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 an X in Table 1 below. Health Maintenance Organization (HMO) Fee- for- Service (FFS) Provider Service Network (PSN) TABLE 1 Capitated PSN Specialty Health Plan for Children with Chronic Conditions Specialty Plan for Recipients Living with HIV/AIDS HMOs that Specialize in HIV/AIDS B. Population(s) to be Served 1. Population Groups The Health Plan shall deliver covered services as defined in Attachment II, Core Contract Provisions to the specific population(s) as denoted by an X in Table 2 below, and as listed in Attachment II, Core Contract Provisions, Section III, Eligibility and Enrollment. TANF SSI Dually Eligible TABLE 2 Frail/ Elderly* HIV/ AIDS** 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 non- HMO that specializes in HIV/AIDS. *** Enrolled in an Agency-authorized specialty plan for children with chronic conditions and screened by the Florida Department of Health (DOH) as clinically eligible for Children s Medical Services using an Agency-approved screening tool as specified in Attachment II, Core Contract Provisions, Section III, Eligibility and Enrollment, Exhibit 3, Eligibility and Enrollment. **** Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS. AHCA Contract No. _, Attachment I, Page 1 of 13

2 2. Age Restrictions The Health Plan s enrollment is restricted as denoted by an X in Table 3 below in regard to the age range for the population groups referenced in Item 1, Population Groups which the Health Plan is authorized by the Agency to serve. None Only ages 0 up to 21 Only ages 21 and over TABLE 3 Age Restriction 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, Maximum Enrollment Levels Effective Date 09/01/12 08/31/15, of this Attachment for and non- populations if those populations are covered in this Contract as specified in Attachment I, Scope of Services, Section B., Population(s) to be Served. The authorized maximum enrollment level listed is effective on September 1, 2012, 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. The Health Plan shall submit requests for county enrollment level increases, decreases or expansions in writing to the Agency Bureau of Health Systems Development (HSD). b. Such approval shall be based upon the Health Plan s satisfactory performance of the 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. When the Statewide Medicaid Managed Care (SMMC) program for the Managed Medical Assistance (MMA) component begins, the authorized counties of operation will be voided on a county-by-county basis to accommodate the transition. C. Service Level Required The Health Plan shall deliver Medicaid covered services at the service level(s) as denoted by an X in Table 4 below. Medicaid State Plan TABLE 4 Plan AHCA Contract No. _, Attachment I, Page 2 of 13

3 D. Service(s) to be Provided 1. Covered Medicaid Services a. The Health Plan shall ensure the provision of the Medicaid services as denoted by an X in Table 5 below, as specified in applicable exhibits to Attachment I, Scope of Services, and as defined in Attachment II, Core Contract Provisions, Section I, Definitions; Section V, Covered Services; and Section VI, Behavioral Health Care, and as specified in applicable exhibits to Attachment II, Core Contract Provisions. b. For non- PSN populations, Medicaid State Plan dental services (notated in Table 5 below 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 an X in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Item 3., Other Service Requirements, of this subsection, and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, for more information regarding optional services. (1) For optional dental services for the non- population, the Health Plan is further limited as follows: (a) 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 Coverage and Limitations & Reimbursement Handbooks. (b) 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 Limitations & Reimbursement Handbook. TABLE 5 Health Plan Covered Services Chart 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 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 AHCA Contract No. _, Attachment I, Page 3 of 13

4 TABLE 5 Health Plan Covered Services Chart Covered Covered 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 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 Rural Health Clinic Services X X Targeted Case Management X 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 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I, Page 4 of 13

5 2. Approved Expanded Benefits The Health Plan agrees to provide the following expanded benefits to enrollees, as denoted in Tables 6 and 7 below in accordance with the Contract provisions including Attachment I, Scope of Services, Section B., Population(s) to be Served, and Attachment II, Core Contract Provisions, Section V, Covered Services of this Contract. TABLE 6 Expanded Services for Populations List approved services here 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, Scope of Services, and Attachment II, Core Contract Provisions, 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 HSD by June 15 th of each contract year or by the date specified in writing by the Agency. These services may be changed on an annual 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, Core Contract Provisions, Section V, Covered Services of this Contract, and as denoted by an X in Table 8 below. TABLE 8 Pharmacy Authorizations The Health Plan shall use a pharmacy benefits manager as specified in Attachment II, Core Contract Provisions, Section V, Covered Services. Authorized REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I, Page 5 of 13

6 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, Core Contract Provisions, Section IV, Enrollee Services, Community Outreach and Marketing, only if denoted by an X in Table 9 below. TABLE 9 Medicaid Redetermination Date Data The Health Plan shall use Medicaid redetermination date data as specified in Attachment II, Core Contract Provisions, 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 denoted by an X in Table 10 below. TABLE 10 Transportation Capitation The Health Plan is authorized to provide transportation as a capitated service. Authorized f. The Health Plan has agreed to and is authorized by the Agency to provide services through telemedicine and as specified in Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, sub-item 22., Telemedicine; Section VI, Behavioral Health Care, Item A., General Provisions; and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, only if denoted by an X in Table 11 below. Table 11 Telemedicine Dental Authorized Behavioral Health Authorized The Health Plan shall provide telemedicine as specified in Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, subitem 22., Telemedicine; Section VI, Behavioral Health Care, Item A., General Provisions; and Attachment II, Core Contract Provisions, Exhibit 5, Covered Services. AHCA Contract No. _, Attachment I, Page 6 of 13

7 g. For FFS PSNs serving the populations listed below, the Health Plan is approved to provide behavioral health as a capitated service as denoted by an X in Table 12 below. TABLE 12 Behavioral Health Capitation Authorized The Health Plan is authorized to provide behavioral health as a capitated service. Authorized X 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, Core Contract Provisions, 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. Administrative Allocation The monthly administrative allocation provided by the Agency to the Health Plan as a percentage of the per capita capitation benchmark (PCCB) is as follows for the effective date(s) indicated below (see Attachment II, Core Contract Provisions, Exhibit 13, Method of Payment). TABLE 13 FFS Health Plan Administrative Effective Start Date Allocation Percentage Effective End Date % XX/XX/XX XX/XX/XX 3. Benchmark Rate and Kick Payment Rate Tables Attachment I, Scope of Services, Exhibit 2-FFS-NR and 2-FFS-R tables provide the capitation rates for both non- and respectively, the kick payment rates used by the Agency for the establishment of the PCCB respective to the authorized areas of operation, and for the specific populations identified. AHCA Contract No. _, Attachment I, Page 7 of 13

8 4. 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 as denoted in Table 14 below for transportation services for each enrollee who appears on the Health Plan s HIPAA-compliant X file, in accordance with Attachment II, Core Contract Provisions, Exhibit 13, Method of Payment. Table 14: Transportation Rates Effective Date: 09/01/12 08/31/13 Area 4 TANF SSI no Medicare Age Gender Rate Age Rate Month 0-2 $4.57 Month 3-11 $1.25 Month 0-2 $ $1.07 Month 3-11 $ $ $ Female $ $ Male $ $ Female $ $ Male $ $ $1.07 HIV/AIDS Dual Eligible HIV $19.17 Any Age $16.86 AIDS $14.16 HIV - Dual $16.15 Children with Chronic Conditions AIDS - Dual $13.53 Any Age $15.82 Area 10 TANF SSI no Medicare Age Gender Rate Age Rate Month 0-2 $3.54 Month 3-11 $0.97 Month 0-2 $ $0.76 Month 3-11 $ $ $ Female $ $ Male $ $ Female $ $ Male $ $ $0.76 AHCA Contract No. _, Attachment I, Page 8 of 13

9 HIV/AIDS Dual Eligible HIV $23.36 Any Age $15.14 AIDS $17.21 HIV - Dual $19.76 Children with Chronic Conditions AIDS - Dual $16.43 Any Age $ Special Provision(s) Capitated Behavioral Health Only Capitation Payments for FFS PSNs Capitated for Behavioral Health Services Each month the Agency shall pay the Health Plan the applicable capitation rate as denoted in Table 15 below for behavioral health services for each enrollee who appears on the Health Plan s HIPAA-compliant X file, in accordance with Attachment II, Core Contract Provisions, Exhibit 13, Method of Payment. Table 15: Behavioral Health Rates Effective Date: 09/01/12 08/31/13 Area 3_ TANF SSI no Medicare Age Gender Rate Age Rate Month 0-2 $0.10 Month 3-11 $0.10 Month 0-2 $ $2.07 Month 3-11 $ $ $ Female $ $ Male $ $ Female $ $ Male $ $ $5.73 Aged & Disabled with Medicare Part B only Any Age $17.34 Aged & Disabled with Medicare Part A & B Any Age $9.95 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I, Page 9 of 13

10 Attachment/ Exhibit* 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 denoted by an X in Table 16 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 16 Applicable Exhibits HMO HMO Specialty Plans for Recipients Living with HIV/AIDS Fee- Capitated Fee- for- PSN for- Service Service PSN PSN Capitated PSN Specialty Plan for Children with Chronic Conditions HMO with Frail/ Elderly Program Att. I, Exh. 1 X X X N/A X N/A X N/A X X Att. I, Exh. 1- FFS Att. I, Exh. 2-NR HMOs that Specialize in HIV/AIDS N/A N/A N/A X N/A X N/A X N/A N/A N/A X N/A N/A X N/A N/A N/A X X Att. I, Exh. 2-R X N/A X N/A N/A N/A X N/A N/A X Att. I, Exh. 2-FFS-NR N/A N/A N/A X N/A N/A N/A N/A N/A N/A Att.I, Exh. 2-FFS-R N/A N/A N/A N/A N/A X N/A X N/A N/A Att. II, Exh. 1 N/A N/A X N/A N/A N/A N/A X N/A X Att. II, Exh. 2 X X X X X X X X X X Att. 2, Exh. 3 X N/A X X N/A X X X X X Att. II, Exh. 4 X N/A X N/A N/A X X X X X Att. II, Exh. 5 X X X X X X X X X X Att. II, Exh. 6 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 7 X X X X X X X X X X Att. II, Exh. 8 X 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 N/A Att. II, Exh. 10 X X X X X X X X X X Att. II, Exh. 11 N/A N/A N/A N/A 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 N/A Att. II, Exh. 13-CAP-R Att. II, Exh. 13-CAP-NR Att. II, Exh. 13-FFS X N/A X N/A N/A X X N/A N/A N/A N/A X N/A N/A X N/A N/A N/A X X N/A N/A N/A X N/A X N/A X N/A N/A Att. II, Exh. 14 N/A 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 X Att. II, Exh. 16 X 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 and non- HMOs that Specialize in HIV/AIDS; Exhibit 5 dental and transportation. Safety- net hospital-based PSNs and PSNs that are approved to subcapitate for services will have additional language in Exhibit 13. FFS PSNs capitated for transportation and/or behavioral health and approved to subcapitate for services will have additional language in Exhibit 15. AHCA Contract No. _, Attachment I, Page 10 of 13

11 REVISED DRAFT SAMPLE EXHIBIT 1 MAXIMUM ENROLLMENT LEVELS EFFECTIVE DATE 09/01/12 08/31/15 Maximum enrollment levels and Health Plan provider numbers associated with the counties and populations served as denoted below. 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. Agency Area 10 Counties: Effective Date: / / County Enrollment Level Provider Number To Be Assigned AHCA Contract No. _, DRAFT Attachment I, Exhibit 1,??? 2012, Page 11 of 13

12 REVISED DRAFT SAMPLE EXHIBIT 2-FFS-NR EXHIBIT 2-FFS-NR SEPTEMBER 1, August 31, 2013 BENCHMARK RATES (MEDICAID CAPITATION RATES) By Area, Age and Eligibility Category Insert Capitation Rate Tables here REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, DRAFT Attachment I, Exhibit 1,??? 2012, Page 12 of 13

13 REVISED DRAFT SAMPLE EXHIBIT 2-FFS-R ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. EXHIBIT 2-FFS-R September 1, August 31, 2013 BENCHMARK RATES (MEDICAID CAPITATION RATES) By Area, Age and Eligibility Category Insert Capitation Rate Tables here REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, DRAFT Attachment I, Exhibit 1,??? 2012, Page 13 of 13