ $ $ Female $ $ Male $ $ Female $ $ Male $ $ $0.80 HIV/AIDS Dual Eligible HIV $24.51 Any Age $15.88 AIDS $18.06 HIV - Dual $20.72 AIDS - Dual $17.24 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, FINAL DRAFT FFS Attachment I, September 2009, Page 7 of 11

8 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 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. Attachment/ Exhibit* HMO HMO Specialty Plan for Recipients Living with HIV/AIDS Table 12 Applicable Exhibits Fee- for- Service PSN Capitated PSN Fee- for- Service PSN Capitated PSN Specialty Plan for Children with Chronic Conditions HMO with Frail/ Elderly Program Att. I, Exh. 1 Att. I, Exh. 1- FFS Att. I, Exh. 2-NR Att. I, Exh. 2-R Att. I, Exh. 2-FFS-NR Att.I, Exh. 2-FFS-R Att. II, Exh. 1 Att. II, Exh. 2 Att. 2, Exh. 3 Att. II, Exh. 4 Att. II, Exh. 5 Att. II, Exh. 6- HMO&R Att. II, Exh. 6- PSN-NR Att. II, Exh. 7 Att. II, Exh. 8 Att. II, Exh. 9 Att. II, Exh. 10 Att. II, Exh. 11 Att. II, Exh. 12 Att. II, Exh. 13-CAP-R Att. II, Exh. 13-CAP-NR Att. II, Exh. 13-FFS Att. II, Exh. 14 Att. II, Exh. 15 Att. II, Exh. 16 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, September 2009, Page 8 of 11

9 DRAFT 8/28/09 SAMPLE EHIBIT 1 MAIMUM 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. 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. 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, September 2009, Page 9 of 11

10 SAMPLE EHIBIT 2-FFS-NR ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. EHIBIT 2-FFS-NR SEPTEMBER 1, August 31, 2012 BENCHMARK RATES (MEDICAID CAPITATION RATES) By Area, Age and Eligibility Category Revised on February 16, 2009 Insert Capitation Rate Tables here REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-FFS-NR, September 2009, Page 10 of 11

11 SAMPLE EHIBIT 2-FFS-R ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. EHIBIT 2-FFS-R September 1, August 31, 2012 BENCHMARK RATES (MEDICAID CAPITATION RATES) By Area, Age and Eligibility Category Revised on February 16, 2009 Insert Capitation Rate Tables here REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-FFS-R, September 2009, Page 11 of 11

ATTACHMENT I SCOPE OF SERVICES Effective Date: October 1, 2014 STATEWIDE MEDICAID MANAGED CARE PROGRAM

ATTACHMENT I SCOPE OF SERVICES Effective Date: October 1, 2014 STATEWIDE MEDICAID MANAGED CARE PROGRAM I. Services to be Provided A. Overview of Contract Structure Part IV of Chapter 409, F.S. established