10-Q

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM 10-Q

(Mark One)

ý QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the quarterly period ended March 31, 2014

or

o TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the transition period from               to             

Commission file number: 001-32209

WELLCARE HEALTH PLANS, INC.

(Exact name of registrant as specified in its charter)

Delaware	47-0937650
(State or other jurisdiction of	(I.R.S. Employer
incorporation or organization)	Identification No.)

8725 Henderson Road, Renaissance One Tampa, Florida	33634
	(Zip Code)

(813) 290-6200

(Registrant's telephone number, including area code)

Indicate by check mark whether the registrant: (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days. Yes ý No o

Indicate by check mark whether the registrant has submitted electronically and posted on its corporate Web site, if any, every Interactive Data File required to be submitted and posted pursuant to Rule 405 of Regulation S-T during the preceding 12 months (or for such shorter period that the registrant was required to submit and post such files). Yes ý No o

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer or a smaller reporting company. See the definitions of "large accelerated filer," "accelerated filer" and "smaller reporting company" in Rule 12b-2 of the Exchange Act.

Large accelerated filer x	Accelerated filer o	Non-accelerated filer o	Smaller reporting company o
		(Do not check if a smaller reporting company)

Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act). Yes o No x

As of May 6, 2014, there were 43,870,733 shares of the registrant's common stock, par value $.01 per share, outstanding.

WELLCARE HEALTH PLANS, INC.

TABLE OF CONTENTS

		Page
Part I — FINANCIAL INFORMATION
Item 1.	Financial Statements
	Condensed Consolidated Statements of Comprehensive Income for the Quarters Ended March 31, 2014 and 2013 (unaudited)	2
	Condensed Consolidated Balance Sheets as of March 31, 2014 and December 31, 2013 (unaudited)	3
	Condensed Consolidated Statement of Changes in Stockholders' Equity for the Quarters Ended March 31, 2014 (unaudited)	5
	Condensed Consolidated Statements of Cash Flows for the Quarters Ended March 31, 2014 and 2013 (unaudited)	6
	Notes to Condensed Consolidated Financial Statements (unaudited)	8
Item 2.	Management's Discussion and Analysis of Financial Condition and Results of Operations	30
Item 3.	Quantitative and Qualitative Disclosures About Market Risk	55
Item 4.	Controls and Procedures	55
Part II — OTHER INFORMATION
Item 1.	Legal Proceedings	56
Item 1A.	Risk Factors	56
Item 2.	Unregistered Sales of Equity Securities and Use of Proceeds	56
Item 3.	Defaults Upon Senior Securities	56
Item 4.	Mine Safety Disclosures	56
Item 5.	Other Information	56
Item 6.	Exhibits	56
	Signatures	57
	Exhibit Index	58

Part I — FINANCIAL INFORMATION

Item 1. Financial Statements.

WELLCARE HEALTH PLANS, INC.

CONDENSED CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME

(Unaudited, in millions, except per share and share data)

	For the Quarters Ended March 31,
	2014			2013
Revenues:
Premium	$	2,975.1		$	2,252.3
Investment and other income	10.6			4.3
Total revenues	2,985.7			2,256.6
Expenses:
Medical benefits	2,629.9			1,987.3
Selling, general and administrative	245.3			213.4
ACA industry fee	32.3			—
Medicaid premium taxes	17.1			21.3
Depreciation and amortization	14.6			10.1
Interest	9.2			1.6
Total expenses	2,948.4			2,233.7
Income from operations	37.3			22.9
Bargain purchase gain	28.3			—
Income before income taxes	65.6			22.9
Income tax expense	21.5			1.4
Net income	44.1			21.5
Other comprehensive (loss) income, before tax:
Change in net unrealized gains and losses on available-for-sale securities	0.2			(0.8		)
Income tax expense (benefit) related to other comprehensive income (loss)	(0.1		)	(0.3		)
Other comprehensive income (loss), net of tax	0.3			(0.5		)
Comprehensive income	$	44.4		$	21.0
Net income per common share:
Basic	$	1.01		$	0.50
Diluted	$	1.00		$	0.49
Weighted average common shares outstanding:
Basic	43,802,047			43,325,381
Diluted	44,123,791			43,952,459

See notes to unaudited condensed consolidated financial statements.

2

WELLCARE HEALTH PLANS, INC.

CONDENSED CONSOLIDATED BALANCE SHEETS

(Unaudited, in millions, except share data)

	March 31, 2014		December 31, 2013
Assets
Current Assets:
Cash and cash equivalents	$	1,658.3	$	1,482.5
Investments	288.7		314.7
Premiums receivable, net	607.4		490.7
Pharmacy rebates receivable, net	235.5		165.5
Receivables from government partners	79.1		—
Funds receivable for the benefit of members	67.0		93.5
Deferred ACA industry fee	96.8		—
Income taxes receivable	—		7.1
Prepaid expenses and other current assets, net	112.9		115.0
Deferred income tax asset	29.5		23.7
Total current assets	3,175.2		2,692.7
Property, equipment and capitalized software, net	152.5		147.4
Goodwill	244.9		236.8
Other intangible assets, net	121.8		66.5
Long-term investments	136.4		80.4
Restricted investments	94.9		82.5
Other assets	10.6		144.4
Total Assets	$	3,936.3	$	3,450.7
Liabilities and Stockholders' Equity
Current Liabilities:
Medical benefits payable	$	1,132.7	$	953.4
Unearned premiums	4.0		0.2
ACA industry fee liability	129.0		—
Accounts payable	19.0		22.3
Income taxes payable	5.0		—
Other accrued expenses and liabilities	370.2		187.7
Current portion of amount payable related to investigation resolution	34.4		36.2
Other payables to government partners	16.7		37.3
Total current liabilities	1,711.0		1,237.1
Deferred income tax liability	58.0		55.4
Amount payable related to investigation resolution	—		34.1
Long-term debt	600.0		600.0
Other liabilities	5.6		6.2
Total liabilities	2,374.6		1,932.8
Commitments and contingencies (see Note 11)	—		—

3

WELLCARE HEALTH PLANS, INC. CONDENSED CONSOLIDATED BALANCE SHEETS (Unaudited, in millions, except share data) - Continued
	March 31, 2014			December 31, 2013
Stockholders' Equity:
Preferred stock, $0.01 par value (20,000,000 authorized, no shares issued or outstanding)	—			—
Common stock, $0.01 par value (100,000,000 authorized, 43,858,148 and 43,766,645 shares issued and outstanding at March 31, 2014 and December 31, 2013, respectively)	0.4			0.4
Paid-in capital	488.8			489.4
Retained earnings	1,073.5			1,029.4
Accumulated other comprehensive loss	(1.0		)	(1.3		)
Total stockholders' equity	1,561.7			1,517.9
Total Liabilities and Stockholders' Equity	$	3,936.3		$	3,450.7

See notes to unaudited condensed consolidated financial statements.

4

WELLCARE HEALTH PLANS, INC.

CONDENSED CONSOLIDATED STATEMENT OF CHANGES IN STOCKHOLDERS' EQUITY

(Unaudited, in millions, except share data)

	Common Stock				Paid in Capital			Retained Earnings		Accumulated Other Comprehensive Loss			Total Stockholders' Equity
	Shares		Amount
Balance at January 1, 2014	43,766,645		$	0.4	$	489.4		$	1,029.4	$	(1.3	)	$	1,517.9
Common stock issued for exercised stock options	11,671		—		0.2			—		—			0.2
Common stock issued for vested restricted stock, restricted stock units and performance stock units	116,010		—		—			—		—			—
Repurchase and retirement of shares to satisfy tax withholding requirements	(36,178	)	—		(2.2		)	—		—			(2.2		)
Equity-based compensation expense, net of forfeitures	—		—		1.2			—		—			1.2
Incremental tax benefit from equity-based compensation	—		—		0.2			—		—			0.2
Comprehensive income	—		—		—			44.1		0.3			44.4
Balance at March 31, 2014	43,858,148		$	0.4	$	488.8		$	1,073.5	$	(1.0	)	$	1,561.7

See notes to unaudited condensed consolidated financial statements.

5

WELLCARE HEALTH PLANS, INC.

CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS

(Unaudited, in millions)

	For the Quarters Ended March 31,
	2014			2013
Cash (used in) provided by operating activities:
Net income	$	44.1		$	21.5
Adjustments to reconcile net income to net cash (used in) provided by operating activities:
Depreciation and amortization	14.6			10.1
Equity-based compensation expense	1.2			3.7
Bargain purchase gain	(28.3		)	—
Deferred ACA industry fee amortization	32.3			—
Incremental tax benefit from equity-based compensation	(0.2		)	(2.1		)
Deferred taxes, net	5.9			9.6
Provision for doubtful receivables	3.7			3.0
Changes in operating accounts, net of effects from acquisitions:
Premiums receivable, net	(33.1		)	(13.6		)
Pharmacy rebates receivable, net	(34.6		)	6.7
Prepaid expenses and other current assets, net	17.2			3.5
Medical benefits payable	51.1			77.0
Unearned premiums	(0.5		)	—
Accounts payable and other accrued expenses	35.3			(45.8		)
Other payables to government partners	(99.7		)	(22.2		)
Amount payable related to investigation resolution	(35.9		)	(13.8		)
Income taxes receivable/payable, net	12.3			(6.5		)
Other, net	0.7			—
Net cash (used in) provided by operating activities	(13.9		)	31.1
Cash provided by (used in) investing activities:
Acquisitions, net of cash acquired	164.2			(39.2		)
Purchases of investments	(90.6		)	(144.5		)
Proceeds from sale and maturities of investments	107.9			138.2
Purchases of restricted investments	(12.3		)	(4.9		)
Proceeds from maturities of restricted investments	6.3			4.9
Additions to property, equipment and capitalized software, net	(13.2		)	(15.9		)
Net cash provided by (used in) investing activities	162.3			(61.4		)
Cash provided by financing activities:
Proceeds from debt, net of financing costs paid	—			228.5
Proceeds from exercises of stock options	0.2			4.0
Incremental tax benefit from equity-based compensation	0.2			2.1
Repurchase and retirement of shares to satisfy tax withholding requirements	(2.2		)	(2.7		)
Payments on debt	—			(9.5		)
Payments on capital leases	(0.4		)	(0.3		)
Funds received for the benefit of members, net	29.6			85.9
Net cash provided by financing activities	27.4			308.0

6

WELLCARE HEALTH PLANS, INC. CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS (Unaudited, in millions) - Continued
	For the Quarters Ended March 31,
	2014		2013
Increase in cash and cash equivalents	175.8		277.7
Balance at beginning of period	1,482.5		1,100.5
Balance at end of period	$	1,658.3	$	1,378.2
SUPPLEMENTAL DISCLOSURES OF CASH FLOW INFORMATION:
Cash paid for taxes	3.3		1.1
Cash paid for interest	0.2		0.7
SUPPLEMENTAL DISCLOSURES OF NON-CASH TRANSACTIONS:
Non-cash additions to property, equipment, and capitalized software	2.1		3.9

See notes to unaudited condensed consolidated financial statements.

7

WELLCARE HEALTH PLANS, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(Unaudited, in millions, except member, per share and share data)

1. ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES

WellCare Health Plans, Inc. (the "Company," "we," "us," or "our"), provides managed care services for government-sponsored health care coverage with a focus on Medicaid and Medicare programs. The Company was formed as a Delaware limited liability company in May 2002 to acquire our Florida, New York and Connecticut health plans. We completed the acquisition of the health plans through two concurrent transactions in July 2002. In July 2004, immediately prior to the closing of our initial public offering, we merged the limited liability company into a Delaware corporation and changed our name to WellCare Health Plans, Inc.

As of March 31, 2014, we served approximately 3.5 million members. During the quarter ended March 31, 2014, we operated Medicaid health plans in Florida, Georgia, Hawaii, Illinois, Kentucky, Missouri, New Jersey, New York and South Carolina. In connection with our acquisitions of Medicaid plans in South Carolina and Missouri (see Note 2), our Medicaid operations in those states began in February 2013 and April 2013, respectively.

Our Medicaid contract in Ohio expired on June 30, 2012. We were not awarded a Medicaid contract in Ohio for the 2013 fiscal year; however, the state contracted with us to provide services to Ohio Medicaid beneficiaries through the transition period, which ended June 30, 2013. As of July 1, 2013, we no longer provided Medicaid services in Ohio. The Ohio Medicaid contract accounted for approximately $65.0 million, or 2.9%, of our consolidated premium revenue for the quarter ended March 31, 2013.

As of March 31, 2014, we also operated Medicare Advantage ("MA") coordinated care plans ("CCPs") in Arizona, Arkansas, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Mississippi, Missouri, New Jersey, New York, Ohio, South Carolina, Tennessee and Texas, as well as stand-alone Medicare prescription drug plans ("PDP") in 49 states and the District of Columbia. Our MA plans in Arkansas, Mississippi, South Carolina and Tennessee are attributable to our acquisition of Windsor Health Group, Inc. ("Windsor") and our MA operations in those states began on January 1, 2014.

Completed and Pending Acquisitions

On January 1, 2014, we acquired all of the outstanding stock of Windsor from Munich Health North America, Inc., a part of Munich Re Group. Through its subsidiaries, Windsor serves Medicare beneficiaries with MA, PDP and Medicare Supplement products. As of March 31, 2014, Windsor offered MA plans in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee through which it served 38,000 members. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it served 48,000 members in 39 states as of March 31, 2014. Windsor also offers PDPs in 11 of the 34 CMS regions, through which it served approximately 109,000 beneficiaries as of March 31, 2014. We included the results of Windsor's operations from the date of acquisition in our condensed consolidated financial statements.

In September 2013, we also entered into an agreement to acquire certain assets of Healthfirst Health Plan of New Jersey, Inc. ("Healthfirst NJ"). As of March 2014, Healthfirst NJ serves approximately 49,000 Medicaid members in 12 counties in the state. The acquisition is expected to close at the end of the second quarter of 2014, subject to customary regulatory approvals. Upon closure of the transaction, we will acquire Healthfirst NJ’s membership and substantially all of its provider network. We expect to start serving Healthfirst NJ members effective July 1, 2014.

Basis of Presentation and Use of Estimates

The accompanying unaudited condensed consolidated balance sheets and statements of comprehensive income, changes in stockholders' equity, and cash flows include the accounts of the Company and all of its majority-owned subsidiaries. We eliminated all intercompany accounts and transactions.

8

The accompanying unaudited condensed consolidated interim financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America ("GAAP") and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, certain information and footnote disclosures normally included in financial statements prepared in accordance with GAAP have been condensed or omitted. The accompanying unaudited condensed consolidated interim financial statements should be read in conjunction with the condensed consolidated financial statements and notes thereto for the fiscal year ended December 31, 2013 included in our Annual Report on Form 10-K, filed with the U.S. Securities and Exchange Commission in February 2014. Results for the interim periods presented are not necessarily indicative of results that may be expected for the entire year or any other interim period.

In the opinion of management, the interim financial statements reflect all normal recurring adjustments that we consider necessary for the fair presentation of our financial position, results of operations and cash flows for the interim periods presented. In accordance with GAAP, we make certain estimates and assumptions that affect the amounts reported in the condensed consolidated interim financial statements and accompanying notes. We base these estimates on our knowledge of current events and anticipated future events and evaluate and update our assumptions and estimates on an ongoing basis; however, actual results may differ from our estimates. We evaluated all material events subsequent to the date of these condensed consolidated interim financial statements.

Significant Accounting Policies

Revenue Recognition

We earn premium revenue through our participation in Medicaid, Medicaid-related and Medicare programs.

State governments individually operate and implement and, together with the federal government's Centers for Medicare & Medicaid Services ("CMS"), fund and regulate the Medicaid program. We provide benefits to low-income and disabled persons under the Medicaid program and are paid premiums based on contracts with government agencies in the states in which we operate health plans. Our Medicaid contracts are generally multi-year contracts subject to annual renewal provisions. Rate changes are typically made at the commencement of each new contract renewal period. In some instances, our fixed Medicaid premiums are subject to risk score adjustments based on the acuity of our membership. State agencies analyze encounter submissions of processed claims data to determine the acuity of our membership relative to the entire state's Medicaid membership.

We operate our MA plans under the Medicare Part C program and provide our eligible members with benefits comparable to those available under Medicare Parts A and B. Most of our MA plans and all of our PDPs offer prescription drug benefits to eligible members under the Medicare Part D program. Premiums for each MA member are based on our annual bids, although the rates vary according to a combination of factors, including upper payment limits established by CMS, the member's geographic location, age, gender, medical history or condition, or the services rendered to the member. Our MA contracts with CMS generally have terms of one year and expire at the end of each calendar year. PDP premiums are also based upon contracts with CMS that have a term of one year and expire at the end of each calendar year. We provide annual written bids to CMS for our PDPs, which reflect the estimated costs of providing prescription drug benefits over the plan year. Changes in MA and PDP members' health status also impact monthly premiums as described under "Risk-Adjusted Medicare Premiums" below. CMS pays all of the premium for Medicare Part C and substantially all of the premium for Medicare Part D coverage. We bill the remaining Medicare Part D premium to PDP and MA members with Part D benefits based on the plan year bid submitted to CMS. For qualifying low-income subsidy ("LIS") members, CMS pays for some or all of the LIS members' monthly premium. The CMS payment is dependent upon the member's income level as determined by the Social Security Administration.

9

We receive premiums from CMS and state agencies on a per member per month ("PMPM") basis for the members that are assigned to, or have selected, us to provide health care services under our Medicare and Medicaid contracts. We recognize premium revenue in the period in which we are obligated to provide services to our members. CMS and state agencies generally pay us in the month in which we provide services. We record premiums earned, but not received as premiums receivable and record premiums received in advance of the period of service as unearned premiums in the condensed consolidated balance sheets. Unearned premiums are recognized as revenue when we provide the related services. On a monthly basis, we bill members for any premiums for which they are responsible according to their respective plan. Member premiums are recognized as revenue in the period of service. We reduce recorded premium revenue and member premiums receivable by the amount we estimate may not be collectible, based on our evaluation of historical trends. We also routinely monitor the collectability of premiums receivable from CMS and state agencies, including Medicaid receivables for obstetric deliveries and newborns and net receivables for member retroactivity. We reduce revenue and premiums receivable by the amounts we estimate may not be collectible. We report premiums receivable, net of an allowance for uncollectible premiums receivable, which was $8.6 million and $15.8 million, at March 31, 2014 and December 31, 2013, respectively. Historically, the allowance for member premiums receivable has not been material relative to consolidated premium revenue.

We record retroactive adjustments to revenues based on changes in the number and eligibility status of our members subsequent to when we recorded revenue related to those members and months of service. We receive premium payments based upon eligibility lists produced by CMS and state agencies. We verify these lists to determine whether we have been paid for the correct premium category and program. From time to time, CMS and state agencies require us to reimburse them for premiums that we received for individuals who were subsequently determined by us, or by CMS or state agencies, to be ineligible for any government-sponsored program or to belong to a plan other than ours. We receive additional premiums from CMS and state agencies for individuals who were subsequently determined to belong to our plan for periods in which we received no premium for those members. We estimate the amount of outstanding retroactivity adjustments and adjust premium revenue based on historical trends, premiums billed, the volume of member and contract renewal activity and other information. We record amounts receivable or payable in premiums receivable, net and other accrued expenses and liabilities in the condensed consolidated balance sheets.

Supplemental Medicaid Premiums

We earn, or earned, supplemental premium payments for eligible obstetric deliveries and newborns of our Medicaid members in Georgia, Illinois, Kentucky, Missouri, New York, South Carolina and, until June 30, 2013, in Ohio. Each state Medicaid contract specifies how and when these supplemental payments are earned and paid. Upon delivery of a newborn, we notify the state agency according to the contract terms. We also earn supplemental Medicaid premium payments in some states for high cost drugs and certain services such as early childhood prevention screenings. We recognize supplemental premium revenue in the period we provide related services to our members.

Risk-Adjusted Medicare Premiums 

CMS employs a risk-adjustment model to determine the premium amount it pays for each MA and PDP member. This model apportions premiums paid to all plans according to the health status of each beneficiary enrolled, resulting in higher scores for members with predictably higher costs. The model uses diagnosis data from inpatient and ambulatory treatment settings to calculate each risk score. We collect claims and encounter data for our MA members and submit the necessary diagnosis data to CMS within prescribed deadlines. After reviewing the respective submissions, CMS establishes the premium payments to MA plans at the beginning of the plan year, and then adjusts premium levels on a retroactive basis. The first retroactive adjustment for a given plan year generally occurs during the third quarter of that year and represents the update of risk scores for the current plan year based on the severity of claims incurred in the prior plan year. CMS then issues a final retroactive risk-adjusted premium settlement for that plan year in the following year.

10

We develop our estimates for risk-adjusted premiums utilizing historical experience and predictive models as sufficient member risk score data becomes available over the course of each CMS plan year. We populate our models with available risk score data on our members and base risk premium adjustments on risk score data from the previous year. We are not privy to risk score data for members new to our plans in the current plan year; therefore we include assumptions regarding these members' risk scores. We periodically revise our estimates of risk-adjusted premiums as additional diagnosis code information is reported to CMS and adjust our estimates to actual amounts when the ultimate adjustment settlements are either received from CMS or we receive notification from CMS of such settlement amounts. As a result of the variability of factors that determine our estimates for risk-adjusted premiums, the actual amount of the CMS retroactive payment could be materially more or less than our estimates and could have a material effect on our results of operations, financial position and cash flows. We record any changes in estimates in current operations as adjustments to premium revenue. Historically, we have not experienced significant differences between our estimates and amounts ultimately received. However, in the third quarter of 2013, we recognized risk adjusted premium received as part of the 2012 final settlement that was higher than our original estimates, mainly related to members in our California MA plan that were new to Medicare in 2012. Additionally, the data provided to CMS to determine members' risk scores is subject to audit by CMS even after the annual settlements occur. An audit may result in the refund of premiums to CMS. While our experience to date has not resulted in a material refund, future refunds could materially reduce premium revenue in the year in which CMS determines a refund is required and could be material to our results of operations, financial position and cash flows. Premiums receivable in the accompanying condensed consolidated balance sheets include risk-adjusted premiums receivable of $178.6 million and $107.2 million as of March 31, 2014 and December 31, 2013, respectively.

Minimum Medical Expense and Risk Corridor Provisions

We may be required to refund certain premium revenue to CMS and state government agencies under various contractual and plan arrangements. We estimate the impact of the following arrangements on a monthly basis and reflect any adjustments to premium revenues in current operations. We report the estimated net amounts due to CMS and state agencies in other payables to government partners in the condensed consolidated balance sheets.

Certain of our Medicaid contracts require us to expend a minimum percentage of premiums on eligible medical benefits expense. To the extent that we expend less than the minimum percentage of the premiums on eligible medical benefits expense, we are required to refund to the state all or some portion of the difference between the minimum and our actual allowable medical benefits expense. We estimate the amounts due to the state agencies as a return of premium based on the terms of our contracts with the applicable state agency.

Our MA and PDP prescription drug plan premiums are subject to risk sharing through the CMS Medicare Part D risk corridor provisions. The risk corridor calculation compares our actual experience to the target amount of prescription drug costs, limited to costs under the standard coverage as defined by CMS, less rebates included in our submitted plan year bid. We receive additional premium from CMS if our actual experience is more than 5% above the target amount. We refund premiums to CMS if our actual experience is more than 5% below the target amount. After the close of the annual plan year, CMS performs the risk corridor calculation and any differences are settled between CMS and our plans. We have not historically experienced material differences between the subsequent CMS settlement amount and our estimates.

Medicare Part D Settlements

We receive certain Part D prospective subsidy payments from CMS for our MA and PDP members based on the estimated costs of providing prescription drug benefits over the plan year. After the close of the annual plan year, CMS reconciles our actual experience to the prospective payments we received and any differences are settled between CMS and our plans. As such, these subsidies represent funding from CMS for which we assume no risk. We do not recognize the receipt of these subsidies as premium revenue and we do not recognize the payments of related prescription drug benefits as medical benefits expense. We report the subsidies received and benefits paid on a net basis as funds receivable (held) for the benefit of members in the condensed consolidated balance sheets. We also report the net receipts and payments as a financing activity in our condensed consolidated statements of cash flows. CMS pays the following subsidies prospectively as a fixed PMPM amount based upon the plan year bid submitted by us:

Low-Income Cost Sharing Subsidy—CMS reimburses us for all or a portion of qualifying LIS members' deductible, coinsurance and co-payment amounts above the out-of-pocket threshold.

Catastrophic Reinsurance Subsidy—CMS reimburses us for 80% of the drug costs after a member reaches his or her out-of-pocket catastrophic threshold through a catastrophic reinsurance subsidy.

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Coverage Gap Discount Subsidy—We advance the pharmaceutical manufacturers gap coverage discounts at the point of sale. On a periodic basis, CMS bills pharmaceutical manufacturers for discounts advanced by us. Pharmaceutical manufacturers remit payments for invoiced amounts directly to us. CMS reduces subsequent prospective payments made to us by the discount amounts billed to manufacturers.

CMS generally performs the Part D payment reconciliation in the fourth quarter of the following plan year based on prescription drug event data we submit to CMS within prescribed deadlines. After the Part D payment reconciliation for coverage gap discount subsidies, we may continue to report discounts to CMS for 37 months following the end of the plan year. CMS will invoice manufacturers for these discounts and we will be paid through the quarterly manufacturer payments. Historically, we have not experienced material adjustments related to the CMS annual reconciliation of prior plan year low-income cost sharing, catastrophic reinsurance, and coverage gap discount subsidies.

Medical Benefits and Medical Benefits Payable

We recognize the cost of medical benefits in the period in which services are provided, including an estimate of the cost of medical benefits incurred but not reported ("IBNR"). Medical benefits expense includes direct medical expenses and certain medically-related administrative costs.

Direct medical expenses include amounts paid or payable to hospitals, physicians and providers of ancillary services, such as laboratories and pharmacies. We also record direct medical expenses for estimated referral claims related to health care providers under contract with us who are financially troubled or insolvent and who may not be able to honor their obligations for the costs of medical services provided by others. In these instances, we may be required to honor these obligations for legal or business reasons. Based on our current assessment of providers under contract with us, such losses have not been and are not expected to be significant. We record direct medical expense for our estimates of provider settlement due to clarification of contract terms, out-of-network reimbursement, claims payment differences and amounts due to contracted providers under risk-sharing arrangements. We estimate pharmacy rebates earned based on historical utilization of specific pharmaceuticals, current utilization and contract terms and record amounts as a reduction of recorded direct medical expenses.

Consistent with the criteria specified and defined in guidance issued by the Department of Health and Human Services ("HHS") for costs that qualify to be reported as medical benefits under the minimum medical loss ratio provision of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the "ACA"), we record certain medically-related administrative costs such as preventive health and wellness, care management, and other quality improvement costs, as medical benefits expense. All other medically-related administrative costs, such as utilization review services, network and provider credentialing and claims handling costs, are recorded in selling, general, and administrative expense.

Medical benefits payable represents amounts for claims fully adjudicated but not yet paid and estimates for IBNR. Our estimate of IBNR is the most significant estimate included in our condensed consolidated financial statements. We determine our best estimate of the base liability for IBNR utilizing consistent standard actuarial methodologies based upon key assumptions which vary by business segment. Our assumptions include current payment experience, trend factors and completion factors. Trend factors in our standard actuarial methodologies include contractual requirements, historic utilization trends, the interval between the date services are rendered and the date claims are paid, denied claims activity, disputed claims activity, benefit changes, expected health care cost inflation, seasonality patterns, maturity of lines of business, changes in membership and other factors.

After determining an estimate of the base liability for IBNR, we make an additional estimate, also using standard actuarial techniques, to account for adverse conditions that may cause actual claims to be higher than the estimated base reserve. We refer to this additional liability as the provision for moderately adverse conditions. Our estimate of the provision for moderately adverse conditions captures the potential adverse development from factors such as:

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• our entry into new geographical markets;

• our provision of services to new populations such as the aged, blind and disabled;

• variations in utilization of benefits and increasing medical costs;

• changes in provider reimbursement arrangements;

• variations in claims processing speed and patterns, claims payment and the severity of claims; and

• health epidemics or outbreaks of disease such as the flu.

We consider the base actuarial model liability and the provision for moderately adverse conditions as part of our overall assessment of our IBNR estimate to properly reflect the complexity of our business, the number of states in which we operate, and the need to account for different health care benefit packages among those states. We evaluate our estimates of medical benefits payable as we obtain more complete claims information and medical expense trend data over time. Volatility in members' needs for medical services, provider claims submissions and our payment processes result in identifiable patterns emerging several months after the causes of deviations from our assumed trends occur. Changes in our estimates of medical benefits payable cannot typically be explained by any single factor, but are the result of a number of interrelated variables, all of which influence the resulting medical cost trend. We record differences between actual experience and estimates used to establish the liability, which we refer to as favorable and unfavorable prior period reserve developments, as increases or decreases to medical benefits expense in the period we identify the differences.

For the quarter ended March 31, 2014, we recognized approximately $32.5 million of net unfavorable development related to prior fiscal years. For the quarter ended March 31, 2013 we recognized approximately $15.9 million of net favorable development related to prior years. The unfavorable development recognized in 2014 was primarily due to higher than expected medical services in our Medicare Health Plan segment, that was not discernible until the impact became clearer over time as claim payments were processed. In addition, we incurred expense associated with adjustments to prior year enhanced payments to Medicaid primary care providers, as mandated by the ACA. The net favorable prior year development recognized in 2013 was due mainly to lower than projected utilization in our Medicaid segment, and to a lesser extent, in our Medicare segment.

Reinsurance

We cede certain premiums and medical benefits to other insurance companies under various reinsurance agreements in order to increase our capacity to write larger risks and maintain our exposure to loss within our capital resources. We are contingently liable in the event the reinsurance companies do not meet their contractual obligations. We evaluate the financial condition of the reinsurance companies on a regular basis and only contract with well-known, well-established reinsurance companies that are supported by strong financial ratings. We account for reinsurance premiums and medical expense recoveries according to the terms of the underlying reinsurance contracts.

ACA Industry Fee

The ACA imposes an annual premium-based health insurance industry assessment (the "ACA industry fee") on health insurers beginning in 2014. The total ACA industry fee levied on the health insurance industry will be $8 billion in 2014, with increasing annual amounts thereafter and growing to $14.3 billion by 2018. After 2018, the ACA industry fee increases according to an index based on net premium growth. The assessment will be levied on certain health insurers that provide insurance in the assessment year, and will be allocated to health insurers based on each health insurer's share of net premiums for all U.S. health insurers in the year preceding the assessment. The ACA industry fee will not be deductible for income tax purposes, which will significantly increase our effective income tax rate. We currently estimate that we will incur approximately $129.0 million in such fees in 2014, based on our estimated share of total 2013 industry premiums. However, the final fee amount will not be determined until August 2014. The estimated liability for the fee was accrued in full as of January 1, 2014, with a corresponding deferred expense asset that is being amortized to expense on a straight line basis. We have recognized approximately $32.3 million of such amortization as ACA industry fee expense in the first quarter of 2014.

We have received amendments, written agreements or other documentation from our state Medicaid customers in Florida, Georgia, Kentucky, Missouri and South Carolina which provides for them to reimburse us for the portion of the ACA industry fee attributable to the Medicaid programs in those states, including the related state and federal income tax gross-ups. Consequently, we recognized $23.6 million of reimbursement for the ACA industry fee as premium revenue in the quarter ended March 31, 2014. We currently expect to be reimbursed by our state Medicaid customers in Hawaii, Illinois, New York and Ohio for the impact of the fee on our Medicaid plans, including its non-deductibility for income tax purposes. However, the revenue recognition for such reimbursement is delayed until we are able to reach contractual agreement with these customers, and the timing of revenue recognition for these other markets will not match the expense recognition of the fee. MA and PDP premiums will not be adjusted to offset the impact of the ACA industry fee.

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Equity-Based Employee Compensation

During the second quarter of 2013, our stockholders approved the WellCare Health Plans, Inc. 2013 Incentive Compensation Plan (the "2013 Plan"). Upon approval of the 2013 Plan, a total of 2,500,000 shares of our common stock were available for issuance pursuant to the 2013 Plan, minus any shares subject to outstanding awards granted on or after January 1, 2013 under our 2004 Equity Incentive Plan ("the Prior Plan"). In addition, shares subject to awards forfeited under the Prior Plan will become available for issuance under the 2013 Plan. No further awards are permitted to be granted under our Prior Plan. The Compensation Committee of our Board of Directors (the "Compensation Committee") awards certain equity-based compensation under our stock plans, including stock options, restricted stock, restricted stock units ("RSUs"), performance stock units ("PSUs") and market stock units ("MSUs"). We estimate equity-based compensation expense based on awards ultimately expected to vest. We make assumptions of forfeiture rates at the time of grant and continuously reassess our assumptions based on actual forfeiture experience.

We estimate compensation cost for stock options, restricted stock, RSUs and MSUs based on the fair value at the time of grant and recognize expense over the vesting period of the award. For stock options, the grant date fair value is measured using the Black-Scholes options-pricing model. For restricted stock and RSUs, the grant date fair value is based on the closing price of our common stock on the grant date. For MSUs, the fair value at the grant date is measured using a Monte Carlo simulation approach which estimates the fair value of awards based on randomly generated simulated stock-price paths through a lattice-type structure. MSUs expected to vest are recognized as expense on a straight-line basis over the vesting period, which is generally three years. The number of shares of common stock earned upon vesting is determined based on the ratio of the Company's common stock price during the last 30 market trading days of the calendar year immediately preceding the vesting date to the comparable common stock price as of the grant date, applied to the base units granted. The performance ratio is capped at 150% or 200%, depending on the grant date. If our common stock price declines by more than 50% over the performance period, no shares are earned by the recipient.

At its sole discretion, the Compensation Committee sets certain financial and quality-based performance goals and a target award amount for each award of PSUs. PSUs generally cliff-vest three years from the grant date based on the achievement of the performance goals and are conditioned on the employee's continued service through the vesting date. The actual number of common stock shares earned upon vesting will range from zero shares up to 150% or 200% of the target award, depending on the award date. PSUs do not have a grant date or grant fair value for accounting purposes as the subjective nature of the terms of the PSUs precludes a mutual understanding of the key terms and conditions. We recognize expense for PSUs ultimately expected to vest over the requisite service period based on our estimates of progress made towards the achievement of the predetermined performance measures and changes in the market price of our common stock.

Medicaid Premium Taxes

Premium rates established in the Medicaid contracts with Georgia, Hawaii and New York, and, until June 30, 2013, Ohio, include, or included, an assessment or tax on Medicaid premiums. We recognize the premium tax assessment as expense in the period during which we earn the related premium revenue and remit the taxes back to the state agencies on a periodic basis.

Property, Equipment and Capitalized Software, net

Property, equipment and capitalized software are stated at historical cost, net of accumulated depreciation. We capitalize certain costs incurred in the development of internal-use software, including external direct costs of materials and services and payroll costs of employees devoted to specific software development. We expense other software development costs, such as training and data conversion costs, as incurred. We capitalize the costs of improvements that extend the useful lives of the related assets.

We record depreciation expense using the straight-line method over the estimated useful lives of the related assets, which ranges from three to ten years for leasehold improvements, five for furniture and equipment, and three to five years for computer equipment and software. We include amortization of equipment under capital leases in depreciation expense. We record maintenance and repair costs as selling, general and administrative expense when incurred.

On an ongoing basis, we review events or changes in circumstances that may indicate that the carrying value of an asset may not be recoverable. If the carrying value of an asset exceeds the sum of estimated undiscounted future cash flows, we recognize an impairment loss in the current period for the difference between estimated fair value and carrying value. If assets are determined to be recoverable but the useful lives are shorter than we originally estimated, we depreciate the remaining net book value of the asset over the newly determined remaining useful lives.

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Goodwill and Intangible Assets

Goodwill represents the excess of the cost over the fair market value of net assets acquired and is attributable to our Medicaid and Medicare Health Plans reporting segments. Goodwill recorded at March 31, 2014 was $244.9 million, which consisted of $134.5 million and $110.4 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Goodwill recorded at December 31, 2013 was $236.8 million, which consisted of $126.8 million and $110.0 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Other intangible assets include provider networks, broker networks, trademarks, state contracts, non-compete agreements, licenses and permits. We amortize other intangible assets over their estimated useful lives ranging from approximately one to 15 years. These assets are allocated to reporting segments for impairment testing purposes.

We review goodwill and intangible assets for impairment at least annually, or more frequently if events or changes in our business climate occur that may potentially affect the estimated useful life or the recoverability of the remaining balance of goodwill or intangible assets. Such events or changes in circumstances would include significant changes in membership, state funding, federal and state government contracts and provider networks. To determine whether goodwill is impaired, we perform a multi-step impairment test. First, we can elect to perform a qualitative assessment of each reporting unit to determine whether facts and circumstances support a determination that their fair values are greater than their carrying values. If the qualitative analysis is not conclusive, or if we elect to proceed directly with quantitative testing, we will then measure the fair values of the reporting units using a two-step approach. In the first step, we determine the fair value of the reporting unit using both income and market approaches. We calculate fair value based on our assumptions of key factors such as projected revenues and the discount factor. While we believe these assumptions and estimates are appropriate, other assumptions and estimates could be applied and may produce significantly different results. If the fair value of the reporting unit is less than its carrying value, we measure and record the amount of the goodwill impairment, if any, by comparing the implied fair value of the reporting unit's goodwill to the carrying value. We perform our annual goodwill impairment test based on our financial position and results of operations through the second quarter of each year, which generally coincides with the finalization of federal and state contract negotiations and our initial budgeting process.

In 2013, we elected to bypass the optional qualitative fair value assessment and conducted our annual quantitative test for goodwill impairment during the third quarter of 2013. Based on the results of our quantitative test, we determined that the fair values of our reporting units exceeded their carrying values and therefore no further testing was required, and we believe that such assets are not impaired as of March 31, 2014.

Income Taxes

We record income tax expense as incurred based on enacted tax rates, estimates of book-to-tax differences in income, and projections of income that will be earned in each taxing jurisdiction. We recognize deferred tax assets and liabilities for the estimated future tax consequences of differences between the carrying amounts of existing assets and liabilities and their respective tax basis. We measure deferred tax assets and liabilities using tax rates applicable to taxable income in the years in which we expect to recover or settle those temporary differences. We record a valuation allowance on deferred taxes if we determine it is more likely than not that we will not fully realize the future benefit of deferred tax assets. We file tax returns after the close of our fiscal year end and adjust our estimated tax receivable or liability to the actual tax receivable or due per the filed state and federal tax returns. Historically, we have not experienced significant differences between our estimates of income tax expense and actual amounts incurred.

State and federal taxing authorities may challenge the positions we take on our filed tax returns. We evaluate our tax positions and only recognize a tax benefit if it is more likely than not that a tax audit will sustain our conclusion. Based on our evaluation of tax positions, we believe that potential tax exposures have been recorded appropriately. State and federal taxing authorities may propose additional tax assessments based on periodic audits of our tax returns. We believe our tax positions comply with applicable tax law in all material aspects and we will vigorously defend our positions on audit. The ultimate resolution of these audits may materially impact our financial position, results of operations or cash flows. We have not experienced material adjustments to our condensed consolidated financial statements as a result of these audits.

We participate in the Internal Revenue Service ("IRS") Compliance Assurance Process ("CAP"). The objective of CAP is to reduce taxpayer burden and uncertainty by working with the IRS to ensure tax return accuracy prior to filing, thereby reducing or eliminating the need for post-filing examinations.

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Pro Forma Financial Information

The results of operations and financial condition for our 2014 and 2013 acquisitions have been included in our condensed consolidated financial statements since the respective acquisition dates. The unaudited pro forma financial information presented below assumes that the acquisitions occurred as of January 1, 2013. The pro forma adjustments include the pro forma effect of the amortization of finite-lived intangible assets arising from the purchase price allocations, adjustments necessary to align the acquired companies' accounting policies to our accounting policies and the associated income tax effects of the pro forma adjustments. The following unaudited pro forma results have been prepared for comparative purposes only and do not purport to be indicative of the results of operations that would have occurred had the acquisitions been consummated at the beginning of the periods presented. Only pro forma results for the first quarter of 2013 have been presented, as Windsor was acquired on January 1, 2014 and their results of operations have been included in our condensed consolidated financial statements from this date.

	Pro forma - unaudited
	For Quarter ended March 31, 2013
(in millions, except per share data)
Premium revenues	$	2,564.9
Net earnings	$	8.4
Earnings per share:
Basic	$	0.19
Diluted	$	0.19

Recently Adopted Accounting Standards

In July 2013, the Financial Accounting Standards Board ("FASB") issued ASU 2013-11, "Incomes Taxes (Topic 740): Presentation of an Unrecognized Tax Benefit When a Net Operating Loss Carryforward, a Similar Tax Loss, or a Tax Credit Carryforward Exists." This update addresses the diversity in practice regarding financial statement presentation of an unrecognized tax benefit when a net operating loss carryforward, a similar tax loss, or a tax credit carryforward exists. The guidance requires an unrecognized tax benefit, or a portion thereof, to be presented in the financial statements as a reduction to a deferred tax asset for a net operating loss carryforward, a similar tax loss, or a tax credit carryforward. To the extent the deferred tax asset is not available at the reporting date to settle any additional income taxes that would result from the disallowance of a tax position, the unrecognized tax benefit should be presented in the financial statements as a liability and should not be combined with the deferred tax asset. The amendments in this standard are effective for reporting periods beginning after December 15, 2013, with early adoption permitted. We adopted this standard effective January 1, 2014, without any material impact on our consolidated financial position, results of operations or cash flows.

In February 2013, the FASB issued ASU 2013-04, "Liabilities (Topic 405): Obligations Resulting from Joint and Several Liability Arrangements for Which the Total Amount of the Obligation Is Fixed at the Reporting Date." This update provides guidance for the recognition, measurement and disclosure of obligations resulting from joint and several liability arrangements for which the total amount of the obligation within the scope of the guidance is fixed at the reporting date. The guidance in this update also requires the entity to disclose the nature and amount of the obligation, as well as other information about such obligations. The guidance is effective for fiscal years beginning after December 15, 2013, with early adoption permitted. We adopted this standard effective January 1, 2014, without any material impact on our consolidated financial position, results of operations or cash flows.

In July 2011, the FASB issued ASU 2011-06, "Other Expenses – Fees Paid to the Federal Government by Health Insurers." This update addresses accounting for the annual fees mandated by the ACA. The ACA imposes an annual fee on health insurers, payable to the U.S. government, calculated on net premiums and third-party administrative agreement fees. The updated standard requires that the liability for the fee be estimated and accrued in full once the entity provides qualifying health insurance in the applicable calendar year in which the fee is payable with a corresponding deferred cost that is amortized to expense. The fees are initiated for calendar years beginning January 1, 2014, and the amendments provided by this update become effective for calendar years beginning after December 31, 2013. We adopted this standard effective January 1, 2014, and at March 31, 2014, our estimated liability for the ACA industry fee is approximately $129.0 million.

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2. ACQUISITIONS

Windsor

On January 1, 2014, we acquired all of the outstanding stock of Windsor from Munich Health North America, Inc., a part of Munich Re Group. Through its subsidiaries, Windsor serves Medicare beneficiaries with MA, PDP and Medicare Supplement products. As of March 31, 2014, Windsor offered MA plans in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee through which it served 38,000 members. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it served 48,000 members in 39 states as of March 31, 2014. Windsor also offers PDPs in 11 of the 34 CMS regions, through which it served approximately 109,000 beneficiaries as of March 31, 2014. We included the results of Windsor's operations from the date of acquisition in our condensed consolidated financial statements. Windsor’s operations contributed premium revenue of $167.6 million and a net pre-tax loss of $17.4 million, including certain one-time costs for severance and integration, which are included in our condensed consolidated statement of comprehensive income for the quarter ended March 31, 2014.

The following table summarizes the preliminary estimated fair values of tangible and intangible assets acquired and liabilities assumed at the acquisition date.

Cash and cash equivalents	$	169.0
Investments	47.1
Premiums receivable, net	87.4
Other intangible assets	54.3
Pharmacy rebates receivable, net	35.4
Other assets	27.9
Deferred tax asset	29.6
Total assets acquired	450.7
Medical benefits payable	(118.1		)
Accrued expenses and other payables	(74.1		)
Deferred tax liability	(20.6		)
Total liabilities assumed	(212.8		)
Fair value of net assets acquired	$	237.9

As a result of the Windsor acquisition, the estimated fair value of the net tangible and intangible assets that we acquired exceeded the total consideration payable to the seller by approximately $28.3 million. When assessing this result from an accounting perspective, we considered:

▪ the seller’s decision to divest Windsor following a review of its business strategy in the U.S. and focus on other types of health businesses;

▪ the value of net assets we acquired included the benefit of net operating losses and other tax benefits that the seller was not able to utilize given its tax position, and

▪ a credit reflected in the purchase price for certain transition costs we expected to incur after the transaction closed.

After consideration of all relevant factors, including those cited above, and verifying that all assets acquired and liabilities assumed were identified, we concluded that the excess fair value of $28.3 million constituted a bargain purchase gain in accordance with accounting rules related to business combinations. The amount of the gain could change depending on the resolution of certain matters related to the purchase price.

As reflected in the table above, we recorded $54.3 million for the preliminary valuation of identified other intangible assets, including MA and Medicare Supplement membership bases of $20.1 million (15-year useful life), PDP membership bases of $17.5 million (8-year useful life), provider networks of $5.2 million (15-year useful life), broker networks of $3.3 million (10-year useful life) and aggregated other identified intangible assets of $8.2 million (9-year useful life). We valued the other intangible assets using a combination of income and cost approaches, where appropriate. Membership bases were valued based on the income approach using a discounted future cash flow analysis based on our consideration of historical financial

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results and expected industry and market trends. We discounted the future cash flows by a weighted-average cost of capital based on an analysis of the cost of capital for guideline companies within our industry. We amortize the intangible assets on a straight-line basis over the period we expect these assets to contribute directly or indirectly to the future cash flows. The weighted average amortization period for these intangibles was 11.5 years. The allocation of the purchase price is based on certain preliminary data and could change when final information is obtained.

WellCare of South Carolina

On January 31, 2013, we acquired all outstanding stock of WellCare of South Carolina, Inc. ("WCSC"), formerly UnitedHealthcare of South Carolina, Inc., a South Carolina Medicaid subsidiary of UnitedHealth Group Incorporated. We included the results of WCSC's operations from the date of acquisition in our condensed consolidated financial statements.

We completed certain aspects of the accounting for the WCSC acquisition during the first quarter of 2014, and based on the final purchase price allocation, we allocated $24.7 million of the purchase price to identified tangible net assets and $9.5 million of the purchase price to identified intangible assets. We recorded the excess of purchase price over the aggregate fair values of $12.7 million as goodwill. The recorded goodwill and other intangible assets related to the WCSC acquisition are deductible for tax purposes.

Missouri Care

On March 31, 2013, we acquired all outstanding stock of Missouri Care, Incorporated, a subsidiary of Aetna Inc. ("Missouri Care"), which participates in the Missouri HealthNet Medicaid program. We began serving Missouri Care members effective April 1, 2013 and we included the results of Missouri Care's operations from the date of acquisition in our condensed consolidated financial statements. As of March 31, 2014, Missouri Care membership approximated 99,000.

We completed certain aspects of the accounting for the Missouri Care acquisition during the first quarter of 2014, and based on the final purchase price allocation, we allocated $10.2 million of the purchase price to identified tangible net assets and $7.1 million of the purchase price to identified intangible assets. We recorded the excess of purchase price over the aggregate fair values of $10.7 million as goodwill, which reflects a $7.7 million increase recognized during the first quarter of 2014. The recorded goodwill and other intangible assets related to the Missouri Care acquisition are deductible for tax purposes.

3. SEGMENT REPORTING

On a regular basis, we evaluate discrete financial information and assess the performance of our three reportable segments, Medicaid Health Plans, Medicare Health Plans and Medicare PDPs, to determine the most appropriate use and allocation of Company resources. Prior to the Windsor acquisition, we identified three operating segments for our company: Medicaid, MA and PDP. In conjunction with the Windsor acquisition, we began offering Medicare Supplement products and we reassessed our segment reporting practices and made revisions to reflect our current method of managing performance and determining resource allocation, which includes reviewing the results of Medicare Supplement and MA operations acquired as part of the Windsor acquisition together with our legacy MA plans. Accordingly, we are including results for Medicare Supplement operations together with MA and have renamed the segment as Medicare Health Plans. Similarly, we are including the PDP operations acquired as part of the Windsor acquisition together with WellCare’s PDPs and have renamed the segment as Medicare PDPs. In addition, we have renamed the Medicaid segment Medicaid Health Plans; however, there were no changes to the composition of this segment.

Medicaid Health Plans

Our Medicaid Health Plans segment includes plans for beneficiaries of Temporary Assistance for Needy Families ("TANF"), Supplemental Security Income ("SSI"), Aged Blind and Disabled ("ABD") and other state-based programs that are not part of the Medicaid program, such as Children's Health Insurance Program ("CHIP"), Family Health Plus ("FHP"), and Managed Long-Term Care ("MLTC") programs. TANF generally provides assistance to low-income families with children. ABD and SSI generally provide assistance to low-income aged, blind or disabled individuals. CHIP and FHP programs provide assistance to qualifying families who are not eligible for Medicaid because their income exceeds the applicable income thresholds. The MLTC program is designed to help people with chronic illnesses or who have disabilities and need health and long-term care services, such as home care or adult day care, to enable them to stay in their homes and communities as long as possible.

Our Medicaid operations in certain states individually account for 10% or more of our consolidated premium revenue. Those states, and the respective Medicaid premium revenue as a percentage of total consolidated premium revenue, are as follows: 

	For the Three Months Ended March 31,
	2014	2013
Georgia	12%	16%
Florida	10%	12%
Kentucky	17%	13%

The state of Florida renewed our Florida Medicaid contracts for a three-year period beginning September 1, 2012 through August 31, 2015. We expect these contracts to be terminated early in connection with the implementation of the new program. In February 2014, we executed a contract with the Florida Agency for Health Care Administration ("AHCA") to provide Medicaid services in eight out of the state's 11 regions. We expect that starting in the second quarter of 2014, two to three regions will be launched per month, and all regions should be launched by late summer or early fall of 2014.

The Georgia Department of Community Health (the "Georgia DCH") exercised its option in June 2013 to extend the term of our Georgia Medicaid contract until June 30, 2014. In April 2014, the Georgia DCH amended our Georgia Medicaid contract to include two additional one-year renewal options, exercisable by the Georgia DCH, which could potentially extend the contract term to June 30, 2016.

Our primary Kentucky contract commenced in July 2011 and has an initial three-year term and provides for four additional one-year option terms, exercisable upon mutual agreement of the parties, which potentially extends the total term until July 2018. The first option term, through June 30, 2015, has been exercised.

Medicare Health Plans

Our Medicare Health Plans reportable segment includes the combined operations of both the MA and Medicare Supplement operating segments. Medicare is a federal program that provides eligible persons age 65 and over and some disabled persons with a variety of hospital, medical and prescription drug benefits. MA is Medicare's managed care alternative to the original Medicare program, which provides individuals standard Medicare benefits directly through CMS. Our MA CCPs generally require members to seek health care services and select a primary care physician from a network of health care providers. In addition, we offer coverage of prescription drug benefits under the Medicare Part D program as a component of most of our MA plans. Medicare Supplement policies are offered in 39 states as of March 31, 2014.

Medicare PDPs

We offer stand-alone Medicare Part D coverage to Medicare-eligible beneficiaries in our Medicare PDPs segment. The Medicare Part D prescription drug benefit is supported by risk sharing with the federal government through risk corridors designed to limit the losses and gains of the participating drug plans and by reinsurance for catastrophic drug costs. The government subsidy is based on the national weighted average monthly bid for this coverage, adjusted for risk factor payments. Additional subsidies are provided for dually-eligible beneficiaries and specified low-income beneficiaries. The Part D program offers national in-network prescription drug coverage that is subject to limitations in certain circumstances.

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Summary of Financial Information

We allocate goodwill and other intangible assets to our reportable operating segments. We do not allocate any other assets and liabilities, investment and other income, or selling, general and administrative, depreciation and amortization, or interest expense to our reportable operating segments, with the exception of the ACA industry fee. The Company's decision-makers primarily use premium revenue, medical benefits expense and gross margin to evaluate the performance of our reportable operating segments. A summary of financial information for our reportable operating segments through the gross margin level and a reconciliation to income before income taxes is presented in the tables below.

	For the Three Months Ended March 31,
	2014			2013
Premium revenue:	(in millions)
Medicaid Health Plans	$	1,638.8		$	1,310.4
Medicare Health Plans	963.3			718.9
Medicare PDPs	373.0			223.0
Total premium revenue	2,975.1			2,252.3
Medical benefits expense:
Medicaid Health Plans	1,389.3			1,130.7
Medicare Health Plans	851.5			625.6
Medicare PDPs	389.1			231.0
Total medical benefits expense	2,629.9			1,987.3
ACA industry fee expense:
Medicaid Health Plans	18.9			—
Medicare Health Plans	10.7			—
Medicare PDPs	2.7			—
Total ACA industry fee expense	32.3			—
Gross margin
Medicaid Health Plans	230.6			179.7
Medicare Health Plans	101.1			93.3
Medicare PDPs	(18.8		)	(8.0		)
Total gross margin	312.9			265.0
Investment and other income	10.6			4.3
Other expenses	(286.2		)	(246.4		)
Income from operations	$	37.3		$	22.9

4.NET INCOME PER COMMON SHARE

We compute basic net income per common share on the basis of the weighted-average number of unrestricted common shares outstanding. We compute diluted net income per common share on the basis of the weighted-average number of unrestricted common shares outstanding plus the dilutive effect of outstanding stock options, restricted stock, RSUs, MSUs and PSUs using the treasury stock method.

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The calculation of the weighted-average common shares outstanding — diluted is as follows:

	For the Three Months Ended March 31,
	2014	2013
Weighted-average common shares outstanding — basic	43,802,047	43,325,381
Dilutive effect of:
Unvested restricted stock, restricted stock units, market stock and performance stock units	308,133	426,593
Stock options	13,611	200,485
Weighted-average common shares outstanding — diluted	44,123,791	43,952,459
Anti-dilutive stock options, restricted stock and performance based awards excluded from computation	72,457	184,536

5. INVESTMENTS

The Company considers all of its investments as available-for-sale securities. The amortized cost, gross unrealized gains or losses and estimated fair value of short-term and long term investments by security type are summarized in the following tables.

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Auction rate securities	$	34.2	$	—	$	(2.3	)	$	31.9
Certificates of deposit	1.1		—		—			1.1
Corporate debt and other securities	79.6		0.2		(0.1		)	79.7
Money market funds	43.4		—		—			43.4
Municipal securities	119.7		0.1		—			119.8
Variable rate bond fund	109.9		0.4		—			110.3
U.S. government securities	38.9		0.1		(0.1		)	38.9
	$	426.8	$	0.8	$	(2.5	)	$	425.1
December 31, 2013
Auction rate securities	$	34.2	$	—	$	(2.4	)	$	31.8
Certificates of deposit	1.6		—		—			1.6
Corporate debt and other securities	104.5		0.1		(0.1		)	104.5
Money market funds	43.4		—		—			43.4
Municipal securities	108.9		—		—			108.9
Variable rate bond fund	84.9		0.4		—			85.3
U.S. government securities	19.5		0.1		—			19.6
	$	397.0	$	0.6	$	(2.5	)	$	395.1

Realized gains and losses on sales and redemptions of investments were not material for the three months ended March 31, 2014 and 2013.

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Contractual maturities of available-for-sale investments at March 31, 2014 are as follows:

	Total		Within 1 Year		1 Through 5 Years		5 Through 10 Years		Thereafter
Auction rate securities	$	31.9	$	—	$	—	$	—	$	31.9
Certificates of deposit	1.1		1.1		—		—		—
Corporate debt and other securities	79.7		47.0		29.6		0.9		2.2
Money market funds	43.4		43.4		—		—		—
Municipal securities	119.8		84.7		31.1		2.5		1.5
Variable rate bond fund	110.3		110.3		—		—		—
U.S. government securities	38.9		2.2		34.1		2.5		0.1
	$	425.1	$	288.7	$	94.8	$	5.9	$	35.7

Actual maturities may differ from contractual maturities due to the exercise of pre-payment options.

Excluding investments in U.S. government securities, we are not exposed to any significant concentration of credit risk in our fixed maturities portfolio. Our long-term investments include $31.9 million estimated fair value of municipal note securities with an auction reset feature ("auction rate securities"), which were issued by various state and local municipal entities for the purpose of financing student loans, public projects and other activities. Liquidity for these auction rate securities is typically provided by an auction process which allows holders to sell their notes and resets the applicable interest rate at pre-determined intervals, usually every seven or 35 days. We consider our auction rate securities to be in an inactive market as auctions have continued to fail in 2014. Our auction rate securities have been in an unrealized loss position for more than twelve months. Two auction rate securities with an aggregate par value of $22.6 million have investment grade security credit ratings and one auction rate security with a par value of $11.6 million has a credit rating below investment grade. Our auction rate securities are covered by government guarantees or municipal bond insurance and we have the ability and intent to hold these securities until maturity or market stability is restored. Accordingly, we do not believe our auction rate securities are impaired and have not recorded any other-than-temporary impairment as of March 31, 2014.

There were no redemptions or sales of our auction rate securities during the quarters ended March 31, 2014 and March 31, 2013, and accordingly, we realized no losses associated with our auction rate securities during either of those periods.

6. RESTRICTED INVESTMENTS

The amortized cost, gross unrealized gains, gross unrealized losses and fair value of our restricted investment securities are as follows: 

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Cash	$	49.3	$	—	$	—		$	49.3
Certificates of deposit	1.4		—		—			1.4
Money market funds	18.9		—		—			18.9
U.S. government securities	25.4		—		(0.1		)	25.3
	$	95.0	$	—	$	(0.1	)	$	94.9
December 31, 2013
Cash	$	40.2	$	—	$	—		$	40.2
Certificates of deposit	1.4		—		—			1.4
Money market funds	19.0		—		—			19.0
U.S. government securities	22.0		—		(0.1		)	21.9
	$	82.6	$	—	$	(0.1	)	$	82.5

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No realized gains or losses were recorded on restricted investments for the quarters ended March 31, 2014 and March 31, 2013.

7. EQUITY-BASED COMPENSATION

Compensation expense related to our equity-based compensation awards was $1.2 million and $3.7 million for the quarters ended March 31, 2014 and March 31, 2013, respectively. As of March 31, 2014, there was $22.3 million of unrecognized compensation cost related to non-vested equity-based compensation arrangements that is expected to be recognized over a weighted-average period of 2.2 years. The unrecognized compensation cost for our PSUs, which are subject to variable accounting, was determined based on the closing common stock price of $63.52 as of March 31, 2014 and amounted to approximately $7.0 million of the total unrecognized compensation. Due to the nature of the accounting for these awards, future compensation cost will fluctuate based on changes in our common stock price.

A summary of stock option activity for the quarter ended March 31, 2014, and the aggregate intrinsic value and weighted average remaining contractual term for stock options as of March 31, 2014, is presented in the table below.

	Shares		Weighted Average Exercise Price		Aggregate Intrinsic Value		Weighted Average Remaining Contractual Term (Years)
Outstanding as of January 1, 2014	31,381		$	29.47
Granted	—		—
Exercised	(13,000	)	19.96
Forfeited and expired	—		—
Outstanding as of March 31, 2014 (1)	18,381		$	36.20	$	0.5	1.5

(1)    All of the Company's outstanding stock options were vested and exercisable as of March 31, 2014.

A summary of RSU activity for the quarter ended March 31, 2014 is presented in the table below.

	RSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	259,836		$	56.51
Granted	137,356		61.71
Vested	(54,869	)	58.80
Forfeited and expired	(12,472	)	57.23
Outstanding as of March 31, 2014	329,851		58.27

A summary of our MSU activity for the quarter ended March 31, 2014 is presented in the table below.

	MSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	83,889		$	79.38
Granted	62,238		70.36
Vested	—		—
Forfeited and expired	(8,236	)	75.72
Outstanding as of March 31, 2014	137,891		75.53

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A summary of the activity for our PSU awards, which are subject to variable accounting, for the quarter ended March 31, 2014 is presented in the table below.

	PSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	288,487		$	55.30
Granted	153,070		59.93
Vested	(62,640	)	40.57
Forfeited and expired	(21,949	)	59.86
Outstanding as of March 31, 2014	356,968		59.59

8. DEBT

Senior Notes due 2020

In November 2013, we completed the offering and sale of $600.0 million aggregate principal amount of 5.75% unsecured senior notes due 2020 (the “Senior Notes”). The aggregate net proceeds from the issuance of the Senior Notes were used to repay the full outstanding balance under our 2011 credit agreement, and the remaining net proceeds are being used for general corporate purposes, including organic growth opportunities and potential acquisitions. The Senior Notes will mature on November 15, 2020, and bear interest at a rate of 5.75% per annum. Interest is computed on the basis of a 360-day year comprised of twelve 30-day months. Interest on the Senior Notes is payable semi-annually on May 15 and November 15 of each year, commencing on May 15, 2014.

The Senior Notes were issued under an indenture, dated as of November 14, 2013 (the “Base Indenture”), as supplemented by the First Supplemental Indenture, dated as of November 14, 2013 (the “First Supplemental Indenture” and, together with the Base Indenture, the “Indenture”) each between us and The Bank of New York Mellon Trust Company, N.A., as trustee. The Indenture under which the notes were issued contains covenants that, among other things, limit our ability and the ability of our restricted subsidiaries to:

• incur additional indebtedness and issue preferred stock;

• pay dividends or make other distributions;

• make other restricted payments and investments;

• sell assets, including capital stock of restricted subsidiaries;

• create certain liens;

• incur restrictions on the ability of restricted subsidiaries to pay dividends or make other payments, and in the case of the our subsidiaries, guarantee indebtedness;

• engage in transactions with affiliates;

• create unrestricted subsidiaries; and

• merge or consolidate with other entities.

Ranking and Optional Redemption

The Senior Notes are senior obligations of our company and rank equally in right of payment with all of our other existing and future unsecured and unsubordinated indebtedness. In addition, the Senior Notes are structurally subordinated to all indebtedness and other liabilities of our subsidiaries (unless our subsidiaries become guarantors of the Senior Notes). We may redeem up to 40% of the aggregate principal amount of the Senior Notes at any time prior to November 15, 2016, at a redemption price equal to 105.75% of the principal amount of the Senior Notes redeemed, plus accrued and unpaid interest.

On or after November 15, 2016, we may on any one or more occasions redeem all or part of the Senior Notes, at the redemption prices (expressed as percentages of principal amount) set forth below, if redeemed during the twelve-month period beginning on November 15 of the years indicated below, subject to the rights of holders of Senior Notes on the relevant record date to receive interest due on the relevant interest payment date:

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Period	Redemption Price
2016	102.875	%
2017	101.438	%
2018 and thereafter	100	%

The Senior Notes are classified as long-term debt in the Company’s condensed consolidated balance sheets at March 31, 2014 and December 31, 2013, respectively, based on their November 2020 maturity date.

Credit Arrangements

In November 2013, we entered into a credit agreement (the "Credit Agreement") which provides for a senior unsecured revolving loan facility (the “Revolving Credit Facility”) of up to $300.0 million, which may be used for general corporate purposes of the Company and its subsidiaries. The Revolving Credit Facility provides for up to $75.0 million for letters of credit. The Credit Agreement also provides that we may, at our option, increase the aggregate amount of the Revolving Credit Facility and/or obtain incremental term loans in an amount up to $75.0 million without the consent of any lenders not participating in such increase, subject to certain customary conditions and lenders committing to provide the increase in funding. The commitments under the Revolving Credit Facility expire on November 14, 2018 and any amounts outstanding under the facility will be payable in full at that time. Unutilized commitments under the Credit Agreement are subject to a fee of 0.25% to 0.375% depending upon our ratio of total debt to cash flow.

The Credit Agreement includes negative and financial covenants that limit certain activities of our company and its subsidiaries, including (i) restrictions on our ability to incur additional indebtedness; and (ii) financial covenants that require (a) the ratio of total debt to cash flow not to exceed a maximum; (b) a minimum interest expense and principal payment coverage ratio; and (c) a minimum level of statutory net worth for our health maintenance organization and insurance subsidiaries. The Credit Agreement also contains customary representations and warranties that must be accurate in order for us to borrow under the Revolving Credit Facility. In addition, the Credit Agreement contains customary events of default. If an event of default occurs and is continuing, we may be required immediately to repay all amounts outstanding under the Credit Agreement. Lenders holding at least 50% of the loans and commitments under the Credit Agreement may elect to accelerate the maturity of the loans and/or terminate the commitments under the Credit Agreement upon the occurrence and during the continuation of an event of default.

As of March 31, 2014 and as of the date of this filing, we have not drawn upon the Revolving Credit Facility and we remain in compliance with all covenants under both the Revolving Credit Facility and the Indenture.

9. FAIR VALUE MEASUREMENTS

Our condensed consolidated balance sheets include the following financial instruments: cash and cash equivalents, investments, receivables, accounts payable, medical benefits payable, long-term debt and other liabilities. We consider the carrying amounts of cash and cash equivalents, receivables, other current assets and current liabilities to approximate their fair value due to the short period of time between the origination of these instruments and the expected realization or payment.

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Recurring Fair Value Measurements

Assets and liabilities measured at fair value on a recurring basis at March 31, 2014 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	0.6	$	—		$	0.6	$	—
Auction rate securities	31.9		—			—		31.9
Certificates of deposit	1.1		—			1.1		—
Corporate debt securities	75.3		—			75.3		—
International government bonds	3.8		—			3.8		—
Money market funds	43.4		43.4			—		—
Municipal securities	119.8		—			119.8		—
U.S. government and agency obligations	38.9		27.6			11.3		—
Variable rate bond fund	110.3		110.3			—		—
Total investments	$	425.1	$	181.3		$	211.9	$	31.9
Restricted investments:
Cash	49.3		49.3			—		—
Certificates of deposit	1.4		—			1.4		—
Money market funds	18.9		18.9			—		—
U.S. government and agency obligations	25.3		25.3		1,800.0	—		—
Total restricted investments	$	94.9	$	93.5		$	1.4	$	—
Amounts accrued related to investigation resolution	$	34.4	$	—		$	34.4	$	—

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Assets and liabilities measured at fair value on a recurring basis at December 31, 2013 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	1.6	$	—		$	1.6	$	—
Auction rate securities	31.8		—			—		31.8
Certificates of deposit	1.6		—			1.6		—
Corporate debt securities	102.9		—			102.9		—
Money market funds	43.4		43.4			—		—
Municipal securities	108.9		—			108.9		—
U.S. government securities	19.6		19.6			—		—
Variable rate bond fund	85.3		85.3			—		—
Total investments	$	395.1	$	148.3		$	215.0	$	31.8
Restricted investments:
Cash	$	40.2	$	40.2		$	—	$	—
Certificates of deposit	1.4		—			1.4		—
Money market funds	19.0		19.0			—		—
U.S. government securities	21.9		21.9		1,800.0	—		—
Total restricted investments	$	82.5	$	81.1		$	1.4	$	—
Amounts accrued related to investigation resolution	$	70.3	$	—		$	70.3	$	—

The following table presents the carrying value and fair value of our senior notes as of March 31, 2014 and December 31, 2013:

	March 31, 2014		December 31, 2013
Long term debt	$	600.0	$	600.0
Approximate fair value of our long-term debt	630.4		615.0

The fair value of our senior notes was determined based on quoted market prices at March 31, 2104 and December 31, 2013, respectively, and therefore would be classified within Level 1 of the fair value hierarchy.

The following table presents the changes in the fair value of our Level 3 auction rate securities for the quarter ended March 31, 2014.

Balance as of January 1, 2014	$	31.8
Realized gains (losses) in earnings	—
Unrealized gains (losses) in other comprehensive income	0.1
Purchases, sales and redemptions	—
Net transfers in or (out) of Level 3	—
Balance as of March 31, 2014	$	31.9

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10. INCOME TAXES

Our effective income tax rate was 32.8% for the quarter ended March 31, 2014 compared to 5.9% for the same period in 2013. In 2014, the effective rate reflects the favorable impact of the Windsor bargain purchase gain, partially offset by the impact of the non-deductible ACA industry fee. The effective tax rate was lower in 2013 mainly due to an issue resolution agreement reached with the IRS in 2013 regarding the tax treatment of the investigation-related litigation and other resolution costs, resulting in approximately $7.6 million in additional tax benefit over what was recorded as of December 31, 2012.

11. COMMITMENTS AND CONTINGENCIES

Government Investigations

Under the terms of settlement agreements entered into on April 26, 2011, and finalized on March 23, 2012, to resolve matters under investigation by the Civil Division of the U.S. Department of Justice ("Civil Division") and certain other federal and state enforcement agencies (the "Settlement"), we agreed to pay the Civil Division a total of $137.5 million in four annual installments of $34.4 million over 36 months, plus interest accrued at 3.125%. The estimated fair value of the discounted remaining liability, and related interest, was $34.4 million at March 31, 2014, all of which has been included in the current amounts payable related to the investigation resolution in the accompanying condensed consolidated balance sheet as of March 31, 2014.

The Settlement also provides for a contingent payment of an additional $35.0 million in the event that we are acquired or otherwise experience a change in control on or before April 30, 2015, provided that the change in control transaction exceeds certain minimum transaction value thresholds as specified in the Settlement.

Securities Class Action Complaint

In December 2010, we entered into a Stipulation and Agreement of Settlement (the "Stipulation Agreement") with the lead plaintiffs in the consolidated securities class action Eastwood Enterprises, L.L.C. v. Farha, et al., Case No. 8:07-cv-1940-VMC-EAJ. The Stipulation Agreement requires us to pay to the class 25% of any sums we recover from Todd Farha, Paul Behrens and/or Thaddeus Bereday related to the same facts and circumstances that gave rise to the consolidated securities class action. Messrs. Farha, Behrens and Bereday are three former executives that were implicated in the government investigations of the Company that commenced in 2007.

Corporate Integrity Agreement

We operate under a Corporate Integrity Agreement (the "Corporate Integrity Agreement") with the Office of Inspector General of the United States Department of Health and Human Services ("OIG-HHS"). The Corporate Integrity Agreement has a term of five years from its effective date of April 26, 2011 and mandates various ethics and compliance programs designed to help ensure our ongoing compliance with federal health care program requirements. The terms of the Corporate Integrity Agreement include certain organizational structure requirements, internal monitoring requirements, compliance training, screening processes for employees, reporting requirements to OIG-HHS, and the engagement of an independent review organization to review and prepare written reports regarding, among other things, WellCare's reporting practices and bid submissions to federal health care programs.

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Indemnification Obligations

Under Delaware law, our charter and bylaws and certain indemnification agreements to which we are a party, we are obligated to indemnify, or we have otherwise agreed to indemnify, certain of our current and former directors, officers and associates with respect to current and future investigations and litigation, including the matters discussed in this footnote. The indemnification agreements for our directors and executive officers with respect to events occurring prior to May 2009 require us to indemnify an indemnitee to the fullest extent permitted by law if the indemnitee was or is or becomes a party to or witness or other participant in any proceeding by reason of any event or occurrence related to the indemnitee's status as a director, officer, employee, agent or fiduciary of the Company or any of our subsidiaries and all expenses, including attorney's fees, judgments, fines, settlement amounts and interest and other charges, and any taxes as a result of the receipt of payments under the indemnification agreement. We will not indemnify the indemnitee if not permitted under applicable law. We are required to advance all expenses incurred by the indemnitee. We are entitled to reimbursement by an indemnitee of expenses advanced if the indemnitee is not permitted to be reimbursed under applicable law after a final judicial determination is made and all rights of appeal have been exhausted or lapsed.

We amended and restated our indemnification agreements in May 2009. The revised agreements apply to our officers and directors with respect to events occurring after that time. Pursuant to the 2009 indemnification agreements, we will indemnify the indemnitee against all expenses, including attorney's fees, judgments, penalties, fines, settlement amounts and any taxes imposed as a result of payments made under the indemnification agreement incurred in connection with any proceedings that relate to the indemnitee's status as a director, officer or employee of the Company or any of our subsidiaries or any other enterprise that the indemnitee was serving at our request. We will also indemnify for expenses incurred by the indemnitee if an indemnitee, by reason of his or her corporate status, is a witness in any proceeding. Further, we are required to indemnify for expenses incurred by an indemnitee in defense of a proceeding to the extent the indemnitee has been successful on the merits or otherwise. Finally, if the indemnitee is involved in certain proceedings as a result of the indemnitee's corporate status, we are required to advance the indemnitee's reasonable expenses incurred in connection with such proceeding, subject to the requirement that the indemnitee repay the expenses if it is ultimately determined that the indemnitee is not entitled to be indemnified. We are not obligated to indemnify an indemnitee for losses incurred in connection with any proceeding if a determination has not been made by the Board of Directors, a committee of disinterested directors or independent legal counsel in the specific case that the indemnitee has satisfied any standards of conduct required as a condition to indemnification under Section 145 of the Delaware General Corporation Law.

Pursuant to our obligations, we have advanced, and will continue to advance, legal fees and related expenses to three former officers and two former associates who were criminally indicted in connection with the government investigations of the Company that commenced in 2007 related to federal criminal health care fraud charges including conspiracy to defraud the United States, false statements relating to health care matters, and health care fraud in connection with their defense of criminal charges. In June 2013, the jury in the criminal trial reached guilty verdicts on multiple charges for the four individuals that were tried in 2013. Sentencing is expected in the second quarter of 2014. At this time, we do not know whether any of these four individuals will appeal. The fifth individual is expected to be tried at a future date.

We have also previously advanced legal fees and related expenses to these five individuals regarding disputes in Delaware Chancery Court related to whether we were legally obligated to advance fees or indemnify certain of these executives; the class actions titled Eastwood Enterprises, L.L.C. v. Farha, et al. and Hutton v. WellCare Health Plans, Inc. et al. filed in federal court; six stockholder derivative actions filed in federal and state courts between October 2007 and January 2008; an investigation by the United States Securities & Exchange Commission (the "Commission"); and an action by the Commission filed in January 2012 against Messrs. Farha, Behrens and Bereday. The Delaware Chancery Court cases have concluded. We settled the class actions in May 2011. In 2010, we settled the stockholder derivative actions and we were realigned as the plaintiff to pursue our claims against Messrs. Farha, Behrens and Bereday. These actions, as well as the action by the Commission, have been stayed until at least 90 days after the conclusion of the criminal trial (including post-trial motions and proceedings).

In connection with these matters, we have advanced, to the five individuals, cumulative legal fees and related expenses of approximately $163.7 million from the inception of the investigations to March 31, 2014. We incurred $7.8 million and $18.9 million of these legal fees and related expenses during the three months ended March 31, 2014 and 2013, respectively. We expense these costs as incurred and classify the costs as selling, general and administrative expense incurred in connection with the investigations and related matters.

We expect the continuing cost of our obligations to the five individuals in connection with their defense and appeal of criminal charges and related litigation to be significant and to continue for a number of years. We have exhausted our insurance policies related to reimbursement of our advancement of fees related to these matters. We are unable to estimate the total amount of these costs or a range of possible loss. Accordingly, we continue to expense these costs as incurred. Though we have

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requested restitution damages in the criminal case and even if it is eventually determined that we are entitled to reimbursement of the advanced expenses, it is possible that we may not be able to recover all or any portion of our damages or advances. Our indemnification obligations and requirements to advance legal fees and expenses may have a material adverse effect on our financial condition, results of operations and cash flows.

Other Lawsuits and Claims

Based on the nature of our business, we are subject to regulatory reviews or other investigations by various state insurance and health care regulatory authorities and other state and federal regulatory authorities. These authorities regularly scrutinize the business practices of health insurance and benefits companies and their reviews focus on numerous facets of our business, including claims payment practices, provider contracting, competitive practices, commission payments, privacy issues and utilization management practices, among others. Some of these reviews have historically resulted in fines imposed on us and some have required changes to our business practices. We continue to be subject to such reviews, which may result in additional fines and/or sanctions being imposed, premium refunds or additional changes in our business practices.

Separate and apart from the legal matters described above, we are also involved in other legal actions in the normal course of our business, including, without limitation, wage and hour claims and provider disputes regarding payment of claims. Some of these actions seek monetary damages including claims for liquidated or punitive damages, which are not covered by insurance. We review relevant information with respect to litigation matters and we update our estimates of reasonably possible losses and related disclosures. We accrue an estimate for contingent liabilities, including attorney's fees related to these matters, if a loss is probable and estimable. Currently, we do not expect that the resolution of any currently pending actions, either individually or in the aggregate, will differ materially from our current estimates or have a material adverse effect on our results of operations, financial condition and cash flows. However, the outcome of any legal actions cannot be predicted, and therefore, actual results may differ from those estimates.

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Item 2. Management's Discussion and Analysis of Financial Condition and Results of Operations.

Forward-Looking Statements

Statements contained in this Form 10-Q for the quarterly period ended March 31, 2014 (“2014 Form 10-Q") which are not historical fact may be forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 and Section 21E of the Exchange Act, and we intend such statements to be covered by the safe harbor provisions for forward-looking statements contained therein. Such statements, which may address, among other things, our financial outlook, the timing of closing of pending acquisitions, the reimbursement of the ACA industry fee by state Medicaid programs, the timing of the launch of new programs, market acceptance of our products and services, our ability to finance growth opportunities, our ability to respond to changes in laws and government regulations, implementation of our growth strategies, projected capital expenditures, liquidity and the availability of additional funding sources may be found in the sections of this 2014 Form 10-Q entitled "Management's Discussion and Analysis of Financial Condition and Results of Operations" and elsewhere in this report generally. In some cases, you can identify forward-looking statements by terminology such as "may," "will," "should," "expects," "plans," "anticipates," "believes," "estimates," "targets," "predicts," "potential," "continues" or the negative of such terms or other comparable terminology. You are cautioned that forward-looking statements involve risks and uncertainties, including economic, regulatory, competitive and other factors that may affect our business. Please refer to the Risk Factors in Part I, Item 1A of our Annual Report on Form 10-K for the year ended December 31, 2013 (“2013 Form 10-K”) for a discussion of certain risks which could materially affect our business, financial condition, cash flows and results of operations. These forward-looking statements are inherently susceptible to uncertainty and changes in circumstances, as they are based on management's current expectations and beliefs about future events and circumstances. We undertake no obligation beyond that required by law to update publicly any forward-looking statements for any reason, even if new information becomes available or other events occur in the future.

Our actual results may differ materially from those indicated by forward-looking statements as a result of various important factors including the expiration, cancellation, suspension or amendment of our state and federal contracts. In addition, our results of operations and estimates of future earnings depend, in large part, on accurately predicting and effectively managing health benefits and other operating expenses. A variety of factors, including competition, changes in health care practices, changes in the demographics of our members, changes in federal or state laws and regulations or their interpretations, inflation, provider contract changes, changes in or suspensions or terminations of our contracts with government agencies, new technologies, such as new, expensive hepatitis C medications, potential reductions in Medicaid and Medicare revenue, including due to sequestration, our ability to negotiate with our state Medicaid customers regarding reimbursement of the Affordable Care Act ("ACA") industry fee, government-imposed surcharges, taxes or assessments, changes to how provider payments are made by governmental payors, the ability of state customers to launch new programs on their announced timeline, major epidemics, disasters and numerous other factors affecting the delivery and cost of health care, such as major health care providers' inability to maintain their operations, may affect our premium revenue, ability to control our medical costs and other operating expenses. Governmental action or inaction could result in premium revenues not increasing to offset any increase in medical costs, the ACA industry fee or other operating expenses. Once set, premiums are generally fixed for one-year periods and, accordingly, unanticipated costs during such periods generally cannot be recovered through higher premiums. Furthermore, if we are unable to estimate accurately incurred but not reported medical costs in the current period, our future profitability may be affected. Due to these factors and risks, we cannot provide any assurance regarding our future premium levels or our ability to control our future medical costs.

In addition, the risks and uncertainties include, but are not limited to, our progress on top priorities such as improving health care quality and access, ensuring a competitive cost position, delivering prudent, profitable growth, and achieving service excellence, our ability to effectively manage growth, our ability to address operational challenges relating to new business, our ability to effectively execute and integrate acquisitions, the satisfaction of the closing conditions for pending acquisitions, the receipt of regulatory approval for pending acquisitions, and the performance of our acquisitions once acquired. Due to these factors and risks, we may be required to write down or take impairment charges of assets associated with acquisitions. Furthermore, at both the federal and state government levels, legislative and regulatory proposals have been made related to, or potentially affecting, the health care industry, including but not limited to limitations on managed care organizations, including changes to membership eligibility, benefit mandates, and reform of the Medicaid and Medicare programs. Any such legislative or regulatory action, including benefit mandates or reform of the Medicaid and Medicare programs, could have the effect of reducing the premiums paid to us by governmental programs, increasing our medical and administrative costs or requiring us to materially alter the manner in which we operate. We are unable to predict the specific content of any future legislation, action or regulation that may be enacted or when any such future legislation or regulation will be adopted. Therefore, we cannot predict accurately the effect or ramifications of such future legislation, action or regulation on our business.

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OVERVIEW

Introduction

We are a leading managed care company for government-sponsored health care coverage with a focus on Medicaid and Medicare programs. Headquartered in Tampa, Florida, we offer a variety of managed care health plans for families, individuals, children, and the aged, blind and disabled, as well as prescription drug plans. As of March 31, 2014, we served approximately 3.5 million members in 49 states and the District of Columbia. We believe that our broad range of experience and government focus allows us to effectively serve our members, partner with our providers and government clients, and efficiently manage our ongoing operations.

Summary of Consolidated Financial Results

Summarized below are the key highlights for the quarter ended March 31, 2014. For additional information, refer to the "Results of Operations" section which discusses both consolidated and segment results in more detail.

▪ Membership at March 31, 2014 increased by 24% compared to December 31, 2013 and by 31% compared to March 31, 2013, mainly driven by acquisitions and organic membership growth across all of our segments. The acquisition of Windsor Health Group, Inc. ("Windsor"), which was completed on January 1, 2014 accounted for increases of 87,000 and 109,000, in our Medicare and PDP segments, respectively. Excluding Windsor, Medicare segment membership increased 18% year over year and 5% compared to December 31, 2013 principally from Medicare Advantage (MA) open enrollment gains, and PDP segment membership increased 54% year over year and 46% compared to December 31, 2013, resulting mainly from our 2014 bid results. Medicaid segment membership increased by 11% year over year and by 6% compared to December 31, 2013, due mainly to membership gains in Kentucky.

▪ Premiums increased 32% in the first quarter of 2014 compared to the prior year, reflecting the Windsor acquisition, a 25% increase in Medicaid premiums, a 14% increase in Medicare premiums excluding Windsor, and an 18% increase in PDP premiums excluding Windsor. The Medicaid increase is driven by the increase in membership discussed above, as well as rate increases in certain markets and the benefit of a full quarter’s results for our South Carolina and Missouri Medicaid plans acquired in the first quarter of 2013, partially offset by the termination of our Ohio Medicaid plan. The Medicare and PDP increases are consistent with the membership changes discussed above. 

▪ Net Income in the first quarter of 2014 increased 105% compared to the prior year due to organic and acquisition-related growth and improved medical cost trend in our Medicaid Health Plans segment, a $28.3 million non-operating bargain purchase gain related to the Windsor acquisition, and organic growth in our Medicare Health Plans segment partially offset by the recognition of net unfavorable prior period reserve development in 2014 compared to net favorable development in 2013, the net impact of the health insurance industry fees mandated by the ACA beginning January 2014 and higher drug unit costs mainly impacting our PDP segment.

Key Developments and Accomplishments

Presented below are key developments and accomplishments relating to progress on our strategic business priorities that have impacted, or are expected to impact, our 2014 results:

• In January 2014, we acquired all of the outstanding stock of Windsor from Munich Health North America, Inc., a part of Munich Re Group. Through its subsidiaries, Windsor serves Medicare beneficiaries with MA, PDP and Medicare Supplement products. As of March 31, 2014, Windsor offered MA plans to 38,000 members in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it serves approximately 48,000 members in 39 states as of March 31, 2014. Windsor also offers PDPs in 11 of the 34 CMS regions to 109,000 members as of March 31, 2014. As a result, in 2014 we are offering MA plans in a total of 402 counties in 18 states.

• We have received amendments, written agreements or other documentation from our state Medicaid customers in Florida, Georgia, Kentucky, Missouri and South Carolina, which provides for them to reimburse us for the portion of the ACA industry fee attributable to the Medicaid programs in those states, including the related state and federal income tax gross-ups. Consequently, we recognized approximately $23.6 million reimbursement as premium revenue in the quarter ended March 31, 2014. We currently expect to be reimbursed by our state Medicaid customers in Hawaii, Illinois, New York and Ohio for the impact of the ACA industry fee on our Medicaid plans, including its non-

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deductibility for income tax purposes. However, the revenue recognition for such reimbursement is delayed until we are able to reach contractual agreement with these customers, and the timing of revenue recognition will not match the expense recognition of the fee, depending on the timing of such agreements.  

• For the 2014 plan year, we have expanded the geographic footprint of our MA plans to offer plans in a total of 210 counties in 14 states, excluding Windsor, but including dual special needs plans (“D-SNPs”) for those who are dually-eligible for Medicare and Medicaid in most of the MA markets we serve. This expansion is consistent with our focus on the lower-income demographic of the market and our ability over time to provide both the Medicaid- and Medicare-related coverage of these members.

• In January 2014, approximately 16,000 beneficiaries from Carolina Medical Homes ("CMH") transferred to us as a result of WellCare's purchase of certain assets from CMH and changes the South Carolina Department of Health and Human Services ("SCDHHS") made to its Healthy Connections Choices Medicaid managed care program.

• In February 2014, we executed a contract with the Florida Agency for Health Care Administration ("AHCA") to provide managed care services to Medicaid recipients in eight of the state’s eleven regions as part of the state’s Managed Medical Assistance ("MMA") program. These regions include the Jacksonville, Miami, Orlando, Tallahassee and Tampa metropolitan areas. As of May 1, we initiated the MMA implementation in three regions, including the Jacksonville area. We are serving over 185,000 members in these regions, a gain of more than 107,000 members compared to April 30, 2014. We anticipate that our Florida Temporary Assistance for Needy Families ("TANF") and SSI membership will increase in 2014 to at least 500,000 from the 394,000 members that we served in December 2013.

• In September 2013, we entered into an agreement to acquire certain assets of Healthfirst Health Plan of New Jersey, Inc. ("Healthfirst NJ"). As of March 31, 2014, Healthfirst NJ serves approximately 49,000 Medicaid members in 12 counties in the state. The acquisition is expected to close on June 30, 2014, with the transfer of membership effective July 1, 2014, subject to customary regulatory approvals. Upon closure of the transaction, we will acquire Healthfirst NJ’s Medicaid membership and substantially all of its provider network. In addition, we began offering Medicaid managed care in Essex, Hudson, Middlesex, Passaic and Union counties in New Jersey beginning January 1, 2014.

Political and Regulatory Developments

Political Developments Impacting our Business 

On April 1, 2014, the President signed the Protecting Access to Medicare Act of 2014. This Act delayed until March 2015 the 24% reduction in Medicare payment rates that was supposed to take effect on April 1, 2014, as a result of the sustainable growth rate formula and replaced it with a 0.5% increase in payments through December 31, 2014. The Act also delayed the implementation of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) prohibiting the Secretary of Health and Human Services from adopting the ICD-10 code sets prior to October 1, 2015.

Medicaid Health Plans

A number of states are evaluating new strategies for their Medicaid programs. Given ongoing fiscal challenges, economic conditions, and the success of Medicaid managed care programs over the long run, states continue to recognize the value of collaborating with managed care plans to deliver quality, cost-effective health care solutions.

Current legislative sessions are winding down in most states. In those states requiring statutory or budget authority to administer Medicaid, some states continue to debate the optional expansion of Medicaid under the ACA. Of the states in which we currently operate Medicaid plans, Hawaii, Illinois, Kentucky, New Jersey and New York have expanded Medicaid eligibility in 2014 under the ACA, while Florida, Georgia, Missouri and South Carolina have stated their intention not to move forward with an expansion in 2014 or 2015. If other states ultimately implement the Medicaid expansion, and depending on the mechanism by which they choose to implement the expansion, our membership could increase or decrease. At this time, we are unable to predict the ultimate impact to our Medicaid membership.

Some states, such as Missouri, are considering some expansions of their Medicaid managed care program, for example, by increasing the population of individuals who would be served by Medicaid managed care. If and how this expansion will occur is yet to be defined.

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In Kentucky, we have received approximately 60,000 new members as a result of the expansion of Medicaid eligibility through March 31, 2014. In addition, for coverage beginning July 1, 2014, members will be able to choose among five statewide plans, instead of the current two; however, our members will not be passively reassigned.

In connection with the implementation of mandatory Medicaid managed care in Illinois, beginning on August 1, 2014, we expect there will be up to 20 plans serving TANF members, including us, in Cook County, compared to the current three plans.  We currently have approximately 120,000 members in Cook County as of March 31, 2014. During the open enrollment period, we may not be auto-assigned new TANF members and existing members may be reassigned to other plans, unless they actively choose us.

The budget for Florida's fiscal year beginning July 1, 2014 provides that certain hospitals will be paid directly by AHCA to compensate them for unreimbursed care, instead of the managed care plans paying these fees as part of their hospital rates. While we expect that this will reduce our Florida Medicaid premium revenue beginning July 1, 2014, we do not anticipate that this will affect the gross margin of the program, as our hospital rates will be reduced to offset this.

Medicare Health Plans

On April 7, 2014, the Centers for Medicare & Medicaid Services ("CMS") revised their proposed 2015 rates, which, combined with all elements of the rate announcement, we estimate will result in a rate decrease in the low single digit percentage from our 2014 rates.

In February 2014, CMS announced an MA coding pattern difference reduction of 0.25% for payment year 2015 compared to 2014. CMS will continue to partially use the risk adjustment model first used in 2014, which most severely affects our rates for those individuals with complex medical conditions, including many of our dual-eligible and lower income members.

In 2015, CMS will continue to tier payments based on the quality ratings of MA plans, paying less to plans scoring less than 5 stars on the CMS star quality rating scale. On average, our MA plans in 2013 were 3 stars, with our Florida plan at 3.5 stars. CMS has also confirmed the end of the quality bonus demonstration in 2014. This means bonus payments to plans like WellCare, which achieve less than 4 stars on CMS’s 5 star scale, will no longer be made.

In April 2014, CMS stated that it will terminate those MA contracts that scored a Part C summary rating of less than three stars in each of the most recent three consecutive rating periods (i.e., 2013, 2014, and 2015 sets of ratings), regardless of their Part D summary rating performance during the same period.  CMS also stated that it will terminate MA contracts that scored a Part D summary rating of less than three stars in each of the most recent three consecutive rating periods (i.e., 2013, 2014, and 2015 sets of ratings) regardless of their Part C summary ratings during the same period.  Stand-alone PDP sponsor contracts will be terminated if those contracts scored less than three stars in each of the most recent three consecutive rating periods (i.e., 2013, 2014, and 2015 sets of ratings). As a result, some of our MA plans could be subject to termination.

PDP

In April 2014, CMS also announced changes for PDPs relating to applicable beneficiary and plan dispensing/vaccine administration fees for drug claims that straddle the coverage gap for the 2015 plan year. In addition, CMS increased the Part D deductible, the initial coverage limit, and the out-of-pocket threshold for the catastrophic benefit. We are still evaluating the effect these changes will have on our 2015 PDP operations.

Dual Eligibles

Individuals qualifying for both Medicare and Medicaid are referred to as "dual-eligibles". For dual-eligibles, if a service is covered by Medicare and Medicaid, Medicare is the primary payer. The ACA created a federal Medicare-Medicaid Coordination Office to serve dual eligibles. This Medicare-Medicaid Coordination Office has initiated a series of state Duals Demonstration Programs intended to provide better coordination and integration of care between Medicare and Medicaid on a capitated or fee for service basis, which is required to produce cost savings.

Thirteen states have been selected by CMS to implement a capitated Duals Demonstration Program; an additional four are implementing a Duals Demonstration Program on a fee-for-service basis and one state is doing both. Of the states that have signed agreements with CMS to implement a capitated Duals Demonstration Program, we operate D-SNPs in eight.

We have received preliminary approval to participate in the Duals Demonstration Programs in New York beginning October 1, 2014. In November 2013, we were selected by South Carolina Healthy Connections Prime Medicaid to provide coordinated

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and integrated care for dual eligibles beginning July 1, 2014, however we have chosen not to participate. Other states in which we operate, including Arizona and Florida, are working toward greater integration of their Medicare and Medicaid programs outside of a demonstration program.

Among the states in which we operate that are planning to implement duals alignment demonstration programs, beneficiaries eligible for a duals alignment demonstration program who are currently enrolled in WellCare products may be subject to passive enrollment in six states: California, Illinois, New York, Ohio, South Carolina and Texas. Those subject to passive enrollment in a Duals Demonstration Program will have the opportunity to opt out of the program and remain in a WellCare plan up until the last day of the month prior to the effective date of enrollment. Beneficiaries will have the ability to opt out of the Duals Demonstration Program on a monthly basis. Because the members are dually eligible, they are entitled to a continuous special election and may enroll in any WellCare MA or PDP for which they are entitled on a monthly basis.

Certain states’ Duals Demonstration Programs have not permitted us to participate, either because those states limit participation to plans currently serving their Medicaid population, or restrict participation to fee-for-service programs. For those states that have a Duals Demonstration Program in which we do not participate, the membership in our MA or PDPs could be reduced, depending on the program design, eligible populations and state implementation time frame. California began implementation of their program in April 2014. Although the California Duals Demonstration Program limits the total number of individuals eligible to 456,000, with no more than 200,000 in Los Angeles County, as of March 31, 2014, we have approximately 24,000 dual-eligible members in Los Angeles County that could be subject to passive enrollment in the program beginning on January 1, 2015. In addition, we are negotiating the renewal of our California D-SNP contract expiring on December 31, 2014, which could result in limitations on the numbers of members permitted to be enrolled in our D-SNP.

Per CMS guidance, Part D auto assignments to another PDP will be limited to January 1, 2014, and January 1, 2015, for 2013 and 2014 demonstration states, respectively.

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RESULTS OF OPERATIONS

Consolidated Financial Results

The following tables set forth condensed consolidated statements of operations data, as well as other key data used in our results of operations discussion for the quarter ended March 31, 2014 compared to the quarter ended March 31, 2013. These historical results are not necessarily indicative of results to be expected for any future period.

	For the Quarters Ended March 31,						Change
	2014			2013			Dollars			Percentage
Revenues:	(Dollars in millions)
Premium	$	2,975.1		$	2,252.3		$	722.8		32.1	%
Investment and other income	10.6			4.3			6.3			146.5	%
Total revenues	2,985.7			2,256.6			729.1			32.3	%
Expenses:
Medical benefits	2,629.9			1,987.3			642.6			32.3	%
Selling, general and administrative	245.3			213.4			31.9			14.9	%
ACA industry fee	32.3			—			32.3			NMF
Medicaid premium taxes	17.1			21.3			(4.2		)	(19.7	)%
Depreciation and amortization	14.6			10.1			4.5			44.6	%
Interest	9.2			1.6			7.6			475.0	%
Total expenses	2,948.4			2,233.7			714.7			32.0	%
Income from operations	37.3			22.9			14.4			62.9	%
Bargain purchase gain	28.3			—			28.3			NMF
Income before income taxes	65.6			22.9			42.7			186.5	%
Income tax expense	21.5			1.4			20.1			NMF
Net income	$	44.1		$	21.5		$	22.6		105.1	%
Effective tax rate	32.8		%	5.9		%				26.9	%

NMF - Not meaningful

Membership

	March 31, 2014			December 31, 2013			March 31, 2013
Segment	Membership	Percentage of Total		Membership	Percentage of Total		Membership	Percentage of Total
Medicaid Health Plans	1,869,000	53.0	%	1,759,000	61.8	%	1,690,000	62.5	%
Medicare Health Plans	390,000	11.0	%	290,000	10.2	%	256,000	9.5	%
Medicare PDPs	1,271,000	36.0	%	797,000	28.0	%	757,000	28.0	%
Total	3,530,000	100.0	%	2,846,000	100.0	%	2,703,000	100.0	%

As of March 31, 2014, we served approximately 3,530,000 members, an increase of approximately 684,000 members, or 24%, compared to December 31, 2013, and an increase of approximately 827,000 members, or 31%, compared to March 31, 2013. The growth in 2014 was mainly driven by acquisitions, including the Windsor acquisition, and organic membership growth in our Medicaid and Medicare Health Plans segments, as well as an increase in Medicare PDPs membership driven by our 2014 bid results. Membership discussion by segment follows:

• Medicaid Health Plans - membership increased by approximately 110,000 compared to December 31, 2013, primarily driven by membership growth in our Kentucky Medicaid program, which increased 80,000 compared to

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December 31, 2013 due to Kentucky's participation in the 2014 Medicaid expansion, as well as the addition of approximately 16,000 CMH beneficiaries to our South Carolina Medicaid program. Medicaid membership in 2014 increased 179,000 compared to March 31, 2013 due to the factors noted above, as well as the addition of 99,000 members resulting from our acquisition of Missouri Care and the transfer of approximately 57,000 beneficiaries to our Kentucky Medicaid plan following Centene Corporation's exit from Kentucky in July 2013, partially offset by a decline of approximately 95,000 members resulting from our exit from Ohio effective July 1, 2013.

• Medicare Health Plans - membership increased by approximately 100,000 members compared to December 31, 2013, primarily attributable to the Windsor acquisition, which contributed approximately 38,000 and 48,000 MA and Medicare Supplement program members, respectively, as of March 2014, as well as an increase of approximately 13,000 members resulting from the 2014 annual election period due to our continued focus on dual-eligible beneficiaries and expansion into new counties. Medicare membership in 2014 increased by 134,000 members compared to March 31, 2013 primarily due to the factors noted above.

• Medicare PDPs - membership increased by approximately 474,000 members compared to December 31, 2013. Excluding Windsor, PDP membership grew by approximately 365,000 members, or 31%, primarily due to the result of our 2014 bid results. As of January 1, 2014, approximately 70% of our PDP membership was comprised of beneficiaries that actively chose us for their current plan. New members will be assigned monthly into our PDPs in 16 of our 18 2014 MA states, enabling cross selling opportunities for our MA and PDPs. The Windsor acquisition contributed approximately 109,000 members to PDP membership as of March 31, 2014. Excluding the impact of Windsor, PDP membership increased by 405,000 members compared to March 31, 2013, due primarily to the factors discussed above.

Net Income

Net income for the quarter ended March 31, 2014 increased by 105% compared to the prior year due to organic and acquisition-related growth and an improved medical cost trend in our Medicaid Health Plans segment, a $28.3 million non-operating bargain purchase gain related to the Windsor acquisition, and organic growth in our Medicare Health Plans segment partially offset by the recognition of net unfavorable prior period reserve development in 2014 compared to net favorable development in 2013, the net impact of the ACA industry fee mandated by the Affordable Care Act (ACA) beginning January 2014 and higher drug unit costs mainly impacting our Medicare PDPs segment.

Outlook

We currently expect our net income for the year ending December 31, 2014 to be substantially consistent with net income for the year ended December 31, 2013, as increased revenue is offset by increased expenses. For example, the effect of the Windsor bargain purchase gain will be offset by Windsor transition costs and integration expenses and the impact of a higher medical benefits ratio ("MBR") for the Windsor MA plans relative to the Medicare Health Plans segment average. The expected increase in gross margin for our Medicaid Health Plans segment is expected to be offset by a higher MBR in our Medicare Health Plans and Medicare PDPs segments. In addition, we are expecting additional selling, general and administrative ("SG&A") expense due to greater membership, growth initiatives, and quality, service and productivity infrastructure investments, offset by productivity gains. Our results will also be impacted by the unreimbursed portion of the new ACA industry fee expense and increased interest expense due to the issuance in November 2013 of $600.0 million in senior notes.

Premium Revenue

Premium revenue for the quarter ended March 31, 2014 increased by approximately $722.8 million, or 32%, compared to the same period in 2013.The increase reflects the impact of the Windsor Acquisition, a 26% increase in Medicaid premiums, a 14% increase in Medicare premiums excluding Windsor, and an 18% increase in PDP premiums excluding Windsor. The Medicaid increase is due to an increase in membership, rate increases in certain markets and the benefit of a full quarter’s results for our South Carolina and Missouri Medicaid plans acquired in the first quarter of 2013, partially offset by the termination of our Ohio Medicaid plan. The Medicare and PDP premium increases are roughly consistent with the increases in membership in those segments. In addition, premium revenue includes $17.1 million of Medicaid premium taxes for the first quarter months ended March 31, 2014 compared to $21.3 million for the same period in 2013.

Outlook

We now expect our consolidated premium revenue, not including premium taxes or Medicaid state ACA industry fee reimbursement, in 2014 to be between $12.0 and $12.1 billion. The Company previously anticipated premium revenue to be

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between $11.6 and $11.8 billion. The increase results mainly from increased growth outlooks for the Medicaid Health Plans and Medicare PDPs segments.

Medical Benefits Expense

The increase in medical benefits expense for the quarter ended March 31, 2014 compared to the same period in 2013 was due mainly to increased membership across all of our segments, a swing from net favorable prior period reserve development in 2013 to net unfavorable prior period reserve development in 2014, Medicaid primary care enhanced payments as mandated by the ACA, and increased drug unit costs, mainly impacting the PDP segment.

For the quarter ended March 31, 2014, medical benefits expense was impacted by approximately $32.5 million of net unfavorable development related to prior periods, compared to $15.9 million of net favorable development recognized during the same period in 2013.  The net unfavorable development recognized in the quarter ended March 31, 2014 was due mainly to higher than projected medical costs in our Medicare Health Plans segment. In addition, we incurred expense associated with adjustments to prior year enhanced payments to Medicaid primary care providers, as mandated by the ACA.

Selling, General and Administrative Expense

SG&A expense includes aggregate costs related to the resolution of the previously disclosed governmental investigations and related litigation, such as settlement accruals and related fair value accretion, legal fees and other similar costs. Refer to Note 11 within the condensed consolidated Financial Statements for additional discussion of investigation-related litigation and other resolution costs. We believe it is appropriate to evaluate SG&A expense exclusive of these investigation-related litigation and other resolution costs because we do not consider them to be indicative of long-term business operations.

The reconciliation of SG&A expense, including and excluding such costs, is as follows:

	For the Quarters Ended March 31,
	2014			2013
SG&A expense	$	245.3		$	213.4
Adjustments:
Investigation-related litigation and other resolution costs	(0.6		)	(0.8		)
Investigation-related administrative costs	(9.0		)	(21.1		)
Total investigation-related litigation and other resolution costs	(9.6		)	(21.9		)
SG&A expense, excluding investigation-related litigation and other resolution costs	$	235.7		$	191.5
SG&A ratio (1)	8.2		%	9.4		%
Adjusted SG&A ratio (2)	8.0		%	8.6		%

(1) SG&A expense, as a percentage of total premium revenue.

(2) SG&A expense, as a percentage of total premium revenue, excluding premium taxes, Medicaid state ACA industry fee reimbursements and investigation-related litigation and other resolution costs.

Excluding total investigation-related litigation and other resolution costs, our SG&A expense for the quarter ended March 31, 2014 increased approximately $44.2 million, or 23%, compared to the same period in 2013. SG&A expense increased mainly due to the growth in membership, investments in technology and infrastructure, including costs necessary to meet regulatory changes, investments related to our medical cost initiatives, increased spending related to the integration of recent acquisitions and our other growth and service initiatives. These cost increases were partially offset by improvements in operating efficiency. Our SG&A ratio was 8.2% for the quarter ended March 31, 2014, compared to 9.4% for the quarter ended March 31, 2013. Our adjusted SG&A ratio, which is adjusted for premium taxes, Medicaid state ACA industry fee reimbursements and investigation-related litigation and other resolution costs, for the quarter ended March 31, 2014 was 8.0% compared to 8.6% for the same period in 2013.

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Outlook

We currently expect that our adjusted SG&A ratio for the full year 2014 will be between approximately 8.4% to 8.5%. Our organic growth, expenditures for the Florida MMA implementation, desired quality, service and productivity improvements and the Windsor integration are driving a need for certain investments and expenditures. We are also making investments to meet the needs of our state and federal customers resulting from implementation of the ACA.

ACA Industry Fee

During the quarter ended March 31, 2014, we recorded $32.3 million of non-deductible expense for the ACA industry fee, based on our estimated share of total 2013 health insurance industry premiums. We expect to record $129.0 million of non-deductible expense for the ACA industry fee expense for the year ended December 31, 2014. As discussed in Key Developments and Accomplishments, we currently expect to be reimbursed by our state Medicaid customers for substantially all of the impact of the ACA industry fee attributable to our Medicaid plans, including its non-deductibility for income tax purposes.

Medicaid Premium Taxes

Medicaid premium taxes incurred for the quarter ended March 31, 2014 were $17.1 million compared to $21.3 million for the same period in 2013. The year-over-year decline of approximately $4.2 million, or 20%, was primarily driven by our exit from the Ohio Medicaid market, which was effective July 1, 2013. As of March 31, 2014, our Medicaid contracts with Georgia, Hawaii and New York included tax assessments on Medicaid premiums.

Depreciation and Amortization

Depreciation and amortization expense for the quarter ended March 31, 2014 increased by $4.5 million mainly due to $1.6 million of amortization related to the intangible assets acquired in conjunction with the Windsor acquisition, as well as amortization related to the Missouri Care and WellCare of South Carolina, Inc. ("WCSC") acquisitions completed in 2013.

Interest Expense

Interest expense for the quarter ended March 31, 2014 was $9.2 million, compared to $1.6 million, for the same period in 2013. The $7.6 million increase was primarily driven by higher average debt levels during 2014, as we issued $600 million of 5.75% senior notes in November 2013.

Bargain Purchase Gain

As a result of the Windsor acquisition, the estimated fair value of the net tangible and intangible assets that we acquired exceeded the total consideration payable to the seller by approximately $28.3 million. After consideration of all relevant factors, we concluded that the excess fair value constituted a bargain purchase gain in accordance with accounting rules related to business combinations. The amount of the gain could change depending on the resolution of certain matters related to the purchase price.

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Income Tax Expense

Our effective income tax rate on pre-tax income was 32.8% and 5.9% for the quarters ended March 31, 2014 and 2013, respectively. In 2014, the effective rate reflects the favorable impact of the Windsor bargain purchase gain, partially offset by the non-deductible ACA industry fee. The effective tax rate is lower in 2013 mainly due to an issue resolution agreement reached with the Internal Revenue Service ("IRS") in 2013 regarding the tax treatment of the investigation-related litigation and other resolution costs, resulting in approximately $7.6 million in additional tax benefit over what was recorded as of December 31, 2012.

Segment Reporting

Reportable operating segments are defined as components of an enterprise for which discrete financial information is available and evaluated on a regular basis by the enterprise's decision-makers to determine how resources should be allocated to an individual segment and to assess performance of those segments. Accordingly, we have three reportable segments: Medicaid Health Plans, Medicare Health Plans and Medicare PDPs.

Segment Financial Performance Measures

In conjunction with the Windsor acquisition, we reassessed our segment reporting practices and made revisions to reflect our current method of managing performance and determining resource allocation, which includes reviewing the results of Medicare Supplement and Medicare Advantage operations acquired as part of the Windsor acquisition together with MA. Accordingly, we are including results for Medicare Supplement operations together with MA and have renamed the segment Medicare Health Plans. Similarly, we are including the PDP operations acquired as part of the Windsor acquisition together with WellCare’s PDPs and have renamed the segment Medicare PDPs. No changes were made to the composition of our Medicaid segment, but we have renamed the segment Medicaid Health Plans.

Our primary tools for measuring profitability of our reportable operating segments are premium revenue, gross margin and MBR. Beginning in 2014, the ACA imposes an annual premium-based health insurance industry fees on health insurers. Since the timing of revenue recognition for state Medicaid reimbursement of the ACA industry fee may be delayed and not match the expense recognition of the fee, and MA and PDP rates will not be adjusted for the ACA industry fee, we have determined to include the ACA industry fee expense in measuring the profitability of our reportable operating segments. Accordingly, gross margin has been redefined as premium revenue less medical benefits expense, less ACA industry fees. MBR measures the ratio of medical benefits expense to premium revenue excluding Medicaid premium taxes and Medicaid state ACA industry fee reimbursement.

We use gross margin and MBR both to monitor our management of medical benefits and medical benefits expense and to make various business decisions, including which health care plans to offer, which geographic areas to enter or exit and which health care providers to include in our networks. Although gross margin and MBR play an important role in our business strategy, we may be willing to enter new geographical markets and/or enter into provider arrangements that might produce a less favorable gross margin and MBR if those arrangements, such as capitation or risk sharing, would likely lower our exposure to variability in medical costs or for other reasons.

Changes in gross margin and MBR from period to period depend in large part on our ability to, among other things, effectively price our medical and prescription drug plans, manage medical costs and changes in estimates related to incurred but not reported claims ("IBNR"), predict and effectively manage medical benefits expense relative to the primarily fixed premiums we receive, negotiate competitive rates with our health care providers, and attract and retain members. In addition, factors such as changes in health care laws, regulations and practices, changes in Medicaid and Medicare funding, changes in the mix of membership, escalating health care costs, competition, levels of use of health care services, general economic conditions, major epidemics, terrorism or bio-terrorism, new medical technologies, including the new, expensive Hepatitis C drugs, and other external factors may affect our operations and may have a material adverse impact on our business, financial condition and results of operations.

For further information regarding premium revenues and medical benefits expense, please refer below to "Premium Revenue Recognition and Premiums Receivable", and "Medical Benefits Expense and Medical Benefits Payable" under "Critical Accounting Estimates."

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Reconciling Segment Results

The following table reconciles our reportable segment results to income before income taxes, as reported in accordance with accounting principles generally accepted in the United States of America ("GAAP").

	For the Quarters Ended March 31,						Change
	2014			2013			Dollars			Percentage
Gross Margin
Medicaid Health Plans	$	230.6		$	179.7		$	50.9		28.3	%
Medicare Health Plans	101.1			93.3			7.8			8.4	%
Medicare PDPs	(18.8		)	(8.0		)	(10.8		)	(135.0	)%
Total gross margin	312.9			265.0			47.9			18.1	%
Investment and other income	10.6			4.3			6.3			146.5	%
Other expenses	(286.2		)	(246.4		)	(39.8		)	16.2	%
Income before income taxes	$	37.3		$	22.9		$	14.4		62.9	%

Medicaid Health Plans

Our Medicaid segment includes plans for beneficiaries of Temporary Assistance for Needy Families ("TANF"), Supplemental Security Income ("SSI"), Aged Blind and Disabled ("ABD") and other state-based programs that are not part of the Medicaid program, such as Children's Health Insurance Program ("CHIP"), Family Health Plus ("FHP") and Managed Long-Term Care ("MLTC") programs. As of March 31, 2014, we operated Medicaid health plans in Florida, Georgia, Hawaii, Illinois, Kentucky, Missouri, New Jersey, New York and South Carolina. We began serving WCSC members on February 1, 2013, and Missouri Care members on April 1, 2013. As of July 1, 2013, we no longer provided Medicaid services in Ohio.

Impacting Our Results

• Effective January 1, 2014, our Kentucky program began serving new members associated with Kentucky's participation in the 2014 ACA Medicaid expansion. Such membership totaled 60,000 as of March 31, 2014.

• We began offering Medicaid services in 45 out of 46 counties in South Carolina effective January 1, 2014, an expansion of six counties from the 39 served at December 31, 2013. Additionally, in January 2014, approximately 16,000 beneficiaries from Carolina Medical Homes ("CMH") transferred to us as a result of WellCare's purchase of certain assets from CMH and changes the South Carolina Department of Health ("SCDHHS") made to its Healthy Connections Choices Medicaid managed care program.

• We have received amendments, written agreements or other documentation from our state Medicaid customers in Florida, Georgia, Kentucky, Missouri and South Carolina which provides for them to reimburse us for the portion of the ACA Insurer Fee attributable to the Medicaid programs in those states, including the related state and federal income tax gross-ups. Consequently, we recognized approximately $23.6 million of reimbursement as premium revenue in the quarter ended March 31, 2014. We currently expect to be reimbursed by our state Medicaid customers in Hawaii, Illinois, New York and Ohio for the impact of the fee on our Medicaid plans, including its non-deductibility for income tax purposes. However, the revenue recognition for such reimbursement is delayed until we are able to reach contractual agreements with these customers, and the timing of revenue recognition will not match the expense recognition of the fee.

The following table sets forth the summarized results of operations and other relevant performance measures for our Medicaid segment for the quarters ended March 31, 2014 and 2013:

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	For the Quarters Ended March 31,						Change
	2014			2013			Dollar			Percentage
	(Dollars in millions)
Premium revenue (1)	$	1,598.1		$	1,289.1		$	309.0		24.0	%
Medicaid premium taxes (1)	17.1			21.3			(4.2		)	(19.7	)%
Medicaid state ACA industry fee reimbursement (1)	23.6			—			23.6			NMF
Total premiums	1,638.8			1,310.4			328.4			25.1	%
Medical benefits expense	1,389.3			1,130.7			258.6			22.9	%
ACA industry fee	18.9			—			18.9			NMF
Gross margin	230.6			179.7			50.9			28.3	%
Medicaid MBR, including premium taxes and Medicaid state ACA industry fee reimbursements	84.8		%	86.3		%				(1.5	)%
Impact of:
Medicaid premium taxes	0.9		%	1.4		%
Medicaid state ACA industry fee reimbursement	1.2		%	—		%
Medicaid MBR (1)	86.9		%	87.7		%				(0.8	)%
Medicaid membership at end of period:
Georgia	553,000			573,000						(3.5	)%
Florida	482,000			472,000						2.1	%
Kentucky	372,000			228,000						63.2	%
Other states	462,000			417,000						10.8	%
Total Medicaid membership	1,869,000			1,690,000						10.6	%

NMF - Not meaningful

(1) MBR measures the ratio of our medical benefits expense to premium revenue excluding reimbursement for Medicaid premium taxes and Medicaid state ACA industry fee reimbursement revenue. Because reimbursements for Medicaid premium tax and ACA industry fee impacts are both included in the premium rates established in certain of our Medicaid contracts and also recognized separately as a component of expense, we exclude these reimbursements from premium revenue when calculating key ratios as we believe that their impact is not indicative of operating performance. For GAAP reporting purposes, Medicaid premium taxes and Medicaid state ACA industry fee reimbursements are included in premium revenue.

Excluding Medicaid premium taxes and Medicaid state ACA industry fee reimbursements, Medicaid premium revenue for the quarter ended March 31, 2014 increased 24% when compared to the same period in 2013. The increase in premium revenues was driven mainly by increased membership in Kentucky, primarily from its participation in the ACA Medicaid expansion and the additional members received from Centene on July 6, 2013. The increase was also due to rate increases in certain other markets in late 2013, changes in geographic and demographic mix of members, Medicaid revenue from payment arrangements with certain states associated with primary care enhanced payments, as mandated by the ACA, and the benefit of a full quarter's memberships from the South Carolina and Missouri Care Medicaid acquisitions completed in 2013. These increases were partially offset by the loss of Ohio effective July 1, 2013.

Medical benefits expense for the quarter ended March 31, 2014 increased by approximately 23% when compared to the same period in 2013 mainly driven by the increase in membership, a swing from recognizing net favorable prior period reserve development in 2013 to net unfavorable prior period reserve development in 2014, primary care provider enhanced payments mandated by the ACA and the impact of a full quarter’s membership from the South Carolina and Missouri Medicaid acquisitions completed in 2013, partially offset by lower medical cost trend on current periods of service and the loss of Ohio. Our Medicaid MBR, excluding the impact of premium taxes and ACA fee reimbursement, decreased by 80 basis points in the quarter ended March 31, 2014 compared to the same period in 2013 due to lower medical cost trend on current periods of

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service and a full quarter’s inclusion of MBR for the Missouri Care and WCSC acquisitions, which were lower than the segment average, partially offset by the impact of the swing to net unfavorable prior period reserve development in 2014. Also partially offsetting the improvement is an increase in spending on hepatitis C drugs as a result of the new, expensive drugs that recently came to market.

Outlook

• We anticipate Medicaid Health Plans segment premium revenue, excluding Medicaid state premium taxes and Medicaid state reimbursements for the ACA industry fee, to increase approximately 27% to 28% compared to 2013, mainly resulting from growth in Kentucky and Georgia, the Florida MMA implementation and our entry in New Jersey.

• We currently expect the Medicaid Health Plans segment MBR in 2014 to be in the range of approximately 88.0% to 88.5%, compared to 88.2% percent in 2013. The expected MBR in 2014 is roughly in line with 2013 results principally due to net unfavorable prior period development recognized in the first quarter and the implementation of the Florida MMA program, which we expect to operate at an MBR that is higher than our 2013 performance in the state, that was offset by better than anticipated medical cost trend and the impact of our medical cost management initiatives.

• In February 2014, we entered into a contract with the AHCA to provide managed care services to Medicaid recipients in eight of the state’s eleven regions as part of the state’s MMA program. These regions include the Jacksonville, Miami, Orlando, Tallahassee and Tampa metropolitan areas. As a result of these awards, we anticipate that our Florida Temporary Assistance for Needy Families ("TANF") and SSI membership will increase in 2014 to at least 500,000 from the 337,000 members that we served in March 2014. We expect that starting in the second quarter of 2014, two to three regions will be launched per month, and all regions should be launched by late summer or early fall of 2014. As of May 1, we initiated the MMA implementation in three regions, including the Jacksonville area. We are serving over 185,000 members in these regions, a gain of more than 107,000 members compared to April 30, 2014. Our anticipated Florida MMA premium also is higher than our historical experience to compensate us for the enhanced benefits and services required in the MMA program, however we also anticipate that our MBR under the MMA program will be higher than our 2013 performance in the state.

• We entered the New Jersey Medicaid program in January 2014 as a result of recent approval from the state to offer Medicaid managed care in certain counties. Our service area and presence in the New Jersey Medicaid program is anticipated to expand significantly upon closure of our pending acquisition of Healthfirst NJ, which is currently anticipated to close on June 30, 2014, with the transfer of membership effective July 1, 2014.

Medicare Health Plans

We contract with CMS under the Medicare program to provide a comprehensive array of Part C and Part D benefits to Medicare eligible persons, provided through our MA and Medicare Supplement plans. Our MA plans are comprised of coordinated care plans ("CCPs"), which are administered through HMOs and generally require members to seek health care services and select a primary care physician from a network of health care providers. In addition, we offer Medicare Part D coverage, which provides prescription drug benefits, as a component of most of our MA plans. As of March 31, 2014, we operated our MA CCPs in Arkansas, Arizona, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Mississippi, Missouri, New Jersey, New York, Ohio, South Carolina, Tennessee and Texas. Medicare Supplement policies are offered in 39 states.

Impacting Our Results

• Our MA business is being subjected to substantial margin compression in 2014. As a result of legislation passed in December 2013, the 2% Federal budget sequestration reduction to Medicare provider and plan payments is continuing in 2014 and will extend through 2023, so our results of operations are being and will continue to be negatively impacted. In addition, CMS implemented revised 2014 benchmark rates, which resulted in a rate decrease of approximately 2.0% to 4.0% from 2013 rates. CMS also made changes to the MA and PDP Medicare risk adjustment system involving a risk coding recalibration which is being phased in over the 2014 and 2015 plan years. Also, CMS is implementing an MA coding intensity reduction of 4.91% for payment year 2014. This new risk adjustment model includes an adjustment to the calculation of health status cost risk based on each beneficiary's diagnosis codes that will reduce the positive adjustments for high-risk patients and increase the negative adjustments for low-risk patients. The change appears to most severely affect our rates for those individuals with complex medical conditions, including

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many of our dual-eligible and lower income members. Our MA premium rates have not been adjusted to specifically offset the impact of the ACA industry fee.

• For the 2014 plan year, we have expanded the geographic footprint of our MA plans to offer plans in a total of 210 counties in 14 states, excluding Windsor, but including dual special needs plans (“D-SNPs”) for those who are dually eligible for Medicare and Medicaid in most of the MA markets we serve.

• Effective January 1, 2014, as a result of the Windsor acquisition, we began serving approximately 38,000 MA members in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it serves approximately 48,000 members in 39 states.

Medicare Health Plans Segment Results

The following table sets forth the summarized results of operations and other relevant performance measures for our Medicare segment for the quarters ended March 31, 2014 and 2013:

	For the Quarters Ended March 31,						Change
	2014			2013			Dollar		Percentage
Medicare Health Plans:	(Dollars in millions)
Premium revenue	$	963.3		$	718.9		$	244.4	34.0	%
Medical benefits expense	851.5			625.6			225.9		36.1	%
ACA industry fee	10.7			—			10.7		NMF
Gross margin	$	101.1		$	93.3		$	7.8	8.4	%
MBR	88.4		%	87.0		%			1.4	%
Membership	390,000			256,000					52.3	%

Medicare premium revenue for the quarter ended March 31, 2014 increased 34% when compared to the same period in 2013. In addition to the impact of the Windsor acquisition, premium revenue increased 14% mainly due to organic membership growth, partially offset by the impact of CMS rate decreases.

Medical benefits expense for the quarter ended March 31, 2014 increased by approximately 36% when compared to the same period in 2013, and was driven by the increase in membership discussed above, and a swing from recognizing net favorable prior period reserve development in 2013 to net unfavorable prior period reserve development in 2014. Our Medicare MBR increased by 140 basis points in 2014 due mainly to the swing to net unfavorable prior period reserve development in 2014, the impact of CMS rate decreases and the federal government's budget sequestration, which took effect in April 2013. Additionally, the increase is partially due to the impact of Windsor, which operated at a higher MBR relative to the segment average. These factors were offset in part by changes to plan benefit designs and cost sharing terms in 2014 compared with 2013, as well as our ongoing medical cost management initiatives.

Outlook

• Currently, we expect Medicare Health Plan segment premium revenue to increase in the range of approximately 23% to 24% for the full year in 2014 compared to 2013. The increase is mainly due to the Windsor acquisition and expected continued membership growth during the remaining months of 2014, as we leverage our success in serving dually-eligible beneficiaries as well as the broader growth in the Medicare population.

• We currently expect the Medicare Health Plans segment MBR to be in the range of approximately 87.0% and 87.5% in 2014 compared to 86.6% in 2013. The increase is due mainly to net unfavorable prior period reserve development in the first quarter of 2014, as well as the performance of the Windsor MA plans. We expect that the performance of our Windsor plans will improve relative to the first quarter once the business is fully integrated and planned medical management and expense initiatives take effect.

Medicare PDPs

We have contracted with CMS to serve as a plan sponsor offering stand-alone Medicare Part D PDPs to Medicare eligible

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beneficiaries through our Medicare PDPs segment. As of March 31, 2014, we offered PDPs in 49 states and the District of Columbia. The PDP benefit design generally results in our incurring a greater portion of the responsibility for total prescription drug costs in the early stages of a plan year, and less in the latter stages of a plan year, due to the members' share of cumulative out-of-pocket costs increasing throughout the plan year. As a result, the Medicare PDPs MBR generally decreases throughout the year. Also, the level and mix of members who are auto-assigned to us and those who actively choose our PDPs will impact the segment MBR pattern across periods.

Impacting Our Results

▪ Our Medicare PDP business is being subjected to substantial margin compression in 2014. As a result of legislation passed in December 2013, the 2% Federal budget sequestration reduction to Medicare provider and plan payments is continuing in 2014 and will extend through 2023, and so our results of operations are being and will continue to be negatively impacted. In addition, our PDP premium rates have not been adjusted to specifically offset the impact of the ACA industry fee.

▪ Based on the outcome of our 2014 stand-alone PDP bids, our plans are below the benchmarks in 30 of the 34 CMS regions and within the de minimis range of the benchmark in three other CMS regions. Comparatively, in 2013, our plans were below the benchmark in 14 regions and within the de minimis range in five other regions. In 2014, we are being auto-assigned newly eligible members into our plans for the 30 regions that are below the benchmark. Membership has increased to approximately 1.3 million as of March 31, 2014, from 757,000 as of December 31, 2013. We expect membership to continue to grow organically during the remaining months of 2014.

Medicare PDPs Segment Results

The following table sets forth the summarized results of operations and other relevant performance measures for our Medicare PDPs segment for the quarter ended March 31, 2014 and 2013:

	For the Quarters Ended March 31,						Change
	2014			2013			Dollar			Percentage
Medicare PDPs:	(Dollars in millions)
Premium revenue	$	373.0		$	223.0		$	150.0		67.3	%
Medical benefits expense	389.1			231.0			158.1			68.4	%
ACA industry fee	2.7			—			2.7			NMF
Gross margin	$	(18.8	)	$	(8.0	)	$	(10.8	)	135.0	%
MBR	104.3		%	103.6		%				0.7	%
Membership	1,271,000			757,000						67.9	%

Medicare PDP premium revenue increased 67% in the quarter ended ended March 31, 2014 when compared to the same period in 2013, primarily due to the increase in membership, which includes 109,000 members from the Windsor acquisition, and the outcome of our 2014 bids. PDP MBR for the quarter ended March 31, 2014 increased 70 basis points compared to the same period in 2013 mainly due to higher drug unit costs, the outcome of our 2014 bids and the impact of CMS rate decreases and the federal government's budget sequestration, which took effect in April 2013. Transition of care costs and higher utilization for new members also contributed to the increased MBR. The transition period concluded at the end of March 2014.

Outlook

• We anticipate that PDP segment premium revenue will increase 46% to 47% in 2014 compared to 2013, primarily as a result of our membership growth, offset in part by lower premium rates resulting from our 2014 bids.

• We currently anticipate our PDP segment MBR for 2014 will be in the range of approximately 88.5% to 89.0%, up from 86.5% in 2013. The expected year-over-year increase results mainly from higher drug unit costs and utilization patterns among members who enrolled in our plans beginning in 2014, partially offset by the realignment of our benefit plans and cost structure, including the launch of our preferred pharmacy network. For our 2014 bids, we were able to modify our enhanced plan through increased premium rates and cost sharing, as well as other changes.

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LIQUIDITY AND CAPITAL RESOURCES

Each of our existing and anticipated sources of cash is impacted by operational and financial risks that influence the overall amount of cash generated and the capital available to us. Additionally, we operate as a holding company in a highly regulated industry. The parent and other non-regulated companies ("non-regulated subsidiaries") are dependent upon dividends and management fees from our regulated subsidiaries, most of which are subject to regulatory restrictions. For a further discussion of risks that can affect our liquidity, see Part I – Item 1A – "Risk Factors" included in our 2013 Form 10-K.

Liquidity

The Company maintains liquidity at two levels: the regulated subsidiary level and the non-regulated parent and subsidiary level.

Regulated subsidiaries

Our regulated subsidiaries' primary liquidity requirements include:

• payment of medical claims and other health care services;

• management fees paid to our non-regulated administrator subsidiary under intercompany services agreements and direct administrative costs, which are not covered by an intercompany services agreement, such as selling expenses and legal costs; and

• federal tax payments to the parent company under an intercompany tax sharing agreement.

Our regulated subsidiaries meet their liquidity needs by:

• maintaining appropriate levels of cash, cash equivalents and short-term investments;

• generating cash flows from operating activities, mainly from premium revenue;

• cash flows from investing activities, including investment income and sales of investments; and

• capital contributions received from our non-regulated subsidiaries.

We refer collectively to the cash, cash equivalents and investment balances maintained by our regulated subsidiaries as "regulated cash and investments," respectively. Our regulated subsidiaries generally receive premiums in advance of payments of claims for medical and other health care services; however, regulated cash and cash equivalents can fluctuate significantly in a particular period depending on the timing of receipts for premiums from our government partners. Our unrestricted regulated cash and investments (which represent our regulated cash and investments not on deposit with a state in which we operate) was $1.6 billion as of March 31, 2014, an increase of $213.0 million from $1.4 billion at December 31, 2013. The increase is due mainly to cash acquired as part of the Windsor acquisition as well as $7.5 million of contributions received from the Parent and non-regulated subsidiaries.

Our regulated subsidiaries are each subject to applicable state regulations that, among other things, require the maintenance of minimum levels of capital and surplus. We continue to maintain significant levels of aggregate excess statutory capital and surplus in our regulated subsidiaries. See further discussion under Regulatory Capital and Dividend Restrictions below.

Parent and non-regulated subsidiaries

Liquidity requirements at the non-regulated parent and subsidiary level generally consist of:

• payment of administrative costs not directly incurred by our regulated operations, including, but not limited to, staffing costs, business development, rent, branding and certain information technology services;

• capital contributions paid to our regulated subsidiaries;

• capital expenditures;

• debt service; and

• federal tax payments.

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Our non-regulated parent and subsidiaries normally meet their liquidity requirements by:

• management fees earned by our non-regulated administrator subsidiary under intercompany services agreements;

• dividends received from our regulated subsidiaries;

• collecting federal tax payments from the regulated subsidiaries;

• proceeds from issuance of debt and equity securities; and

• cash flows from investing activities, including investment income and sales of investments.

Unregulated cash, cash equivalents and investments was approximately $487.8 million as of March 31, 2014, a $7.3 million decrease from a balance of $495.1 million as of December 31, 2013. The decrease is due to $7.5 million of capital contributions made to certain regulated subsidiaries.

Auction Rate Securities

As of March 31, 2014, $31.9 million of our long-term investments were comprised of municipal note securities with an auction reset feature ("auction rate securities"), which are issued by various state and local municipal entities for the purpose of financing student loans, public projects and other activities and carry investment grade credit ratings. Liquidity for these auction rate securities is typically provided by an auction process which allows holders to sell their notes and resets the applicable interest rate at pre-determined intervals, usually every seven or 35 days. As of the date of this 2014 Form 10-Q, auctions have failed for our auction rate securities and there is no assurance that auctions will succeed in the future. An auction failure means that the parties wishing to sell their securities could not be matched with an adequate volume of buyers. In the event that there is a failed auction the indenture governing the security requires the issuer to pay interest at a contractually defined rate that is generally above market rates for other types of similar instruments. The securities for which auctions have failed will continue to accrue interest at the contractual rate and be auctioned every seven or 35 days until the auction succeeds, the issuer calls the securities, or they mature. As a result, our ability to liquidate and fully recover the carrying value of our remaining auction rate securities in the near term may be limited or non-existent. In addition, while all of our auction rate securities currently carry investment grade ratings, if the issuers are unable to successfully close future auctions and their credit ratings deteriorate, we may be required to record an impairment charge on these investments in the future.

Although auctions continue to fail, we believe we will be able to liquidate these securities without significant loss. There are government guarantees or municipal bond insurance in place and we have the ability and the present intent to hold these securities until maturity or market stability is restored. Accordingly, we do not believe our auction rate securities are impaired and as a result, we have not recorded any impairment losses for our auction rate securities. However, it could take until the final maturity of the underlying securities to realize our investments' recorded value. The final maturity of the underlying securities could be as long as 23 years. The weighted-average life of the underlying securities for our auction rate securities portfolio is 19 years.

Cash Flow Activities

Our cash flows are summarized as follows:

	For the Quarters Ended March 31,
	2014			2013
	(In millions)
Net cash (used in) provided by operating activities	$	(13.9	)	$	31.1
Net cash provided by (used in) investing activities	162.3			(61.4		)
Net cash provided by financing activities	27.4			308.0
Total net increase in cash and cash equivalents	$	175.8		$	277.7

Net Cash Provided by Operating Activities

We generally receive premiums in advance of payments of claims for health care services; however, cash flows related to our operations can fluctuate significantly in a particular period depending on the timing of premiums receipts from our government partners or payments related to the resolution of government investigations and related litigation.

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The decrease in cash flow from operating activities for the quarter ended March 31, 2014 compared to the same period in 2013 resulted mostly from the timing of premium receipts from our government partners, partially offset by the increase in premiums associated with the growth in membership. Additionally, operating cash flows for the quarter ended March 31, 2014 were negatively impacted by a $36.5 million payment made to the Civil Division, compared to a $14.6 million payment remitted to the Civil Division during the 2013 quarter.

Net Cash Used In Investing Activities

During the quarter ended March 31, 2014, cash used in investing activities increased mainly due to $164.2 million of cash acquired from the Windsor acquisition. Excluding acquisitions, cash and investment activities primarily reflect our investment in marketable securities and restricted investments of approximately $102.9 million and purchases of property and equipment of $13.2 million, partially offset by $114.2 million of proceeds from maturities of marketable securities and restricted investments.

During the quarter ended March 31, 2013, cash used in investing activities primarily reflects our investment in marketable securities and restricted investments of approximately $149.4 million and purchases of property and equipment of $15.9 million, partially offset by $143.1 million of proceeds from maturities of marketable securities and restricted investments. Cash consideration paid for acquisitions, net of cash acquired, was $39.2 million in 2013 related to the WCSC and Missouri Care acquisitions.

Net Cash Provided By Financing Activities

Net cash provided by financing activities is mainly impacted by net funds received or paid for the benefit of members. Net funds received for the benefit of members provided net cash of approximately $29.6 million and $85.9 million during the quarters ended March 31, 2014 and March 31, 2013, respectively. These funds represent subsidies received from CMS, net of related prescription drug benefits we paid, in connection with the low-income cost sharing, catastrophic reinsurance and coverage gap discount components of the Medicare Part D program for which we assume no risk.

Financial Impact of Government Investigation and Litigation

Under the terms of settlement agreements entered into by us on April 26, 2011, and finalized on March 23, 2012, to resolve matters under investigation by the Civil Division of the U.S. Department of Justice (the "Civil Division") and certain other federal and state enforcement agencies (the "Settlement"), WellCare agreed to pay the Civil Division a total of $137.5 million in four equal annual principal payments, plus interest accrued at 3.125%. The estimated fair value of the discounted remaining liability was $34.4 million at March 31, 2014.

The Settlement also provides for a contingent payment of an additional $35.0 million in the event that we are acquired or otherwise experience a change in control on or before April 30, 2015, provided that the change in control transaction exceeds certain minimum transaction value thresholds as specified in the Settlement.

Capital Resources

Senior Notes

In November 2013, we completed the offer and sale of $600.0 million of 5.75% unsecured senior notes due 2020 (the “Senior Notes”). We received net proceeds of $587.9 million upon issuance of the Senior Notes, which consists of the $600.0 million principal balance of the notes less approximately $12.1 million incurred in debt issuance costs. The Senior Notes will mature on November 15, 2020, with interest on the Senior Notes being payable semi-annually on May 15 and November 15 of each year, commencing on May 15, 2014. We used a portion of the net proceeds from the offering to repay the full $336.5 million outstanding under our 2011 credit agreement, and the remaining net proceeds are being used for general corporate purposes, including organic growth opportunities and potential acquisitions.

The indenture under which the Senior Notes were issued contains covenants that, among other things, limit the ability of our company and its restricted subsidiaries to:

• incur additional indebtedness and issue preferred stock;

• pay dividends or make other distributions;

• make other restricted payments and investments;

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• sell assets, including capital stock of restricted subsidiaries;

• create certain liens;

• incur restrictions on the ability of restricted subsidiaries to pay dividends or make other payments, and in the case of our subsidiaries, guarantee indebtedness;

• engage in transactions with affiliates;

• create unrestricted subsidiaries; and

• merge or consolidate with other entities.

Credit Facilities

In November 2013, we entered into a credit agreement (the "Credit Agreement") which provides for a senior unsecured revolving loan facility (the “Revolving Credit Facility”) of up to $300.0 million, which may be used for general corporate purposes of the Company and its subsidiaries. The Revolving Credit Facility provides for up to $75.0 million for letters of credit. The Credit Agreement also provides that we may, at our option, increase the aggregate amount of the Revolving Credit Facility and/or obtain incremental term loans in an amount up to $75.0 million without the consent of any lenders not participating in such increase, subject to certain customary conditions and lenders committing to provide the increase in funding. The commitments under the Revolving Credit Facility expire on November 14, 2018 and any amounts outstanding under the facility will be payable in full at that time. Unutilized commitments under the Credit Agreement are subject to a fee of 0.25% to 0.375% depending upon our ratio of total debt to cash flow.

The Credit Agreement includes negative and financial covenants that limit certain activities of our company and its subsidiaries, including (i) restrictions on our ability to incur additional indebtedness; and (ii) financial covenants that require (a) the ratio of total debt to cash flow not to exceed a maximum; (b) a minimum interest expense and principal payment coverage ratio; and (c) a minimum level of statutory net worth for our health maintenance organization and insurance subsidiaries. The Credit Agreement also contains customary representations and warranties that must be accurate in order for us to borrow under the Revolving Credit Facility. In addition, the Credit Agreement contains customary events of default. If an event of default occurs and is continuing, we may be required immediately to repay all amounts outstanding under the Credit Agreement. Lenders holding at least 50% of the loans and commitments under the Credit Agreement may elect to accelerate the maturity of the loans and/or terminate the commitments under the Credit Agreement upon the occurrence and during the continuation of an event of default.

Additionally, in November 2013, we terminated our 2011 credit agreement in connection with our entry into the Credit Agreement described above. All amounts outstanding under the 2011 Credit Agreement were paid in full on November 14, 2013.

For additional information on our long-term debt, see Note 8– Debt to the Condensed Consolidated Financial Statements.

Shelf Registration Statement

In August 2012, we filed a shelf registration statement on Form S-3 with the United States Securities & Exchange Commission (the "Commission") that became automatically effective covering the registration, issuance and sale of an indeterminate amount of our securities, including common stock, preferred stock, senior or subordinated debt securities, depository shares, securities purchase contracts, units or warrants. We may publicly offer securities in the future at prices and terms to be determined at the time of the offering.

Initiatives to Increase Our Unregulated Cash

We may pursue alternatives to raise additional unregulated cash. Some of these initiatives may include, but are not limited to, obtaining dividends from certain of our regulated subsidiaries, provided sufficient capital in excess of regulatory requirements exists in these subsidiaries, and/or accessing the debt and equity capital markets. However, we cannot provide any assurances that we will obtain applicable state regulatory approvals for additional dividends to our non-regulated subsidiaries by our regulated subsidiaries or be successful in accessing the capital markets if we determine to do so.

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Regulatory Capital and Dividend Restrictions

Each of our HMO and insurance subsidiaries must maintain a minimum amount of statutory capital determined by statute or regulation. The minimum statutory capital requirements differ by state and are generally based on a percentage of annualized premium revenue, a percentage of annualized health care costs, a percentage of certain liabilities, a statutory minimum, risk-based capital ("RBC") requirements or other financial ratios. The RBC requirements are based on guidelines established by the NAIC, and have been adopted by most states. As of March 31, 2014, our operating HMO and insurance company subsidiaries in all states except California, New York and Florida were subject to RBC requirements. The RBC requirements may be modified as each state legislature deems appropriate for that state. The RBC formula, based on asset risk, underwriting risk, credit risk, business risk and other factors, generates the authorized control level ("ACL"), which represents the amount of capital required to support the regulated entity's business. For states in which the RBC requirements have been adopted, the regulated entity typically must maintain a minimum of the greater of 200% of the required ACL or the minimum statutory net worth requirement calculated pursuant to pre-RBC guidelines. Our subsidiaries operating in Texas and Ohio are required to maintain statutory capital at RBC levels equal to 225% and 300%, respectively, of the applicable ACL. Failure to maintain these requirements would trigger regulatory action by the state. At March 31, 2014, our HMO and insurance subsidiaries were in compliance with these minimum capital requirements.

The statutory framework for our regulated subsidiaries' minimum capital requirements changes over time. For instance, RBC requirements may be adopted by more of the states in which we operate. These subsidiaries are also subject to their state regulators' overall oversight powers. For example, the State of New York adopted regulations that increase the reserve requirement annually until 2018. In addition, regulators could require our subsidiaries to maintain minimum levels of statutory net worth in excess of the amount required under the applicable state laws if the regulators determine that maintaining such additional statutory net worth is in the best interest of our members and other constituencies. Moreover, if we expand our plan offerings in a state or pursue new business opportunities, we may be required to make additional statutory capital contributions.

In addition to the foregoing requirements, our regulated subsidiaries are subject to restrictions on their ability to make dividend payments, loans and other transfers of cash. Dividend restrictions vary by state, but the maximum amount of dividends which can be paid without prior approval from the applicable state is subject to restrictions relating to statutory capital, surplus and net income for the previous year. Some states require prior approval of all dividends, regardless of amount. States may disapprove any dividend that, together with other dividends paid by a subsidiary in the prior 12 months, exceeds the regulatory maximum as computed for the subsidiary based on its statutory surplus and net income. No dividends were received from our regulated subsidiaries during the quarter ended March 31, 2014.

For additional information on regulatory requirements, see Note 16– Regulatory Capital and Dividend Restrictions to the Condensed Consolidated Financial Statements included in our 2013 Form 10-K.

CRITICAL ACCOUNTING ESTIMATES

In the ordinary course of business, we make a number of estimates and assumptions relating to the reporting of our results of operations and financial condition in conformity with GAAP. We base our estimates on historical experience and on various other assumptions that we believe to be reasonable under the circumstances. Actual results could differ significantly from those estimates under different assumptions and conditions. We believe that our accounting estimates relating to premium revenue recognition, medical benefits expense and medical benefits payable, and goodwill and intangible assets, are those that are most important to the portrayal of our financial condition and results and require management's most difficult, subjective and complex judgments, often as a result of the need to make estimates about the effect of matters that are inherently uncertain. We have not changed our methodology in deriving these critical accounting estimates from those previously disclosed in our 2013 Form 10-K.

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Premium Revenue Recognition and Premiums Receivable

We earn premium revenue through our participation in Medicaid, Medicaid-related and Medicare programs.

State governments individually operate and implement and, together with the federal government's CMS, fund and regulate the Medicaid program. We provide benefits to low-income and disabled persons under the Medicaid program and are paid premiums based on contracts with government agencies in the states in which we operate health plans. Our Medicaid contracts are generally multi-year contracts subject to annual renewal provisions. Rate changes are typically made at the commencement of each new contract renewal period. In some instances, our fixed Medicaid premiums are subject to risk score adjustments based on the acuity of our membership. State agencies analyze encounter submissions of processed claims data to determine the acuity of our membership relative to the entire state's Medicaid membership.

We operate our MA plans under the Medicare Part C program and provide our eligible members with benefits comparable to those available under Medicare Parts A and B. Most of our MA plans and all of our PDPs offer prescription drug benefits to eligible members under the Medicare Part D program. Premiums for each MA member are established by contract, although the rates vary according to a combination of factors, including upper payment limits established by CMS, the member's geographic location, age, gender, medical history or condition, or the services rendered to the member. Our MA contracts with CMS generally have terms of one year and expire at the end of each calendar year. PDP premiums are also based upon contracts with CMS that have a term of one year and expire at the end of each calendar year. We provide annual written bids to CMS for our PDPs, which reflect the estimated costs of providing prescription drug benefits over the plan year. Changes in MA and PDP members' health status also impact monthly premiums as described under "Risk-Adjusted Medicare Premiums" below. CMS pays all premium for Medicare Part C and substantially all of the premium for Medicare Part D coverage. We bill the remaining Medicare Part D premium to PDP and MA members with Part D benefits based on the plan year bid submitted to CMS. For qualifying low-income subsidy ("LIS") members, CMS pays for some or all of the LIS member's monthly premium. The CMS payment is dependent upon the member's income level as determined by the Social Security Administration.

We receive premiums from CMS and state agencies on a per member per month ("PMPM") basis for the members that are assigned to, or have selected, us to provide health care services under our Medicare and Medicaid contracts. We recognize premium revenue in the period in which we are obligated to provide services to our members. CMS and state agencies generally pay us in the month in which we provide services. We record premiums earned but not received as premiums receivable and record premiums received in advance of the period of service as unearned premiums in the condensed consolidated balance sheets. Unearned premiums are recognized as revenue when we provide the related services. On a monthly basis, we bill members for any premiums for which they are responsible according to their respective plan. Member premiums are recognized as revenue in the period of service. We reduce recorded premium revenue and member premiums receivable by the amount we estimate may not be collectible, based on our evaluation of historical trends. We also routinely monitor the collectability of premiums receivable from CMS and state agencies, including Medicaid receivables for obstetric deliveries and newborns and net receivables for member retroactivity. We reduce revenue and premiums receivable by the amount we estimate may not be collectible. We report premiums receivable, net of an allowance for uncollectible premiums receivable, which was $8.6 million and $15.8 million, at March 31, 2014 and December 31, 2013, respectively. Historically, the allowance for member premiums receivable has not been material relative to consolidated premium revenue.

We record retroactive adjustments to revenues based on changes in the number and eligibility status of our members subsequent to when we recorded revenue related to those members and months of service. We receive premium payments based upon eligibility lists produced by CMS and state agencies. We verify these lists to determine whether we have been paid for the correct premium category and program. From time to time, CMS and state agencies require us to reimburse them for premiums that we received for individuals who were subsequently determined by us, or by CMS or state agencies, to be ineligible for any government-sponsored program or to belong to a plan other than ours. We receive additional premiums from CMS and state agencies for individuals who were subsequently determined to belong to our plan for periods in which we received no premium for those members. We estimate the amount of outstanding retroactivity adjustments and adjust premium revenue based on historical trends, premiums billed, the volume of member and contract renewal activity and other information. We record amounts receivable or payable in premiums receivable, net and other accrued expenses and liabilities in the condensed consolidated balance sheets.

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Risk-Adjusted Medicare Premiums 

CMS employs a risk-adjustment model to determine the premium amount it pays for each MA and PDP member. This model apportions premiums paid to all plans according to the health status of each beneficiary enrolled, resulting in higher scores for members with predictably higher costs. The model uses diagnosis data from inpatient and ambulatory treatment settings to calculate each risk score. We collect claims and encounter data for our MA members and submit the necessary diagnosis data to CMS within prescribed deadlines. After reviewing the respective submissions, CMS establishes the premium payments to MA plans at the beginning of the plan year, and then adjusts premium levels on a retroactive basis. The first retroactive adjustment for a given plan year generally occurs during the third quarter of that year and represents the update of risk scores for the current plan year based on the severity of claims incurred in the prior plan year. CMS then issues a final retroactive risk-adjusted premium settlement for that plan year in the following year.

We develop our estimates for risk-adjusted premiums utilizing historical experience and predictive models as sufficient member risk score data becomes available over the course of each CMS plan year. We populate our models with available risk score data on our members and base risk premium adjustments on risk score data from the previous year. We are not privy to risk score data for members new to our plans in the current plan year; therefore we include assumptions regarding these members' risk scores. We periodically revise our estimates of risk-adjusted premiums as additional diagnosis code information is reported to CMS and adjust our estimates to actual amounts when the ultimate adjustment settlements are either received from CMS or we receive notification from CMS of such settlement amounts. As a result of the variability of factors that determine our estimates for risk-adjusted premiums, the actual amount of the CMS retroactive payment could be materially more or less than our estimates and could have a material effect on our results of operations, financial position and cash flows. We record any changes in estimates in current operations as adjustments to premium revenue. Historically, we have not experienced significant differences between our estimates and amounts ultimately received. However, in the third quarter of 2013, we recognized risk adjusted premium received as part of the 2012 final settlement that was higher than our original estimates, mainly related to members in our California MA plan that were new to Medicare in 2012. Additionally, the data provided to CMS to determine members' risk scores is subject to audit by CMS even after the annual settlements occur. An audit may result in the refund of premiums to CMS. While our experience to date has not resulted in a material refund, future refunds could materially reduce premium revenue in the year in which CMS determines a refund is required and could be material to our results of operations, financial position and cash flows. Premiums receivable in the accompanying condensed consolidated balance sheets include risk-adjusted premiums receivable of $178.6 million and $107.2 million as of March 31, 2014 and December 31, 2013, respectively.

Minimum Medical Expense and Risk Corridor Provisions

We may be required to refund certain premium revenue to CMS and state government agencies under various contractual and plan arrangements. We estimate the impact of the following arrangements on a monthly basis and reflect any adjustments to premium revenues in current operations. We report the estimated net amounts due to CMS and state agencies in other payables to government partners in the condensed consolidated balance sheets.

Certain of our Medicaid contracts require us to expend a minimum percentage of premiums on eligible medical benefits expense. To the extent that we expend less than the minimum percentage of the premiums on eligible medical benefits expense, we are required to refund to the state all or some portion of the difference between the minimum and our actual allowable medical benefits expense. We estimate the amounts due to the state agencies as a return of premium based on the terms of our contracts with the applicable state agency.

Our MA and PDP prescription drug plan premiums are subject to risk sharing through the CMS Medicare Part D risk corridor provisions. The risk corridor calculation compares our actual experience to the target amount of prescription drug costs, limited to costs under the standard coverage as defined by CMS, less rebates included in our submitted plan year bid. We receive additional premium from CMS if our actual experience is more than 5% above the target amount. We refund premiums to CMS if our actual experience is more than 5% below the target amount. After the close of the annual plan year, CMS performs the risk corridor calculation and any differences are settled between CMS and our plans. We have not historically experienced material differences between the subsequent CMS settlement amount and our estimates.

Medicare Part D Settlements

We receive certain Part D prospective subsidy payments from CMS for our MA and PDP members based on the estimated costs of providing prescription drug benefits over the plan year. After the close of the annual plan year, CMS reconciles our actual experience to the prospective payments we received and any differences are settled between CMS and our plans. As such, these

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subsidies represent funding from CMS for which we assume no risk. We do not recognize the receipt of these subsidies as premium revenue and we do not recognize the payments of related prescription drug benefits as medical benefits expense. We report the subsidies received and benefits paid on a net basis as funds receivable (held) for the benefit of members in the condensed consolidated balance sheets. We also report the net receipts and payments as a financing activity in our condensed consolidated statements of cash flows. CMS pays the following subsidies prospectively as a fixed PMPM amount based upon the plan year bid submitted by us:

Low-Income Cost Sharing Subsidy—CMS reimburses us for all or a portion of qualifying LIS members' deductible, coinsurance and co-payment amounts above the out-of-pocket threshold.

Catastrophic Reinsurance Subsidy—CMS reimburses us for 80% of the drug costs after a member reaches his or her out-of-pocket catastrophic threshold through a catastrophic reinsurance subsidy.

Coverage Gap Discount Subsidy—We advance the pharmaceutical manufacturers gap coverage discounts at the point of sale. On a periodic basis, CMS bills pharmaceutical manufacturers for discounts advanced by us. Pharmaceutical manufacturers remit payments for invoiced amounts directly to us. CMS reduces subsequent prospective payments made to us by the discount amounts billed to manufacturers.

CMS generally performs the Part D payment reconciliation in the fourth quarter of the following plan year based on prescription drug event data we submit to CMS within prescribed deadlines. After the Part D payment reconciliation for coverage gap discount subsidies, we may continue to report discounts to CMS for 37 months following the end of the plan year. CMS will invoice manufacturers for these discounts and we will be paid through the quarterly manufacturer payments. Historically, we have not experienced material adjustments related to the CMS annual reconciliation of prior plan year low-income cost sharing, catastrophic reinsurance and coverage gap discount subsidies.

Medical Benefits Expense and Medical Benefits Payable

Medical benefits payable is the most significant estimate included in the condensed consolidated financial statements. We use a consistent methodology to record management's best estimate of medical benefits payable based on the experience and information available to us at the time. This estimate is determined utilizing standard actuarial methodologies based upon historical experience and key assumptions consisting of trend factors and completion factors using an assumption of moderately adverse conditions, which vary by business segment. These standard actuarial methodologies include:

• contractual requirements;

• historic utilization trends;

• the interval between the date services are rendered and the date claims are paid;

• denied and disputed claims activity and changes in benefits;

• expected health care cost inflation;

• seasonality patterns;

• maturity of lines of business; and

• changes in membership.

Many aspects of the managed care business are not predictable. These aspects include incidences of illness or disease (such as congestive heart failure cases, cases of upper respiratory illness, the length and severity of the flu season, diabetes cases, the number of full-term versus premature births and the number of neonatal intensive care babies). Therefore, we must continually monitor our historical experience in determining our trend assumptions to reflect the ever-changing mix, needs and size of our membership. Among the factors considered by management are:

• changes in the level of benefits provided to members;

• seasonal variations in utilization;

• identified industry trends; and

• changes in provider reimbursement arrangements, including changes in the percentage of reimbursements made on a capitation as opposed to a fee-for-service basis.

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The factors and assumptions described above that are used to develop our estimate of medical benefits expense and medical benefits payable inherently are subject to greater variability when there is more limited experience or information available to us. The ultimate claims payment amounts, patterns and trends for new products and geographic areas cannot be precisely predicted at their onset, since we, the providers and the members do not have experience in these products or geographic areas. Standard accepted actuarial methodologies, discussed above, would allow for this inherent variability. This can result in larger differences between the originally estimated medical benefits payable and the actual claims amounts paid. Conversely, during periods where our products and geographies are more stable and mature, we have more reliable claims payment patterns and trend experience. With more reliable data, we should be able to more closely estimate the ultimate claims payment amounts; therefore, we may experience smaller differences between our original estimate of medical benefits payable and the actual claim amounts paid.

In developing our estimates, we apply different estimation methods depending on the month for which incurred claims are being estimated. For the more recent months, which constitute the majority of the amount of the medical benefits payable, we estimate claims incurred by applying observed trend factors to the fixed fee PMPM costs for prior months, which costs have been estimated using completion factors, in order to estimate the PMPM costs for the most recent months. We validate our estimates of the most recent PMPM costs by comparing the most recent months' utilization levels to the utilization levels in prior months and actuarial techniques that incorporate a historical analysis of claim payments, including trends in cost of care provided and timeliness of submission and processing of claims.

These considerations are reflected in the trends in our medical benefits expense. Other external factors such as government-mandated benefits or other regulatory changes, catastrophes and epidemics may impact medical cost trends. Other internal factors such as system conversions and claims processing interruptions may impact our ability to accurately predict estimates of historical completion factors or medical cost trends. Medical cost trends potentially are more volatile than other segments of the economy. Management uses considerable judgment in determining medical benefits expense trends and other actuarial model inputs. We believe that the amount of medical benefits payable as of March 31, 2014 is adequate to cover our ultimate liability for unpaid claims as of that date; however, actual payments may differ from established estimates. If the completion factors we used in estimating our IBNR for the quarter ended March 31, 2014 were decreased by 1%, our net income would decrease by approximately $39.0 million. If the completion factors were increased by 1%, our net income would increase by approximately $37.9 million.

Changes in medical benefits payable estimates are primarily the result of obtaining more complete claims information and medical expense trend data over time. Volatility in members' needs for medical services, provider claims submissions and our payment processes result in identifiable patterns emerging several months after the causes of deviations from assumed trends occur. Since our estimates are based upon PMPM claims experience, changes cannot typically be explained by any single factor, but are the result of a number of interrelated variables, all of which influence the resulting medical cost trend. Differences between actual experience and estimates used to establish the liability, which we refer to as prior period developments, are recorded in the period when such differences become known and have the effect of increasing or decreasing the reported medical benefits expense in such periods.

Because of the complexity of our business, the number of states in which we operate, and the need to account for different health care benefit packages among those states, we make an overall assessment of IBNR after considering the base actuarial model reserves and the provision for moderately adverse conditions. We consistently apply our IBNR estimation methodology from period to period. We review our overall estimates of IBNR on a monthly basis. As additional information becomes known to us, we adjust our assumptions accordingly to change our estimate of IBNR. Therefore, if moderately adverse conditions do not occur, evidenced by more complete claims information in the following period, then our prior period estimates will be revised downward, resulting in favorable development. However, when a portion of the development related to the prior year incurred claims is offset by an increase determined to address moderately adverse conditions for the current year incurred claims, we do not consider that development amount as having any impact on net income during the period. If moderately adverse conditions occur and are more than we estimated, then our prior period estimates will be revised upward, resulting in unfavorable development, which would decrease current period net income.

For the quarter ended March 31, 2014, we recognized approximately $32.5 million of net unfavorable development related to prior fiscal years. For the quarter ended March 31, 2013, we recognized approximately $15.9 million of net favorable development related to prior years. The unfavorable development recognized in 2014 was primarily due to higher than expected medical services in our Medicare Health Plans segment, that was not discernible until the impact became clearer over time as claim payments were processed. In addition, we incurred expense associated with adjustments to prior year enhanced payments to Medicaid primary care providers, as mandated by the ACA. The net favorable prior year development recognized in 2013 was due mainly to lower than projected utilization in our Medicaid segment, and to a lesser extent, in our Medicare segment.

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See Note 1 – Organization, Basis of Presentation and Significant Accounting Policies, to the Condensed Consolidated Financial Statements for additional information regarding assumptions and methods used to estimate this liability.

Goodwill and Intangible Assets

Goodwill represents the excess of the cost over the fair market value of net assets acquired and is attributable to our Medicaid and Medicare Heath Plans reporting segments. Goodwill recorded at March 31, 2014 was $244.9 million, which consisted of $134.5 million and $110.4 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Goodwill recorded at December 31, 2013 was $236.8 million, which consisted of $126.8 million and $110.0 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Other intangible assets include provider networks, broker networks, trademarks, state contracts, non-compete agreements, licenses and permits. We amortize other intangible assets over their estimated useful lives ranging from approximately one to 15 years. These assets are allocated to reporting segments for impairment testing purposes.

We review goodwill and intangible assets for impairment at least annually, or more frequently if events or changes in our business climate occur that may potentially affect the estimated useful life or the recoverability of the remaining balance of goodwill or intangible assets. Such events or changes in circumstances would include significant changes in membership, state funding, federal and state government contracts and provider networks. To determine whether goodwill is impaired, we perform a multi-step impairment test. First, we can elect to perform a qualitative assessment of each reporting unit to determine whether facts and circumstances support a determination that their fair values are greater than their carrying values. If the qualitative analysis is not conclusive, or if we elect to proceed directly with quantitative testing, we will then measure the fair values of the reporting units using a two-step approach. In the first step, we determine the fair value of the reporting unit using both income and market approaches. We calculate fair value based on our assumptions of key factors such as projected revenues and the discount factor. While we believe these assumptions and estimates are appropriate, other assumptions and estimates could be applied and may produce significantly different results. If the fair value of the reporting unit is less than its carrying value, we measure and record the amount of the goodwill impairment, if any, by comparing the implied fair value of the reporting unit's goodwill to the carrying value. We perform our annual goodwill impairment test based on our financial position and results of operations through the second quarter of each year, which generally coincides with the finalization of federal and state contract negotiations and our initial budgeting process.

In 2013, we elected to bypass the optional qualitative fair value assessment and conducted our annual quantitative test for goodwill impairment during the third quarter of 2013. Based on the results of our quantitative test, we determined that the fair values of our reporting units exceeded their carrying values, therefore, no further testing was required as we believe that such assets are not impaired as of March 31, 2014.

Commitments and Contingencies

Based on the nature of our business, we are subject to regulatory reviews or other investigations by various state insurance and health care regulatory authorities and other state and federal regulatory authorities. These authorities regularly scrutinize the business practices of health insurance and benefits companies and their reviews focus on numerous facets of our business, including claims payment practices, provider contracting, competitive practices, commission payments, privacy issues and utilization management practices, among others. Some of these reviews have historically resulted in fines imposed on us and some have required changes to our business practices. We continue to be subject to such reviews, which may result in additional fines and/or sanctions being imposed, premium refunds or additional changes in our business practices.

We are also involved in other legal actions in the normal course of our business, including, without limitation, wage and hour claims and provider disputes regarding payment of claims. Some of these actions seek monetary damages including claims for liquidated or punitive damages, which are not covered by insurance. We review relevant information with respect to litigation matters and we update our estimates of reasonably possible losses and related disclosures. We accrue an estimate for contingent liabilities, including attorney's fees related to these matters, if a loss is probable or estimable. Currently, we do not expect that the resolution of any currently pending actions, either individually or in the aggregate, will differ materially from our current estimates or have a material adverse effect on our results of operations, financial condition and cash flows. However, the outcome of any legal actions cannot be predicted, and therefore, actual results may differ from those estimates.

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Item 3. Quantitative and Qualitative Disclosures About Market Risk.

Investment Return Market Risk

As of March 31, 2014, we had cash and cash equivalents of $1,658.3 million, investments classified as current assets of $288.7 million, long-term investments of $136.4 million and restricted investments on deposit for licensure of $94.9 million. The short-term investments classified as current assets consist of highly liquid securities with maturities between three and twelve months and longer term bonds with floating interest rates that are considered available for sale. Restricted assets consist of cash and cash equivalents and U.S. Treasury instruments deposited or pledged to state agencies in accordance with state rules and regulations. These restricted assets are classified as long-term regardless of the contractual maturity date due to the nature of the states' requirements. The investments classified as long term are subject to interest rate risk and will decrease in value if market rates increase. Because of their contractual maturity dates, however, we would not expect the value of these investments to decline significantly as a result of a sudden change in market interest rates. Assuming a hypothetical and immediate 1% increase in market interest rates at March 31, 2014, the fair value of our fixed income investments would decrease by approximately $3.8 million. Similarly, a 1% decrease in market interest rates at March 31, 2014 would increase the fair value of our investments by approximately $4.3 million.

Item 4. Controls and Procedures.

Evaluation of Disclosure Controls and Procedures

Our management carried out an evaluation required by Rule 13a-15 under the Exchange Act, under the leadership and with the participation of our Chief Executive Officer ("CEO") and Chief Financial Officer ("CFO"), of the effectiveness of our disclosure controls and procedures as defined in Rule 13a-15 under the Exchange Act ("Disclosure Controls"). Based on the evaluation, our CEO and CFO concluded that our Disclosure Controls were effective as of the end of the period covered by this 2014 Form 10-Q.

Changes in Internal Control over Financial Reporting

There has not been any change in our internal control over financial reporting (as defined in Rule 13a-15(f) of the Exchange Act) identified in connection with the evaluation required by Rule 13a-15(d) under the Exchange Act during the quarter ended March 31, 2014 that has materially affected, or is reasonably likely to materially affect, our internal control over financial reporting.

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Part II – OTHER INFORMATION

Item 1. Legal Proceedings.

For information regarding legal proceedings, see Note 11 – Commitments and Contingencies, included in the Condensed Consolidated Financial Statements of this 2014 Form 10-Q.

Item 1A. Risk Factors.

Certain risk factors may have a material adverse effect on our business, financial condition and results of operations and you should carefully consider them. The discussion in "Item 2. Forward Looking Financial Statements" is incorporated herein by reference. There have been no material updates to the risk factors as disclosed in Part I – Item 1A – Risk Factors included in our 2013 Form 10-K.

Item 2. Unregistered Sales of Equity Securities and Use of Proceeds.

Recent Sales of Unregistered Securities

None.

Issuer Purchases of Equity Securities

None.

Dividends

We have never paid cash dividends on our common stock. We currently intend to retain any future earnings to fund our business, and we do not anticipate paying any cash dividends in the foreseeable future. In addition, our Credit Agreement and the indenture governing our Senior Notes have certain restrictions on our ability to pay cash dividends.

Our ability to pay dividends is partially dependent on, among other things, our receipt of cash dividends from our regulated subsidiaries. The ability of our regulated subsidiaries to pay dividends to us is limited by the state departments of insurance in the states in which we operate or may operate, as well as requirements of the government-sponsored health programs in which we participate. Any future determination to pay dividends will be at the discretion of our board and will depend upon, among other factors, our results of operations, financial condition, capital requirements and contractual restrictions. For more information regarding restrictions on the ability of our regulated subsidiaries to pay dividends to us, please see Part I – Financial Information, Item 2 – Management's Discussion and Analysis of Financial Condition and Results of Operations – Liquidity and Capital Resources.

Item 3. Defaults Upon Senior Securities.

Not Applicable.

Item 4. Mine Safety Disclosures.

Not Applicable.

Item 5. Other Information.

Not Applicable.

Item 6. Exhibits.

Exhibits are incorporated herein by reference or are filed with this report as set forth in the Exhibit Index.

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SIGNATURES

Pursuant to the requirements of the Securities and Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned thereunto duly authorized in Tampa, Florida on May 8, 2014.

WELLCARE HEALTH PLANS, INC.
By:	/s/ Thomas L. Tran
	Thomas L. Tran
	Senior Vice President and Chief Financial Officer (Principal Financial Officer)
By:	/s/ Maurice S. Hebert
	Maurice S. Hebert
	Chief Accounting Officer (Principal Accounting Officer)

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EXHIBIT INDEX

		INCORPORATED BY REFERENCE
Exhibit Number	Description	Form	Filing Date with SEC	Exhibit Number
3.1	Amended and Restated Certificate of Incorporation of the Registrant	10-Q	August 13, 2004	3.1
3.1.1	Amendment to Amended and Restated Certificate of Incorporation	10-Q	November 4, 2009	3.1.1
3.2	Third Amended and Restated Bylaws of the Registrant	8-K	November 2, 2010	3.2
4.1	Specimen common stock certificate	10-Q	November 4, 2010	4.1
4.2	Base Indenture, dated November 14, 2013 between WellCare Health Plans, Inc. and The Bank of New York Mellon Trust Company, N.A., as trustee	8-K	November 18, 2013	4.1
4.2.1	First Supplemental Indenture, dated November 14, 2013 between WellCare Health Plans, Inc. and The Bank of New York Mellon Trust Company, N.A., as trustee (including the form of 5.75% Senior Note due 2020)	8-K	November 18, 2013	4.2
10.1	Notice of Termination of Employment / Letter of Agreement between WellCare Health Plans, Inc. and Thomas L. Tran dated February 20, 2014*	8-K	February 21, 2014	10.1
10.2	Non-Employee Director Compensation Policy as amended and restated (effective commencing February 27, 2014)*†
10.3	Amendment No. 1 to Amended and Restated Medicaid Managed Care Contract between WellCare Health Insurance Company of Kentucky, Inc. (f/k/a WellCare Health Insurance of Illinois, Inc., d/b/a WellCare of Kentucky, Inc.) and the Commonwealth of Kentucky, Finance and Administration Cabinet	8-K	January 9, 2014	10.1
10.4	Amendment No. 7 to Contract No. FA971 by and between the State of Florida, Agency for Health Care Administration (“AHCA”) and WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida (“Staywell”) (Medicaid 2012-2015)	8-K	January 15, 2014	10.2
10.5	Amendment No. 8 to Contract No. FA971 by and between AHCA and Staywell (Medicaid 2012-2015)	8-K	April 3, 2014	10.1
10.6	Amendment No. 5 to Contract No. FA972 by and between AHCA and WellCare of Florida, Inc. d/b/a HealthEase (“HealthEase”) (Medicaid 2012-2015)	8-K	January 15, 2014	10.2
10.7	Amendment No. 6 to Contract No. FA972 by and between AHCA and HealthEase (Medicaid 2012-2015) †	8-K	April 3, 2014	10.2
10.8	Letter Agreement dated March 3, 2014 from the Georgia Department of Community Health to WellCare of Georgia, Inc.	8-K	March 6, 2014	10.1
10.9	Amendment No. 16 to Contract 0654 (Amended and Restated Contract 0654) by and between the Georgia Department of Community Health and WellCare of Georgia, Inc.	8-K	April 14, 2014	10.2
10.10	Contract No. FP020 by and between AHCA and Staywell (Florida MMA 2014-2018) †
31.1	Certification of President and Chief Executive Officer pursuant to Section 302 of Sarbanes-Oxley Act of 2002 †
31.2	Certification of Chief Financial Officer pursuant to Section 302 of Sarbanes-Oxley Act of 2002 †
32.1	Certification of President and Chief Executive Officer pursuant to Section 906 of Sarbanes-Oxley Act of 2002 †
32.2	Certification of Chief Financial Officer pursuant to Section 906 of Sarbanes-Oxley Act of 2002 †
101.INS	XBRL Taxonomy Instance Document ††

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		INCORPORATED BY REFERENCE
Exhibit Number	Description	Form	Filing Date with SEC	Exhibit Number
101.SCH	XBRL Taxonomy Extension Schema Document ††
101.CAL	XBRL Taxonomy Extension Calculation Linkbase Document ††
101.LAB	XBRL Taxonomy Extension Label Linkbase Document ††
101.PRE	XBRL Taxonomy Extension Presentation Linkbase Document ††
101.DEF	XBRL Taxonomy Extension Definition Linkbase Document ††
	* Denotes a management contract or compensatory plan, contract or arrangement.
	** Portions of this exhibit have been omitted pursuant to a request for confidential treatment.
	† Filed herewith.
	†† Furnished herewith and not filed for purposes of Section 11 and Section 12 of the Securities Act of 1933 and Section 18 of the Securities Exchange Act of 1934.

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EX-10.2

Exhibit 10.2

WELLCARE HEALTH PLANS, INC.

Non-Employee Director Compensation Policy

This Non-Employee Director Compensation Policy (the “Policy”) sets forth the compensation to be paid to non-employee members (“Non-EmployeeDirectors”) of the Board of Directors (the “Board”) of WellCare Health Plans, Inc. (the “Company”), which shall remain in effect until amended, replaced or rescinded by further action of the Board.

Annual Retainers and Fees

Effective October 31, 2013, the retainers and fees for Non-Employee Directors will be as set forth below and shall be cumulative.

Board Service:

• A base annual retainer of $90,000.

• Chairman of the Board – The non-executive Chairman of the Board, if any, shall receive an additional annual retainer of $250,000.

• Lead Director – The lead director, if any, shall receive an additional annual retainer of $20,000.

Standing Committees:

• Audit and Finance Committee – Each member of the Audit and Finance Committee shall receive an additional annual retainer of $20,000, except the chairperson who shall receive an additional retainer of $35,000.

• Compensation Committee – Each member of the Compensation Committee shall receive an additional annual retainer of $12,000, except the chairperson who shall receive an additional retainer of $22,000.

• Each member of the Nominating and Corporate Governance Committee, the Health Care Quality and Access Committee and the Regulatory Compliance Committee shall receive an additional annual retainer of $8,000,except the chairpersons who shall receive an additional retainer of $18,000.

Non-Standing Committees:

• Retainers for each non-standing committee will be evaluated periodically and based on expected roles and responsibilities.

Payments

The annual retainers for service on the Board and committees of the Board as set forth above shall be paid by the Company in quarterly installments as soon as practicable after the end of each of the Company’s fiscal quarters for which the member shall have served. A member of the Board or any of its committees

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who serves on such during a portion of a quarterly period, shall be entitled to the full quarterly installment for such quarterly period.

Notwithstanding the foregoing, the annual retainer paid to a member serving on a non-standing committee for a portion of a quarterly period, shall be entitled to the quarterly installment calculated on a pro-rata, monthly basis.

Initial Equity Awards

Unless otherwise determined by the Compensation Committee and subject to the Compensation Committee’s approval, upon, and contingent on, a new Non-Employee Director’s appointment or election to the Board, a newly elected or appointed Non-Employee Director shall receive an initial equity award of restricted stock units with a fair market value of approximately $150,000, pro-rated (based on a 365 day year) for the number of days between the appointment or election date of the Non-Employee Director and the anticipated date of the next annual meeting of stockholders at the time of appointment or election as determined by the Secretary of the Company, rounded to the nearest whole share, as determined by reference to the officially-quoted closing selling price of the Company’s common stock on the New York Stock Exchange on the grant date, pursuant to and in accordance with the terms and provisions of a restricted stock unit agreement and the Company’s 2013 Incentive Compensation Plan (the “2013 Plan”); provided, however, that the fair market value of a Non-Employee Director’s initial equity award is limited to approximately $150,000; provided, further, that the fair market value of a Non-Employee Director’s initial equity award will be approximately $150,000 if the Non-Employee Director is joining the Board at the annual meeting of stockholders. Such equity awards shall vest in full on the earlier of the first anniversary of the date of grant or the date of the next annual meeting of stockholders.

Annual Equity Awards

Unless otherwise determined by the Compensation Committee and subject to the Compensation Committee’s approval, each Non-Employee Director, other than a Non-Employee Director joining the Board at the annual meeting, shall receive an annual equity award of either restricted stock units or deferred stock units, as elected by the Non-Employee Director, with a fair market value of approximately $150,000, rounded to the nearest whole share, as determined by reference to the officially-quoted closing selling price of the Company’s common stock on the New York Stock Exchange on the grant date, pursuant to and in accordance with the terms and provisions of a restricted stock unit agreement or deferred stock unit agreement, as the case may be, and the 2013 Plan. Unless otherwise determined by the Compensation Committee, all such annual equity awards shall be granted on the date of the Company’s annual meeting of stockholders. Such equity awards shall vest in full on the earlier of the first anniversary of the date of grant or the date of the next annual meeting of stockholders.

Stock Ownership Guidelines

Non-Employee Directors are required to own shares of the Company’s common stock (the “Ownership Requirement”) having a value (as described below) equal to the sum of five (5) times the base annual retainer payable to each Non-Employee Director as set forth in this Policy as in effect from time to time.

For purposes of determining ownership, the following will be used in determining whether a Non-Employee Director has satisfied the Ownership Requirement:

2

• One hundred percent (100%) of the value of shares of the Company’s common stock owned individually, either directly or indirectly, including vested and unvested restricted stock, restricted stock unit awards, deferred stock unit awards or shares acquired upon exercise of stock options; and

• Shares of the Company’s common stock owned jointly, or separately by a spouse, domestic partner and/or minor children, directly or indirectly.

No other rights to acquire shares of Company common stock (including stock options or similar rights) shall be considered shares of Company common stock for purposes of meeting the Ownership Requirements under this Policy.

For purposes hereof, the value of a share of the Company’s common stock, including vested and unvested restricted stock, restricted stock units and deferred stock units, shall be calculated on April 1^st of each year based on the average closing price of the Company’s common stock during the most recently completed fiscal quarter at the time of the calculation (a “Determination Date”). If a Non-Employee Director does not meet the Ownership Requirement as of a Determination Date, such Non-Employee Director must satisfy the Ownership Requirement on the next Determination Date.

In the event the base annual retainer increases, each Non-Employee Director will have five (5) years from the time of the increase to acquire any additional shares needed to satisfy the Ownership Requirement.

A Non-Employee Director shall have until the end of the first Determination Date following the fifth anniversary of such Non-Employee Director’s election or appointment to the Board or upon otherwise becoming a Non-Employee Director of the Board to satisfy the Ownership Requirement; provided, however, that a Non-Employee Director who was a Non-Employee Director of the Company as of April 1, 2009, shall have until December 31, 2013 to meet the Ownership Requirement.

Approved by the Board: March 23, 2009

Amended by the Board April 29, 2009

Amended by the Board August 5, 2010

Amended by the Board December 16, 2010

Amended by the Board May 24, 2012

Amended by the Board May 23, 2013

Amended by the Board September 12, 2013

Amended by the Board October 31, 2013

Amended by the Board December 13, 2013

Amended by the Board February 27, 2014

3

EX-10.10

Exhibit 10.10                                    Contract No. FP020

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STANDARD CONTRACT

THIS CONTRACT is entered into between the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency", whose address is 2727 Mahan Drive, Tallahassee, Florida 32308, and WELLCARE OF FLORIDA, INC., D/B/A STAYWELL HEALTH PLAN OF FLORIDA, INC. hereinafter referred to as the "Vendor", or “Health Plan” whose address is 8735 Henderson Road, Renaissance 2, Tampa, Florida 33634, a Florida Corporation, to provide approved Medicaid services to eligible beneficiaries.

I.    THE VENDOR HEREBY AGREES:

A.    General Provisions

1. To provide services according to the terms and conditions set forth in this Contract, Attachment I, Scope of Services, Attachment II, Core Contract Provisions and all other attachments named herein which are attached hereto and incorporated by reference (collectively referred to herein as the “Contract”).

2. To perform as an independent vendor and not as an agent, representative, or employee of the Agency.

3. To recognize that the State of Florida, by virtue of its sovereignty, is not required to pay any taxes on the services or goods purchased under the terms of this Contract.

B.    Federal Laws and Regulations

1. This Contract contains federal funds, therefore, the Vendor shall comply with the provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other applicable regulations.

2. This Contract contains federal funding in excess of $100,000.00, therefore, the Vendor must, upon Contract execution, complete the Certification Regarding Lobbying form, Attachment IV. If a Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may be obtained from the Agency’s Contract Manager. All disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to the Agency’s Procurement Office.

3. Pursuant to 2 CFR, Part 376, the Vendor must, upon Contract execution, complete the Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Contracts/Subcontracts, Attachment V.

C.    Audits and Records

1. To maintain books, records, and documents (including electronic storage media) pertinent to performance under this Contract in accordance with generally accepted accounting procedures and practices which sufficiently and properly reflect all revenues and expenditures of funds provided by the Agency under this Contract.

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AHCA Form 2100-0007 (Rev. JUL 13)

2. To assure that these records shall be subject at all reasonable times to inspection, review, or audit by state personnel and other personnel duly authorized by the Agency, as well as by federal personnel.

3. To maintain and file with the Agency such progress, fiscal and inventory reports as specified in Attachment II, Core Contract Provisions, and other reports as the Agency may require within the period of this Contract. In addition, access to relevant computer data and applications which generated such reports should be made available upon request.

4. To comply with public record laws as outlined in Section 119.0701, Florida Statutes.

5. To ensure that all related party transactions are disclosed to the Agency Contract Manager.

6. To include these aforementioned audit and record keeping requirements in all approved subcontracts and assignments.

D.    Retention of Records

1. To retain all financial records, supporting documents, statistical records, and any other documents (including electronic storage media) pertinent to performance under this Contract for a period of six (6) years after termination of this Contract, or if an audit has been initiated and audit findings have not been resolved at the end of six (6) years, the records shall be retained until resolution of the audit findings.

2. Persons duly authorized by the Agency and federal auditors, pursuant to 45 CFR, Part 74 and/or 45 CFR, Part 92, shall have full access to and the right to examine any of said records and documents.

3. The rights of access in this section must not be limited to the required retention period but shall last as long as the records are retained.

E.    Monitoring

1. To provide reports as specified in Attachment II, Core Contract Provisions. These reports will be used for monitoring progress or performance of the contractual services as specified in Attachment I, Scope of Services and Attachment II, Core Contract Provisions.

2. To permit persons duly authorized by the Agency to inspect any records, papers, documents, facilities, goods and services of the Vendor which are relevant to this Contract.

F.    Indemnification

The Vendor shall save and hold harmless and indemnify the State of Florida and the Agency against any and all liability, claims, suits, judgments, damages or costs of whatsoever kind and nature resulting from the use, service, operation or performance of work under the terms of this Contract, resulting from any act, or failure to act, by the Vendor, its subcontractor, or any of the employees, agents or representatives of the Vendor or subcontractor.

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AHCA Form 2100-0007 (Rev. JUL 13)

G.    Insurance

1. To the extent required by law, the Vendor shall be self-insured against, or will secure and maintain during the life of this Contract, Workers’ Compensation Insurance for all its employees connected with the work of this project and, in case any work is subcontracted, the Vendor shall require the subcontractor similarly to provide Workers’ Compensation Insurance for all of the latter’s employees unless such employees engaged in work under this Contract are covered by the Vendor’s self insurance program. Such self insurance or insurance coverage shall comply with the Florida Workers’ Compensation law. In the event hazardous work is being performed by the Vendor under this Contract and any class of employees performing the hazardous work is not protected under Workers’ Compensation statutes, the Vendor shall provide, and cause each subcontractor to provide, adequate insurance satisfactory to the Agency, for the protection of its employees not otherwise protected.

2. The Vendor shall secure and maintain Commercial General Liability insurance including bodily injury, property damage, personal & advertising injury and products and completed operations. This insurance will provide coverage for all claims that may arise from the services and/or operations completed under this Contract, whether such services and/or operations are by the Vendor or anyone directly employed by it. Such insurance shall include the State of Florida as an Additional Named Insured for the entire length of the Contract and hold the State of Florida harmless from subrogation. The Vendor shall set the limits of liability necessary to provide reasonable financial protections to the Vendor and the State of Florida under this Contract.

3. All insurance policies shall be with insurers licensed or eligible to transact business in the State of Florida. The Vendor’s current insurance policy(ies) shall contain a provision that the insurance will not be canceled for any reason except after thirty (30) calendar days written notice. The Vendor shall provide thirty (30) calendar days written notice of cancellation to the Agency’s Contract Manager.

H.    Assignments and Subcontracts

To neither assign the responsibility of this Contract to another party nor subcontract for any of the work contemplated under this Contract without prior written approval of the Agency. No such approval by the Agency of any assignment or subcontract shall be deemed in any event or in any manner to provide for the incurrence of any obligation of the Agency in addition to the total dollar amount agreed upon in this Contract. All such assignments or subcontracts shall be subject to the conditions of this Contract and to any conditions of approval that the Agency shall deem necessary.

I.    Return of Funds

To return to the Agency any overpayments due to unearned funds or funds disallowed pursuant to the terms of this Contract that were disbursed to the Vendor by the Agency. The Vendor shall return any overpayment to the Agency within forty (40) calendar days after either discovery by the Vendor, its independent auditor, or notification by the Agency, of the overpayment.

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AHCA Form 2100-0007 (Rev. JUL 13)

J.    Purchasing

1. P.R.LD.E.

It is expressly understood and agreed that any articles which are the subject of, or required to carry out this Contract shall be purchased from the corporation identified under Chapter 946, Florida Statutes, if available, in the same manner and under the same procedures set forth in Section 946.515(2), and (4), Florida Statutes; and, for purposes of this Contract, the person, firm or other business entity carrying out the provisions of this Contract shall be deemed to be substituted for this Agency insofar as dealings with such corporation are concerned.

The "Corporation identified" is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:

P.R.I.D.E.

12425 28th Street North, Suite 300

St. Petersburg, FL 33716

E-Mail: info@pride-enterprises.org

(727) 556-3300

Toll Free: 1-800-643-8459

Fax: (727) 570-3366

2. RESPECT of Florida

It is expressly understood and agreed that any articles that are the subject of, or required to carry out, this Contract shall be purchased from a nonprofit agency for the blind or for the severely handicapped that is qualified pursuant to Chapter 413, Florida Statutes, in the same manner and under the same procedures set forth in Section 413.036(1) and (2), Florida Statutes; and, for purposes of this Contract, the person, firm, or other business entity carrying out the provisions of this Contract shall be deemed to be substituted for this Agency insofar as dealings with such qualified nonprofit agency are concerned.

The "nonprofit agency" identified is RESPECT of Florida which may be contacted at:

RESPECT of Florida.

2475 Apalachee Parkway, Suite 205

Tallahassee, Florida 32301-4946

(850) 487-1471

Website: www.respectofflorida.org

3. Procurement of Products or Materials with Recycled Content

It is expressly understood and agreed that any products which are required to carry out this Contract shall be procured in accordance with the provisions of Section 403.7065, Florida Statutes.

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AHCA Form 2100-0007 (Rev. JUL 13)

K.    Civil Rights Requirements/Vendor Assurance

The Vendor assures that it will comply with:

1. Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et seq., which prohibits discrimination on the basis of race, color, or national origin.

2. Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794, which prohibits discrimination on the basis of handicap.

3. Title IX of the Education Amendments of 1972, as amended, 20 U.S.C. 1681 et seq., which prohibits discrimination on the basis of sex.

4. The Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq., which prohibits discrimination on the basis of age.

5. Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended, 42 U.S.C. 9849, which prohibits discrimination on the basis of race, creed, color, national origin, sex, handicap, political affiliation or beliefs.

6. The Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits discrimination on the basis of disability and requires reasonable accommodation for persons with disabilities.

7. All regulations, guidelines, and standards as are now or may be lawfully adopted under the above statutes.

The Vendor agrees that compliance with this assurance constitutes a condition of continued receipt of or benefit from funds provided through this Contract, and that it is binding upon the Vendor, its successors, transferees, and assignees for the period during which services are provided. The Vendor further assures that all contractors, subcontractors, subgrantees, or others with whom it arranges to provide services or benefits to participants or employees in connection with any of its programs and activities are not discriminating against those participants or employees in violation of the above statutes, regulations, guidelines, and standards.

L.    Discrimination

An entity or affiliate who has been placed on the discriminatory vendor list may not submit a bid, proposal, or reply on a contract to provide any goods or services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity for the construction or repair of a public building or public work; may not submit bids, proposals, or replies on leases of real property to a public entity; may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and may not transact business with any public entity. The Florida Department of Management Services is responsible for maintaining the discriminatory vendor list and intends to post the list on its website. Questions regarding the discriminatory vendor list may be directed to the Florida Department of Management Services, Office of Supplier Diversity at (850) 487-0915.

M.    Requirements of Section 287.058, Florida Statutes

1. To submit bills for fees or other compensation for services or expenses in detail sufficient for a proper pre-audit and post-audit thereof.

2. Where applicable, to submit bills for any travel expenses in accordance with Section 112.061, Florida Statutes. The Agency may establish rates lower than the maximum provided in Section 112.061, Florida Statutes.

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AHCA Form 2100-0007 (Rev. JUL 13)

3. To provide units of deliverables, including reports, findings, and drafts, in writing and/or in an electronic format agreeable to both Parties, as specified in Attachment I, Scope of Services and Attachment II, Core Contract Provisions to be received and accepted by the Contract Manager prior to payment.

4. To comply with the criteria and final date, as specified herein, by which such criteria must be met for completion of this Contract.

This Contract shall begin upon execution by both Parties or January 1, 2014, (whichever is later) and end on December 31, 2018, inclusive.

5. The Vendor agrees that the Agency may unilaterally cancel this Contract for refusal by the Vendor to allow public access to all documents, papers, letters, or other material made or received by the Vendor in conjunction with this Contract, unless the records are exempt from Section 24(a) of Art. I of the State Constitution and Section 119.07(1), Florida Statutes.

6. To comply with Patents, Royalties, Copyrights, Right to Data, and Works for Hire/Software requirements as follows:

The Vendor, without exception, shall indemnify and hold harmless the Agency and its employees from liability of any nature or kind, including cost and expenses for or on account of any copyrighted, patented, or unattended invention, process, or article manufactured or supplied by the Vendor. The Vendor has no liability when such claim is solely and exclusively due to the combination, operation or use of any article supplied hereunder with equipment or data not supplied by the Vendor or is based solely and exclusively upon the Agency’s alteration of the article.

The Agency will provide prompt written notification of a claim of copyright or patent infringement and shall afford the Vendor full opportunity to defend the action and control the defense. Further, if such a claim is made or is pending, the Vendor may, at its option and expense procure for the Agency the right to continue the use of, replace or modify the article to render it non-infringing (if none of the alternatives is reasonably available, the Agency agrees to return the article on request to the Vendor and receive reimbursement, if any, as may be determined by a court of competent jurisdiction).

If the Vendor brings to the performance of this Contract a pre-existing patent, patent-pending and/or copyright at the time of Contract execution, the Vendor shall retain all rights and entitlements to that pre-existing patent, patent-pending and/or copyright, unless this Contract provides otherwise.

If the Vendor uses any design, device, or materials covered by letter, patent, or copyright, it is mutually agreed and understood without exception that the proposed prices shall include all royalties or cost arising from the use of such design, device, or materials in any way involved in the work. Prior to the initiation of services under this Contract, the Vendor shall disclose, in writing, all intellectual properties relevant to the performance of this Contract which the Vendor knows, or should know, could give rise to a patent or copyright. The Vendor shall retain all rights and entitlements to any pre-existing intellectual property which is so disclosed. Failure to disclose will indicate that no such property exists. The Agency will then have the right to all patents and copyrights

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AHCA Form 2100-0007 (Rev. JUL 13)

which arise as a result of performance under this Contract as provided in this section.

If any discovery or invention arises or is developed in the course of, or as a result of, work or services performed under this Contract, or in any way connected herewith, the Vendor shall refer the discovery or invention to the Agency for a determination whether patent protection will be sought in the name of the State of Florida. Any and all patent rights accruing under or in connection with the performance of this Contract are hereby reserved to the State of Florida. All materials to which the Agency is to have patent rights or copyrights shall be marked and dated by the Vendor in such a manner as to preserve and protect the legal rights of the Agency.

Where activities supported by this Contract produce original writing, sound recordings, pictorial reproductions, drawings or other graphic representation and works of any similar nature, the Agency has the right to use, duplicate and disclose such materials in whole or in part, in any manner, for any purpose whatsoever and to have others acting on behalf of the Agency to do so. If the materials so developed are subject to copyright, trademark, or patent, legal title and every right, interest, claim, or demand of any kind in and to any patent, trademark or copyright, or application for the same, shall vest in the State of Florida, Department of State for the exclusive use and benefit of the state. Pursuant to Section 286.021, Florida Statutes, no person, firm, corporation, including Parties to this Contract shall be entitled to use the copyright, patent, or trademark without the prior written consent of the Florida Department of State.

The Agency will have unlimited rights to use, disclose, or duplicate, for any purpose whatsoever, all information and data developed, derived, documented, or furnished by the Vendor under this Contract.

All rights and title to works for hire under this Contract, whether patentable or copyrightable or not, shall belong to the Agency and shall be subject to the terms and conditions of this Contract.

The computer programs, materials and other information furnished by the Agency to the Vendor hereunder shall be and remain the sole and exclusive property of the Agency, free from any claim or right of retention by or on behalf of the Vendor. The services and products listed in this Contract shall become the property of the Agency upon the Vendor’s performance and delivery thereof. The Vendor hereby acknowledges that said computer programs, materials and other information provided by the Agency to the Vendor hereunder, together with the products delivered and services performed by the Vendor hereunder, shall be and remain confidential and proprietary in nature to the extent provided by Chapter 119, Florida Statutes, and that the Vendor shall not disclose, publish or use same for any purpose other than the purposes provided in this Contract; however, upon the Vendor first demonstrating to the Agency’s satisfaction that such information, in part or in whole, (1) was already known to the Vendor prior to its receipt from the Agency; (2) became known to the Vendor from a source other than the Agency; or (3) has been disclosed by the Agency to third parties without restriction, the Vendor shall be free to use and disclose same without restriction. Upon completion of the Vendor’s performance or otherwise cancellation or termination of this Contract, the Vendor shall surrender and

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AHCA Form 2100-0007 (Rev. JUL 13)

deliver to the Agency, freely and voluntarily, all of the above-described information remaining in the Vendor's possession.

The Vendor warrants that all materials produced hereunder will be of original development by the Vendor and will be specifically developed for the fulfillment of this Contract and will not knowingly infringe upon or violate any patent, copyright, trade secret or other property right of any third party, and the Vendor shall indemnify and hold the Agency harmless from and against any loss, cost, liability or expense arising out of any breach or claimed breach of this warranty.

The terms and conditions specified in this section shall also apply to any subcontract made under this Contract. The Vendor shall be responsible for informing the subcontractor of the provisions of this section and obtaining disclosures.

7. The financial consequences that the Agency must apply if the Vendor fails to perform in accordance with this Contract are outlined in Attachment II, Core Contract Provisions.

N.    Sponsorship

Pursuant to Section 286.25, Florida Statutes, any nongovernmental organization which sponsors a program financed partially by state funds or funds obtained from a state agency shall, in publicizing, advertising, or describing the sponsorship of the program, state:

“Sponsored by WELLCARE OF FLORIDA, INC., D/B/A STAYWELL HEALTH PLAN OF FLORIDA, INC. and the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION.”

If the sponsorship reference is in written material, the words "State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION" shall appear in the same size letters or type as the name of the organization.

O.    Use Of Funds For Lobbying Prohibited

To comply with the provisions of Section 216.347, Florida Statutes, which prohibits the expenditure of Contract funds for the purpose of lobbying the Legislature, the judicial branch or a state agency.

P.    Public Entity Crime

A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for category two, for a period of thirty-six (36) months from the date of being placed on the convicted vendor list.

Q.    Health Insurance Portability and Accountability Act

To comply with the Department of Health and Human Services Privacy Regulations in the Code of Federal Regulations, Title 45, Sections 160 and 164, regarding

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AHCA Form 2100-0007 (Rev. JUL 13)

disclosure of protected health information as specified in Attachment III, Business Associate Agreement.

R. Confidentiality of Information

Not to use or disclose any confidential information, including social security numbers that may be supplied under this Contract pursuant to law, and also including the identity or identifying information concerning a Medicaid recipient or services under this Contract for any purpose not in conformity with state and federal laws, except upon written consent of the recipient, or his/her guardian.

S.    Employment

To comply with Section 274A (e) of the Immigration and Nationality Act. The Agency will consider the employment by any contractor of unauthorized aliens a violation of this Act. If the Vendor knowingly employs unauthorized aliens, such violation shall be cause for unilateral cancellation of this Contract. The Vendor shall be responsible for including this provision in all subcontracts with private organizations issued as a result of this Contract.

T. Work Authorization Program

The Immigration Reform and Control Act of 1986 prohibits employers from knowingly hiring illegal workers. The Vendor shall only employ individuals who may legally work in the United States (U.S.) – either U.S. citizens or foreign citizens who are authorized to work in the U.S. The Vendor shall use the U.S. Department of Homeland Security’s E-Verify Employment Eligibility Verification system, https://e-verify.uscis.gov/emp, to verify the employment eligibility of all new employees hired by the Vendor during the term of this Contract and shall also include a requirement in its subcontracts that the subcontractor utilize the E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor performing work or providing services pursuant to this Contract.

U. Scrutinized Companies Lists

The Vendor shall complete Attachment VI, Vendor Certification Regarding Scrutinized Companies List, certifying that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to Section 215.473, Florida Statutes. Pursuant to Section 287.135(5), Florida Statutes, the Vendor agrees the Agency may immediately terminate this Contract for cause if the Vendor is found to have submitted a false certification or if the Vendor is placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List during the term of the Contract.

II.    THE AGENCY HEREBY AGREES:

A.    Contract Amount

To pay for contracted services according to the conditions of Attachment I, Scope of Services and Attachment II, Core Contract Provisions, in an amount not to exceed $11,789,499,367.00, subject to the availability of funds. Funding for this Contract is appropriated in the 2013-2014 Legislative Budget, under the Prepaid Health Plan

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AHCA Form 2100-0007 (Rev. JUL 13)

line. The State of Florida's performance and obligation to pay under this Contract is contingent upon an annual appropriation by the Legislature.

III.    THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

A.    Termination

1. Termination at Will

This Contract may be terminated by the Agency upon no less than thirty (30) calendar days written notice, without cause, unless a lesser time is mutually agreed upon by both Parties. Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of delivery.

2. Termination Due To Lack of Funds

In the event funds to finance this Contract become unavailable, the Agency may terminate the Contract upon no less than twenty-four (24) hours’ written notice to the Vendor. Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of delivery. The Agency will be the final authority as to the availability of funds. The Vendor shall be compensated for all work performed up to the time notice of termination is received.

3. Termination for Breach

Unless the Vendor's breach is waived by the Agency in writing, the Agency may, by written notice to the Vendor, terminate this Contract upon no less than twenty-four (24) hours’ written notice. Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of delivery. If applicable, the Agency may employ the default provisions in Florida Administrative Code Rule 60A-1.006(3).

Waiver of breach of any provisions of this Contract shall not be deemed to be a waiver of any other breach and shall not be construed to be a modification of the terms of this Contract. The provisions herein do not limit the Agency's right to remedies at law or to damages.

B. Contract Managers

1. The Agency’s Contract Manager’s contact information is as follows:

Tayna Hand

Agency for Health Care Administration

2727 Mahan Drive, MS# 50

Tallahassee, FL 32308

(850) 412-4060

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AHCA Form 2100-0007 (Rev. JUL 13)

2. The Vendor’s Contract Manager’s contact information is as follows:

Elizabeth Miller

WellCare of Florida, Inc., d/b/a

Staywell Health Plan of Florida, Inc.

8735 Henderson Road, Ren. 2

Tampa, FL 33634

(813) 206-1123

3. All matters shall be directed to the Contract Managers for appropriate action or disposition. A change in Contract Manager by either Party shall be reduced to writing through an amendment or minor modification to this Contract by the Agency.

C. Renegotiation or Modification

1. Modifications of provisions of this Contract shall only be valid when they have been reduced to writing and duly signed during the term of the Contract. The Parties agree to renegotiate this Contract if federal and/or state revisions of any applicable laws, or regulations make changes in this Contract necessary.

2. The rate of payment and the total dollar amount may be adjusted retroactively to reflect price level increases and changes in the rate of payment when these have been established through the appropriations process and subsequently identified in the Agency's operating budget.

D. Name, Mailing and Street Address of Payee

1. The name (Vendor name as shown on Page 1 of this Contract) and mailing address of the official payee to whom the payment shall be made;

WellCare of Florida, Inc., d/b/a

Staywell Health Plan of Florida, Inc.

P.O. Box 31379

Tampa, FL 33634

2. The name of the contact person and street address where financial and administrative records are maintained:

Thomas Tran

WellCare of Florida, Inc., d/b/a

Staywell Health Plan of Florida, Inc.

8735 Henderson Road, Renaissance 2

Tampa, FL 33634

E. All Terms and Conditions

This Contract and its attachments as referenced herein contain all the terms and conditions agreed upon by the Parties.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

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AHCA Form 2100-0007 (Rev. JUL 13)

IN WITNESS THEREOF, the Parties hereto have caused this four hundred thirty-four (434) page Contract, which includes any referenced attachments, to be executed by their undersigned officials as duly authorized. This Contract is not valid until signed and dated by both Parties.

WELLCARE OF FLORIDA, INC. D/B/A    STATE OF FLORIDA, AGENCY FOR

STAYWELL HEALTH PLAN OF FLORIDA,    HEALTH CARE ADMINISTRATION

INC.

SIGNED		SIGNED
BY:	/s/ David McNichols	BY:	/s/ Elizabeth Dudek
NAME:	David McNichols	NAME:	Elizabeth Dudek
TITLE:	State President	TITLE:	Secretary
DATE:	February 3, 2014	DATE:	2/4/14

FEDERAL ID NUMBER (or SS Number for an individual): 59-2583622

VENDOR FISCAL YEAR ENDING DATE: December 31^st

List of Attachments included as part of this Contract:

Specify	Letter/
Type	Number	Description
Attachment	I	Scope of Services (18 Pages)
Attachment	II	Core Contract Provisions (397 Pages)
Attachment	III	Business Associate Agreement (4 Pages)
Attachment	IV	Certification Regarding Lobbying (1 Page)
Attachment	V	Certification Regarding Debarment, Suspension,Ineligibility and Voluntary Exclusion Contracts/Subcontracts (1 Page)
Attachment	VI	Vendor Certification Regarding Scrutinized
		Companies List (1 Page)

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AHCA Contract No. FP020, Page 12 of 12

AHCA Form 2100-0007 (Rev. JUL 13)

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

SCOPE OF SERVICES

STATEWIDE MEDICAID MANAGED CARE PROGRAM

I. Services to be Provided

A. Overview of Contract Structure

Part IV of Chapter 409, F.S. established Florida Medicaid’s statewide managed care program, referred to as statewide Medicaid managed care (SMMC). Contracted managed care plans participate in one, or both, of two SMMC programs: one, for managed medical assistance (MMA) and one for long-term care (LTC). Additionally, some managed care plans participating in the MMA program component serve specialty populations who meet specified criteria based on age, condition or diagnosis.

The Contract consists of distinct parts as follows:

(1) Attachment I, Scope of Services, includes contract provisions that are unique to the particular managed care plan.

(a) Exhibit I-A, Approved Expanded Benefits Coverage and Limitations;

(b) Exhibit I-B, Medicaid Provider Identification Numbers;

(c) Exhibit I-C, Managed Care Plan Rates.

(2) Attachment II, Core Contract Provisions, includes contract provisions that apply to all managed care plans unless specifically noted otherwise.

(3) Exhibits to Attachment II, include contract provisions that are unique to the specific component of SMMC:

(a) Exhibit II-A, Managed Medical Assistance (MMA) Program, i.e. the MMA Exhibit;

(b) Exhibit II-B, Long-Term Care (LTC) Managed Care Program, i.e. the LTC Exhibit;

(c) Exhibit II-C, Specialty Plan (if applicable).

B. Authorized Regions and Program Enrollment Levels

The Managed Care Plan is authorized to provide services pursuant to this Contract in the region(s), and up to the maximum enrollment levels for such region(s), for the applicable SMMC program as specified in Table 1 below.

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AHCA Contract No. FP020, Attachment I, Page 1 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

Table 1: Regions and Program Enrollment Levels
Region	Program Component
	MMA	LTC	Specialty
Region 1
Region 2	117,516
Region 3	130,444
Region 4	152,143
Region 5	95,177
Region 6	118,754
Region 7	129,577
Region 8	104,607
Region 9
Region 10
Region 11	114,124

The authorized maximum enrollment levels listed are effective upon Contract execution unless otherwise specified. The maximum enrollment levels may be altered during the life of this Contract pursuant to Attachment II and its Exhibits.

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AHCA Contract No. FP020, Attachment I, Page 2 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

C. Covered Services

The Managed Care Plan shall ensure the provision of covered services in accordance with the provisions of Attachment II and its Exhibits, summarized in Table 2a (MMA) and/or Table 2b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

	Table 2a: Required MMA Services
(1)	Advanced Registered Nurse Practitioner
(2)	Ambulatory Surgical Center Services
(3)	Assistive Care Services
(4)	Behavioral Health Services
(5)	Birth Center and Licensed Midwife Services
(6)	Clinic Services
(7)	Chiropractic Services
(8)	Dental Services
(9)	Child Health Check Up
(10)	Immunizations
(11)	Emergency Services
(12)	Emergency Behavioral Health Services
(13)	Family Planning Services and Supplies
(14)	Healthy Start Services
(15)	Hearing Services
(16)	Home Health Services and Nursing Care
(17)	Hospice Services
(18)	Hospital Services
(19)	Laboratory and Imaging Services
(20)	Medical Supplies, Equipment, Protheses and Orthoses
(21)	Optometric and Vision Services
(22)	Physician Assistant Services
(23)	Physician Services
(24)	Podiatric Services
(25)	Prescribed Drug Services
(26)	Renal Dialysis Services
(27)	Therapy Services
(28)	Transportation Services

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AHCA Contract No. FP020, Attachment I, Page 3 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

	Table 2b: Required LTC Services
(1)	Adult Companion Care
(2)	Adult Day Health Care
(3)	Assistive Care Services
(4)	Assisted Living
(5)	Attendant Care
(6)	Behavioral Management
(7)	Caregiver Training
(8)	Care Coordination/Case Management
(9)	Home Accessibility Adaptation Services
(10)	Home Delivered Meals
(11)	Homemaker Services
(12)	Hospice
(13)	Intermittent and Skilled Nursing
(14)	Medical Equipment and Supplied
(15)	Medical Administration
(16)	Medication Management
(17)	Nutritional Assessment/Risk Reduction Services
(18)	Nursing Facility Services
(19)	Personal Care
(20)	Personal Emergency Response Systems (PERS)
(21)	Respite Care
(22)	Occupational Therapy
(23)	Physical Therapy
(24)	Respiratory Therapy
(25)	Speech Therapy
(26)	Transportation

D. Approved Expanded Benefits

The Managed Care Plan shall provide the following expanded benefits, in accordance with the provisions of Attachment II and its Exhibits and the coverage and limitations specified in Exhibit I-A of this Attachment, denoted by “X” in Table 3a (MMA) and/or Table 3b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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AHCA Contract No. FP020, Attachment I, Page 4 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

Table 3a: Approved MMA Expanded Benefits
X	Primary Care Visits (Non-Pregnant Adults)
X	Home Health Care (Non-Pregnant Adults)
X	Physician Home Visits
X	Prenatal/Perinatal Visits
X	Outpatient Services
X	Over-The-Counter (OTC) Medication/Supplies
X	Adult Dental Services
X	Waived Copayments
X	Vision Services
X	Hearing Services
X	Newborn Circumcision
X	Adult Pneumonia Vaccine
X	Adult Influenza Vaccine
X	Adult Shingles Vaccine
X	Post Discharge Meals
X	Nutritional Counseling
X	Pet Therapy
X	Art Therapy
X	Equine Therapy
X	Medically Related Lodging and Food
Table 3b: Approved LTC Expanded Benefits
	ALF/AFCH Bed Hold
	Cellular Phone Services
	Dental Services
	Emergency Financial Assistance
	Hearing Evaluation
	Mobile Personal Emergency Response System
	Non-Medical Transportation
	Over-The-Counter (OTC) Medication/Supplies
	Support to Transition Out of a Nursing Facility
	Vision Services
	Wellness Grocery Discount
Additional LTC Expanded Benefits
These benefits will not appear in Choice Counseling materials
	Box Fan
	Caregiver information/Support
	Document Keeper
	Household Set-Up Kit
	Welcome Home Basket
	Nurse Helpline Services
	Pill Organizer

II. Manner of Service Provision

A. Plan Qualification

The Managed Care Plan is approved to provide contracted services as a qualified entity under s 409.962(6), F.S., as denoted by “X” in Table 4 below.

AHCA Contract No. FP020, Attachment I, Page 5 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

Table 4: Plan Qualification
X	Health Maintenance Organization (HMO)
	Provider Service Network (PSN)
	Exclusive Provider Organization (EPO)
	Accountable Care Organization (ACO)
	Other Insurer

B. Plan Type

The Managed Care Plan is approved to provide contracted services as one or more of four plan types, denoted by authorized region(s) in Table 5 below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

(1) MMA Managed Care Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1)(a) through (cc), F.S.

(2) LTC Managed Care Plans are those plans that provide covered services specified in the LTC Exhibit, including those covered under s. 409.98(1) through (19), F.S.

(3) Comprehensive LTC Plans are those plans that provide services described in s. 409.973, F.S., and also provide the services described in s. 409.98, F.S.

(4) Specialty Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1)(a) through (cc), F.S., to only eligible recipients defined as a specialty population in the Attachment II and its Exhibits.

Table 5: SMMC Plan Type
Region	SMMC Program
	MMA/LTC	Specialty
Region 1
Region 2	MMA Plan
Region 3	MMA Plan
Region 4	MMA Plan
Region 5	MMA Plan
Region 6	MMA Plan
Region 7	MMA Plan
Region 8	MMA Plan
Region 9
Region 10
Region 11	MMA Plan

III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $11,789,499,367.00 shall be paid to the Managed Care Plan in accordance with Attachment II and its Exhibits. The Agency shall make payments through its fiscal agent using the Medicaid Provider Identification Number(s) specified in Exhibit I-B.

B. Capitation Rates

AHCA Contract No. FP020, Attachment I, Page 6 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

The capitation rate payment shall be in accordance with Attachment II and its Exhibits. The capitation rates are contained Exhibit I-C of this Attachment. These rates are titled “MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

IV. Special Provision

A. Order of Precedence

The Managed Care Plan shall perform its contracted duties in accordance with this Contract, the ITN(s), including all addenda and the Vendor’s response to the ITN(s). In the event of conflict among Contract documents, any identified inconsistency in this Contract shall be resolved by giving precedence in the following order:

(1) This Contract, including all attachments;

(2) The ITN(s), including all addenda; and

(3) The Vendor’s response to the ITN(s), including information provided during negotiations.

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AHCA Contract No. FP020, Attachment I, Page 7 of 7

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-A

Approved Expanded Benefit Coverage and Limitations Managed Medical Assistance (MMA)
Approved Benefit	Approved Limitations
Primary Care Visits (Non-Pregnant Adults)	Unlimited visits.
Home Health Care (Non-Pregnant Adults)	One (1) visit per day, subject to medical necessity and prior authorization
Physician Home Visits	Unlimited visits; limited to homebound enrollees who are frail, have a chronic disability and/or complex medical needs; subject to medical necessity
Prenatal/Perinatal Visits	Unlimited prenatal visits; unlimited postnatal visits for the first four (4) weeks post-partum.
Outpatient Services	One-thousand dollars ($1,000) for outpatient services per fiscal year (July 1-June 30); subject to prior authorization.
Over-The Counter (OTC) Medication/Supplies	Twenty-five dollars ($25) per household per month; enrollee purchases limited to an approved list of products.
Adult Dental Services	One (1) exam every six (6) months; one (1) cleaning every six (6) months; one (1) x-ray per year.
Waived Copayments	Enrollees shall not be subject o co-payment charges except: non-emergency emergency room visits and chiropractic services.
Vision Services	One-hundred dollars ($100) with which enrollees may purchase frames, lenses and contact lenses per year.
Hearing Services	One (1) hearing exam every two (2) years; one (1) hearing aid every two (2) years.
Newborn Circumcision	Available upon request up to three (3) months old; subject to prior authorization.
Adult Pneumonia Vaccine	Administered as medically advised; limit one (1) vaccination per lifetime.
Adult Influenza Vaccine	One (1) vaccination per year.
Adult Shingles Vaccine	Limit one (1) vaccination every six (6) years; subject to prior authorization.
Post Discharge Meals	Ten (1) meals within two weeks of an enrollees being discharged from an inpatient facility; limited to SDI and Medicare/Medicaid dual eligible enrollees; subject to prior authorization.
Nutritional Counseling	Unlimited visits; limited to enrollees who receive a home health service with a chronic disability or a complex medical need; subject to medical necessity and prior authorization.
Pet Therapy	Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.

AHCA Contract No. FP020, Attachment II, Exhibit I-A, Page 1 of 2

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

Art Therapy	Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.
Equine Therapy	Ten (10) visits per year; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; enrollee must be more than one (1) year old; subject to prior authorization.
Medically Related Lodging and Food	Unlimited coverage for enrollees and traveling partners; benefit only available if enrollee is required to travel more than fifty (50) miles from their home for non-emergent specialist or hospital treatment; overnight stay required; adult enrollees are limited to one (1) travel partner; child enrollees are limited to two (2) travel partners; subject to prior authorization.

All expanded benefits are in excess of benefits specified in the Medicaid State Plan.

The Managed Care Plan may require enrollees to use an established network of providers, approved by the Agency, to obtain expanded benefits under this Contract.

Unless otherwise specified in this Exhibit, expanded benefits are not subject to prior authorization or co-payment charges.

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AHCA Contract No. FP020, Attachment II, Exhibit I-A, Page 2 of 2

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-B

Medicaid Provider Identification Numbers
Region	MMA	LTC	Specialty
1
2	TBD
3	TBD
4	TBD
5	TBD
5	TBD
7	TBD
8	TBD
9
10
11	TBD

The Agency will provide Medicaid Provider Identification Numbers to the Managed Care Plan subsequent to the Agency’s completion of a plan-specific readiness review and prior to enrolling recipient in the Managed Care Plan in each authorized region.

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AHCA Contract No. FP020, Attachment I, Exhibit I-B, Page 1 of 1

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 2

REGION 2									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,305.22		$20,746.91				$1,469.88
3-11 Months		$183.63		$3,944.76				$421.03
1-13 Years		$107.01		$355.36				$336.22
14-54 Years Female		$322.68
14-54 Years Male		$131.26
14+ Years (Female and Male)				$791.75				$622.98
55+ Years (Female and Male)		$355.85
Under Age 65						$161.30								$296.95		$2,053.17
Age 65+						$111.44								$163.46		$1,381.41
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$162.00		$2,750.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 1 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 3

REGION 3									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,524.23		$24,932.62				$1,528.29
3-11 Months		$214.44		$4,740.62				$437.76
1-13 Years		$124.97		$427.05				$349.58
14-54 Years Female		$376.83
14-54 Years Male		$153.28
14+ Years (Female and Male)				$951.48				$647.73
55+ Years (Female and Male)		$415.56
Under Age 65						$158.08								$304.95		$2,393.91
Age 65+						$109.22								$167.86		$1,610.66
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$190.00		$2,800.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 2 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 4

REGION 4									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,367.96		$24,570.90				$1,759.83
3-11 Months		$192.45		$4,671.84				$504.08
1-13 Years		$112.16		$420.86				$402.54
14-54 Years Female		$338.19
14-54 Years Male		$137.57
14+ Years (Female and Male)				$937.68				$745.86
55+ Years (Female and Male)		$372.96
Under Age 65						$179.37								$294.88		$2,571.25
Age 65+						$123.93								$162.32		$1,729.98
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$160.00		$2,550.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 3 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 5

REGION 5									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,731.48		$27,327.79				$2,112.01
3-11 Months		$243.60		$5,196.03				$604.96
1-13 Years		$141.96		$468.08				$483.10
14-54 Years Female		$428.06
14-54 Years Male		$174.13
14+ Years (Female and Male)				$1,042.89				$895.12
55+ Years (Female and Male)		$472.07
Under Age 65						$135.35								$283.14		$2,592.37
Age 65+						$93.52								$155.86		$1,744.19
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$158.00		$3,000.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 4 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 6

REGION 6									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,506.57		$24,186.03				$1,574.26
3-11 Months		$211.95		$4,598.67				$450.93
1-13 Years		$123.52		$414.27				$360.10
14-54 Years Female		$372.46
14-54 Years Male		$151.51
14+ Years (Female and Male)				$922.99				$667.22
55+ Years (Female and Male)		$410.75
Under Age 65						$131.77								$290.00		$2,503.12
Age 65+						$91.04								$159.63		$1,684.14
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$168.00		$3,050.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 5 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 7

REGION 7									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,404.70		$24,057.01				$1,802.88
3-11 Months		$197.62		$4,574.13				$516.42
1-13 Years		$115.17		$412.06				$412.39
14-54 Years Female		$347.28
14-54 Years Male		$141.26
14+ Years (Female and Male)				$918.07				$764.11
55+ Years (Female and Male)		$382.97
Under Age 65						$132.24								$289.80		$2,705.38
Age 65+						$91.37								$159.53		$1,820.23
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$168.00		$2,925.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 6 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 8

REGION 8									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,505.48		$25,939.47				$1,391.90
3-11 Months		$211.80		$4,932.06				$398.70
1-13 Years		$123.43		$444.30				$318.38
14-54 Years Female		$372.19
14-54 Years Male		$151.40
14+ Years (Female and Male)				$989.91				$589.93
55+ Years (Female and Male)		$410.45
Under Age 65						$139.16								$238.14		$2,387.98
Age 65+						$96.15								$131.09		$1,606.67
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$172.00		$2,950.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 7 of 8

WellCare of Florida, Inc.

d/b/a Staywell Health Plan of Florida

ATTACHMENT I

EXHIBIT I-C

MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.

REGION 11

REGION 11									HIV/AIDS				Long-Term Care Program
Age Band	TANF		SSI No Medicare		Dual Eligible		Child Welfare		Dual Eligible		Medicaid Only		Dual Eligible		Medicaid Only
0-2 Months		$1,582.86		$29,647.73				$2,292.43
3-11 Months		$222.69		$5,637.14				$656.64
1-13 Years		$129.78		$507.82				$524.37
14-54 Years Female		$391.32
14-54 Years Male		$159.18
14+ Years (Female and Male)				$1,131.42				$971.60
55+ Years (Female and Male)		$431.55
Under Age 65						$178.07								$289.82		$2,787.50
Age 65+						$123.03								$159.53		$1,875.48
Medicare Advantage/D-SNP					TBD
HIV-AIDS										$165.00		$3,525.00

_______________

1.    This exhibit reflects the negotiated standard plan rates with the draft age factors provided in the ITN applied. Final rates will be adjusted for effective time period for the region, changes in hospital rates, CHIP transition children, and any other program changes that may occur prior to implementation.

2.    A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for individuals enrolled in both the MMA and LTC components of a comprehensive plan.

3.    Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Page 8 of 8

ATTACHMENT II

CORE CONTRACT PROVISIONS

Table of Contents

Section I. Definitions and Acronyms			4
	A.	Definitions	4
	B.	Acronyms	28
Section II. General Overview			32
	A.	Background	32
	B.	Purpose	32
	C.	Responsibilities of the State of Florida	32
	D.	General Responsibilities of the Managed Care Plan	35
Section III. Eligibility and Enrollment			41
	A.	Eligibility	41
	B.	Enrollment	43
	C.	Disenrollment	46
	D.	Marketing	51
Section IV. Enrollee Services and Grievance Procedures			65
	A.	Enrollee Material	65
	B.	Enrollee Services	75
	C.	Grievance System	80
Section V. Covered Services			86
	A.	Required Benefits	86
	B.	Expanded Benefits	87
	C.	Excluded Services	89
	D.	Coverage Provisions	89
	E.	Care Coordination/Case Management	91
	F.	Quality Enhancements	94
Section VI. Provider Network			96
	A.	Network Adequacy Standards	96
	B.	Network Development and Management Plan	97

AHCA Contract No. FP020, Attachment II, Page 1 of 214

	C.	Provider Credentialing and Contracting	100
	D.	Provider Services	110
	E.	Medical/Case Records Requirements	114
Section VII. Quality and Utilization Management			117
	A.	Quality Improvement	117
	B.	Performance Measures (PMs)	121
	C.	Performance Improvement Projects (PIPs)	123
	D.	Satisfaction and Experience Surveys	125
	E.	Provider-Specific Performance Monitoring	126
	F.	Other Quality Management Requirements	128
	G.	Utilization Management (UM)	130
	H.	Continuity of Care in Enrollment	134
Section VIII. Administration and Management			136
	A.	Organizational Governance and Staffing	136
	B.	Subcontracts	138
	C.	Information Management and Systems	143
	D.	Claims and Provider Payment	152
	E.	Encounter Data Requirements	155
	F.	Fraud and Abuse Prevention	159
Section IX. Method of Payment			168
	A.	Fixed Price Unit Contract	168
	B.	Payment Provisions	168
Section X. Financial Requirements			178
	A.	Insolvency Protection	178
	B.	Surplus	179
	C.	Interest	180
	D.	Third Party Resources	180
	E.	Assignment	182
	F.	Financial Reporting	183
	G.	Inspection and Audit of Financial Records	183

AHCA Contract No. FP020, Attachment II, Page 2 of 214

Section XI. Sanctions			184
	A.	Contract Violations and Non-Compliance	184
	B.	Performance Measure Action Plans (PMAP) and Corrective Action Plans (CAP)	184
	C.	Performance Measure Sanctions	184
	D.	Other Sanctions	185
	E.	Notice of Sanctions	186
	F.	Dispute of Sanctions	186
Section XII. Special Terms and Conditions			188
	A.	Applicable Laws and Regulations	188
	B.	Entire Agreement	188
	C.	Licensing	189
	D.	Ownership and Management Disclosure	189
	E.	Conflict of Interest	192
	F.	Withdrawing Services from a Region	192
	G.	Termination Procedures	193
	H.	Agency Contract Management	195
	I.	Disputes	196
Section XIII. Liquidated Damages			199
	A.	Damages	199
	B.	Issues and Amounts	200
Section XIV. Reporting Requirements			212
	A.	Managed Care Plan Reporting Requirements	212

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AHCA Contract No. FP020, Attachment II, Page 3 of 214

Section I. Definitions and Acronyms

A. Definitions

The following terms as used in this Contract shall be construed and/or interpreted as follows, unless the Contract otherwise expressly requires a different construction and/or interpretation. Some defined terms do not appear in all contracts.

Abandoned Call — A call in which the caller elects an option and is either not permitted access to that option or disconnects from the system.

Abuse(for program integrity functions) — Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid program.

Abuse, Neglect and Exploitation — In accordance with Chapter 415, F.S., and Chapter 39, F.S.:

“Abuse” means any willful act or threatened act by a caregiver that causes or is likely to cause significant impairment to an enrollee’s physical, mental, or emotional health. Abuse includes acts and omissions.

“Exploitation” of a vulnerable adult means a person who:

1. Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use, a vulnerable adult’s funds, assets, or property for the benefit of someone other than the vulnerable adult.

2. Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use, the vulnerable adult’s funds, assets, or property with the intent to temporarily or permanently deprive the vulnerable adult of the use, benefit, or possession of the funds, assets, or property for the benefit of someone other than the vulnerable adult.

“Neglect” of an adult means the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and behavioral health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well-being of the vulnerable adult. The term “neglect” also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. “Neglect” is repeated conduct or a single incident of carelessness that produces, or could reasonably be expected to result in, serious physical or psychological injury or a substantial risk of death.

“Neglect” of a child occurs when a child is deprived of, or is allowed to be deprived of, necessary food, clothing, shelter, or medical treatment, or a child is permitted to live in an environment when such deprivation or environment causes the child’s physical, behavioral, or emotional health to be significantly impaired or to be in danger of being significantly impaired.

Accountable Care Organization (ACO) — An entity qualified as an accountable care organization in accordance with federal regulations (see 42 CFR Part 425), and which meets

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the requirements of a provider service network (PSN) as described in s. 409.912(4)(d), F.S., as determined by the Agency.

Action — The denial or limited authorization of a requested service, including the type or level of service, pursuant to 42 CFR 438.400(b). The reduction, suspension or termination of a previously authorized service. The denial, in whole or in part, of payment for a service. The failure to provide services in a timely manner, as defined by the state. The failure of the Managed Care Plan to act within ninety (90) days from the date the Managed Care Plan receives a grievance, or forty-five (45) days from the date the Managed Care Plan receives an appeal. For a resident of a rural area with only one (1) managed care entity, the denial of an enrollee’s request to exercise the right to obtain services outside the network.

Activities of Daily Living (ADL) — Basic tasks of everyday life which include, dressing, grooming, bathing, eating, transferring in and out of bed or a chair, walking, climbing stairs, toileting, bladder/bowel control, and the wearing and changing of incontinence briefs.

Acute Care Services — Short-term medical treatment that may include, but is not limited to, community behavioral health, dental, hearing, home health, independent laboratory and x-ray, inpatient hospital, outpatient hospital/emergency medical, practitioner, prescribed drug, vision, or hospice services.

Adjudicated Claim – A claim for which a determination has been made to pay or deny the claim.

Advance Directive — A written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated.

Advanced Registered Nurse Practitioner (ARNP) — A licensed advanced practice registered nurse who works in collaboration with a practitioner according to Chapter 464, F.S., according to protocol, to provide diagnostic and clinical interventions. An ARNP must be authorized to provide these services by Chapter 464, F.S., and protocols filed with the Board of Medicine.

Adverse Incident — Critical events that negatively impact the health, safety, or welfare of enrollees. Adverse incidents may include events involving abuse, neglect, exploitation, major illness or injury, involvement with law enforcement, elopement/missing, or major medication incidents.

After Hours — The hours between five PM (5pm) and eight AM (8am) local time, Monday through Friday inclusive, and all-day Saturday and Sunday. State holidays are included.

Agency — State of Florida, Agency for Health Care Administration (AHCA) or its designee.

Agent — A term that refers to certain independent contractors with the state that perform administrative functions, including but not limited to: fiscal agent activities; outreach, eligibility and enrollment activities; and systems and technical support. The term as used herein does not create a principal-agent relationship.

Aging and Disability Resource Center (ADRC) — An agency designated by the DOEA to develop and administer a plan for a comprehensive and coordinated system of services for older and disabled persons.

Aging Network Service Provider — A system of essential community providers including all providers that have previously participated in home and community-based waivers serving elders or community service programs administered by the Department of Elder Affairs (DOEA)

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pursuant to s. 409.982(1)(c), F.S., or s. 430.205, F.S., and to whom the Agency or DOEA has made payments in the six months prior to the release of the long-term managed care ITN.

Ancillary Provider — A provider of ancillary medical services who has contracted with a Managed Care Plan to serve the Managed Care Plan’s enrollees.

Appeal — A formal request from an enrollee to seek a review of an action taken by the Managed Care Plan pursuant to 42 CFR 438.400(b).

Area Agency on Aging — An agency designated by the DOEA to develop and administer a plan for a comprehensive and coordinated system of services for older persons.

Assistive Care Services – A Medicaid service as defined in the Assistive Care Services Coverage and Limitations Handbook.

Authoritative Host — A system that contains the master or “authoritative” data for a particular data type, e.g., enrollee, provider, Managed Care Plan, etc. The authoritative host may feed data from its master data files to other systems in real time or in batch mode. Data in an authoritative host is expected to be up to date and reliable.

Baker Act — The Florida Mental Health Act, pursuant to ss. 394.451 through 394.47891, F.S.

Bed Hold Day(s) — The reservation of a bed in a nursing facility (including beds for individuals receiving hospice services), when a resident is admitted into the hospital or is on therapeutic leave during a Medicaid covered stay.

Behavioral Health Care Provider — A licensed or certified behavioral health professional, such as a clinical psychologist under Chapter 490, F.S., clinical social worker, mental health professional under Chapter 491, F.S.; certified addictions professional; or registered nurse qualified due to training or competency in behavioral health care, who is responsible for the provision of behavioral health care to patients, or a physician licensed under Chapters 458 or 459, F.S., who is under contract to provide behavioral health services to enrollees.

Behavioral Health Services — Services listed in the Community Behavioral Health Services Handbook and the Mental Health Targeted Case Management Coverage and Limitations Handbook as specified in Section V, Covered Services and the MMA or LTC Exhibit, respectively.

Beneficiary Assistance Program — A state external conflict resolution program authorized under s. 409.91211(3)(q), F.S., available to Medicaid participants, that provides an additional level of appeal if the Managed Care Plan’s process does not resolve the conflict.

Benefits — A schedule of health care services to be delivered to enrollees covered by the Managed Care Plan as set forth in Section V, Covered Services and the MMA or LTC Exhibit, respectively.

Biometric Technology — The use of computer technology to identify people based on physical or behavioral characteristics such as fingerprints, retinal or voice scans.

Blocked Call — A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up behind a defined threshold.

Business Days — Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday, and Friday. State holidays are excluded.

Calendar Days — All seven (7) days of the week. Unless otherwise specified, the term “days” in this Contract refers to calendar days.

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Capitation Rate — The per-member, per-month amount, including any adjustments, that is paid by the Agency to a Managed Care Plan for each Medicaid recipient enrolled under a Contract for the provision of Medicaid services during the payment period.

Care Coordination/Case Management — A process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an enrollee’s health needs using communication and all available resources to promote quality outcomes. Proper care coordination/case management occurs across a continuum of care, addressing the ongoing individual needs of an enrollee rather than being restricted to a single practice setting.

Case Record — A record that includes information regarding the management of services for an enrollee including the plan of care and documentation of care coordination/case management activities.

Cause — Special reasons that allow mandatory enrollees to change their Managed Care Plan choice outside their open enrollment period. May also be referred to as “good cause.” (See 59G-8.600, F.A.C.)

Centers for Independent Living (CIL) – Non-profit agencies serving all Florida counties with an array of services to enable people of all ages with disabilities to live at home, work, maintain their health, care for their families, and take part in community activities.

Centers for Medicare & Medicaid Services (CMS) — The agency within the United States Department of Health & Human Services that provides administration and funding for Medicare under Title XVIII, Medicaid under Title XIX, and the Children’s Health Insurance Program under Title XXI of the Social Security Act.

Certification — The process of determining that a facility, equipment or an individual meets the requirements of federal or state law, or whether Medicaid payments are appropriate or shall be made in certain situations.

Check Run Summary File — Required Managed Care Plan file listing all amounts paid to providers for each provider payment adjudication cycle. For each provider payment in each adjudication cycle, the file must detail the total encounter payments to each respective provider. This file must be submitted along with the encounter data submissions. The file must be submitted in a format and in timeframes specified by the Agency.

Child Health Check-Up Program (CHCUP) — A set of comprehensive and preventive health examinations provided on a periodic basis to identify and correct medical conditions in children/adolescents. Policies and procedures are described in the Child Health Check-Up Services Coverage and Limitations Handbook. (See definition of Early and Periodic Screening, Diagnosis and Treatment Program.)

Children/Adolescents — Enrollees under the age of 21.

Children's Medical Services Network — A primary care case management program for children from birth through age twenty-one (21) with special health care needs, administered by the Department of Health for physical health services and the Department of Children and Families for behavioral health.

Children’s Medical Services (CMS) Plan — A Medicaid specialty plan for children with chronic conditions operated by the Florida Department of Health’s Children’s Medical Services Network as specified in s. 409.974(4), F.S., through a single, statewide contract with the Agency that is

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not subject to the SMMC procurement requirements, or regional plan limits, but must meet all other plan requirements for the MMA program.

Claim – (1) A bill for services, (2) a line item of service, or (3) all services for one (1) recipient within a bill, pursuant to 42 CFR 447.45, in a format prescribed by the Agency through its Medicaid provider handbooks.

Clean Claim — A claim that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity, pursuant to 42 CFR 447.45.

Cold Call Marketing — Any unsolicited personal contact with a Medicaid recipient by the Managed Care Plan, its staff, its volunteers, or its vendors with the purpose of influencing the Medicaid recipient to enroll in the Managed Care Plan or either to not enroll in, or disenroll from, another Managed Care Plan.

Commission for the Transportation Disadvantaged (CTD) — An independent commission housed administratively within the Florida Department of Transportation. The CTD’s mission is to ensure the availability of efficient, cost-effective, and quality transportation services for transportation-disadvantaged persons.

Community Care for the Elderly Lead Agency — An entity designated by an Area Agency on Aging and given the authority and responsibility to coordinate services for functionally impaired elderly persons.

Community Living Support Plan — A written document prepared by or on behalf of a mental health resident of an assisted living facility with a limited mental health license and the resident’s behavioral health case manager in consultation with the administrator of the facility or the administrator’s designee. A copy must be provided to the administrator. The plan must include information about the supports, services, and special needs that enable the resident to live in the assisted living facility and a method by which facility staff can recognize and respond to the signs and symptoms particular to that resident that indicate the need for professional services.

Community Outreach — The provision of health or nutritional information or information for the benefit and education of, or assistance to, a community in regard to health-related matters or public awareness that promotes healthy lifestyles. Community outreach also includes the provision of information about health care services, preventive techniques, and other health care projects and the provision of information related to health, welfare, and social services or social assistance programs offered by the State of Florida or local communities.

Community Outreach Materials – Materials regarding health or nutritional information or information for the benefit and education of, or assistance to, a community on health-related matters or public awareness that promotes healthy lifestyles. Such materials are meant specifically for the community at large and may also include information about health care services, preventive techniques, and other health care projects and the provision of information related to health, welfare, and social services or social assistance programs offered by the State of Florida or local communities. Community outreach materials are limited to brochures, fact sheets, billboards, posters, and ad copy for radio, television, print, or the Internet.

Community Outreach Representative — A person who provides health information, information that promotes healthy lifestyles, information that provides guidance about social assistance programs, and information that provides culturally and linguistically appropriate

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health or nutritional education. Such representatives must be appropriately trained, certified, and/or licensed, including but not limited to, social workers, nutritionists, physical therapists, and other health care professionals.

Complaint— Any oral or written expression of dissatisfaction by an enrollee submitted to the Managed Care Plan or to a state agency and resolved by close of business the following business day. Possible subjects for complaints include, but are not limited to, the quality of care, the quality of services provided, aspects of interpersonal relationships such as rudeness of a provider or Managed Care Plan employee, failure to respect the enrollee’s rights, Managed Care Plan administration, claims practices or provision of services that relates to the quality of care rendered by a provider pursuant to the Managed Care Plan’s Contract. A complaint is a subcomponent of the grievance system.

Comprehensive Assessment and Review for Long-Term Care Services (CARES) — A program operated by the DOEA that is Florida’s federally mandated long-term care preadmission screening program for Medicaid Institutional Care Program nursing facility and Medicaid waiver program applicants. An assessment is performed to identify long-term care needs; establish level of care (medical eligibility for nursing facility care); and recommend the least restrictive, most appropriate placement. Emphasis is on enabling people to remain in their homes through provision of home-based services or with alternative placements such as assisted living facilities.

Comprehensive Long-Term Care Plan — A Managed Care Plan that provides services described in s. 409.973, F.S., and also provides the services described in s. 409.98, F.S. Also referred to as Comprehensive LTC Managed Care Plan. For purposes of this Contract, Comprehensive LTC Managed Care Plans must comply with all general requirements of Managed Care Plans, LTC Managed Care Plans and MMA Managed Care Plans unless otherwise indicated.

Continuous Quality Improvement — A management philosophy that mandates continually pursuing efforts to improve the quality of products and services produced by an organization.

Contract, Comprehensive Long-Term Care Plan — As a result of receiving a regional award from the Agency pursuant to s. 409.966(2), F.S., and/or s. 409.974, F.S., and s. 409.981, F.S., and successfully meeting all plan readiness requirements, the agreement between the Managed Care Plan and the Agency where the Managed Care Plan will provide Medicaid-covered services to enrollees, comprising the Contract and any addenda, appendices, attachments, or amendments thereto, and be paid by the Agency as described in the terms of the agreement. Also referred to as the “Contract”.

Contract, Long-Term Care — As a result of receiving a regional award from the Agency pursuant to s. 409.966(2), F.S., and/or s. 409.981, F.S., and successfully meeting all plan readiness requirements, the agreement between the Managed Care Plan and the Agency where the Managed Care Plan will provide Medicaid-covered services to enrollees, comprising the Contract and any addenda, appendices, attachments, or amendments thereto, and be paid by the Agency as described in the terms of the agreement. Also referred to as the “Contract”.

Contract, Medical Assistance — As a result of receiving a regional award from the Agency pursuant to s. 409.966(2), F.S., and/or s. 409.974, F.S., and successfully meeting all plan readiness requirements, the agreement between the Managed Care Plan and the Agency where the Managed Care Plan will provide Medicaid-covered services to enrollees, comprising the Contract and any addenda, appendices, attachments, or amendments thereto, and be paid by the Agency as described in the terms of the agreement. Also referred to as the “Contract”.

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Contracting Officer — The Secretary of the Agency or designee.

County Health Department (CHD) — Organizations administered by the Department of Health to provide health services as defined in Chapter 154, Part I., F.S., including promoting public health, controlling and eradicating preventable diseases, and providing primary health care for special populations.

Coverage & Limitations Handbook and/or Provider General Handbook (Handbook) — A Florida Medicaid document that provides information to a Medicaid provider about enrollee eligibility; claims submission and processing; provider participation; covered care, goods and services; limitations; procedure codes and fees; and other matters related to participation in the Medicaid program.

Covered Services — Those services provided by the Managed Care Plan in accordance with this Contract, and as outlined in Section V, Covered Services, and the MMA or LTC Exhibit, respectively.

Crisis Support — Services for persons initially perceived to need emergency behavioral health services, but upon assessment, do not meet the criteria for such emergency care. These are acute care services available twenty-four hours a day, seven days a week (24/7) for intervention. Examples include: mobile crisis, crisis/emergency screening, crisis hot line, and emergency walk-in.

Customized Benefit Package (CBP) — Covered services, which may vary in amount, scope, and/or duration from those listed in Section V, Covered Services and the MMA Exhibit. The CBP must meet state standards for actuarial equivalency and sufficiency as specified in this Contract. CBP is also referred to as “benefit grid.”

Department of Children and Families (DCF) — The state agency responsible for overseeing programs involving behavioral health, childcare, family safety, domestic violence, economic self-sufficiency, refugee services, homelessness, and programs that identify and protect abused and neglected children and adults.

Department of Elder Affairs (DOEA) — The primary state agency responsible for administering human services programs to benefit Florida’s elders and developing policy recommendations for long-term care in addition to overseeing the implementation of federally funded and state-funded programs and services for the state’s elderly population.

Department of Health — The state agency responsible for public health, public primary care and personal health, disease control, and licensing of health professionals.

Direct Ownership Interest — The ownership of stock, equity in capital or any interest in the profits of a disclosing entity.

Direct Secure Messaging (DSM) — Enables Managed Care Organizations and providers to securely send patient health information to many types of organizations.

Direct Service Behavioral Health Care Provider — An individual qualified by training or experience to provide direct behavioral health services.

Direct Service Provider, Long-Term Care — A person eighteen (18) years of age or older who, pursuant to a program to provide services to the elderly or disabled, has direct, face-to-face contact with a client while providing services to the client and has access to the client’s living areas, funds, personal property, or personal identification information as defined in s.

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817.568, F.S. The term includes coordinators, managers, and supervisors of residential facilities and volunteers. (See s. 430.0402(1)(b), F.S.)

Disclosing Entity — A Medicaid provider, other than an individual practitioner or group of practitioners, or a fiscal agent that furnishes services or arranges for funding of services under Medicaid, or health-related services under the social services program.

Disease Management — A system of coordinated health care intervention and communication for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care; emphasizes prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health.

Disenrollment — The Agency-approved discontinuance of an enrollee’s participation in a Managed Care Plan.

Downward Substitution — The use of less restrictive, lower cost services than otherwise might have been provided, that are considered clinically acceptable and necessary to meet specified objectives outlined in an enrollee’s plan of treatment, provided as an alternative to higher cost services.

Dual Eligible — An enrollee who is eligible for both Medicaid (Title XIX) and Medicare (Title XVIII) programs.

Durable Medical Equipment (DME) — Medical equipment that can withstand repeated use, is customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury and is appropriate for use in the enrollee’s home.

Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) — As defined by 42 CFR 440.40(b)(2012) or its successive regulation, means: (1) Screening and diagnostic services to determine physical or mental defects in recipients under age 21; and (2) Health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered. Pursuant to s. 42 CFR 441.56 (2012) or its successive regulation, this is a program about which all eligible individuals and their families must be informed. EPSDT includes screening (periodic comprehensive child health assessments): consisting of regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth. As a minimum, these screenings must include, but are not limited to: (a) comprehensive health and developmental history, (b) comprehensive unclothed physical examination, (c) appropriate vision testing, (d) appropriate hearing testing, (e) appropriate laboratory tests, (vi) dental screening services furnished by direct referral to a dentist for children beginning at 3 years of age. Screening services must be provided in accordance with reasonable standards of medical and dental practice determined by the Agency after consultation with recognized medical and dental organizations involved in child health care. Requirements for screenings are contained in the Medicaid Child Health Check-Up Coverage and Limitations handbook. Diagnosis and treatment include: (a) diagnosis of and treatment for defects in vision and hearing, including eyeglasses and hearing aids; (b) dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health; and (c) appropriate immunizations. (If it is determined at the time of screening that immunization is needed and appropriate to provide at the time of screening, then immunization treatment must be provided at that time.) (See definition of Child Health Check-up program.)

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Early Intervention Services (EIS) – A Medicaid program designed for children receiving services through the Department of Health’s Early Steps program. Early Steps serves eligible infants and toddlers from birth to thirty-six (36) months who have development delays or a condition likely to result in a developmental delay. EIS services are authorized in the child’s Early Steps Individualized Family Support Plan and are delivered by Medicaid-enrolled EIS providers throughout the state.

Eligible Plan — In accordance with s. 409.962(6), F.S., a health insurer authorized under Chapter 624, an exclusive provider organization (EPO) authorized under Chapter 627, a health maintenance organization (HMO) authorized under Chapter 641, F.S., or an accountable care organization (ACO) authorized under federal law. For purposes of the managed medical assistance (MMA) SMMC program, the term also includes a provider service network (PSN) authorized under s. 409.912(4)(d), the Children’s Medical Services Network (or Children’s Medical Services (CMS) Plan) authorized under Chapter 391, or comprehensive long-term care plans authorized under s. 409.962(4), F.S. For purposes of the long-term care SMMC program, the term also includes entities qualified under 42 CFR Part 422 as Medicare Advantage Preferred Provider Organizations, Medicare Advantage Provider-sponsored Organizations, and Medicare Advantage Special Needs Plan, Program of All-Inclusive Care for the Elderly, and long-term care PSNs, in accordance with s. 409.981(1), F.S., or comprehensive long-term care plans authorized under s. 409.962(4), F.S.

Emergency Behavioral Health Services — Those services required to meet the needs of an individual who is experiencing an acute crisis, resulting from a mental illness, which is a level of severity that would meet the requirements for an involuntary examination (see s. 394.463, F.S.), and in the absence of a suitable alternative or psychiatric medication, would require hospitalization.

Emergency Medical Condition — (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could result in any of the following: (1) serious jeopardy to the health of a patient, including a pregnant woman or fetus; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: (1) that there is inadequate time to effect safe transfer to another hospital prior to delivery; (2) that a transfer may pose a threat to the health and safety of the patient or fetus; (3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes (see s. 395.002, F.S.).

Emergency Services and Care — Medical screening, examination and evaluation by a physician or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists. If such a condition exists, emergency services and care include the care or treatment necessary to relieve or eliminate the emergency medical condition within the service capability of the facility.

Emergency Transportation — The provision of emergency transportation services in accordance with s. 409.908 (13)(c)4., F.S.

Encounter Data — A record of diagnostic or treatment procedures or other medical, allied, or long-term care provided to the Managed Care Plan’s Medicaid enrollees, excluding services paid by the Agency on a fee-for-service basis.

Enrollee — A Medicaid recipient enrolled in a Managed Care Plan.

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Enrollees with Special Health Care Needs — Enrollees who face physical, behavioral or environmental challenges daily that place at risk their health and ability to fully function in society. This includes individuals with mental retardation or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care; and all enrollees in LTC Managed Care Plans.

Enrollment — The process by which an eligible Medicaid recipient signs up to participate in a Managed Care Plan.

Enrollment Broker — The state’s contracted or designated entity that performs functions related to outreach, education, enrollment, and disenrollment of potential enrollees into a Managed Care Plan.

Enrollment Files — X-12 834 files sent by the Agency’s Medicaid fiscal agent to the Managed Care Plans to provide the Managed Care Plans with their official Medicaid recipient enrollment. Supplemental enrollment files are provided by the Agency’s Medicaid enrollment broker; these files contain additional demographic data and provider choice data not available on the X-12 834 enrollment files.

Enrollment Specialists — Individuals, authorized through an Agency-approved process, who provide one-on-one information to Medicaid recipients to help them choose the Managed Care Plan that best meets the health care needs of them and their families.

Excluded Parties List System (EPLS) — The EPLS, or its equivalent is a federal database containing information regarding entities debarred, suspended, proposed for debarment, excluded, or disqualified under the nonprocurement common rule, or otherwise declared ineligible from receiving federal contracts, certain subcontracts, and certain federal assistance and benefits.

Exclusive Provider Organization — Pursuant to Chapter 627, F.S., a group of health care providers that have entered into a written agreement with an insurer to provide benefits under a health insurance policy. Must be capitated by the Agency.

Expanded Benefit — A benefit offered to all enrollees in specific population groups, covered by the Managed Care Plan for which the Managed Care Plan receives no direct payment from the Agency. These specific population groups are as follows: TANF; SSI No Medicare, non-LTC eligible; SSI with Medicare, non-LTC eligible; Dual Eligible, LTC eligible; Medicaid Only, LTC eligible; HIV/AIDS Specialty Population, with Medicare; HIV/AIDS Specialty Population, No Medicare; and Child Welfare Specialty Population.

Expedited Appeal Process — The process by which the appeal of an action is accelerated because the standard timeframe for resolution of the appeal could seriously jeopardize the enrollee’s life, health or ability to obtain, maintain or regain maximum function.

External Quality Review (EQR) — The analysis and evaluation by an EQRO of aggregated information on quality, timeliness, and access to the health care services that are furnished to Medicaid recipients by a Managed Care Plan.

External Quality Review Organization (EQRO) — An organization that meets the competence and independence requirements set forth in 42 CFR 438.354, and performs EQR, other related activities as set forth in federal regulations, or both.

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Facility-Based— As the term relates to services, services the enrollee receives from a residential facility in which the enrollee lives. Under this Contract, assisted living facility services, assistive care services, adult family care homes and nursing facility care are facility-based services.

Federal Fiscal Year — The United States government’s fiscal year, which starts October 1 and ends on September 30.

Federally Qualified Health Center (FQHC) — An entity that is receiving a grant under section 330 of the Public Health Service Act, as amended. (Also see s. 1905(l)(2)(B) of the Social Security Act.) FQHCs provide primary health care and related diagnostic services and may provide dental, optometric, podiatry, chiropractic and behavioral health services.

Fee-for-Service (FFS) — A method of making payment by which the Agency sets prices for defined medical or allied care, goods or services.

Fee Schedule – A list of medical, dental or mental health services or products covered by the Florida Medicaid program which provide the associated reimbursement rates for each covered service or product and are promulgated into rule.

Fiscal Agent — Any corporation, or other legal entity, that enters into a contract with the Agency to receive, process and adjudicate claims under the Medicaid program.

Fiscal Year — The State of Florida’s Fiscal Year, which starts July 1 and ends on June 30.

Florida Medicaid Management Information System (FMMIS or FL MMIS) — The information system used to process Florida Medicaid claims and payments to Managed Care Plans, and to produce management information and reports relating to the Florida Medicaid program. This system is used to maintain Medicaid eligibility data and provider enrollment data.

Florida Medical School Quality Network – The network as specified in s. 409.975(2), F.S.

Florida Mental Health Act — Includes the Baker Act that covers admissions for persons who are considered to have an emergency mental health condition (a threat to themselves or others) as specified in ss. 394.451 through 394.47891, F.S.

Fraud — An intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person. The term includes any act that constitutes fraud under applicable federal or state law.

Full Benefit Dual Eligible – An enrollee who is eligible for full Medicaid benefits under Medicaid (Title XIX) and Medicare (Title XVIII) programs.

Full-Time Equivalent (FTE) Position/Employee — The equivalent of one (1) full-time employee who works forty (40) hours per week.

Functional Status — The ability of an individual to perform self-care, self-maintenance and physical activities in order to carry on typical daily activities.

Good Cause — See Cause.

Grievance — An expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to, the quality of care, the quality of services provided and aspects of interpersonal relationships such as rudeness of a provider or Managed Care Plan employee or failure to respect the enrollee’s rights.

Grievance Process — The procedures for addressing enrollees' grievances.

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Grievance System — The system for reviewing and resolving enrollee complaints, grievances and appeals. Components must include a complaint process, a grievance process, an appeal process, access to an applicable review outside the Managed Care Plan (Beneficiary Assistance Program), and access to a Medicaid Fair Hearing through the Department of Children and Families.

Health Assessment — A complete health evaluation combining health history, physical assessment and the monitoring of physical and psychological growth and development.

Healthcare Effectiveness Data and Information Set (HEDIS) — The data and information set developed and published by the National Committee for Quality Assurance. HEDIS includes technical specifications for the calculation of performance measures.

Health Care-Acquired Condition (HCAC) — A condition, occurring in any inpatient hospital or inpatient psychiatric hospital setting, including crisis stabilization units (CSUs), identified as a hospital-acquired condition (HAC) by the Secretary of Health and Human Services under section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program as specified in the Florida Medicaid State Plan. By federal law, Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE), as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients, are not reportable PPCs/HCACs. HCACs also include never events.

Health Care Professional — A physician or any of the following: podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech-language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), a licensed clinical social worker, registered respiratory therapist and certified respiratory therapy technician.

Health Care Service Pools — Any person, firm, corporation, partnership, or association engaged for hire in the business of providing temporary employment in health care facilities, residential facilities, and agencies for licensed, certified, or trained health care personnel including, without limitation, nursing assistants, nurses’ aides, and orderlies. (See s. 400.980, F.S.)

Health Fair — An event conducted in a setting that is open to the public or segment of the public (such as the "elderly" or "schoolchildren") during which information about health care services, facilities, research, preventive techniques or other health care subjects is disseminated. At least one (1) community organization or two (2) health-related organizations that are not affiliated under common ownership must actively participate in the health fair.

Health Information Exchange (HIE) -– the secure, electronic exchange of health information among authorized stakeholders in the health care community – such as care providers, patients, and public health agencies – to drive timely, efficient, high-quality, preventive, and patient-centered care.

Health Insurance Premium Payment (HIPP) Program — A program that reimburses part or all of a Medicaid recipient’s share of employer-sponsored health care coverage, if available and cost-effective.

Health Maintenance Organization (HMO) — An organization or entity licensed in accordance with Chapter 641, F.S., or in accordance with the Florida Medicaid State Plan definition of an HMO.

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Healthy Behaviors (MMA Managed Care Plans Only) — A program offered by Managed Care Plans that encourages and rewards behaviors designed to improve the enrollee’s overall health.

Health Information Technology for Economic and Clinical Health (HITECH) Act — The Health Information Technology Act, found in Title XIII of the American Recovery and Reinvestment Act of 2009, Public Law 111-005.

Hospital — A facility licensed in accordance with the provisions of Chapter 395, F.S., or the applicable laws of the state in which the service is furnished.

Hospital Services Agreement — The agreement between the Managed Care Plan and a hospital to provide medical services to the Managed Care Plan’s enrollees.

Home and Community Based Services— (HCBS) Services offered in the community setting designed to prevent or delay nursing facility placement of elderly or disabled adults.

Hub Site — The telecommunication distance site in Florida at which the consulting physician, dentist or therapist is delivering telemedicine services.

Indirect Ownership— Ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of five percent (5%) or more in the disclosing entity. Example: If “A” owns ten percent (10%) of the stock in a corporation that owns eighty percent (80%) of the stock of the disclosing entity, “A’s” interest equates to an eight percent (8%) indirect ownership and must be reported.

Information — As the term relates to Information Management and Systems, (a) Structured Data: Data that adhere to specific properties and validation criteria that are stored as fields in database records. Structured queries can be created and run against structured data, where specific data can be used as criteria for querying a larger data set; (b) Document: Information that does not meet the definition of structured data includes text files, spreadsheets, electronic messages and images of forms and pictures.

Information System(s) — A combination of computing and telecommunications hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e., structured data (which may include digitized audio and video) and documents as well as non-digitalized audio and video; and/or (b) the processing and/or calculating of information and non-digitalized audio and video for the purposes of enabling and/or facilitating a business process or related transaction.

Insolvency — A financial condition that exists when an entity is unable to pay its debts as they become due in the usual course of business, or when the liabilities of the entity exceed its assets.

Insurer — Pursuant to s. 624.03, F.S., every person engaged as indemnitor, surety, or contractor in the business of entering into contracts of insurance or of annuity.

Instrumental Activities of Daily Living (IADL) — Activities related to independent living which include, but are not limited to, preparing meals, taking medications, using transportation, managing money, shopping for groceries or personal items, performing light or heavy housework and using a telephone.

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Kick Payment (MMA Managed Care Plans only) — The method of reimbursing Managed Care Plans in the form of a separate one (1) time fixed payment for specific services.

Level of Care (LOC) — The type of Long-Term care required by an enrollee based on medical needs. The criteria for Intermediate LOC (Level I and II) are described in 59G-4.180, FAC, and the criteria for Skilled LOC are described in 59G-4.290, FAC. Department of Elder Affairs CARES staff establish level of care for Medicaid enrollees.

Licensed — A facility, equipment, or an individual that has formally met state, county, and local requirements, and has been granted a license by a local, state or federal government entity.

Licensed Practitioner of the Healing Arts — A psychiatric nurse, registered nurse, advanced registered nurse practitioner, physician assistant, clinical social worker, mental health counselor, marriage and family therapist, or psychologist.

List of Excluded Individuals and Entities (LEIE)— A database maintained by the Department of Health & Human Services, Office of the Inspector General. The LEIE provides information to the public, health care providers, patients and others relating to parties excluded from participation in Medicare, Medicaid and all other federal health care programs.

Long-Term Care Assessment — An individualized, comprehensive appraisal of an individual’s medical, developmental, behavioral, social, financial, and environmental status conducted by a qualified individual for the purpose of determining the need for long-term care services. This includes all LTC assessments required by this Contract.

Long-Term Care Plan (LTC Plan) — A Managed Care Plan that provides the services described in s. 409.98, F.S., for the long-term care program of the statewide Medicaid managed care program.

Long-Term Care Provider Service Network (LTC PSN) — Pursuant to s. 409.962(8), F.S., and s. 409.981(1), F.S., a provider service network, a controlling interest of which is owned by one or more licensed nursing facilities, assisted living facilities with seventeen (17) or more beds, home health agencies, community care for the elderly lead agencies, or hospices. LTC PSNs may be paid by the Agency on a capitated/prepaid or FFS basis. Also refer to Provider Service Network.

Managed Behavioral Health Organization (MBHO) — A behavioral health care delivery system managing quality, utilization and cost of services. Additionally, an MBHO measures performance in the area of mental disorders.

Managed Care Plan — An eligible plan under Contract with the Agency to provide services in the LTC or MMA Statewide Medicaid Managed Care Program.

Managed Care Plan Report Guide – A companion guide to the SMMC LTC and MMA Managed Care Plan Contracts that provides detailed information about standard reports required by the Contract to be submitted by the Managed Care Plans to the Agency. Such detailed information includes report-specific format and submission requirements, instructions for completion, and report templates and supplemental tables.

Mandatory Assignment — The process the Agency uses to assign enrollees to a Managed Care Plan. The Agency automatically assigns those enrollees required to be in a Managed Care Plan who did not voluntarily choose one.

Mandatory Enrollee — The categories of eligible Medicaid recipients who must be enrolled in a Managed Care Plan.

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Mandatory Potential Enrollee — A Medicaid recipient who is required to enroll in a Managed Care Plan but has not yet made a choice.

Marketing — Any activity or communication conducted by or on behalf of any Managed Care Plan with a Medicaid recipient who is not enrolled with the Managed Care Plan or an individual potentially eligible for Medicaid that can reasonably be interpreted as intended to influence such individual to enroll in the particular Managed Care Plan.

Medicaid — The medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., and regulations thereunder, as administered in the State of Florida by the Agency under s. 409.901 et seq., F.S.

Medicaid Fair Hearing — An administrative hearing conducted by DCF to review an action taken by a Managed Care Plan that limits, denies, or stops a requested service.

Medicaid Pending — A process in which individuals who apply for the Statewide Medicaid Managed Long-Term Care Program for HCBS and who meet medical eligibility choose to receive services before being determined financially eligible for Medicaid by DCF.

Medicaid Program Integrity (MPI) — The unit of the Agency responsible for preventing and identifying fraud and abuse in the Medicaid program.

Medicaid Recipient — Any individual whom DCF, or the Social Security Administration on behalf of DCF, determines is eligible, pursuant to federal and state law, to receive medical or allied care, goods or services for which the Agency may make payments under the Medicaid program, and who is enrolled in the Medicaid program.

Medicaid State Plan — A written plan between a state and the federal government that outlines the state’s Medicaid eligibility standards, provider requirements, payment methods, and health benefit packages. A Medicaid State Plan is submitted by each state and approved by the Centers for Medicare and Medicaid Services (CMS).

Medical Assistance Plan (MMA Plan) — A Managed Care Plan that provides the services described in s. 409.973, F.S., for the medical assistance (MMA) Statewide Medicaid Managed Care (SMMC) program.

Medical Foster Care Services — Services provided to enable children, who are under the age of 21, have medically complex needs, and whose parents cannot care for them in their own home, to live and receive care in foster homes rather than in hospitals or other institutional settings. Medical foster care services are authorized by Title XIX of the Social Security Act and s. 409.903, F.S., and Chapter 59G, F.A.C.

Medical/Case Record — Documents corresponding to clinical, allied, or long-term care, goods or services furnished in any place of business. The records may be on paper, magnetic material, film or other media. In order to qualify as a basis for reimbursement, the records must be dated, legible and signed or otherwise attested to, as appropriate to the media, and meet the requirements of 42 CFR 456.111 and 42 CFR 456.211.

Medically Complex — An individual who is medically fragile who may have multiple co-morbidities or be technologically dependent on medical apparatus or procedures to sustain life.

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Medically Necessary or Medical Necessity — Services that include medical, allied, or long-term care, goods or services furnished or ordered to:

1. Meet the following conditions:

a. Be necessary to protect life, to prevent significant illness or significant disability or to alleviate severe pain;

b. Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under treatment and not in excess of the patient’s needs;

c. Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not be experimental or investigational;

d. Be reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide; and

e. Be furnished in a manner not primarily intended for the convenience of the enrollee, the enrollee’s caretaker or the provider.

2. For those services furnished in a hospital on an inpatient basis, medical necessity means that appropriate medical care cannot be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.

3. The fact that a provider has prescribed, recommended or approved medical, allied, or long-term care goods or services does not, in itself, make such care, goods or services medically necessary, a medical necessity or a covered service/benefit.

Medicare — The medical assistance program authorized by Title XVIII of the Social Security Act.

Medicare Advantage Plan — A Medicare-approved health plan offered by a private company that covers both hospital and medical services, often includes prescription drug coverage, and may offer extra coverage such as vision, hearing, dental and/or wellness programs. Each plan can charge different out-of-pocket costs and have different rules for how to get services. Such plans can be organized as health maintenance organizations, preferred provider organizations, coordinated care plans, and special needs plans.

Meds AD — Individuals who have income up to 88% of federal poverty level and assets up to $5,000 ($6,000 for a couple) and who do not have Medicare, or who have Medicare and are receiving institutional care or hospice care, are enrolled in PACE or an HCBS waiver program, or live in an assisted living facility or adult family care home licensed to provide assistive care services.

Mental Health Targeted Case Manager — An individual who provides mental health targeted case management services directly to or on behalf of an enrollee on an individual basis in accordance with 65E-15, F.A.C., and the Florida Medicaid Mental Health Targeted Case Management Coverage and Limitations Handbook.

Mixed Services – Medicaid services listed in statute as covered by the LTC Managed Care Plan under s. 409.98, F.S., and the MMA Managed Care Plan under s. 409.973, F.S. These include the following services: home health and nursing care (intermittent and skilled nursing), hospice services, medical equipment and supplies (including durable medical equipment), therapy services (physical, occupational, respiratory and speech) and non-emergency transportation services.

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National Provider Identifier (NPI) — An identification number assigned through the National Plan and Provider Enumerator System of the federal Department of Health & Human Services. NPIs can be obtained online at https://nppes.cms.hhs.gov.

Never Event (NE) — As defined by the National Quality Forum (NQF), an error in medical care that is of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization. Currently, in Florida Medicaid, never event health care settings are limited to inpatient hospitals and inpatient psychiatric hospitals, including CSUs.

Newborn— A live child born to an enrollee who is a member of the Managed Care Plan.

Non-Covered Service — A service that is not a benefit under either the Medicaid State Plan or the Managed Care Plan.

Non-Participating Provider — A person or entity eligible to provide Medicaid services that does not have a contractual agreement with the Managed Care Plan to provide services. In order to receive payment for covered services, non-participating providers must be eligible for a Medicaid provider agreement and recognized in the Medicaid system (FMMIS) as either actively enrolled Medicaid providers or as Managed Care Plan registered providers.

Normal Business Hours — The hours between eight AM (8am) and five PM (5pm) local time, Monday through Friday inclusive. State holidays are excluded.

Nursing Facility — An institutional care facility that furnishes medical or allied inpatient care and services to individuals needing such services. (See Chapters 395 and 400, F.S.)

Open Enrollment — The sixty-(60) day period before the end of certain enrollees’ enrollment year, during which the enrollee may choose to change Managed Care Plans for the following enrollment year.

Other Provider-Preventable Condition (OPPC) — A condition occurring in any health care setting that:

• Is identified in the Florida Medicaid State Plan,

• Is reasonably preventable through the application of procedures supported by evidence-based guidelines,

• Has a negative consequence for the beneficiary,

• Is auditable, and

• Includes, at a minimum, the following:

◦ Wrong surgical or other invasive procedure performed on a patient,

◦ Surgical or other invasive procedure performed on the wrong body part, and

◦ Surgical or other invasive procedure performed on the wrong patient.

Outpatient — A patient of an organized medical facility, or distinct part of that facility, who is expected by the facility to receive, and who does receive, professional services for less than a twenty-four (24) hour period, regardless of the hours of admission, whether or not a bed is used and/or whether or not the patient remains in the facility past midnight.

Overpayment — Overpayment defined in accordance with s. 409.913, F.S., includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of

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inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

Participant Direction Option (PDO) — A service delivery enrollee option that enables long-term care enrollees to exercise decision-making authority and control over allowable services and how those services are delivered, including the ability to hire and fire service providers. An enrollee choosing participant direction accepts responsibility for taking a direct role in managing his/her care.

Participant Direction Option Services (PDO Services) — The services an enrollee may choose for the participant direction option. They include: adult companion care, attendant care, homemaker services, intermittent and skilled nursing, and personal care services.

Participating Provider — A health care practitioner or entity authorized to do business in Florida and contracted with the Managed Care Plan to provide services to the Managed Care Plan’s enrollees.

Participating Specialist — A physician, licensed to practice medicine in the State of Florida, who contracts with the Managed Care Plan to provide specialized medical services to the Managed Care Plan’s enrollees.

Patient Responsibility — The cost of Medicaid long-term care services not paid for by the Medicaid program, for which the enrollee is responsible. Patient responsibility is the amount enrollees must contribute toward the cost of their care. This is determined by the Department of Children and Families’ Economic Self Sufficiency only and is based on income and type of placement.

Peer Review — An evaluation of the professional practices of a provider by the provider’s peers. The evaluator assesses the necessity, appropriateness and quality of care furnished by comparing the care to that customarily furnished by the provider’s peers and to recognized health care standards.

Penultimate Saturday — The Saturday preceding the last Saturday of the month.

Person (entity) — Any natural person, corporation, partnership, association, clinic, group, or other entity, whether or not such person is enrolled in the Medicaid program or is a provider of health care. (See Florida Medicaid Provider General Handbook.)

Person-Centered Approach — A nondirective approach to care planning that encourages the maximum participation of an enrollee and the enrollee’s family in the decision making process.

Pharmacy Benefits Administrator — An entity contracted to or included in a Managed Care Plan that accepts pharmacy prescription claims for enrollees in the Managed Care Plan; assures these claims conform to coverage policy; and determines the allowed payment.

Physician Assistant (PA) — A person who is a graduate of an approved program or its equivalent or meets standards approved by the Board of Medicine or the Board of Osteopathic Medicine, and is certified to perform medical services delegated by the supervising physician in accordance with Chapter 458, F.S.

Physicians' Current Procedural Terminology (CPT®) — A systematic listing and coding of procedures and services published annually by the American Medical Association.

Plan Factor (MMA Only) — A budget-neutral calculation using a Managed Care Plan’s available historical enrollee diagnosis data grouped by a health-based risk assessment model. A Managed Care Plan’s plan factor is developed from the aggregated individual risk scores of

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the Managed Care Plan’s prior month’s enrollment. The plan factor modifies a Managed Care Plan’s monthly capitation payment to reflect the health status of its enrollees.

Plan of Care — A plan which describes the service needs of each enrollee, showing the projected duration, desired frequency, type of provider furnishing each service, and scope of the services to be provided.

Portable X-Ray Equipment — X-ray equipment transported to a setting other than a hospital, clinic or office of a physician or other licensed practitioner of the healing arts.

Post-Stabilization Care Services — Covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain, improve or resolve the enrollee’s condition pursuant to 42 CFR 422.113.

Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid recipient who is subject to mandatory assignment or who may voluntarily elect to enroll in a given Managed Care Plan, but is not yet an enrollee of a specific Managed Care Plan.

Preadmission Screening and Resident Review (PASRR) — Pursuant to 42 CFR Part 483, the process of screening and determining if nursing facility services and specialized mental health services or mental retardation services are needed by nursing facility applicants and residents. A DCF Office of Mental Health contractor completes the Level II reviews for those residents identified as having a mental illness. Agency for Persons with Disabilities staff complete reviews for those residents identified with a diagnosis of mental retardation.

Pre-Enrollment — The provision of marketing materials to a Medicaid recipient.

Preferred Drug List — A listing of prescription products selected by a pharmaceutical and therapeutics committee as cost-effective choices for clinician consideration when prescribing for Medicaid recipients.

Prescribed Pediatric Extended Care (PPEC) — A nonresidential health care center for children who are medically complex or technologically dependent and require continuous therapeutic intervention or skilled nursing services.

Primary Care — Comprehensive, coordinated and readily accessible medical care including: health promotion and maintenance; treatment of illness and injury; early detection of disease; and referral to specialists when appropriate.

Primary Care Case Management — The provision or arrangement of enrollees’ primary care and the referral of enrollees for other necessary medical services on a twenty-four (24) hour basis.

Primary Care Provider (PCP) — A Managed Care Plan staff or participating provider practicing as a general or family practitioner, internist, pediatrician, obstetrician, gynecologist, advanced registered nurse practitioner, physician assistant or other specialty approved by the Agency, who furnishes primary care and patient management services to an enrollee.

Primary Dental Provider (PDP) — A Managed Care Plan staff or subcontracted dentist practicing as a general dentist or pediatric dentist who furnishes primary dental care and patient management services to an enrollee.

Prior Authorization— The act of authorizing specific services before they are rendered.

Program of All-Inclusive Care for the Elderly (PACE) — A program that is operated by an approved PACE organization and that provides comprehensive services to PACE enrollees in

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accordance with a PACE program agreement. PACE provides a capitated benefit for individuals age 55 and older who meet nursing home level of care as determined by CARES. It features a comprehensive service delivery system and integrated Medicare and Medicaid financing. (See ss. 1894 and 1934 of the Social Security Act and 42 CFR Part 460.)

Protected Health Information (PHI) — For purposes of this Attachment, protected health information shall have the same meaning and effect as defined in 45 CFR 160 and 164, limited to the information created, received, maintained or transmitted by the Managed Care Plan from, or on behalf of, the Agency.

Protocols — Written guidelines or documentation outlining steps to be followed for handling a particular situation, resolving a problem or implementing a plan of medical, nursing, psychosocial, developmental and educational services.

Provider — A person or entity eligible for a Medicaid provider agreement.

Provider-Preventable Condition (PPC) — A condition that meets the definition of a health care-acquired condition or other provider-preventable condition as defined in 42 CFR 447.26(b). PPCs include health care-acquired conditions (HCACs) and other provider-preventable conditions (OPPCs) in inpatient hospital and inpatient psychiatric hospital settings, including crisis stabilization units (CSUs).

Provider Contract — An agreement between the Managed Care Plan and a health care provider to serve Managed Care Plan enrollees.

Provider Service Network (MMA Only) — A network established or organized and operated by a health care provider, or group of affiliated health care providers, that provides a substantial proportion of the health care items and services under a contract directly through the provider or affiliated group of providers. The PSN may make arrangements with physicians or other health care professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians, by other health professionals, or through the institutions. The health care providers must have a controlling interest in the governing body of the provider service network organization. PSNs are paid by the Agency on a capitated/prepaid basis. Also refer to the definition for LTC PSN. (See s. 409.912(4)(d), F.S.)

Public Event — An event that is organized or sponsored by an organization for the benefit and education of or assistance to a community in regard to health-related matters or public awareness. A Managed Care Plan may sponsor a public event if the event includes active participation of at least one (1) community organization or two (2) health-related organizations not affiliated with the Managed Care Plan.

Quality — The degree to which a Managed Care Plan increases the likelihood of desired health outcomes of its enrollees through its structural and operational characteristics and through the provision of health services that are consistent with current professional knowledge.

Quality Enhancements — Certain health-related, community-based services that the Managed Care Plan must offer and coordinate access to its enrollees. Managed Care Plans are not reimbursed by the Agency/Medicaid for these types of services.

Quality Improvement (QI) — The process of monitoring that the delivery of health care services is available, accessible, timely, and medically necessary. The Managed Care Plan must have a quality improvement program (QI program) that includes standards of excellence. It also must

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have a written quality improvement plan (QI plan) that draws on its quality monitoring to improve health care outcomes for enrollees.

Region — The designated geographical area within which the Managed Care Plan is authorized by the Contract to furnish covered services to enrollees. The Managed Care Plan must serve all counties in the Region(s) for which it is contracted. The 67 Florida counties are divided into 11 regions pursuant to s. 409.966(2), F.S. May also be referred to as “service area.”

Registered Nurse (RN) — An individual who is licensed to practice professional nursing in accordance with Chapter 464, F.S.

Registered Provider — A provider that is registered with FMMIS via the Managed Care Plan. Such providers cannot bill Medicaid through fee-for-service claims submissions. Registered providers are assigned a Medicaid provider identification number for encounter data purposes only.

Remediation — The act or process of correcting a fault or deficiency.

Residential Commitment Facilities — As applied to the Department of Juvenile Justice, refers to the out-of-home placement of adjudicated youth who are assessed and deemed by the court to be a low or moderate risk to their own safety and to the safety of the public; for use in a level 4, 6, 8, or 10 facility as a result of a delinquency disposition order. Also referred to as a residential commitment program.

Residential Facility — Those facilities where individuals live and that are licensed under Chapter 400 or 429, F.S., including nursing facilities, assisted living facilities and adult family care homes.

Risk Adjustment (also Risk-Adjusted) — In a managed health care setting, risk adjustment of capitation payments is the process used to distribute capitation payments across Managed Care Plans based on the expected health risk of the members enrolled in each Managed Care Plan.

Risk Assessment — The process of collecting information from a person about hereditary, lifestyle and environmental factors to determine specific diseases or conditions for which the person is at risk.

Rural — An area with a population density of less than one hundred (100) individuals per square mile, or an area defined by the most recent United States Census as rural, i.e., lacking a metropolitan statistical area (MSA).

Rural Health Clinic (RHC) — A clinic that is located in an area that has a health care provider shortage. An RHC provides primary health care and related diagnostic services and may provide optometric, podiatry, chiropractic and behavioral health services. An RHC employs, contracts or obtains volunteer services from licensed health care practitioners to provide services.

Sanctions — In relation to Section VIII.F: Any monetary or non-monetary penalty imposed upon a provider, entity, or person (e.g., a provider entity, or person being suspended from the Medicaid program). A monetary sanction under Rule 59G-9.070, F.A.C. may be referred to as a “fine.” A sanction may also be referred to as a disincentive.

Screen or Screening — A brief process, using standardized health screening instruments, used to make judgments about an enrollee’s health risks in order to determine if a referral for further assessment and evaluation is necessary.

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Serious Injury - Any significant impairment of the physical condition of the resident as determined by qualified medical personnel. This includes, but is not limited to, burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else as defined in 42 CFR. 483 352.

Service Authorization — The Managed Care Plan’s approval for services to be rendered. The process of authorization must at least include an enrollee’s or a provider’s request for the provision of a service.

Service Delivery Systems — Mechanisms that enable provision of certain health care benefits and related services for Medicaid recipients as provided in s. 409.973, F.S., which include but are not limited to the Medicaid fee-for-service program and the Medicaid Managed Medical Assistance Program.

Service Location — Any location at which an enrollee obtains any health care service provided by the Managed Care Plan under the terms of the Contract.

Sick Care — Non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated (e.g., chronic disease).

Social Networking — Web-based applications and services (excluding the Managed Care Plan’s state-mandated website content, member portal, and provider portal) that provide a variety of ways for users to interact, such as email, comment posting, image sharing, invitation and instant messaging services.

Span of Control — Information systems and telecommunications capabilities that the Managed Care Plan itself operates or for which it is otherwise legally responsible according to the terms and conditions of this Contract. The span of control also includes systems and telecommunications capabilities outsourced by the Managed Care Plan.

Special Supplemental Nutrition Program for Women, Infants & Children (WIC) — Program administered by the Department of Health that provides nutritional counseling; nutritional education; breast-feeding promotion and nutritious foods to pregnant, postpartum and breast-feeding women, infants and children up to the age of five (5) who are determined to be at nutritional risk and who have a low to moderate income. An individual who is eligible for Medicaid is automatically income eligible for WIC benefits. Additionally, WIC income eligibility is automatically provided to an enrollee’s family that includes a pregnant woman or infant certified eligible to receive Medicaid.

Specialty Plan — An MMA plan that serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis.

Spoke Site — The provider office location in Florida where an approved service is being furnished through telemedicine.

Spoken Script – Standardized text used by Managed Care Plan staff in verbal interactions with enrollees and/or potential enrollees designed to provide information and/or to respond to questions and requests. Spoken scripts also include interactive voice recognition (IVR) and on-hold messages. Marketing scripts are intended to influence such individual to enroll in the particular Managed Care Plan.

State — State of Florida.

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Statewide Inpatient Psychiatric Program (SIPP) — A twenty-four (24) hour inpatient residential treatment program funded by Medicaid that provides mental health services to children under twenty-one (21) years of age.

Statewide Medicaid Managed Care Program — A program authorized by the 2011 Florida Legislature through House Bill 7107, creating Part IV of Chapter 409, F.S., to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services, including long-term care services. This program is referred to as statewide Medicaid managed care (SMMC) and includes two programs: one for managed medical assistance (MMA) and one for long-term care (LTC).

Subcontract — An agreement entered into by the Managed Care Plan for the delegation of some of its functions, services or responsibilities for providing services under this Contract.

Subcontractor — Any person or entity with which the Managed Care Plan has contracted or delegated some of its functions, services or responsibilities for providing services under this Contract.

Substitute Service (MMA only) — In relation to behavioral health, a service covered by the Managed Care Plan as a downward substitution for a covered behavioral health service for which the Managed Care Plan receives no direct payment from the Agency.

Surface Mail — Mail delivery via land, sea, or air, rather than via electronic transmission.

Surplus — Net worth (i.e., total assets minus total liabilities).

System Unavailability — As measured within the Managed Care Plan’s information systems’ span of control, when a system user does not get the complete, correct full-screen response to an input command within three (3) minutes after depressing the “enter” or other function key.

Systems — See Information Systems.

Telebehavioral Health — The use of telemedicine to provide behavioral health individual and family therapy.

Telecommunication Equipment — Electronic equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time, interactive communication between the enrollee and the provider for the provision of covered services through telemedicine.

Telemedicine —The practice of health care delivery using telecommunication equipment by the treating provider (at the spoke site) for the provision of approved covered services by the consulting provider (at the hub site) for the purpose of evaluation, diagnosis, or treatment.

Telepsychiatry — The use of telemedicine to provide behavioral health medication management.

Temporary Assistance to Needy Families (TANF) — Public financial assistance provided to low-income families through DCF.

Temporary Loss Period – Period in which an enrollee loses eligibility and regains it, allowing the recipient to be re-enrolled in the Managed Care Plan in which the recipient was enrolled prior to the eligibility loss.

Transportation — An appropriate means of conveyance furnished to an enrollee to obtain Medicaid authorized/covered services.

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Unborn Activation — The process by which an unborn child, who has been assigned a Medicaid ID number, is made Medicaid eligible upon birth.

Urban — An area with a population density of greater than one-hundred (100) individuals per square mile or an area defined by the most recent United States Census as urban, i.e., as having a metropolitan statistical area (MSA).

Urgent Behavioral Health Care — Those situations that require immediate attention and assessment within twenty-three (23) hours even though the enrollee is not in immediate danger to self or others and is able to cooperate in treatment.

Urgent Care — Services for conditions, which, though not life-threatening, could result in serious injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe pain) or substantially restrict an enrollee’s activity (e.g., infectious illnesses, influenza, respiratory ailments).

Validation — The review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias and in accord with standards for data collection and analysis.

Vendor — An entity submitting a proposal to become a Managed Care Plan.

Violation — A determination by the Agency that a Managed Care Plan failed to act as specified in this Contract or applicable statutes, rules or regulations governing Managed Care Plans. For the purposes of this Contract, each day that an ongoing violation continues shall be considered to be a separate violation. In addition, each instance of failing to furnish necessary and/or required medical services or items to each enrollee shall be considered to be a separate violation. As well, each day that the Managed Care Plan fails to furnish necessary and/or required medical services or items to enrollees shall be considered to be a separate violation.

Voluntary Enrollee — A Medicaid recipient who is not mandated to enroll in a Managed Care Plan, but chooses to do so.

Voluntary Potential Enrollee — A Medicaid recipient who is not mandated to enroll in a Managed Care Plan, has expressed a desire to do so, but is not yet enrolled in a Managed Care Plan.

Well Care Visit — A routine medical visit for one of the following: CHCUP visit, family planning, routine follow-up to a previously treated condition or illness, adult physical or any other routine visit for other than the treatment of an illness.

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B. Acronyms

AAA — Area Agencies on Aging

ACCESS — Automated Community Connection to Economic Self-Sufficiency, the Department of Children and Families’ public assistance service delivery system

ADL — Activities of Daily Living

ADRC – Aging and Disabilities Resource Center

AFCH — Adult Family Care Home

AHCA— Agency for Health Care Administration (Agency)

ALF — Assisted Living Facility

APD — Agency for Persons with Disabilities

ARNP — Advanced Registered Nurse Practitioner

BAP — Beneficiary Assistance Program

BMHC — Bureau of Managed Health Care

CAHPS — Consumer Assessment of Healthcare Providers and Systems

CAP — Corrective Action Plan

CARES — Comprehensive Assessment and Review for Long-Term Care Services

CBP – Customized Benefit Package

CCE — Community Care for the Elderly

CCP — Cultural Competency Program

CDC — Centers for Disease Control and Prevention

CFARS — Children’s Functional Assessment Rating Scales

CEO — Chief Executive Officer

CFO — Chief Financial Officer

CFR — Code of Federal Regulations (cites may be searched online at: http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR)

CHCUP — Child Health Check-Up Program

CHD — County Health Department

CMS — Centers for Medicare & Medicaid Services

COPD— Chronic Obstructive Pulmonary Disease

CPR — Cardiopulmonary Resuscitation

CPT® — Physicians’ Current Procedural Terminology

CSU — Crisis Stabilization Unit

CTD — Commission for the Transportation Disadvantaged

DCF — Department of Children and Families

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DD — Developmental Disability or Developmental Disabilities

DEA — Drug Enforcement Administration

DFS — Department of Financial Services

DHHS — United States Department of Health & Human Services

DJJ — Department of Juvenile Justice

DME — Durable Medical Equipment

DOEA — Department of Elder Affairs

DOH — Department of Health

DSM — Direct Secure Messaging

EDI — Electronic Data Interchange

EH — Emotionally Handicapped

EIS – Early Intervention Services

EOMB —Explanation of Medicaid Benefits

EPLS – Excluded Parties List System

EPO — Exclusive Provider Organization

EPSDT — Early and Periodic Screening, Diagnosis and Treatment Program

EQR — External Quality Review

EQRO — External Quality Review Organization

ET — Eastern Time

F.A.C. — Florida Administrative Code

FARS — Functional Assessment Rating Scales

FAR— Florida Administrative Register

FFS — Fee-for-Service

FMSQN — Florida Medical School Quality Network

FMV — Fair Market Value

FQHC — Federally Qualified Health Center

F.S. — Florida Statutes

FSFN — Florida Safe Families Network (formerly HomeSafeNet), also known as SACWIS, (Statewide Automated Child Welfare Information System)

FTE— Full-Time Equivalent Position

HCBS — Home and Community-Based Services

HEDIS — Healthcare Effectiveness Data and Information Set

HIPAA — Health Insurance Portability and Accountability Act

HIPP – Health Insurance Premium Payment

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HITECH Act — Health Information Technology for Economic and Clinical Health Act

HMO— Health Maintenance Organization

HSA — Hernandez Settlement Agreement

HSD — Bureau of Medicaid Health Systems Development

IADL — Instrumental Activities of Daily Living

ICP—Institutional Care Program

IBNR — Incurred But Not Reported

ITN — Invitation to Negotiate

LEIE— List of Excluded Individuals & Entities

LTC — Long-Term Care

LOC — Level of Care

MBHO — Managed Behavioral Health Organization

MCP— Managed Care Plan

MEDS— Medicaid Encounter Data System

MFCU — Medicaid Fraud Control Unit, Office of the Attorney General

MMA— Managed Medical Assistance

MPI — Medicaid Program Integrity Bureau, Office of the AHCA Inspector General

MPO — Medicaid Program Oversight

NCPDP — National Council for Prescribed Drug Programs

NCQA — National Committee for Quality Assurance

NMHPA — Newborns and Mothers Health Protection Act

NPI— National Provider Identifier

ODBC — Open Database Connectivity

OIG — Office of the Inspector General

OIR—Office of Insurance Regulation

PA — Physician Assistant

PACE — Program of All-Inclusive Care for the Elderly

PASRR — Preadmission Screening and Resident Review

PCCB — Per Capita Capitation Benchmark

PCSB — Per Capita Services Benchmark

PCP — Primary Care Provider

PERS — Personal Emergency Response Systems

PDL— Preferred Drug List

PDO — Participant Direction Option

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PHI — Protected Health Information, as defined in 45 CFR 160 and 164, and 42 CFR 431.305(b)

PIP — Performance Improvement Project

PM — Performance Measure

PMAP — Performance Measures Action Plan

PPEC — Prescribed Pediatric Extended Care

PSN— Provider Service Network

QE — Quality Enhancement

QI— Quality Improvement

RFP — Request for Proposal

RHC — Rural Health Clinic

SACWIS — Statewide Automated Child Welfare Information System, also known as Florida Safe Families Network (FSFN, formerly HomeSafeNet)

SAM — System for Award Management

SAMH— Substance Abuse & Mental Health Office of the Florida Department of Children and Families

SFTP — Secure File Transfer Protocol

SIPP— Statewide Inpatient Psychiatric Program

SMMC — Statewide Medicaid Managed Care Program

SNIP — Strategic National Implementation Process

SOBRA — Sixth Omnibus Budget Reconciliation Act

SQL — Structured Query Language

SSI — Supplemental Security Income

TANF — Temporary Assistance for Needy Families

TGCS — Therapeutic Group Care Services

UM— Utilization Management

USDA — United States Department of Agriculture

WEDI — Workgroup for Electronic Data Interchange

WIC — Special Supplemental Nutrition Program for Women, Infants & Children

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AHCA Contract No. FP020, Attachment II, Page 31 of 214

Section II. General Overview

A. Background

Florida has offered Medicaid services since 1970. Medicaid provides health care coverage for eligible children, seniors, disabled adults and pregnant women. It is funded by both the state and federal governments. The 2011 Florida Legislature passed House Bill 7107 (creating part IV of Chapter 409, F.S.) to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services, including long-term care services. This program is referred to as statewide Medicaid managed care (SMMC) and includes two programs: one for medical assistance (MMA) and one for long-term care (LTC).

B. Purpose

Under the SMMC program, the Agency contracts with Managed Care Plans, as defined in Section I, Definitions and Acronyms, to provide services to recipients.

The provisions in this Contract apply to all Managed Care Plans unless specifically noted otherwise. Provisions unique to a specific type of Managed Care Plan are described in this Contract and its Exhibits specific to either the LTC managed care program or the MMA managed care program, respectively.

C. Responsibilities of the State of Florida

1. The Agency for Health Care Administration (Agency) is responsible for administering the Medicaid program. The Agency will administer contracts, monitor Managed Care Plan performance, and provide oversight in all aspects of Managed Care Plan operations. The Agency shall be responsible for imposing liquidated damages as a result of failure to meet any aspect of the responsibilities of the Contract, sanctions for Contract violations or other non-compliance, requiring corrective actions for a violation of or any other non-compliance with this Contract

2. The state has sole authority for determining eligibility for Medicaid. The Department of Children and Families acts as the Agency’s agent by enrolling recipient in Medicaid. The Agency shall have the sole authority for determining whether Medicaid recipients are required to enroll in, may volunteer to enroll in, may not enroll in a Managed Care Plan or are subject to annual open enrollment. The Agency or its agent(s) shall be responsible for enrollment, including algorithms to assign mandatory potential enrollees, and disenrollment, including determinations regarding involuntary disenrollment, in accordance with this Contract.

3. The Department of Elder Affairs shall assist the Agency in determining clinical eligibility for enrollment in LTC managed care plans, monitor LTC managed care plan performance and measure quality of service delivery, assist enrollees and their families to address complaints with the LTC managed care plans, facilitate working relationships between LTC managed care plans and providers serving elders and adults with disabilities, and perform other functions specified in a memorandum of agreement between the Agency and DOEA.

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4. The state shall be responsible for accepting complaints directly from Medicaid recipients and providers, operating the Beneficiary Assistance Panel, conducting Medicaid Fair Hearings, as well as reviewing complaints, grievances and appeals reported by Managed Care Plans to ensure appropriate resolution and monitor for contractual compliance, plan performance and trends that may reflect policy changes or operational changes needed.

5. The Agency shall be responsible for promulgating coverage requirements applicable to Managed Care Plan through the Florida Medicaid Coverage and Limitations Handbooks, Provider General Handbook, Medicaid fee schedules and the Florida Medicaid State Plan, as well as policy transmittals specific to changes in federal and state law, rules or regulations and federal Centers for Medicare and Medicaid Services waivers applicable to this Contract.

6. The Agency shall be responsible for providing Managed Care Plans with instructions for customize benefit packages for non-pregnant adults, vary cost-sharing provisions, and provide coverage for additional services, as well as evaluating the Managed Care Plan’s customized benefits packages for actuarial equivalency and sufficiency of benefits.

7. The Agency shall be responsible for establishing standards and requirements for provider networks, reviewing Managed Care Plan’s provider networks and monitoring such Managed Care Plans to ensure provider networks are capable of meeting the needs of their enrollees and are sufficient to meet the enrollment levels in this Contract,

8. The Agency shall be responsible for establishing standards and requirements for quality improvement (QI), including performance measures, targets, improvement plans, satisfaction surveys and medical/case record reviews, and providing instructions to Managed Care Plans through the Managed Care Plan Report Guide and Performance Measures Specifications Manual.

9. The Agency shall be responsible for contracting with an external quality review organization (EQRO) and conducting other QI activities, to include but not limited to audits of. medical/case records, enrollee plans of care, provider credentialing records, service provider reimbursement records, contractor personnel records, and other documents and files as required under this Contract. The Agency shall be responsible for establishing incentives to high-performing Managed Care Plans and restricting enrollment activities if the Managed Care Plans do not meet acceptable quality improvement and performance indicators.

10. The Agency shall be responsible for the operations of the Florida Medicaid Management Information System (FMMIS) and contracting with the state’s fiscal agent to exchange data with Managed Care plans, enroll Medicaid providers, process Medicaid claims, distribute Medicaid forms and publications, and send written notification and information to all potential enrollees. The Agency is responsible also for the administration of programs for Florida’s Medicaid Electronic Health Record Incentive Program, the Florida Health Information Network and other efforts to provide information and resources relating to Health Information Technology (HIT) and Health Information Exchange (HIE), as well as collecting data and statistics for the purpose of developing public policy and promoting the transparency of consumer health care information through www.FloridaHealthFinder.gov.

11. The Agency shall be responsible for establishing standards and requirements to ensure receipt of complete and accurate data for program administration as required to determine compliance with Title XIX of the Social Security Act, the Balanced Budget Act of 1997, 42

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CFR 438, and Chapters 409 and 641, Florida Statutes, and to determine Managed Care Plan compliance with contractual requirements and to measure health outcomes of Medicaid recipients. The Agency shall be responsible for establishing systems, processes, standards and requirements, including but not limited to encounter data collection and submission, and providing instructions to Managed Care Plans through the Medicaid Companion Guides, Pharmacy Payer Specifications.

12. The Agency shall be is responsible for coordinating Medicaid overpayment and abuse prevention, detection and recovery efforts. The Attorney General’s office is responsible for investigating and prosecuting Medicaid fraud. The Agency shall operate the Medicaid program integrity program, which includes but is not limited to such monitoring may be done as desk reviews or on site as determined by the Agency. These reviews may be conducted by various Agency bureaus and the Agency will provide appropriate notice for requesting documents as needed and for conducting on-site reviews, as well as providing Managed Care Plans with the result of such reviews. The Agency, Bureau of Medicaid Program Integrity (MPI), audits and investigates providers suspected of overbilling or defrauding the Florida Medicaid Program, recovers overpayments, issues administrative sanctions and refers cases of suspected fraud for criminal investigation to the Medicaid Fraud Control Unit (MFCU). The Agency shall conduct, or cause to be conducted by contract or otherwise, reviews, investigations, analyses, audits, or any combination thereof, to determine possible fraud, abuse, overpayment, or recipient neglect in the Medicaid program and shall report the findings of any overpayments in audit reports as appropriate.

13. The Agency shall be responsible for administration of the Medicaid prescribed drug program, including negotiating supplemental rebates and favorable net pricing, and maintaining the Medicaid Pharmaceutical and Therapeutics (P&T) Committee reviews drug options within to maintain an array of choices for prescribers within each therapeutic class on the Medicaid Preferred Drug List (PDL). In order to promote an effective transition of recipients during implementation of the SMMC, the Agency will require Managed Care Plans use the Medicaid PDL for at least the first year of operation.

14. The Agency shall be responsible for making payment to the Managed Care Plan as specified in Section IX, Method of Payment, adjusting applicable capitation rates to reflect budgetary changes in the Medicaid program, and reconciling payments for SIPPs, nursing facilities and hospices pursuant to ss. 409.9876(2), F.S., 409.983(6) and 409.983(7), F.S.

15. In accordance with s. 409.967(3), F.S., the Agency shall be responsible for verifying the Managed Care Plan’s achieved savings rebate as specified in this Contract. The Agency will contract with independent certified public accountants to conduct compliance audits for the purpose of auditing Managed Care Plan financial information in order to determine and validate the Managed Care Plan’s achieved savings rebate.

D. General Responsibilities of the Managed Care Plan

1. The Managed Care Plan shall comply with all provisions of this Contract, including all attachments, applicable exhibits, and any amendments and shall act in good faith in the performance of the Contract provisions. The Managed Care Plan agrees that failure to comply with all provisions of this Contract may result in the assessment of sanctions and/or termination of the Contract, in whole or in part, in accordance with Section XI, Sanctions. The Managed Care Plan agrees that failure to meet any aspect of the responsibilities of the

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Contract may result in the assessment of damages in accordance with Section XIII, Liquidated Damages.

2. The Managed Care Plan shall comply with all requirements of the Managed Care Plan Report Guide referenced in Section XIV, Reporting Requirements, and other applicable requirements of this Contract. The Managed Care Plan may be required to provide to the Agency or its agents information or data relative to this Contract. In such instances, and at the direction of the Agency, the Managed Care Plan shall fully cooperate with such requests and furnish all data or information in a timely manner, in the format in which it is requested. The Managed Care Plan shall have at least thirty (30) days to fulfill such ad hoc requests, unless the Agency directs the Managed Care Plan to provide data or information in less than thirty (30) days. The Managed Care Plan shall verify that data and information it submits to the Agency is accurate.

3. The Managed Care Plan shall develop and maintain written policies and procedures to implement and comply with all the provisions of this Contract.

4. The Managed Care Plan shall submit all policies and procedures to the Agency as required by this Contract. Unless specified elsewhere in the Contract, policies and procedures required by this Contract shall be submitted to the Agency at least seventy-five (75) days before the proposed effective date of the policy and procedure or change. Other policies and procedures related to this Contract shall be submitted to the Agency, upon request. If the Agency has requested policies and procedures, the Managed Care Plan shall notify the Agency of any subsequent changes in such materials. Comprehensive LTC managed care plans shall submit one (1) set of policies and procedures that include all MMA and LTC contractually required provisions.

5. The Managed Care Plan shall submit model provider contract templates to the Agency for review as specified in Section VII, Provider Network.

6. The Managed Care Plan shall submit any proposed delegation of responsibility to the Agency for prior written approval as required in Section VIII.B., Subcontracts. Except as otherwise provided in this Contract, the Managed Care Plan shall submit subcontracts to the Agency for review as specified in Section VIII.B., Subcontracts. Unless specified elsewhere in the Contract, subcontracts shall be submitted to the Agency at least forty-five (45) days before the proposed effective date of the subcontract or change.

7. The Managed Care Plan shall submit enrollee, community outreach and marketing materials related to this Contract to the Agency for review and approval before implementation. Any changes in such materials must be prior approved by the Agency before they take effect.

a. The Managed Care Plan shall submit written materials for Agency review as follows unless specified elsewhere in the Contract:

(1) Enrollee material shall be submitted to the Agency at least seventy-five (75) days before the proposed use of the enrollee material or revised material.

(2) Marketing and community outreach material shall be submitted to the Agency at least forty-five (45) days before the proposed use of the marketing material or revised material.

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(3) Other written materials shall be submitted to the Agency upon request.

b. The Managed Care Plan shall conduct a quality check and ensure that all materials are consistent with this Contract and state and federal requirements prior to submitting materials for review to the Agency. Generally, the Agency will not review materials for typographical or grammatical errors, unless such errors render the marketing materials inaccurate or misleading.

c. To expedite the review of previously disapproved material, the Managed Care Plan shall clearly indicate all changes/updates made to a material when it is resubmitted. The Managed Care Plan may meet this requirement by highlighting any text changes and/or inserting notes to altered areas on the material. The Managed Care Plan may develop an alternative process for identifying changes, provided the Managed Care Plan discusses the alternative with and receives approval from the Agency.

d. The Managed Care Plan shall ensure that non-English enrollee and marketing materials are based on previously approved English versions of the same material. The Managed Care Plan shall ensure that any changes or revisions that are made to the English version are accurately reflected in non-English materials and re-submitted to the Agency as required.

e. The Managed Care Plan shall provide written notice of such any changes affecting enrollees to those enrollees at least thirty (30) days before the effective date of change.

8. The Managed Care Plan shall coordinate with the Agency and its agent(s) as necessary for all enrollment and disenrollment functions. The Managed Care Plan or its subcontractors, providers or vendors shall not provide or assist in the completion of enrollment or disenrollment requests or restrict the enrollee’s right to disenroll voluntarily in any way.

9. The Managed Care Plan shall accept Medicaid recipients without restriction and in the order in which they enroll. The Managed Care Plan shall not discriminate on the basis of religion, gender, race, color, age or national origin, health status, pre-existing condition or need for health care services and shall not use any policy or practice that has the effect of such discrimination.

10. The Managed Care Plan shall establish and maintain an enrollee services function with the capability to answer enrollee inquiries and ensure that enrollees are notified of their rights and responsibilities through written materials, telephone, electronic and face-to-face communication.

11. The Managed Care Plan shall establish and maintain a grievance system for reviewing and resolving enrollee complaints, grievances and appeals. Components must include a complaint process, a grievance process, an appeal process, access to an applicable review outside the Managed Care Plan (Beneficiary Assistance Program), and access to a Medicaid Fair Hearing through the Department of Children and Families.

12. The Managed Care Plan shall ensure the provision of services in sufficient amount, duration and scope to be reasonably expected to achieve the purpose for which the services are furnished and shall ensure the provision of the covered services defined and specified in this Contract.

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13. The Managed Care Plan shall comply with all current promulgated Florida Medicaid handbooks (Handbooks) as noticed in the Florida Administrative Register (FAR), and incorporated by reference in rules relating to the provision of services, except where the provisions of the Contract alter the requirements set forth in the Handbooks and Medicaid fee schedules.

14. MMA Managed Care Plans and Comprehensive Managed Care Plans shall provide all prescription drugs listed in the Agency’s Medicaid Preferred Drug List (PDL) in accordance with the following:

a. Prior authorization, step–edit therapy and protocols for PDL drugs may be no more restrictive than those posted on the Agency website.

b. Certain drugs that are required to be covered by Medicaid are not listed on the PDL, and the AHCA fee-for-service program requires prior authorization because of clinical concerns or the risk of fraud or misuse. Plans may use the same prior authorization criteria that are posted to the AHCA website, or may develop their own criteria that are no more restrictive.

c. No sooner than the end of the first year of operation, the Managed Care Plan may develop a Managed Care Plan-specific PDL for the Agency’s consideration, if requested by the Agency at that time. During the time that the Managed Care Plan is utilizing the Agency’s PDL, the Managed Care Plan shall participate in the Agency’s Pharmaceutical and Therapeutics Committee, as requested by the Agency.

15. The Managed Care Plan shall provide care coordination/case management services offer and coordinate access to quality enhancements (QEs), and provide approved expanded benefits as specified under this Contract.

16. Managed Care Plan shall develop and maintain a provider network that meets the needs of enrollees in accordance with the requirements of this Contract, including contracting with a sufficient number of credentialed providers to provide all covered services to enrollees and ensuring that each covered service is provided promptly and is reasonably accessible and that each enrollee is afforded choice of participating providers in accordance with 42 CFR 431.51.

17. The Managed Care Plan shall establish and maintain a formal provider relations function to respond timely and adequately to inquiries, questions and concerns from participating providers, including provider complaints and disputes proposed actions, billing, payment and service authorizations.

18. The Managed Care Plan shall have a quality improvement program that ensures enhancement of quality of care and emphasizes improving the quality of patient outcomes, including establishing metrics for monitoring the quality and performance of each participating provider. evaluating the provider’s performance and determining continued participation in the network.

19. The Managed Care Plan shall cooperate with the Agency and the EQRO and shall contract with the Florida Medical School Quality Network when the network becomes operational, in accordance with s. 409.975(2), F.S.

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20. The Managed Care Plan shall established and maintain a utilization management system to monitor utilization of services, including an automated service authorization systems for denials, service limitations and reductions of authorization. The Managed Care Plan shall not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the enrollee’s diagnosis, type of illness or condition.

21. The Managed Care Plan shall meet all requirements for doing business in the State of Florida, and shall be responsible for the administration and management of all aspects of this Contract, including, but not limited to, delivery of services, provider network, provider education, claims resolution and assistance, and all subcontracts, employees, agents and services performed by anyone acting for or on behalf of the Managed Care Plan. The Managed Care Plan shall comply with all pertinent Agency rules in effect throughout the duration of the Contract.

22. The Managed Care Plan shall have a centralized executive administration, and must ensure adequate staffing and information systems capability to ensure the Managed Care Plan can appropriately manage financial transactions, record keeping, data collection, and other administrative functions, including the ability to submit any financial, programmatic, encounter data or other information required by this Contract.

23. The Managed Care Plan shall have information management processes and information systems of sufficient capacity that enable it to meet Agency and federal reporting requirements, other Contract requirements, and all applicable Agency policies, state and federal laws, rules and regulations, including HIPAA. The Managed Care Plan shall be responsible for establishing connectivity to the Agency’s/state’s wide area data communications network, and the relevant information systems attached to this network, in accordance with all applicable Agency and/or state policies, standards and guidelines, as well as coordinating activities and developing cohesive systems strategies across vendors and agencies.

24. The Managed Care Plan shall encourage its providers to connect to the Florida Health Information Exchange (HIE) and promote provider use of the HIE, including educating providers on the benefits of using the HIE and the availability of incentive funding. The Managed Care Plan shall encourage network providers to participate in the Agency’s Direct Secure Messaging (DSM) service when it is implemented.

25. The Managed Care Plan shall collect and submit encounter data in accordance with generally accepted industry best practices and the requirements of this Contract. The Managed Care Plan shall ensure that its provision of provider information to the Agency is sufficient to ensure that its providers are recognized as participating providers of the Managed Care Plan for plan selection and encounter data acceptance purposes, and shall participate in Agency-sponsored workgroups directed at continuous improvements in encounter data quality and operations.

26. In the event the Agency establishes systems and processes to collect submitted claims data, including denied claims, from the providers directly, the Managed Care Plan must be capable of sending and receiving any claims information directly to the Agency in standards and timeframes specified by the Agency within 60 days’ notice. The Managed Care Plan shall also work cooperatively with the Agency during any transition period for network providers to move to submitting claims through the State instead of directly to the Managed Care Plan.

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27. The Managed Care Plan shall establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall have adequate staffing, resources, internal controls, and policies and procedures to prevent, reduce, detect, correct and report known or suspected fraud and abuse and overpayment. activities. The Managed Care Plan shall meet with the Agency periodically, at the Agency’s request, to discuss fraud, abuse, neglect and overpayment issues.

28. The Managed Care Plan shall meet all financial requirements established by this Contract and report financial information, including but not limited to quarterly and annual financial statements, in accordance with Section XIV, Reporting Requirements, the Managed Care Plan Report Guide and other Agency instructions. The Managed Care Plan shall verify that information it submits to the Agency is accurate.

29. Prior to enrolling recipients in the Managed Care Plan in each authorized Region, the Agency will conduct a plan-specific readiness review to assess the Managed Care Plan’s readiness and ability to provide services to recipients. The plan readiness review may include, but is not limited to, desk and onsite review of plan policies and procedures and corresponding documents, the plan’s provider network and corresponding Contracts, a walk-through of the plan’s operations, system demonstrations, and interviews with plan staff. The scope of the plan readiness review may include any and all Contract requirements, as determined by the Agency. The Agency will not enroll recipients into the Managed Care Plan until the Agency has determined that the Managed Care Plan meets all Contract requirements.

a. The Managed Care Plan shall provide the Agency, on a weekly basis and at any time upon request of the Agency, with sufficient evidence that the Managed Care Plan has the capacity to provide covered services to all enrollees up to the maximum enrollment level, including evidence that the Managed Care Plan:

(1) Maintains a Region-wide network of providers offering an appropriate range of services in sufficient numbers to meet the access standards established by the Agency, pursuant to Section 409.967(2)(c)(1), Florida Statutes; and

(2) Maintains a sufficient number, mix and geographic distribution of providers, including providers who are accepting new Medicaid patients as specified in s. 1932(b)(5) of the Social Security Act, as enacted by s. 4704(a) of the Balanced Budget Act of 1997.

b. If the Managed Care Plan does not meet the plan readiness review deadlines established by the Agency for its respective Region, the following options may be exercised by the Agency:

(1) The Agency may grant an extension for the Managed Care Plan to correct deficiencies; however the Managed Care Plan will lose the initial enrollment of eligible recipients into the affected region(s) and will lose its transition enrollment, if applicable; and /or

(2) The Agency will impose liquidated damages for failure to meet plan readiness review deadlines and/or specific plan readiness goals set by the Agency.

c. After an extension is granted by the Agency, the Managed Care Plan will have until the penultimate Saturday before the respective Region’s enrollment effective date, as

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established by the Agency, to be deemed ready for recipient enrollment. If a Managed Care Plan is not deemed ready for recipient enrollment by the Agency by the penultimate Saturday before the respective Region enrollment effective date, the Contract between the Managed Care Plan and the Agency will be terminated.

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Section III. Eligibility and Enrollment

A.    Eligibility

Except as otherwise provided below, all Medicaid recipients shall receive Medicaid covered services through the SMMC program. The following populations represent broad categories that may contain multiple eligibility groups. Certain exceptions may apply within the broad categories and will be determined by the Agency.

1.    Mandatory Populations

a. Recipients in any of the following programs or eligibility categories are required to enroll in a Managed Care Plan:

(1) Temporary Assistance to Needy Families (TANF);

(2) SSI (Aged, Blind and Disabled);

(3) Hospice;

(4) Low Income Families and Children;

(5) Institutional Care;

(6) Medicaid (MEDS) - Sixth Omnibus Budget Reconciliation Act (SOBRA) for children born after 9/30/83 (age 18 to 19);

(7) MEDS AD (SOBRA) for aged and disabled;

(8) Protected Medicaid (aged and disabled);

(9) Full Benefit Dual Eligibles (Medicare and Medicaid -FFS);

(10) Full Benefit Dual Eligibles - Part C – Medicare Advantage Plans Only; and

(11) The Florida Assertive Community Treatment Team (FACT Team).

b. Subject to approval by the Centers for Medicare and Medicaid Services, recipients eligible for the Medically Needy program are required to enroll in a Managed Care Plan for services to be provided in accordance with the MMA Exhibit. Additional mandatory recipient eligibility criteria for MMA and Comprehensive LTC managed care plans are specified in the MMA Exhibit.

c. Additional mandatory recipient eligibility criteria for LTC and Comprehensive LTC managed care plans are specified in the LTC Exhibit.

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2. Voluntary Populations

Certain recipients may voluntarily enroll in a Managed Care Plan to receive services. These recipients are not subject to mandatory open enrollment periods.

a. Voluntary recipients for MMA and Comprehensive LTC managed care plans are specified in the MMA Exhibit.

b. Voluntary recipients for LTC and Comprehensive LTC managed care plans are specified in the LTC Exhibit.

3.    Excluded Populations

a. Recipients in any eligibility category not listed in sub-items A.1. or A.2. above are excluded from enrollment in a managed care plan. This includes, but is not limited to, recipients in the following eligibility categories:

(1) Presumptively eligible pregnant women;

(2) Family planning waiver;

(3) Women enrolled through the Breast and Cervical Cancer Program;

(4) Emergency shelter/Department of Juvenile Justice (DJJ) residential;

(5) Emergency assistance for aliens;

(6) Qualified Individual (QI);

(7) Qualified Medicare beneficiary (QMB);

(8) Special low-income beneficiaries (SLMB); and

(9) Working disabled.

b. In addition, regardless of eligibility category, the following recipients are excluded from enrollment in a Managed Care Plan:

(1) Children receiving services in a prescribed pediatric extended care center (PPEC); and

(2) Recipients in the Health Insurance Premium Payment (HIPP) program.

c. Additional excluded populations for LTC and Comprehensive LTC managed care plans are specified in the LTC Exhibit.

4. Medicaid Pending for Home and Community-Based Services

a. Medicaid pending for HCBS is specified in the LTC Exhibit.

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B. Enrollment

1.    General Provisions

a. Only Medicaid recipients who meet eligibility requirements and are living in a region with authorized Managed Care Plans are eligible to enroll and receive services from the Managed Care Plan.

b. Each recipient shall have a choice of Managed Care Plans and may select any authorized Managed Care Plan unless the Managed Care Plan is restricted by this Contract to a specific population that does not include the recipient.

c. The Agency or its enrollment broker shall be responsible for enrollment, including enrollment into the Managed Care Plan, disenrollment and outreach and education activities. The Agency will use an established algorithm to assign mandatory potential enrollees who do not select a Managed Care Plan during their thirty- (30) day choice period. The process may differ for MMA Managed Care Plans, LTC Managed Care Plans and Comprehensive LTC Managed Care Plans as required by 409.977, F.S. and s. 409.984, F.S. and any other state law and federally approved State Plan amendments and/or waivers. The Managed Care Plan shall coordinate with the Agency and its enrollment broker as necessary for all enrollment and disenrollment functions.

d. The Agency or its agents will notify the Managed Care Plan of an enrollee’s selection or assignment to the Managed Care Plan. The Agency or its enrollment broker will send written confirmation to enrollees of the chosen or assigned Managed Care Plan. Notice to the enrollee will be sent by surface mail. Notice to the Managed Care Plan will be by file transfer.

For MMA Managed Care Plans, if the enrollee has not chosen a PCP, the Agency’s confirmation notice will advise the enrollee that a PCP will be assigned by the Managed Care Plan.

e. Enrollment in a Managed Care Plan, whether chosen or assigned, will be effective at 12:01 a.m. on the first calendar day of the month following a selection or assignment that occurs between the first calendar day of the month and the penultimate Saturday of the month. For those enrollees who choose or are assigned a Managed Care Plan between the Sunday after the penultimate Saturday and before the last calendar day of the month, enrollment in a Managed Care Plan will be effective on the first calendar day of the second month after choice or assignment.

f. Conditioned on continued eligibility, mandatory enrollees have a lock-in period of up to twelve (12) consecutive months. After an initial ninety- (90) day change period, mandatory enrollees may disenroll from the Managed Care Plan only for cause. The Agency or its enrollment broker will notify enrollees at least once every twelve (12) months, and for mandatory enrollees at least sixty (60) days before the lock-in period ends that an open enrollment period exists giving them an opportunity to change Managed Care Plans. Mandatory enrollees who do not make a change during open enrollment will be deemed to have chosen to remain with the current Managed Care Plan, unless that Managed Care Plan no longer participates. In that case, the enrollee will be transitioned to a new Managed Care Plan.

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g. The Agency will automatically reinstate an enrollee into the Managed Care Plan in which the person was most recently enrolled if the enrollee has a temporary loss of eligibility. In this instance, for mandatory enrollees, the lock-in period will continue as though there had been no break in eligibility, keeping the original twelve- (12) month period.

(1) For LTC managed care plans, the “temporary loss period” is defined as no more than sixty (60) days.

(2) For MMA managed care plans, the “temporary loss period” is defined as no more than one hundred eighty (180) days.

(3) For Comprehensive LTC managed care plans, the “temporary loss period” is defined as no more than sixty (60) days for recipients with LTC benefits and one hundred eighty (180) days for recipients without LTC benefits.

h. If a temporary loss of eligibility causes the enrollee to miss the open enrollment period, the Agency will enroll the person in the Managed Care Plan in which he or she was enrolled before loss of eligibility. The enrollee will have ninety (90) days to disenroll without cause.

2. Enrollment in an MMA Specialty Plan

a. In addition to meeting the eligibility requirements listed in this section, a Specialty Plan may enroll eligible recipients who meet specific criteria by age, medical condition and/or diagnoses as defined in the Section III.A of the applicable Specialty Plan Exhibit.

b. The Agency or its agent will be responsible for identifying the defined specialty population and enrollment of such recipients in a Specialty Plan in accordance with this section. Clinical assessment and/or referral may be required to determine eligibility for Specialty Plan enrollment, as defined in Section III.B of the applicable Specialty Plan Exhibit.

(1) If clinical assessment and/or referral are required to be conducted by the Specialty Plan to determine eligibility for Specialty Plan enrollment, as defined in this Contract, the Specialty Plan shall establish and maintain policies and procedures to accomplish such assessments and /or referrals.

(2) The Specialty Plan shall submit clinical assessments and/or referral policies and procedures for approval by the Agency on an annual basis, at a date determined by the Agency.

(3) The Agency reserves the right to make adjustments to administrative data or other mechanisms used to identify recipients eligible to enroll in a Specialty Plan.

c. In addition to benefits required in Section V, Covered Services and the MMA Exhibit, the Specialty Plan shall provide such other services and care coordination and/or case management services to eligible recipients enrolled in a Specialty Plan as defined in Section V.E of the applicable Specialty Plan Exhibit .

d. In addition to the provider network standards required in Section VI, Provider Network and the MMA Exhibit, the Specialty Plan shall comply with such other provider network standards as defined in Section VI.A of the applicable Specialty Plan Exhibit.

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e. In addition to the quality management activities required in Section VII, Quality and Utilization Management and the MMA Exhibit, the Specialty Plan shall comply with such other requirements for quality management as defined in Section VII of the applicable Specialty Plan Exhibit.

3.    Verification of Enrollment

a. The Managed Care Plan shall review its X12-834 enrollment files in accordance with the schedule specified in the file exchange calendar posted on the Florida Medicaid provider portal to ensure that all enrollees are eligible to receive services from the Managed Care Plan, including that:

(1) Each enrollee of the Managed Care Plan is residing in the same region in which they were enrolled; and

(2) Each enrollee of the Managed Care Plan is not ineligible for services under the MMA, Specialty, Comprehensive LTC or LTC Managed Care Plan, respectively, in accordance with this section and the applicable Exhibits.

b. The Managed Care Plan shall notify the Agency of any discrepancies in enrollment, including enrollees not residing in the same region in which they were enrolled and enrollees not eligible for the Managed Care Plan, within five (5) days of receipt of the enrollment file.

4. Notification of Enrollee Pregnancy

a. Upon notification that an enrollee is pregnant or has given birth to a newborn, the Managed Care Plan shall notify DCF in a manner prescribed by the Agency.

b. MMA and Comprehensive LTC Managed Care Plans shall notify DCF and follow the unborn activation and newborn enrollment processes in accordance with the MMA Exhibit.

5. Maximum Enrollment Levels

a. The Agency assigns the Managed Care Plan an authorized maximum enrollment level for the region(s), which cannot be exceeded by the Managed Care Plan. Any increases requested by the Managed Care Plan must be approved by the Agency.

b. The Agency does not guarantee that the Managed Care Plan will receive any particular enrollment level; however, the enrollment level may not be exceeded unless a plan-specific enrollment level increase has been approved by the Agency.

c. The Agency must approve in writing any increase or decrease in the Managed Care Plan’s maximum enrollment level for the region(s) to be served as specified in this Contract.

6. Temporarily Stopping or Limiting Enrollment

a. The Managed Care Plan may ask the Agency to halt or reduce enrollment temporarily for any enrollment amount above the Agency’s set regional enrollment limit if continued

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full enrollment would exceed the Managed Care Plan’s capacity to provide required services under the Contract. The Agency may not approve or may also limit Managed Care Plan enrollments when such action is considered to be in the Agency’s best interest in accordance with the provisions of this Contract.

b. For MMA Managed Care Plans, if a request to halt or reduce enrollment temporarily is received and approved by the Agency, it shall not affect the enrollment of newborns as specified in the MMA Exhibit.

7. Increasing Enrollment Levels

a. The Managed Care Plan may request a higher regional enrollment level, in writing, to the Agency; however, the Managed Care Plan must be able to serve the enrollment level.

b. If the Managed Care Plan requests an increase in the regional enrollment level, the Agency will review such request and approve it in writing if the Agency determines the Managed Care Plan’s regional provider network is sufficient to meet the increased enrollment level requested and the Managed Care Plan has satisfactorily performed the terms of the Contract, and the Agency has approved the Managed Care Plan’s administrative, financial and service resources, as specified in this Contract, in support of the requested enrollment level. If after an enrollment increase is approved by the Agency and a Managed Care Plan determines lower enrollment levels are desired, the Managed Care Plan may request an enrollment level decrease, as long as the decrease requested is not below the required enrollment levels for the region.

c. If the Agency has approved the Managed Care Plan’s regional enrollment level increase, the Managed Care Plan must then maintain a provider network, as specified in this Contract, sufficient to meet the increased recipient enrollment level, and this enrollment level shall become the Managed Care Plan’s maximum enrollment level upon execution of a Contract amendment stating such.

C.    Disenrollment

1.    General Provisions

a. The Agency will notify enrollees of their right to request disenrollment. The Agency will process all disenrollments from the Managed Care Plan. The Agency or its agent will make final determinations about granting disenrollment requests and will notify the Managed Care Plan by file transfer and the enrollee by surface mail of any disenrollment decision. Enrollees dissatisfied with an Agency determination may request a Medicaid Fair Hearing.

b. An enrollee may request disenrollment at any time. The Agency or its enrollment broker performs disenrollment as follows:

(1) For good cause, at any time.

(2) Without cause, for mandatory enrollees at the times specified in Section III. C.4.

(3) Without cause, for voluntary enrollees at any time.

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c. The Managed Care Plan shall ensure that it does not restrict the enrollee’s right to disenroll voluntarily in any way.

d. The Managed Care Plan or its subcontractors, providers or vendors shall not provide or assist in the completion of a disenrollment request or assist the Agency’s enrollment broker in the disenrollment process.

e. The Managed Care Plan shall ensure that enrollees who are disenrolled and wish to file an appeal have the opportunity to do so. All enrollees shall be afforded the right to file an appeal on disenrollment except for the following reasons:

(1) Moving out of the region;

(2) Loss of Medicaid eligibility;

(3) Determination that an enrollee is in an excluded population, as defined in this Contract; or

(4) Enrollee death.

2.    Disenrollment Due to Enrollee Change of Region

a. On the first day of the month after receiving notice from FMMIS that the enrollee has moved to another region, the Agency will automatically disenroll the enrollee from the Managed Care Plan and treat the recipient as if the recipient is a new Medicaid recipient eligible to choose another Managed Care Plan pursuant to the Agency’s enrollment process (see s. 409.969(2)d., F.S.) but without having to be placed on the long term care wait list if enrolled in a LTC Managed Care Plan.

3.    Disenrollment for Good Cause

a. A mandatory enrollee may request disenrollment from the Managed Care Plan for cause at any time. Such request shall be submitted to the Agency or its enrollment broker.

b. The following reasons constitute cause for disenrollment from the Managed Care Plan:

(1) The enrollee does not live in a region where the Managed Care Plan is authorized to provide services, as indicated in FMMIS.

(2) The provider is no longer with the Managed Care Plan.

(3) The enrollee is excluded from enrollment.

(4) A substantiated marketing or community outreach violation has occurred.

(5) The enrollee is prevented from participating in the development of his/her treatment plan/plan of care.

(6) The enrollee has an active relationship with a provider who is not on the Managed Care Plan’s panel, but is on the panel of another Managed Care Plan. “Active relationship” is defined as having received services from the provider within the six months preceding the disenrollment request.

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(7) The enrollee is in the wrong Managed Care Plan as determined by the Agency.

(8) The Managed Care Plan no longer participates in the region.

(9) The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR 438.702(a)(3).

(10) The enrollee needs related services to be performed concurrently, but not all related services are available within the Managed Care Plan network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk.

(11) The Managed Care Plan does not, because of moral or religious objections, cover the service the enrollee seeks.

(12) The enrollee missed open enrollment due to a temporary loss of eligibility.

(13) Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., including, but not limited to: poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee’s health care needs; or fraudulent enrollment.

c. Voluntary enrollees may disenroll from the Managed Care Plan at any time.

4.    Disenrollment without Cause

a. A mandatory enrollee subject to open enrollment may submit to the Agency or its enrollment broker a request to disenroll from the Managed Care Plan. This may be done without cause at the following times:

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(1) During the ninety (90) days following the enrollee’s initial enrollment, or the date the Agency or its enrollment broker sends the enrollee notice of the enrollment, whichever is later;

(2) At least every twelve (12) months during a recipient’s annual open enrollment period;

(3) If the temporary loss of Medicaid eligibility has caused the enrollee to miss the open enrollment period;

(4) When the Agency or its enrollment broker grants the enrollee the right to terminate enrollment without cause (done on a case-by-case basis); and

(5) During the thirty (30) days after the enrollee is referred for hospice services in order to enroll in another Managed Care Plan to access the enrollee’s choice of hospice provider.

b. Voluntary enrollees not subject to open enrollment may disenroll without cause at any time.

5.    Involuntary Disenrollment

a. With proper written documentation, the Managed Care Plan may submit involuntary disenrollment requests to the Agency or its enrollment broker in a manner prescribed by the Agency.

b. The following are acceptable reasons for which the Managed Care Plan may submit involuntary disenrollment request:

(1) Fraudulent use of the enrollee identification (ID) card. In such cases the Managed Care Plan shall notify MPI of the event.

(2) Falsification of prescriptions by an enrollee. In such cases the Managed Care Plan shall notify MPI of the event.

(3) The enrollee’s behavior is disruptive, unruly, abusive or uncooperative to the extent that enrollment in the Managed Care Plan seriously impairs the organization’s ability to furnish services to either the enrollee or other enrollees.

(a) This provision does not apply to enrollees with medical or mental health diagnoses if the enrollee’s behavior is attributable to the diagnoses.

(b) An involuntary disenrollment request related to enrollee behavior must include documentation that the Managed Care Plan:

(i) Provided the enrollee at least one (1) oral warning and at least one (1) written warning of the full implications of the enrollee’s actions;

(ii) Attempted to educate the enrollee regarding rights and responsibilities;

(iii) Offered assistance through care coordination/case management that would enable the enrollee to comply; and

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(iv) Determined that the enrollee’s behavior is not related to the enrollee’s medical or mental health condition.

(4) The enrollee will not relocate from an assisted living facility or adult family care home that does not, and will not, conform to HCB characteristics required by this Contract.

c. The Managed Care Plan shall not request disenrollment of an enrollee due to:

(1) Health diagnosis;

(2) Adverse changes in an enrollee’s health status;

(3) Utilization of medical services;

(4) Diminished mental capacity;

(5) Pre-existing medical condition;

(6) Uncooperative or disruptive behavior resulting from the enrollee’s special needs (with the exception of Section III.C.5.b.(3)(b));

(7) Attempt to exercise rights under the Managed Care Plan's grievance system; or

(8) Request of a provider to have an enrollee assigned to a different provider out of the Managed Care Plan.

d. The Managed Care Plan shall promptly submit such disenrollment requests to the Agency. In no event shall the Managed Care Plan submit a disenrollment request at such a date as would cause the disenrollment to be effective later than forty-five (45) days after the Managed Care Plan’s receipt of the reason for involuntary disenrollment. The Managed Care Plan shall ensure that involuntary disenrollment documents are maintained in an identifiable enrollee record.

e. When the Managed Care Plan requests an involuntary disenrollment, it shall notify the enrollee in writing that the Managed Care Plan is requesting disenrollment, the reason for the request, and an explanation that the Managed Care Plan is requesting that the enrollee be disenrolled in the next Contract month, or earlier if necessary. Until the enrollee is disenrolled, the Managed Care Plan shall be responsible for the provision of services to that enrollee.

f. All requests will be reviewed on a case-by-case basis and subject to the sole discretion of the Agency. Any request not approved is final and not subject to Managed Care Plan dispute or appeal.

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6. Effective Date of Disenrollment

a. The effective date of an approved disenrollment shall be the last calendar day of the month in which disenrollment was made effective by the Agency or its enrollment broker. In no case shall disenrollment be later than the first calendar day of the second month following the month in which the enrollee or the Managed Care Plan files the disenrollment request. If the Agency or its enrollment broker fails to make a disenrollment determination within this timeframe, the disenrollment is considered approved as of the date Agency action was required.

b. When disenrollment is necessary because an enrollee loses Medicaid eligibility, disenrollment shall be at the end of the month in which eligibility was lost.

D. Marketing

1. General Provisions

a. The Managed Care Plan shall not market nor distribute any marketing materials without first obtaining Agency approval.

b. The Managed Care Plan shall ensure compliance with the Contract and all state and federal marketing requirements, including monitoring and overseeing the activities of its subcontractors and all persons acting for, or on behalf of, the Managed Care Plan (see 42 CFR 438.104; s. 409.912, F.S.; s. 641.3901, F.S.; s. 641.3903, F.S.; s. 641.386, F.S., s. 626.112, F.S.; s. 626.342, F.S.; s. 626.451, F.S.; s. 626.471, F.S.; s. 626.511, F.S.; and s. 626.611, F.S.). If the Agency finds that the Managed Care Plan failed to comply with applicable contract, federal or state marketing requirements, the Agency may take compliance action, including sanctions (see Section XI, Sanctions).

c. The Managed Care Plan shall document compliance with applicable marketing requirements.

d. The Managed Care Plan shall ensure that marketing, including marketing plans and materials, is accurate and does not mislead, confuse, or defraud recipients or the Agency.

e. The Managed Care Plan shall not engage in unfair methods of competition or unfair or deceptive acts or practices as defined in s. 641.3903, F.S.

f. The Managed Care Plan shall not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, actual or perceived health status, claims experience, medical history, genetic information, evidence of insurability or geographic location.

g. The Managed Care Plan may use social/electronic media (e.g., Facebook, Twitter, Scan Code, or QR Code). However, the Agency considers such tools to be marketing materials, and the Managed Care Plan shall ensure that the use of social/electronic media complies with the requirements of this Contract and federal and state law.

h. In accordance with s. 409.912, F.S., marketing to Medicaid recipients in State offices is prohibited unless approved in writing and approved by the affected state agency

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when solicitation occurs in the office of another state agency. The Agency shall ensure that marketing representatives stationed in state offices market to Medicaid recipients only in designated areas and in such a way as to not interfere with the Medicaid recipients’ activities in the State office. The Managed Care Plan shall not use any other State facility, program, or procedure in the recruitment of Medicaid recipients except as authorized in writing by the Agency. Request for approval of activities at State offices must be submitted to the Agency at least thirty (30) days prior to the activity.

2. Prohibited Statements and Claims

a. The Managed Care Plan shall ensure that marketing materials are accurate and do not mislead, confuse, or defraud recipients. The Managed Care Plan shall not distribute marketing materials that are materially inaccurate, misleading, or otherwise make material misrepresentations.

b. The Managed Care Plan shall not, either orally or in writing:

(1) Claim that the recipient must enroll in the Managed Care Plan in order to obtain benefits or in order to not lose benefits;

(2) Claim that it is recommended or endorsed by CMS, the federal or state government, or similar entity.

(3) Claim that the state or the county recommends that a Medicaid recipient enroll with the Managed Care Plan.

(4) Claim that marketing representatives are employees of the federal, state or county government, or of anyone other than the Managed Care Plan or the organization by whom they are reimbursed.

(5) Claim that a Medicaid recipient will lose benefits under the Medicaid program or any other health or welfare benefits to which the recipient is legally entitled if the recipient does not enroll with the Managed Care Plan.

3. Prohibited Activities

a. The Managed Care Plan shall not enlist the assistance of any employee, officer, elected official or agency of the state including the state’s enrollment broker in recruitment of Medicaid recipients except as authorized in writing by the Agency.

b. The Managed Care Plan shall not provide any gift, commission or any form of compensation to the enrollment broker, including its full-time, part-time or temporary employees and subcontractors.

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4. Marketing of Multiple Lines of Business

a. Pursuant to 42 CFR 438.104(b)(1)(iv), the Managed Care Plan shall not influence enrollment in conjunction with the sale or offering of any private insurance. However, the Managed Care Plan may market other lines of business (both health-related and non health-related), other than private insurance, provided that such materials are in compliance with applicable state law governing the other lines of business.

b. The Managed Care Plan shall ensure that marketing materials sent to recipients or enrollees describing other health-related lines of business contain instructions that describe how recipients or enrollees may opt out of receiving such communications. The Managed Care Plan shall ensure that recipients and enrollees who ask to opt out of receiving future marketing communications are not sent such communications. In marketing multiple lines of business, the Managed Care Plan shall comply with HIPAA rules regarding use of enrollee information.

c. If the Managed Care Plan advertises multiple lines of business within the same marketing document, it shall keep the Managed Care Plan’s lines of business clearly and understandably distinct from the Medicaid Managed Care Plan.

d. The Managed Care Plan shall not include enrollment applications for non-Medicaid lines of business in mailings that combine Medicaid Managed Care Plan information with other product information.

5. Compliance with State Licensure and Appointment Laws

a. In order to use marketing agents to market, the Managed Care Plan shall comply with applicable state licensure and/or appointment laws.

b. The Managed Care Plan shall register each marketing agent with the Agency within fifteen (15) days after the marketing agent’s appointment to the Managed Care Plan. The registration shall consist of providing the Agency with the agent’s name; address; telephone number; cellular telephone number; DFS license number; the names of all Managed Care Plans with which the marketing agent was previously employed; and the name of the Managed Care Plan with which the marketing agent is presently employed.

c. The Managed Care Plan shall implement and maintain procedures to ensure the use of background and reference checks in its marketing agent hiring practices.

d. The Managed Care Plan shall maintain and make available to the Agency upon request evidence of current licensure and contractual agreements with all marketing representatives used by the Managed Care Plan to recruit Medicaid recipients.

e. The Managed Care Plan shall ensure that all marketing agents (including employed agents) are trained and tested annually on state and federal requirements and on details specific to the Managed Care Plan. The Managed Care Plan shall ensure that its training and testing programs are designed and implemented in a way that maintains the integrity of the training and testing and shall provide this information to the Agency upon request.

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f. The Managed Care Plan shall report to DFS and the Agency any marketing agent who violates any requirements of this Contract, within fifteen (15) days of knowledge of such violation.

g. The Managed Care Plan shall report the termination of any marketing agents and the reasons for the termination to the state in which the marketing agent has been appointed in accordance with the state appointment law. The Managed Care Plan shall submit reports to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, and in the manner and format determined by the Agency.

6. Marketing through Unsolicited Contacts Prohibited

a. The Managed Care Plan shall not, directly or indirectly, engage in door-to-door, telephone, or other cold-call marketing activities or market through unsolicited contacts, including but not limited to:

(1) Leaving information such as a leaflet or flyer at a residence or car.

(2) Approaching recipients in common areas (e.g., parking lots, hallways, lobbies, sidewalks, etc.).

(3) Telephonic or electronic solicitation, including leaving electronic voicemail messages or text messaging.

b. If the Managed Care Plan has a pre-scheduled personal/individual marketing appointment that becomes a “no-show,” the Managed Care Plan may leave information at the no-show recipient’s residence.

c. If the Managed Care Plan receives permission to call or otherwise contact a recipient, the Managed Care Plan shall treat the permission as event-specific and shall not interpret the permission as an open-ended permission to contact the recipient after the recipient’s inquiry or questions have been answered by the Managed Care Plan.

7. Telephonic Activities and Scripts

a. The Managed Care Plan may contact enrollees at any time to discuss Managed Care Plan business. The Managed Care Plan shall not engage in the following telephonic activities:

(1) Bait-and-switch strategies - making unsolicited calls about other business as a means of generating leads for the Managed Care Plan.

(2) Calls based on referrals. If an enrollee would like to refer a friend or relative to the Managed Care Plan, the Managed Care Plan may provide contact information such as a business card that the enrollee may give to the friend or family member. In all cases, a referred individual needs to contact the Managed Care Plan directly.

(3) Calls to former enrollees or to enrollees who are in the process of voluntarily disenrolling, for the purpose of marketing the Managed Care Plan or other products.

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(4) Calls to recipients who attended a marketing event, unless the recipient gave express permission at the event for a follow-up call (including documentation of permission to be contacted).

(5) Calls to recipients to confirm receipt of mailed information.

b. The Managed Care Plan may do the following:

(1) Contact its enrollees to discuss educational events.

(2) Contact its enrollees to conduct normal business related to enrollment in the Managed Care Plan.

(3) Call former enrollees within one month after the disenrollment effective date to conduct disenrollment surveys for quality improvement purposes. Such disenrollment surveys shall be approved by the Agency before Managed Care Plan implementation. Disenrollment surveys may be done by phone or sent by mail, but the Managed Care Plan shall ensure that neither calls nor mailings include marketing information.

(4) Call recipients who have expressly given permission for the Managed Care Plan to contact them, for example, by filling out a business reply card or asking an enrollee service representative to have a marketing representative contact them.

(5) Return phone calls or messages, as these are not unsolicited.

(6) Contact its enrollees via an automated telephone notification to inform them about general information such as the availability of flu shots, upcoming Managed Care Plan changes, and other important information.

c. The Managed Care Plan’s informational scripts (scripts designed to respond to recipient questions and requests and provide objective information about the Managed Care Plan and SMMC) shall not ask the recipient if he or she wants to be transferred to the marketing department, and the Managed Care Plan shall not automatically transfer calls to the enrollee services lines to the marketing department. The Managed Care Plan shall only transfer calls to the marketing department at the proactive request of the recipient.

d. The Managed Care Plan shall clearly inform the recipient of any change in the nature of a call from informational to marketing. This shall be done with the full and active concurrence of the recipient, ideally with a yes/no question.

e. The Managed Care Plan may not:

(1) Include information about other lines of business in scripts.

(2) Request recipient identification numbers (e.g., Social Security number, bank account numbers, credit card number) except as required to verify enrollment or determine enrollment eligibility.

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(3) Use language in scripts that implies the Managed Care Plan is endorsed by the Agency, calling on behalf of the Agency, or that the Agency asked the Managed Care Plan to call the recipient.

f. Any telephone marketing scripts (scripts designed to steer a recipient to the Managed Care Plan) must be prior approved by the Agency. The Managed Care Plan shall submit all telephone marketing scripts verbatim (bullets or talking points are unacceptable).

8. Standards for Written Materials

a. The Managed Care Plan shall ensure that all marketing materials comply with the standards for written materials specified in Section IV.A.

b. The Managed Care Plan shall ensure that all marketing materials include the statement that the Managed Care Plan contracts with the Agency. The Managed Care Plan shall use the following statement as the contracting statement: “[insert Managed Care Plan’s legal or marketing name] is a Managed Care Plan with a Florida Medicaid contract.” The Managed Care Plan shall not modify the statement and shall include the statement either in the text of the piece or at the end/bottom of the piece.

c. The Managed Care Plan shall include the following disclaimers in any marketing materials that include information on benefits:

(1) “The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the Managed Care Plan.”

(2) “Limitations, copayments, and restrictions may apply.”

(3) “[Benefits, formulary, pharmacy network, premium and/or co-payments/co- insurance] may change.”

d. If there are any changes or corrections made to materials, the Managed Care Plan shall correct those materials for prospective enrollees and may be required by the Agency to send errata sheets/addenda/reprints to current enrollees.

e. The Managed Care Plan shall include a TTY number in conjunction with the Managed Care Plan’s toll-free enrollee help line number. This requirement in does not apply to outdoor advertising or banner/banner-like ads or radio ads.

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9. Regional Distribution of Marketing Materials

a. If the Managed Care Plan markets, it shall distribute marketing materials to the entire region served by the Managed Care Plan.

b. The Managed Care Plan shall not advertise outside of its service area unless such advertising is unavoidable. For situations in which this cannot be avoided (e.g., advertising in print or broadcast media with a statewide audience or with an audience that includes some individuals outside of the region), the Managed Care Plan shall clearly disclose its service area.

c. If the Managed Care plan is a joint enterprise, it shall market the Managed Care Plan under a single name throughout the region.

10. Use of Superlatives in Marketing Materials

a. The Managed Care Plan may not use absolute superlatives (e.g., “the best,” “highest ranked,” “rated number 1”), unless they are substantiated with supporting data provided to the Agency as a part of the marketing review process.

b. The Managed Care Plan may use statements in its logos and in its product tag lines (e.g., “Your health is our major concern,” “Quality care is our pledge to you,” ”). The Managed Care Plan shall not use superlatives in logos/product tag lines (e.g., “XYZ plan means the first in quality care” or “XYZ Plus means the best in managed care”).

11. References to Studies

a. The Managed Care Plan may only compare itself to another Managed Care Plan by referencing an independent study. If the Managed Care Plan references a study in a marketing piece, it must provide the following information, either in the text or as a footnote, on the market piece:

(1) The source and date of the study.

(2) Information about the Managed Care Plan’s relationship with the entity that conducted the study including funding source.

(3) The study sample size and number of Managed Care Plans surveyed (unless the study that is referenced is a CMS or Agency study).

(4) Reference information (e.g., publication, date, page number).

b. The Managed Care Plan shall not compare itself to another Managed Care Plan by name unless it has written concurrence from all Managed Care Plans being compared. The Managed Care Plan shall include this documentation when the material is submitted to the Agency as part of the marketing review process.

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12. Product Endorsements/Testimonials

a. The Managed Care Plan shall not pay or compensate enrollees in any way to endorse or promote the Managed Care Plan. A Medicaid recipient may offer endorsement of the Managed Care Plan, provided the recipient is a current enrollee and voluntarily chooses to endorse the Managed Care Plan.

b. The Managed Care Plan shall ensure that all product endorsements and testimonials adhere to the following:

(1) The speaker must identify the Managed Care Plan by name.

(2) If an individual, such as an actor, is paid to portray a real or fictitious situation, the ad must clearly state it is a “Paid Actor Portrayal.”

c. The endorsement or testimonial cannot use any quotes by physicians, health care providers, and/or by Medicaid recipients not enrolled in the Managed Care Plan.

d. The endorsement or testimonial cannot use negative testimonials about other Managed Care Plans.

13. Promotional Activities and Nominal Gifts

a. The Managed Care Plan may use nominal gifts to attract the attention of potential enrollees as long as the gifts are of nominal value and provided regardless of enrollment.

b. Nominal value is defined as an individual item/service worth fifteen dollars ($15) or less (based on the retail value of the item).

c. The Managed Care Plan shall follow the following rules when providing gifts:

(1) If a nominal gift is one large gift that is enjoyed by all in attendance (e.g., a concert), the total retail cost must be fifteen dollars ($15) or less when it is divided by the estimated attendance. For planning purposes, anticipated attendance may be used, but must be based on venue size, response rate, or advertisement circulation.

(2) Nominal gifts may not be in the form of cash or other monetary rebates. Cash gifts are prohibited even if their worth is less than fifteen dollars ($15). Cash gifts include charitable contributions made on behalf of potential enrollees, and those gift certificates and gift cards that can be readily converted to cash, regardless of dollar amount.

d. The Managed Care Plan may use promotional activities to attract the attention of prospective enrollees and/or encourage retention of current enrollees.

e. The Managed Care Plan shall ensure that any promotional activities or items offered by the Managed Care Plan:

(1) Are worth fifteen dollars ($15) or less with a maximum aggregate of fifty dollars ($50) per person, per year;

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(2) Are offered to all individuals regardless of enrollment and without discrimination;

(3) Are not items that are considered a health benefit (e.g., a free checkup);

(4) Do not consist of lowering or waiving co-payments;

(5) Are not used or included with the enrollee handbook;

(6) Do not inappropriately influence the enrollee’s selection of a provider, practitioner, or supplier of any item or service;

(7) Are tracked and documented during the contract year; and

(8) Are not tied directly or indirectly to the provision of any other covered item or service.

f. The Managed Care Plan shall track and document items given to enrollees. The Managed Care Plan is not required to track pre-enrollment promotional items on a per person basis; however, the Managed Care Plan shall not structure pre-enrollment activities with the intent to give recipients or enrollees more than fifty dollars ($50) per year.

g. The Managed Care Plan shall not provide meals (or have meals subsidized) at marketing or educational events.

h. The Managed Care Plan shall include a written statement on all marketing materials promoting drawings, prizes or any promise of a free gift that there is no obligation to enroll in the Managed Care Plan. For example: “Eligible for a free drawing and prizes with no obligation.” or “Free drawing without obligation.”

14. Marketing Events

a. Marketing events are events designed to steer, or attempt to steer, potential enrollees toward the Managed Care Plan. At marketing events, the Managed Care Plan may discuss Managed Care Plan-specific information. All marketing events must be kept in a log and reported to the Agency, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

b. There are two main types of marketing events – formal and informal.

(1) Formal marketing events are typically structured in an audience/presenter style with the Managed Care Plan formally providing specific Managed Care Plan information via a presentation on the products being offered.

(2) Informal marketing events are conducted with a less structured presentation or in a less formal environment. They typically utilize a table, kiosk or a recreational vehicle (RV) that is staffed by a representative of the Managed Care Plan who can discuss the merits of the Managed Care Plan.

c. The Managed Care Plan shall submit all marketing scripts and presentations for approval to the Agency prior to their use during a marketing event.

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d. The Managed Care Plan shall obtain Agency approval prior to conducting any marketing events.

e. The Managed Care Plan shall ensure that advertisements and invitations to marketing events (in any form of media) used to invite recipients to attend a group session include the following two statements on marketing materials:

(1) “A health plan representative will be present with information.”

(2) “For accommodation of persons with special needs at marketing events call <insert phone and TTY number>.”

f. At a marketing event, the Managed Care Plan shall not:

(1) Conduct health screening or other like activities that could give the impression of “cherry picking.”

(2) Require recipients to provide any contact information as a prerequisite for attending the event. This includes requiring an email address or any other contact information as a condition to RSVP for an event online or through mail. The Managed Care Plan shall clearly indicate on any sign-in sheets that completion of any contact information is optional.

(3) Use personal contact information obtained to notify recipients of raffle or drawing winnings for any other purpose.

g. The Managed Care Plan shall notify the Agency of cancelled marketing events in advance of the scheduled event. In addition the Managed Care plan shall take the following actions to notify potential attendees:

(1) If a marketing event is cancelled less than forty-eight (48) hours before its originally scheduled date and time, the Managed Care Plan shall ensure a Managed Care Plan representative is present at the site of the cancelled event, at the time that the event was scheduled to occur, to inform attendees of the cancellation and distribute information about the Managed Care Plan. The representative should remain onsite at least fifteen (15) minutes after the scheduled start of the event. If the event was cancelled due to inclement weather, a Managed Care Plan representative is not required to be present at the site.

(2) If a marketing event is cancelled more than forty-eight (48) hours before the originally scheduled date and time, the Managed Care Plan shall notify recipients of the cancellation by the same means the Managed Care Plan used to advertise the event. A representative is not required to be present at the site.

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15. Personal/Individual Marketing Appointments

a. Personal/individual marketing appointments are one-on-one appointments that typically take place in the recipient’s home; however, these appointments can also take place in other venues such as a library or coffee shop.

b. All personal/individual appointments with recipients are considered marketing events, and all marketing materials used for personal/individual appointments must be kept in a log and reported to the Agency, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

c. During a personal/individual marketing appointment, the Managed Care Plan shall not:

(1) Discuss products that were not agreed to by the recipient.

(2) Market any health care related product beyond the scope agreed upon by the recipient, and documented by the Managed Care Plan, prior to the appointment.

(3) Market non-health care related products (such as annuities or life insurance).

(4) Ask a recipient for referrals.

d. During a personal/individual marketing appointment, the Managed Care Plan shall only discuss those products that have been agreed upon by the recipient for that appointment. If other products need to be discussed at the request of the recipient, the Managed Care Plan shall document a second scope of appointment for the new product type and then the marketing appointment may be continued.

e. The documentation of appointment scope can be in writing, in the form of a signed agreement by the recipient, or a recorded oral agreement. The Managed Care Plan is allowed and encouraged to use a variety of technological means to fulfill the scope of appointment requirement, including conference calls, fax machines, designated recording line, pre-paid envelopes, and email, etc.

f. A recipient may set a scope of appointment at a marketing event for a future personal/individual marketing appointment.

g. The Managed Care Plan shall submit all business reply cards for documenting recipient scope of appointment or agreement to be contacted to the Agency. The Managed Care Plan should include a statement on the business reply card informing the recipient that a marketing representative may call as a result of the recipient returning a business reply card.

h. In instances where a recipient visits the Managed Care Plan on his/her own accord, the Managed Care Plan shall document the scope of appointment prior to discussing the Managed Care Plan.

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16. Marketing in the Health Care Setting

a. The Managed Care Plan shall not conduct marketing activities in health care settings except in common areas. Common areas where marketing activities are allowed include areas such as hospital or nursing home cafeterias, community or recreational rooms, and conference rooms. If a pharmacy counter area is located within a retail store, common areas would include the space outside of where patients wait for services or interact with pharmacy providers and obtain medications.

b. The Managed Care Plan shall not conduct marketing presentations or solicit recipients in areas where patients primarily intend to receive health care services or are waiting to receive health care services. These restricted areas generally include, but are not limited to, waiting rooms, exam rooms, hospital patient rooms, dialysis center treatment areas (where patients interact with their clinical team and receive treatment), and pharmacy counter areas (where patients interact with pharmacy providers and obtain medications). The prohibition against conducting marketing activities in health care settings extends to activities planned in health care settings outside of Normal Business Hours.

c. The Managed Care Plan shall only schedule appointments with recipients residing in long-term care facilities (including nursing facilities and assisted living facilities) upon request by the recipient.

17. Provider-Based Marketing Activities

a. The Managed Care Plan shall ensure, through provider education, outreach and monitoring that its providers are aware of and comply with the following: Providers are permitted to make available and/or distribute Managed Care Plan marketing materials as long as the provider and/or the facility distributes or makes available marketing materials for all Managed Care Plans with which the provider participates. The Agency does not expect providers to proactively contact all Managed Care Plans; rather, if a provider agrees to make available and/or distribute Managed Care Plan marketing materials it should do so knowing it must accept future requests from other Managed Care Plans with which it participates. Providers are also permitted to display posters or other materials in common areas such as the provider’s waiting room. Additionally, long-term care facilities are permitted to provide materials in admission packets announcing all Managed Care Plan contractual relationships.

b. The Managed Care Plan shall ensure, through provider education, outreach and monitoring that its providers are aware of and comply with the following:

(1) To the extent that a provider can assist a recipient in an objective assessment of his/her needs and potential options to meet those needs, the provider may do so. Providers may engage in discussions with recipients should a recipient seek advice. However, providers must remain neutral when assisting with enrollment decisions.

(2) Providers may not:

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(a) Offer marketing/appointment forms.

(b) Make phone calls or direct, urge or attempt to persuade recipients to enroll in the Managed Care Plan based on financial or any other interests of the provider.

(c) Mail marketing materials on behalf of the Managed Care Plan.

(d) Offer anything of value to induce recipients/enrollees to select them as their provider.

(e) Offer inducements to persuade recipients to enroll in the Managed Care Plan.

(f) Conduct health screening as a marketing activity.

(g) Accept compensation directly or indirectly from the Managed Care Plan for marketing activities.

(h) Distribute marketing materials within an exam room setting.

(i) Furnish to the Managed Care Plan lists of their Medicaid patients or the membership of any Managed Care Plan.

(3) Providers may:

(a) Provide the names of the Managed Care Plans with which they participate.

(b) Make available and/or distribute Managed Care Plan marketing materials.

(c) Refer their patients to other sources of information, such as the Managed Care Plan, the enrollment broker or the local Medicaid Area Office.

(d) Share information with patients from the Agency’s website or CMS’ website.

(4) Provider Affiliation Information

(a) Providers may announce new or continuing affiliations with the Managed Care Plan through general advertising (e.g., radio, television, websites).

(b) Providers may make new affiliation announcements within the first thirty (30) days of the new provider contract.

(c) Providers may make one announcement to patients of a new affiliation that names only the Managed Care Plan when such announcement is conveyed through direct mail, email, or phone.

(d) Additional direct mail and/or email communications from providers to their patients regarding affiliations must include a list of all Managed Care Plans with which the provider contracts.

(e) Any affiliation communication materials that include Managed Care Plan-specific information (e.g., benefits, formularies) must be prior approved by the Agency.

c. Multiple Managed Care Plans can either have one Managed Care Plan submit the material on behalf of all the other Managed Care Plans, or have the piece submitted and approved by the Agency prior to use for each Managed Care Plan. Materials that indicate the provider has an affiliation with certain Managed Care Plans and that only list Managed Care Plan names and/or contact information do not require Agency approval.

d. Providers may distribute printed information provided by the Managed Care Plan to their patients comparing the benefits of all of the different Managed Care Plans with which the providers contract. The Managed Care Plan shall ensure that:

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(1) Materials do not “rank order” or highlight specific Managed Care Plans and include only objective information.

(2) Such materials have the concurrence of all Managed Care Plans involved in the comparison and are approved by the Agency prior to distribution.

(3) The Managed Care Plans identify a lead Managed Care Plan to coordinate submission of the materials.

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AHCA Contract No. FP020, Attachment II, Page 64 of 214

Section IV. Enrollee Services and Grievance Procedures

A.    Enrollee Material

1.    General Provision

The Managed Care Plan shall ensure that enrollees are notified of their rights and responsibilities; the role of PCPs; how to obtain care; what to do in an emergency or urgent medical situation; how to pursue a complaint, a grievance, appeal or Medicaid Fair Hearing; how to report suspected fraud and abuse; how to report abuse, neglect and exploitation; and all other requirements and benefits of the Managed Care Plan.

2.    Requirements for Written Material

a. The Managed Care Plan shall provide enrollee information in accordance with 42 CFR 438.10, which addresses information requirements related to written and oral information provided to enrollees, including: languages; format; Managed Care Plan features, such as benefits, cost sharing, provider network and physician incentive plans; enrollment and disenrollment rights and responsibilities; grievance system; and advance directives. The Managed Care Plan shall notify enrollees, on at least an annual basis, of their right to request and obtain information in accordance with the above requirements.

b. All enrollee communications, including written materials, spoken scripts and websites shall be at or near the fourth (4^th) grade comprehension level. Readability test to determine whether the written materials meet this requirement are:

(1) Fry Readability Index;

(2) PROSE The Readability Analyst (software developed by Education Activities, Inc.);

(3) Gunning FOG Index;

(4) McLaughlin SMOG Index; and/or

(5) The Flesch-Kincaid Index; and or

(6) Other readability test approved by the Agency.

c. The Managed Care Plan shall make all written material available in English, Spanish and all other appropriate foreign languages. The appropriate foreign languages comprise all languages in the Managed Care Plan Contract region(s) spoken by approximately five percent (5%) or more of the total population. Upon request, the Managed Care Plan shall provide, free of charge, interpreters for potential enrollees or enrollees whose primary language is not English. (See 42 CFR 438.10(c)(3).)

d. The Managed Care Plan shall make all written materials available in alternative formats and in a manner that takes into consideration the enrollee’s special needs, including those who are visually impaired or have limited reading proficiency. The Managed Care Plan shall notify all enrollees and, upon request, potential enrollees that information is available in alternative formats and how to access those formats.

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3.    Requirements for Mailing Material to Enrollees

a. The Managed Care Plan shall mail all enrollee materials to the enrollee’s payee address provided by the Agency on the Managed Care Plan’s monthly enrollment file.

b. When enrollee materials are returned to the Managed Care Plan as undeliverable, the Managed Care Plan shall re-mail the materials to the enrollee residence address provided by the Agency if that address is different from the payee address. The Managed Care Plan shall use and maintain in a file a record of all of the following methods to contact the enrollee:

(1) Routine checks of the Agency enrollment files for changes of address and/or presence of the enrollee’s residence address, maintaining a record of returned mail and attempts to re-mail to either a new payee address or residence address as provided by the Agency;

(2) Telephone contact at the number obtained from Agency enrollment files, the local telephone directory, directory assistance, city directory or other directory; and

(3) Routine checks (at least once a month for the first three (3) months of enrollment) on services or claims authorized or denied by the Managed Care Plan to determine if the enrollee has received services, and to locate updated address and telephone number information.

c. In order to ensure that recipients and enrollees can quickly and easily identify the contents of the Managed Care Plan’s mailing, the Managed Care Plan shall prominently display one of the following four statements on the front of the envelope or if no envelope is being sent, the mailing itself:

(1) Advertising pieces – “This is an advertisement”

(2) Managed care plan information – “Important managed care plan information”

(3) Health and wellness information – “Health or wellness or prevention information”

(4) Non-health or non-managed care plan information - “Non-health or non-managed care plan related information”

The Managed Care Plan shall ensure that all mailings include one of these four mailing statements. The Managed Care Plan shall not modify these mailing statements and shall use them verbatim. The Managed Care Plan may meet this requirement through the use of ink stamps or stickers, in lieu of pre-printed statements. The Agency does not require resubmission of envelopes based only on a change in the envelope size. If the Managed Care Plan uses the same mailing statement on three different mailing packages (e.g., 8 x 12 envelope, letter size envelope, and box) the Managed Care Plan is only required to submit the envelope once as part of the material submission, provided the required mailing statement remains unchanged and additional information is not included.

d. The Managed Care Plan shall ensure that its Managed Care Plan name or logo is included in every mailing to current and prospective enrollees (either on the front envelope or on the mailing when no envelope accompanies the mailer).

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e. Mailing envelopes for enrollee materials shall contain a request for address correction.

f. The Managed Care Plan shall not send emails unless the enrollee or potential recipient has agreed to receive those emails.

g. The Managed Care Plan shall not rent or purchase email lists to distribute information about its Medicaid managed care plan to enrollees or potential enrollees.

h. The Managed Care Plan shall not email enrollees or potential recipients at email addresses obtained through friends or referrals.

i. The Managed Care Plan shall provide an opt-out process for enrollees and potential recipients to no longer receive email communications.

4.    Required Enrollment Notice

a. The Managed Care Plan shall notify, in writing, each person who is to be enrolled with the Managed Care Plan.

b. The Managed Care Plan’s enrollment notification shall include, at a minimum, the following information:

(1) The effective date of enrollment;

(2) The enrollees’ right to change their Managed Care Plan selections, subject to Medicaid limitations. The notifications shall distinguish between enrollees subject to open enrollment and those who are not and shall include information about change procedures for cause, or general Managed Care Plan change procedures through the Agency’s toll-free enrollment broker telephone number as appropriate;

(3) A notice that enrollees who lose eligibility and are disenrolled shall be automatically reinstated in the Managed Care Plan if eligibility is regained within the temporary loss period;

(4) 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 Managed Care Plan and through DCF and/or the Social Security Administration; and

(5) A postage-paid, pre-addressed return envelope.

c. The Managed Care Plan shall notify, in writing, each person who is to be reinstated, of the effective date of the reinstatement. The notification shall also instruct the enrollee to contact the Managed Care Plan if a new enrollee card, new enrollee handbook, and/or a new provider directory are needed.

d. The Managed Care Plan shall provide such notice to each affected enrollee by the first calendar day of the month following the Managed Care Plan’s receipt of the notice of enrollment or reinstatement or within five (5) days from receiving the enrollment file, whichever is later.

e. MMA Managed Care Plan’s new enrollment and reinstatement notifications shall include the enrollee’s assigned primary care provider.

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5.    New Enrollee Procedures and Materials

a. By the first day of the assigned enrollee’s enrollment or within five (5) days following receipt of the X12-834 enrollment file from the Agency or its fiscal agent, whichever is later, the Managed Care Plan shall mail or hand deliver to the new enrollee:

(1) An enrollee identification (ID) card;

(2) An enrollee handbook;

(3) A printed provider directory; and

(4) For MMA Managed Care Plans and Comprehensive LTC Plans, the following information:

(a) Name, telephone number and address of the MMA enrollee’s PCP assignment;

(b) An explanation that enrollees may choose to have all family members served by the same PCP or may choose different PCPs; and

(c) A postage-paid, pre-addressed return envelope.

b. For enrollees with LTC benefits, as long as the materials are provided within five (5) days, the LTC Managed Care Plan or Comprehensive LTC Managed Care Plan may provide new enrollee materials to enrollees as part of the initial case management visit.

c. New enrollee materials are not required for a former enrollee who was disenrolled because of the loss of Medicaid eligibility and who regains eligibility within their temporary loss period, as specified in Section II.C.11., and is automatically reinstated in the Managed Care Plan, unless there was change in enrollee materials or the provider directory during the timeframe in which the recipient was disenrolled.

d. A notation of the effective date of the reinstatement is to be made on the most recent application or conspicuously identified in the enrollee’s administrative file.

e. Enrollees who were previously enrolled in the Managed Care Plan, and who lose and regain eligibility in a number of days in excess of the temporary loss period, as specified in Section II. C. 11., will be treated as new enrollees.

f. The Managed Care Plan may send new enrollment material in separate mailings. Each mailing/provision of materials shall be documented in the Managed Care Plan’s records.

6.    Enrollee ID Card Requirements

a. The Managed Care Plan shall furnish each enrollee an enrollee ID card that shall include, at a minimum, the following information:

(1) The enrollee’s name and Medicaid ID number;

(2) The Managed Care Plan’s name, address and enrollee help line number; and

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(3) A telephone number that a non-participating provider may call for billing information.

b. The Managed Care Plan shall provide replacement ID cards at the enrollee’s request.

7.    Enrollee Handbook Requirements

a. The Managed Care Plan shall furnish each enrollee an enrollee handbook that shall include, at a minimum, the following information:

(1) Table of contents;

(2) Terms, conditions and procedures for enrollment including the reinstatement process and enrollee rights and protections;

(3) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s enrollment broker. The Managed Care Plan shall include the following language verbatim in the enrollee handbook:

Enrollment:

If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in [INSERT MANAGED CARE PLAN NAME] or the state enrolls you in a plan, you will have 90 days from the date of your first enrollment to try the Managed Care Plan. During the first 90 days you can change Managed Care Plans for any reason. After the 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called “lock-in.”

Open Enrollment:

If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called “open enrollment.” You do not have to change Managed Care Plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you may change Managed Care Plans during your 60 day open enrollment period.

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Disenrollment:

If you are a mandatory enrollee and you want to change plans after the initial 90-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change Managed Care Plans: [INSERT CAUSE LIST FROM THIS SECTION].

(4) Procedures for filing a request for disenrollment for cause. As noted in the section, the state-approved for-cause reasons listed shall be listed verbatim in the disenrollment section of the enrollee handbook. In addition, the Managed Care Plan shall include the following language verbatim in the disenrollment section of the enrollee handbook:

Some Medicaid recipients may change Managed Care Plans whenever they choose, for any reason. To find out if you may change plans, call the Enrollment Broker [INSERT APPROPRIATE TELEPHONE NUMBER].

(5) Information regarding newborn enrollment, including the mother’s responsibility to notify the Managed Care Plan and DCF of the pregnancy and the newborn’s birth;

(6) Enrollee rights and responsibilities, including the extent to which and how enrollees may obtain services from non-participating providers and other provisions in accordance with 42 CFR 438.100;

(7) Description of services provided, including limitations and general restrictions on provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among participating providers;

(8) Procedures for obtaining required services, including second opinions at no expense to the enrollee (in accordance with 42 CFR 438.206(3) and s. 641.51, F.S.), and authorization requirements, including any services available without prior authorization;

(9) The extent to which, and how, After Hours and emergency coverage is provided, and that the enrollee has a right to use any hospital or other setting for emergency care;

(10) Cost sharing for the enrollee, if any;

(11) Information that interpretation services and alternative communication systems are available, free of charge, including for all foreign languages and vision and hearing impairment, and how to access these services;

(12) How and where to access any benefits that are available under the Medicaid State Plan but are not covered under this Contract, including any cost sharing;

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(13) Procedures for reporting fraud, abuse and overpayment that includes the following language verbatim:

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at: https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx;

If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twenty-five percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected.

(14) Clear specifics on the required procedural steps in the grievance process, including the address, telephone number and office hours of the grievance staff. The Managed Care Plan shall specify telephone numbers to call to present a complaint, grievance, or appeal. Each telephone number shall be toll-free within the caller’s geographic area and provide reasonable access to the Managed Care Plan without undue delays;

(15) Fair Hearing procedures;

(16) Information that services will continue upon appeal of a denied authorization and that the enrollee may have to pay in case of an adverse ruling;

(17) Information about the Beneficiary Assistance Program (BAP) process, including an explanation that a review by the BAP must be requested within one (1) year after the date of the occurrence that initiated the appeal, how to initiate a review by the BAP and the BAP address and telephone number:

Agency for Health Care Administration

Beneficiary Assistance Program

Building 3, MS #26

2727 Mahan Drive, Tallahassee, FL 32308

(850) 412-4502

(888) 419-3456 (toll-free)

(18) Information regarding HIPAA relative to the enrollee’s personal health information (PHI);

(19) Information to help the enrollee assess a potential behavioral health problem;

(20) Procedures for reporting abuse, neglect, and exploitation, including the abuse hotline number: 1-800-96-ABUSE;

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(21) Information regarding health care advance directives pursuant to ss. 765.302 through 765.309, F.S., 42 CFR 438.6(i)(1)-(4) and 42 CFR 422.128, as follows:

(a) The Managed Care Plan’s information shall include a description of state law and must reflect changes in state law as soon as possible, but no later than ninety (90) days after the effective change.

(b) The Managed Care Plan shall provide these policies and procedures to all enrollee’s age 18 and older and shall advise enrollees of the enrollee’s rights under state law, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

(c) The Managed Care Plan’s written policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience.

(d) The Managed Care Plan’s information shall inform enrollees that complaints about non-compliance with advance directive laws and regulations may be filed with the state’s complaint hotline.

(e) The Managed Care Plan shall educate enrollees about their ability to direct their care using this mechanism and shall specifically designate which staff and/or participating providers are responsible for providing this education.

(22) How to get information about the structure and operation of the Managed Care Plan and any physician incentive plans, as set forth in 42 CFR 438.10(g)(3);

(23) Instructions explaining how enrollees may obtain information from the Managed Care Plan about how it rates on performance measures in specific areas of service;

(24) How to obtain information from the Managed Care Plan about quality enhancements (QEs) as specified in Section V.F.; and

(25) Toll-free telephone number of the appropriate Medicaid Area Office and Aging and Disabilities Resource Centers.

b. In accordance with 42 CFR 438.10, for a counseling or referral service that the Managed Care Plan does not cover because of moral or religious objections, the Managed Care Plan need not furnish information on how and where to obtain the service.

c. The Managed Care Plan shall include additional information in its handbooks with respect to the applicable SMMC program, as follows:

(1) MMA Managed Care Plans shall include the additional information specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall include the additional information specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall include additional information as specified in both the MMA Exhibit and the LTC Exhibit.

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8.    Printed Provider Directory

a. The Managed Care Plan shall ensure its initial provider directory printed prior to enrolling recipients in the Managed Care Plan in each authorized Region matches the provider network submission used by the Agency to determine the Managed Care Plan has the capacity to provide covered services to all enrollees up to the maximum enrollment level. After the Agency’s initial provider directory approval as part of the plan-specific readiness review specified in Section II, Responsibilities of the State of Florida, the Managed Care Plan shall ensure its provider directory (either printed or online) matches the most recent provider network file that the Managed Care Plan submitted to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide

b. The Managed Care Plan shall furnish a printed provider directory to all enrollees. The Managed Care Plan shall update the printed provider directory at least every six months and provide the most recently printed provider directory to new enrollees. Comprehensive LTC Managed Care Plans shall distribute a separate LTC and MMA printed provider directory to enrollees with both LTC and MMA benefits.

c. When distributing printed provider directories, the Managed Care Plan must append to the provider directory a list of the providers who have left the network and those who have been added since the directory was printed or, in lieu of the appendix to the provider directory, enclose a letter stating that the most current listing of providers is available by calling the Managed Care Plan at its toll-free telephone number and at the Managed Care Plan’s website. The letter shall include the telephone number and the Internet address that will take the enrollee directly to the online provider directory.

d. The provider directory shall include the names, locations, office hours, telephone numbers of, and non-English languages spoken by current Managed Care Plan providers. The provider directory also shall identify providers that are not accepting new patients.

e. The Managed Care Plan shall arrange the provider directory by county as follows:

(1) Providers listed by name in alphabetical order, showing the provider’s specialty; and

(2) Providers listed by specialty, in alphabetical order by name.

f. In accordance with s. 1932(b)(3) of the Social Security Act, the provider directory shall include a statement that some providers may choose not to perform certain services based on religious or moral beliefs.

g. The Managed Care Plan is not required to include outpatient-based specialty providers in ambulatory surgical centers and hospital-based providers in the online or printed provider directory. However, the Managed Care Plan shall include these providers in the provider network file it submits to the Agency.

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h. In addition to the provision of a printed provider directory to new enrollees, the Managed Care Plan shall provide a printed provider directory to those enrollees who were reinstated after the open enrollment period.

9.    Online Enrollee Materials

a. The Managed Care Plan shall make enrollee materials, including the provider directory and enrollee handbook(s), available online at the Managed Care Plan’s website without requiring enrollee log-in. The Managed Care Plan may provide a link to applications (smartphone applications) for enrollee use that will take enrollees directly to existing Agency-approved materials on the Managed Care Plan’s website, such as the Managed Care Plan’s enrollee handbook and provider directory. Smartphone applications may also be known as “apps.” See Section VIII.C.

b. The Managed Care Plan shall maintain an accurate and complete online provider directory containing all the information required in the printed provider directory as well as information about licensure or registration, specialty credentials and other certifications, and specific performance indicators. The online provider directory must be searchable by:

(1) Name,

(2) Provider type,

(3) Distance from the enrollee’s address,

(4) Zip code, and

(5) Whether the provider is accepting new patients.

c. The online provider directory shall also have the capability to compare the availability of providers to network adequacy standards and accept and display feedback from each provider’s patients.

d. The Managed Care Plan shall update the online provider directory at least weekly to match the most recent provider network file submitted to the Agency and shall file an attestation to this effect with the Agency each week, even if no changes have occurred. (See s. 409.967(2)(c), F.S.)

e. MMA Managed Care Plans and Comprehensive Managed Care Plans shall provide a link to the Agency’s Medicaid preferred drug list (PDL) on the Managed Care Plan’s website without requiring enrollee log-in. Such Managed Care Plans shall also post prior authorization, step-edit criteria and protocol, and updates to the list of non-Medicaid PDL drugs that are subject to prior authorization within twenty one (21) days after the prior authorization and step-edit criteria and protocol and updates have been approved by the Managed Care Plan’s Pharmaceutical and Therapeutics Committee.

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10.    Procedures for Provider Network Changes

a. The Managed Care Plan shall have procedures to inform potential enrollees and enrollees, upon request, of any changes to service delivery and/or the provider network including the following:

(1) Up-to-date information about any restrictions on access to providers, including providers who are not taking new patients;

(2) Any restrictions on counseling and referral services based on moral or religious grounds within ninety (90) days after adopting the policy with respect to any service.

b. The Managed Care Plan shall have procedures to inform enrollees of adverse changes to its provider network.

B. Enrollee Services

1. General Provisions

The Managed Care Plan shall have the capability to answer enrollee inquiries through written materials, telephone, electronic transmission and face-to-face communication.

a. The enrollee’s guardian or legally authorized responsible person, as provided in s. 765.401, F.S., is permitted to act on the enrollee’s behalf in matters relating to the enrollee’s enrollment, plan of care, and/or provision of services, if the enrollee:

(1) Was adjudicated incompetent in accordance with the law;

(2) Is found by the provider to be medically incapable of understanding his or her rights; or

(3) Exhibits a significant communication barrier.

b. Notices may be sent to the enrollee’s guardian or legally authorized responsible person as applicable.

c. The Managed Care Plan shall provide written notice of changes affecting enrollees to those enrollees at least thirty (30) days before the effective date of change.

2. Toll-Free Enrollee Help Line

a. The Managed Care Plan shall operate a toll-free help line equipped with caller identification, automatic call distribution equipment capable of handling the expected volume of calls, a telecommunication device for the deaf (TTY/TDD), and access to the interpreter services for non-English speaking beneficiaries. The Managed Care Plan may use an automated telephone triage system. The toll-free enrollee help line shall respond to all areas of enrollee inquiry.

b. The Managed Care Plan shall develop and implement an administrative policies and procedures manual relevant to the call center that includes the specifications of

AHCA Contract No. FP020, Attachment II, Page 75 of 214

operation of all call center activities. The administrative policies and procedures shall address:

(1) Covered services, referrals, provider network and transportation;

(2) Data entry;

(3) Internal quality control of telephone staff; and

(4) Reporting.

c. The Managed Care Plan shall have telephone call policies and procedures that shall include requirements for staffing, personnel, hours of operation, call response times, maximum hold times and maximum abandonment rates, monitoring of calls via recording or other means and compliance with performance standards.

d. The Managed Care Plan shall staff the enrollee help line twenty-four hours a day, seven days a week (24/7) to handle care related inquiries from enrollees and caregivers. The enrollee help line staff shall be trained to respond to enrollee questions in all areas.

e. The Managed Care Plan may have an automated system available between the hours of 7:00 p.m. and 8:00 a.m., in the enrollee’s time zone, Monday through Friday and at all hours on weekends and holidays. This automated system must provide, at a minimum, callers with clear instructions on what to do in case of an emergency, a voice mailbox option for callers to leave messages, and an option to speak to a Managed Care Plan representative.

f. If the Managed Care Plan utilizes a voice mail option, the Managed Care Plan shall ensure that the voice mailbox has adequate capacity to receive all messages. A Managed Care Plan representative shall respond to messages on the next business day.

g. If the Managed Care Plan utilizes an automated system, the Managed Care Plan’s enrollee help line must include the option for enrollees to bypass the automated attendant/IVR and speak with an enrollee help line staff member.

h. The Managed Care Plan shall develop performance standards and monitor enrollee help line performance by recording calls and employing other monitoring activities. Such standards shall be submitted to and approved by the Agency before the Managed Care Plan begins operation, and the Managed Care Plan shall report its performance on these standards as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. At a minimum, the standards shall require that, measured on a monthly basis:

(1) The average speed of answer (ASA) shall not exceed thirty (30) seconds.

(2) The call blockage rate for direct calls to the Managed Care Plan shall not exceed one half of one percent (0.5%).

(3) The average call abandonment rate for direct calls to the Managed Care Plan shall not exceed three percent (3%). A system, which places calls in queue, may be used but the wait time in the queue shall not exceed sixty (60) seconds.

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i. The Managed Care Plan shall ensure that hold time messages do not include non-health related items (e.g., life insurance, disability). The Managed Care Plan shall submit hold time messages that promote the Managed Care Plan or include benefit information to the Agency for prior approval.

3.    Translation Services and Availability of Translated Materials

a. The Managed Care Plan is required to provide oral translation services to any enrollee who speaks any non-English language regardless of whether the enrollee speaks a language that meets the threshold of a prevalent non-English language.

b. The Managed Care Plan is required to notify its enrollees of the availability of oral interpretation services and to inform them of how to access such services. Oral interpretation services are required for all Managed Care Plan information provided to enrollees, including notices of adverse action. There shall be no charge to the enrollee for translation services.

c. If the Managed Care Plan meets the five percent (5%) threshold for language translation, the Managed Care Plan shall place the following alternate language disclaimer on all enrollee materials:

“This information is available for free in other languages. Please contact our customer service number at [insert enrollee help line and TTY/TTD numbers and hours of operation].”

The Managed Care Plan shall include the alternate language disclaimer in both English and all non-English languages that meet the five percent (5%) threshold. The Managed Care Plan shall place the non-English disclaimer(s) below the English version and in the same font size as the English version.

4.    Cultural Competency Plan

a. In accordance with 42 CFR 438.206, the Managed Care Plan shall have a comprehensive written cultural competency plan (CCP) describing the Managed Care Plan’s program to ensure that services are provided in a culturally competent manner to all enrollees, including all services and settings and including those with limited English proficiency. The CCP must describe how providers, Managed Care Plan employees, and systems will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes, values, affirms and respects the worth of the individual enrollees and protects and preserves the dignity of each. The CCP shall be updated annually and submitted to the Agency by June 1 for approval for implementation by September 1 of each Contract year.

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b. The Managed Care Plan may distribute a summary of the CCP to participating providers if the summary includes information about how the provider may access the full CCP on the website. This summary shall also detail how the provider can request a hard copy of the cultural competency plan from the Managed Care Plan at no charge to the provider.

c. The Managed Care Plan shall complete an annual evaluation of the effectiveness of its CCP. This evaluation may include results from the CAHPS or other comparative member satisfaction surveys, outcomes for certain cultural groups, member grievances, member appeals, provider feedback and Managed Care Plan employee surveys. The Managed Care Plan shall track and trend any issues identified in the evaluation and shall implement interventions to improve the provision of services. A description of the evaluation, its results, the analysis of the results and interventions to be implemented shall be described in the CCP submitted to the Agency annually by June 1 of each Contract year.

5.    Educational Events

a. An educational event is an event designed to inform recipients about Medicaid programs and does not include marketing (i.e., the event sponsor does not steer, or attempt to steer, potential enrollees toward a specific Managed Care Plan or limited number of Managed Care Plans). All educational events must be kept in a log and reported to the Agency, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

b. Educational events may be hosted by the Managed Care Plan or an outside entity and must be held in a public venue. The Managed Care Plan shall ensure that events are not held at in-home or one-on-one settings.

c. Educational events may not include any marketing activities such as the distribution of marketing materials. The Managed Care shall explicitly advertise educational events as “educational;” otherwise, the Agency will consider the event to be a marketing event.

d. The Managed Care Plan shall ensure that materials distributed or made available at an educational event are free of Managed Care Plan-specific information (including Managed Care Plan-specific benefits, co-payments, or contact information), and any bias toward one Managed Care Plan over another.

e. The following are examples of acceptable materials and activities by the Managed Care Plan at an educational event:

(1) A banner with the Managed Care Plan name and/or logo displayed.

(2) Promotional items, including those with Managed Care Plan name, logo, and toll-free enrollee help line number and/or website. The Managed Care Plan shall ensure that promotional items are free of benefit information and consistent with the definition of nominal gift specified in Section III.D.5.a.

(3) Respond to questions asked at an educational event.

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f. At educational events, the Managed Care Plan shall not:

(1) Discuss Managed Care Plan-specific benefits.

(2) Distribute Managed Care Plan-specific materials.

(3) Distribute or display business reply cards, scope of appointment forms or sign-up sheets.

(4) Set up individual marketing appointments or get permission for an outbound call to the recipient.

(5) Attach business cards or Managed Care Plan contact information to educational materials, unless requested by the recipient.

(6) Advertise an educational event and then have a marketing event immediately following in the same general location (e.g., same hotel).

g. If the Managed Care Plan holds enrollee-only events, the Managed Care Plan shall not conduct marketing activities at these events. In addition, the Managed Care Plan shall advertise these events in a way that reasonably targets only current enrollees (e.g., direct mail flyers) and not the mass marketplace (e.g., radio or newspaper ad).

h. The Managed Care Plan shall submit information on educational events to the Agency for prior approval.

6.    Medicaid Redetermination Assistance

a. The Agency will provide Medicaid recipient redetermination date information to the Managed Care Plan. This information shall be used by the Managed Care Plan only as indicated in this section.

b. MMA Managed Care Plans shall notify the Agency, in writing, if it wants to provide assistance with Medicaid eligibility redetermination to enrollees in order to promote continuous Medicaid eligibility. The Managed Care Plan’s participation in using this information is voluntary. If requested and approved by the Agency, the MMA Managed Care Plan shall participate as specified in the MMA Exhibit.

c. LTC Managed Care Plans shall develop a process for providing assistance with Medicaid eligibility redetermination to in order to ensure continuous Medicaid eligibility, including both financial and medical/functional eligibility, as specified in the LTC Exhibit.

d. Comprehensive LTC Managed Care Plans shall develop a process for providing assistance with Medicaid eligibility redetermination for enrollees with both LTC and MMA benefits as specified in the LTC Exhibit. Comprehensive LTC Managed Care Plans may provide assistance, subject to Agency approval, for enrollees with MMA benefits only as specified in the MMA Exhibit.

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C. Grievance System

1. General Provisions    

a. Federal law requires Medicaid managed care organizations to have internal grievance procedures under which Medicaid enrollees, or providers acting as authorized representatives, may challenge denial of coverage of, or payment for, medical assistance. The Managed Care Plan’s grievance system shall comply with the requirements set forth in s. 641.511, F.S., if applicable, and with all applicable federal and state laws and regulations, including 42 CFR 431.200 and 42 CFR Part 438, Subpart F, “Grievance System”.

b. For purposes of this Contract, these procedures must include an opportunity to file a complaint, a grievance and/or an appeal and to seek a Medicaid Fair Hearing through DCF.

c. A Managed Care Plan that covers services through a subcontractor shall ensure that the subcontractor meets the complaint and grievance system requirements all delegated services.

2. Use of Independent Review Organization

a. The Managed Care Plan may elect to have all of its grievance and appeal issues subject to external review processes by an independent review organization.

b. The Managed Care Plan must notify the Agency in writing if it elects to have all its contracts subject to such external review.

3. Information to be Provided

a. The Managed Care Plan shall include all necessary procedural steps for filing complaints, grievances, appeals and requests for a Medicaid Fair Hearing in the enrollee handbook.

b. Where applicable, the Managed Care Plan’s grievance system must include information for enrollees on seeking a state level appeal through the Beneficiary Assistance Program.

c. The Managed Care Plan shall provide information about the grievance system to all providers and subcontractors in the provider handbook when they enter into a contract.

d. Types of Issues

(1) A complaint is the lowest level of challenge and provides the Managed Care Plan an opportunity to resolve a problem without it becoming a formal grievance. Complaints shall be resolved by close of business the day following receipt or be moved into the grievance system within twenty-four (24) hours.

(2) A grievance expresses dissatisfaction about any matter other than an action.

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(3) An action is any denial, limitation, reduction, suspension or termination of service, denial of payment, or failure to act in a timely manner.

(4) An appeal is a request for review of an action.

4. Process for Grievances and Appeals

a. The Managed Care Plan shall adhere to the following timeframes for filing of grievances and appeals:

(1) A grievance may be filed orally or in writing within one (1) year of the occurrence.

(2) An appeal may be filed orally or in writing within thirty (30) days of the enrollee’s receipt of the notice of action and, except when expedited resolution is required, must be followed with a written notice within ten (10) days of the oral filing. The date of oral notice shall constitute the date of receipt.

b. The Managed Care Plan shall refer all enrollees and/or providers on behalf of the enrollee (whether participating or non-participating) who are dissatisfied with the Managed Care Plan or its activities to the Managed Care Plan’s grievance/appeal coordinator for processing and documentation of the issue.

c. The Managed Care Plan shall provide any reasonable help to the enrollee in completing forms and following the procedures for filing a grievance or appeal or requesting a Medicaid Fair Hearing. This includes interpreter services, toll-free calling, and TTY/TTD capability.

d. The Managed Care Plan shall acknowledge in writing within five (5) business days of receipt of each grievance and appeal unless the enrollee requests an expedited resolution. The Managed Care Plan shall notify enrollees in their primary language of grievance and appeal resolutions.

e. The Managed Care Plan shall handle grievances and appeals as follows:

(1) Provide the enrollee a reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing.

(2) Ensure the enrollee understands any time limits that may apply.

(3) Provide opportunity before and during the process for the enrollee or an authorized representative to examine the case file, including medical/case records, and any other material to be considered during the process.

(4) Consider as parties to the appeal the enrollee or an authorized representative or, if the enrollee is deceased, the legal representative of the estate.

f. The Managed Care Plan shall ensure that all decision makers are health care professionals with clinical expertise in treating the enrollee’s condition when deciding the following:

(1) Appeal of denial based on lack of medical necessity;

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(2) Grievance of denial of expedited resolution of an appeal; and

(3) Grievance or appeal involving clinical issues.

g. The Managed Care Plan shall ensure that decision makers on grievances and appeals were not involved in previous levels of review or decision

5. Standard Timeframes

a. The Managed Care Plan shall follow Agency guidelines in resolving grievances and appeals as expeditiously as possible, observing required timeframes and taking into account the enrollee’s health condition.

b. A grievance shall be reviewed and written notice of results sent to the enrollee no later than ninety (90) days from the date the Managed Care Plan receives it.

c. For standard resolution, an appeal shall be heard and notice of results sent to the enrollee no later than forty-five (45) days from the date the Managed Care Plan receives it.

d. The timeframe for a grievance or appeal may be extended up to fourteen (14) days if:

(1) The enrollee asks for an extension, or the Managed Care Plan documents that additional information is needed and the delay is in the enrollee’s interest;

(2) If the timeframe is extended other than at the enrollee’s request, the Managed Care Plan shall notify the enrollee within five (5) business days of the determination, in writing, of the reason for the delay.

e. The Managed Care Plan shall complete the grievance process in time to accommodate an enrollee’s disenrollment effective date, which can be no later than the first day of the second month after the filing of a request for disenrollment.

6. Expedited Appeals

a. The Managed Care Plan shall have an expedited review process for appeals for use when taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain or regain maximum function.

b. The Managed Care Plan shall resolve each expedited appeal and provide notice to the enrollee, as quickly as the enrollee’s health condition requires, within state established timeframes not to exceed seventy-two (72) hours after the Managed Care Plan receives the appeal request, whether the appeal was made orally or in writing.

c. The Managed Care Plan shall ensure that no punitive action is taken against a provider who requests or supports a request for an expedited appeal.

d. If the Managed Care Plan denies the request for expedited appeal, it shall immediately transfer the appeal to the timeframe for standard resolution and so notify the enrollee.

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7. Disposition Notice Requirements

a. The Managed Care Plan shall provide written notice of disposition of an appeal. In the case of an expedited appeal denial, the Managed Care Plan shall also provide oral notice by close of business on the day of disposition, and written notice within two (2) days of the disposition.

b. Content of notice — The written notice of resolution must include:

(1) The results of the resolution process and the date it was completed;

(2) If not decided in the enrollee’s favor, information on the right to request a Medicaid Fair Hearing and how to do so; the right to request to receive benefits while the hearing is pending, and how to make the request;

(3) If the Managed Care Plan does not have an independent external review organization for its grievance process, the right to appeal an adverse decision on an appeal to the Beneficiary Assistance Program (BAP), including how to initiate such a review and the following:

(a) Before filing with the BAP, the enrollee must complete the Managed Care Plan’s appeal process;

(b) The enrollee must submit the appeal to the BAP within one (1) year after receipt of the final decision letter from the Managed Care Plan;

(c) The BAP will not consider an enrollee appeal that has already been to a Medicaid Fair Hearing;

(d) The address and toll-free telephone number for enrollee appeals to the BAP are:

Agency for Health Care Administration

Beneficiary Assistance Program

Building 3, MS #26

2727 Mahan Drive

Tallahassee, Florida 32308

(850) 412-4502

(888) 419-3456 (toll-free)

(e) That the enrollee may have to pay for the cost of those benefits if the Medicaid Fair Hearing upholds the Managed Care Plan’s action.

8. Documentation and Reporting

a. The Managed Care Plan must maintain a record of all complaints, grievances and appeals.

b. The Managed Care Plan shall address, log, track and trend all complaints, regardless of the degree of seriousness or whether the enrollee or provider expressly requests filing the concern.

AHCA Contract No. FP020, Attachment II, Page 83 of 214

c. The log of complaints that do not become grievances must include date, complainant and enrollee name(s), Medicaid ID number, nature of complaint, description of resolution and final disposition. The Managed Care Plan shall submit this complaint log upon request of the Agency.

d. The Managed Care Plan shall report on complaints, grievances and appeals to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, and in the manner and format determined by the Agency.

9. Medicaid Fair Hearings (see 65-2.042-2.069, F.A.C.)

a. An enrollee may seek a Medicaid Fair Hearing without having first exhausted the Managed Care Plan’s grievance and appeal process.

b. An enrollee who chooses to exhaust the Managed Care Plan’s grievance and appeal process may still file for a Medicaid Fair Hearing within ninety (90) days of receipt of the Managed Care Plan’s notice of resolution.

c. An enrollee who chooses to seek a Medicaid Fair Hearing without pursuing the Managed Care Plan’s process must do so within ninety (90) days of receipt of the Managed Care Plan’s notice of action.

d. Parties to the Medicaid Fair Hearing include the Managed Care Plan as well as the enrollee, or that person’s authorized representative.

e. The addresses and phone numbers for Medicaid Fair Hearings can be found at:

Department of Children and Families

Office of Appeal Hearings

Building 5, Room 255

1317 Winewood Boulevard

Tallahassee, FL 32399-0700

(850) 488-1429

(850) 487-0662 (fax)

Appeal_Hearings@dcf.state.fl.us (email)

http://www.myflfamilies.com/about-us/office-inspector-general/investigation-reports/appeal-hearings

10. Continuation of Benefits

a. The Managed Care Plan shall continue the enrollee’s benefits if:

(1) The enrollee or the enrollee’s authorized representative files an appeal with the Managed Care Plan regarding the Managed Care Plan’s decision:

(a) Within ten (10) business days after the notice of the adverse action is mailed; or

(b) Within ten (10) business days after the intended effective date of the action, whichever is later.

AHCA Contract No. FP020, Attachment II, Page 84 of 214

(2) The appeal involves the termination, suspension or reduction of a previously authorized course of treatment;

(3) The services were ordered by an authorized provider;

(4) The original period covered by the original authorization has not expired; and

(5) The enrollee requests extension of benefits.

b. If, at the enrollee’s request, the Managed Care Plan continues or reinstates the benefits while the appeal is pending, benefits must continue until one (1) of the following occurs:

(1) The enrollee withdraws the appeal;

(2) Ten (10) business days pass after the Managed Care Plan sends the enrollee the notice of resolution of the appeal against the enrollee, unless the enrollee within those ten (10) days has requested a Medicaid Fair Hearing with continuation of benefits;

(3) The Medicaid Fair Hearing office issues a hearing decision adverse to the enrollee; or

(4) The time period or service limits of a previously authorized service have been met.

c. If the final resolution of the appeal is adverse to the enrollee and the Managed Care Plan’s action is upheld, the Managed Care Plan may recover the cost of services furnished to the enrollee while the appeal was pending to the extent they were furnished solely because of the continuation of benefits requirement.

d. If the Medicaid Fair Hearing officer reverses the Managed Care Plan’s action and services were not furnished while the appeal was pending, the Managed Care Plan shall authorize or provide the disputed services promptly.

e. If the Medicaid Fair Hearing officer reverses the Managed Care Plan’s action and the enrollee received the disputed services while the appeal was pending, the Managed Care Plan shall pay for those services in accordance with this Contract.

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AHCA Contract No. FP020, Attachment II, Page 85 of 214

Section V. Covered Services

A. Required Benefits

1. General Provisions

a. The Managed Care Plan shall ensure the provision of services in sufficient amount, duration and scope to be reasonably expected to achieve the purpose for which the services are furnished and shall ensure the provision of the covered services defined and specified in this Contract.

b. The Managed Care Plan shall not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the enrollee’s diagnosis, type of illness or condition. The Managed Care Plan may place appropriate limits on a service on the basis of such criteria as medical necessity, as defined by the Agency, or for utilization control, consistent with the terms of this Contract, provided the services furnished can be reasonably expected to achieve their purpose.

c. The Managed Care Plan shall comply with all current Florida Medicaid Handbooks (Handbooks) as noticed in the Florida Administrative Register (FAR), or incorporated by reference in rules relating to the provision of services, except where the provisions of the Contract alter the requirements set forth in the Handbooks and Medicaid fee schedules.

d. The Managed Care Plan is responsible for ensuring that all providers, service and product standards specified in the Agency’s Medicaid Services Coverage & Limitations Handbooks and the Managed Care Plan’s own provider handbooks are incorporated into the Managed Care Plan’s provider contracts. This includes professional licensure and certification standards for all service providers. Exceptions exist where different standards are specified elsewhere in this Contract.

e. The Managed Care Plan shall require non-participating providers to coordinate with respect to payment and must ensure that cost to the enrollee is no greater than it would be if the covered services were furnished within the network.

f. LTC Managed Care Plans and Comprehensive LTC Managed Care Plans shall be responsible for tracking enrollees with LTC benefits that transition from the nursing facility into an ALF or other residence in the community, as well as those individuals that transition from the ALF or other residence in the community into a nursing facility. The LTC Managed Care Plan or Comprehensive LTC Managed Care Plan shall notify DCF of the date of nursing facility/ALF admission/discharge prior to the respective admission/discharge date. LTC Managed Care Plans and Comprehensive LTC Managed Care Plans shall submit reports on these transitions to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. In addition, for each enrollee transitioning from a nursing facility into an ALF or other residence in the community, the Managed Care Plan shall complete and submit to DCF a 2515 form (Certification of Enrollment Status HCBS) within five (5) days after the date the Managed Care Plan becomes aware of nursing facility discharge. The Managed Care Plan shall retain proof of submission of the completed 2515 form to DCF.

AHCA Contract No. FP020, Attachment II, Page 86 of 214

2. Specific Services to be Provided

a. MMA Managed Care Plans and Comprehensive LTC Managed Care Plans shall ensure the provision of the covered services specified in the MMA Exhibit, including those covered under s. 409.973(1)(a) through (cc), F.S.

b. LTC Managed Care Plans and Comprehensive LTC Managed Care Plans shall ensure the provision of the covered services specified in the LTC Exhibit, including those covered under s. 409.98(1) through (19), F.S.

c. LTC Managed Care Plans and Comprehensive LTC Managed Care Plans are responsible for implementing and managing the Participant Direction Option (PDO) for enrollees with LTC benefits, as defined in Section I, Definitions and Acronyms, and as specified in the LTC Exhibit.

d. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those specified in the Handbooks and Medicaid fee schedules except that, pursuant to s. 409.973(2), F.S., the Managed Care Plan may customize benefit packages for non-pregnant adults, vary cost-sharing provisions, and provide coverage for additional MMA services as specified in the MMA Exhibit.

B. Expanded Benefits

1. General Provisions

a. The Managed Care Plan may offer expanded benefits as approved by the Agency.

b. The Managed Care Plan shall offer the approved expanded benefits to all enrollees in the applicable Managed Care program, subject to any Agency-agreed service limitations set forth in Attachment I of this Contract as follows:

(1) MMA enrollees shall receive MMA expanded benefits;

(2) LTC enrollees shall receive LTC expanded benefits;

(3) Specialty Plan enrollees shall receive both Specialty Plan and MMA expanded benefits; and

(4) Comprehensive LTC enrollees shall receive both MMA and LTC expanded benefits.

c. In instances where an expanded benefit is also a Medicaid covered service, the Managed Care Plan shall administer the benefit in accordance with any applicable service standards pursuant to this Contract, the Florida Medicaid State Plan and any Medicaid Coverage and Limitations Handbooks.

AHCA Contract No. FP020, Attachment II, Page 87 of 214

2. Types of Expanded Benefits

a. The Managed Care Plan may offer services in excess of the amount, duration and scope of those listed in the MMA Exhibit for MMA Managed Care Plans and Comprehensive LTC Plans, and the LTC Exhibit for Comprehensive LTC Managed Care Plans and LTC Managed Care Plans.

b. The Managed Care Plan may offer other services and benefits not listed in the MMA Exhibit and the LTC Exhibit upon approval of the Agency. The Managed Care Plan shall define such expanded benefits specifically in writing and submit them to the Agency for approval before implementation. Such expanded benefits are those services or benefits not otherwise covered or that exceed limits outlined in the in the Medicaid State Plan and the Florida Medicaid Coverage and Limitations Handbooks and the Florida Medicaid Fee Schedules.

c. The Managed Care Plan may offer an over-the-counter expanded drug benefit. Such benefits shall be limited to nonprescription drugs containing a national drug code (NDC) number, first aid supplies, vitamins and birth control supplies. Such benefits must be offered directly through the Managed Care Plan’s fulfillment house or through a subcontractor, in which a debit card system may be used. The Managed Care Plan shall make payments for the over-the-counter drug benefit directly to the subcontractor, if applicable. Over-the-counter expanded drug benefits shall not exceed the following limits:

(1) For MMA Managed Care Plans, such benefits shall not to exceed twenty-five dollars ($25) per household per month for enrollees with MMA benefits.

(2) In addition to MMA Managed Care Plan benefits, LTC Managed Care Plan benefits shall not to exceed fifteen dollars ($15) per individual per month for enrollees with LTC benefits.

3. Changes to Expanded Benefits Offered

a. The Managed Care Plan shall submit to the Agency for approval, by the date specified by the Agency, of each Contract year, a Plan Evaluation Tool (PET) for a CBP.

b. Such changes in the Managed Care Plan’s expanded benefits shall only be for additional expanded benefits or if the Managed Care Plan is proposing to exchange an expanded benefit for another, the proposed expanded benefit must be determined to be actuarially equivalent, by the Agency, to the expanded benefit being proposed to be removed. In no instance may the Managed Care Plan reduce or remove an expanded benefit if supplemental expanded benefit(s) are not proposed by the Managed Care Plan and approved by the Agency.

c. The Managed Care Plan’s expanded benefits may be changed on a Contract year basis and only as approved in writing by the Agency.

AHCA Contract No. FP020, Attachment II, Page 88 of 214

C. Excluded Services

1. General Provisions

The Managed Care Plan is not obligated to provide any services not specified in this Contract. Enrollees who require services available through Medicaid but not covered by this Contract shall receive the services through other appropriate Medicaid programs, including the Medicaid fee-for-service system. In such cases, the Managed Care Plan’s responsibility shall include care coordination/case management and referral. Therefore, the Managed Care Plan shall determine the potential need for the services and refer the enrollee to the appropriate Medicaid program and/or service provider. The Managed Care Plan may request assistance from the local Medicaid Area Office or ADRC for referral to the appropriate Medicaid program and/or service setting.

2. Moral or Religious Objections

The Managed Care Plan shall provide or arrange for the provision of all covered services. If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Managed Care Plan elects not to provide, reimburse for, or provide counseling or referral to a covered service because of an objection on moral or religious grounds, the Managed Care Plan shall notify:

a. The Agency within one-hundred twenty (120) days before implementing the policy with respect to any covered service; and

b. Enrollees within thirty (30) days before implementing the policy with respect to any covered service.

D.    Coverage Provisions

1. Service-Specific Requirements

The Managed Care Plan shall provide the services listed in this Contract in accordance with the provisions herein, and shall comply with all state and federal laws pertaining to the provision of such services. The Managed Care Plan shall provide coverage in accordance with the Florida Medicaid Coverage and Limitations Handbooks, Medicaid fee schedules and the Florida Medicaid State Plan, as well as specific coverage requirements with respect to the applicable SMMC program, as follows:

a. MMA Managed Care Plans must comply with additional provisions for covered services specified in the MMA Exhibit.

b. LTC Managed Care Plans must comply with additional provisions for covered services specified in the LTC Exhibit.

c. Comprehensive LTC Managed Care Plans must comply with additional provisions for covered services specified in both the MMA Exhibit and the LTC Exhibit.

AHCA Contract No. FP020, Attachment II, Page 89 of 214

2. Behavioral Health

a. For SMMC enrollees, behavioral health services will be provided to enrollees by other sources, including Medicare, and state-funded programs and services. The Managed Care Plan shall coordinate with other entities, including MMA Managed Care Plans, Medicare plans, Medicare providers, and state-funded programs and services.

b. LTC Managed Care Plans shall be responsible for coordinating with other entities’ MMA Managed Care Plans available to provide behavioral health services for these enrollees as specified in the LTC Exhibit.

c. MMA Managed Care Plans and Comprehensive LTC Managed Care Plans shall provide a full range of medically necessary behavioral health services for enrollees as authorized under the Medicaid State Plan and specified in the MMA Exhibit.

3. Managing Mixed Services

a. The Managed Care Plan shall provide case management and care coordination with other Managed Care Plans for enrollees with both MMA benefits and LTC benefits to ensure mixed services are not duplicative but rather support the enrollee in an efficient and effective manner. Mixed Services include:

(1) Assistive Care Services;

(2) Home health and nursing care (intermittent and skilled nursing);

(3) Hospice services;

(4) Medical equipment and supplies (including durable medical equipment); and

(5) Therapy services (physical, occupational, respiratory and speech).

b. MMA Managed Care Plans shall provide mixed services to enrollees with only MMA benefits.

c. The Managed Care Plan, if a Comprehensive LTC Plan, shall provide mixed services to enrollees receiving LTC benefits from the Managed Care Plan.

d. LTC Managed Care Plans shall provide mixed services to enrollees with LTC benefits, regardless of an enrollee’s enrollment in an MMA Managed Care Plan.

e. Comprehensive LTC Plans shall provide mixed services to enrollees with both MMA benefits and LTC benefits enrolled in the Comprehensive LTC Plan for both MMA benefits and LTC benefits.

f. Managed Care Plans shall provide non-emergency transportation (NET) services to enrollees with both MMA benefits and LTC benefits as follows:

(1) MMA Managed Care Plans shall provide NET to all MMA benefits.

(2) LTC Managed Care Plans shall provide NET to all LTC benefits.

AHCA Contract No. FP020, Attachment II, Page 90 of 214

(3) Comprehensive LTC Managed Care Plans shall provide NET to enrollees with both MMA and LTC benefits, and provide NET to all MMA benefits for enrollees with only MMA benefits.

g. The Managed Care Plan shall also provide case management and care coordination with other service delivery systems serving enrollees in the Managed Care Plan to ensure services are not duplicative but rather support the enrollee in an efficient and effective manner.

E. Care Coordination/Case Management

1. General Provisions

a. The Managed Care Plan shall be responsible for care coordination and case management for all enrollees.

b. The Managed Care Plan shall provide care coordination and case management to enrollees as specified in this Contract and with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall comply with care coordination and case management requirements specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall comply with care coordination and case management requirements specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall comply with care coordination and case management requirements specified in the MMA Exhibit and the LTC Exhibit.

c. The Managed Care Plan shall provide disease management programs as follows:

(1) MMA Managed Care Plans shall provide disease management programs specified in Attachment I of this Contract.

(2) LTC Managed Care Plans shall provide disease management programs specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall provide disease management programs specified inAttachment I of this Contract and the LTC Exhibit.

2. Transition of Care

a. The Managed Care Plan shall develop and maintain transition of care policies and procedures that address all transitional care coordination/care management requirements and submit these policies and procedures for review and approval to the Agency. Transition of care policies and procedures shall include the following minimum functions:

(1) Appropriate support to case managers, and to enrollees and caregivers as needed, for referral and scheduling assistance for enrollees needing specialty health care, transportation or other service supports;

AHCA Contract No. FP020, Attachment II, Page 91 of 214

(2) Determination of the need for non-covered services and referral of the enrollee for assessment and referral to the appropriate service setting with assistance, as needed, by the Agency. Transfer of medical/case records in compliance with HIPAA privacy and security rules;

(3) Documentation of referral services in enrollee medical/case records, including follow up resulting from the referral;

(4) Monitoring of enrollees with co-morbidities and complex medical conditions and coordination of services for high utilizers to identify gaps in services and evaluate progress of case management;

(5) Identification of enrollees with hospitalizations, including emergency care encounters and documentation in enrollee medical/case records of appropriate follow-up to assess contributing reasons for emergency visits and develop actions to reduce avoidable emergency room visits and potentially avoidable hospital admissions;

(6) Transitional care coordination/care management that includes coordination of hospital/institutional discharge planning and post-discharge care, including conducting a comprehensive assessment of enrollee and family caregiver needs, coordinating the patient’s discharge plan with the family and hospital provider team, collaborating with the hospital or institution’s care coordinator/case manager to implement the plan in the patient’s home and facilitating communication and the transition to community providers and services. The policy and procedures shall define reporting requirements for nursing facility transition, including reporting schedules for case management and submission to the Agency on a quarterly basis; and

(7) 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 describing the requirements regarding the privacy of individually identifiable health information.

b. The Managed Care Plan shall be responsible for coordination of care for new enrollees transitioning into the Managed Care Plan.

c. The Managed Care Plan shall be responsible for coordination of care for enrollees transitioning to another Managed Care Plan or delivery system and shall assist the new Managed Care Plan with obtaining the enrollee’s medical/case records.

d. The Managed Care Plan shall implement a process determined by the Agency to ensure records and information are shared and passed to the new Managed Care Plan within thirty (30) days.

AHCA Contract No. FP020, Attachment II, Page 92 of 214

4. Health Management

a. The Managed Care Plan shall develop and maintain written policies and procedures that address components of effective health management including, but not limited to, anticipation, identification, monitoring, measurement, evaluation of enrollee’s health care needs and effective action to promote quality of care.

b. The Managed Care Plan shall define and implement improvements in processes that enhance clinical efficiency, provide effective utilization and focus on improved outcome management achieving the highest level of success.

c. The Managed Care Plan, through its QI plan, shall demonstrate specific interventions in its health management to better manage the care and promote healthier enrollee outcomes.

5. Disease Management Program

a. Disease management programs provided by the Managed Care Plan shall address co-morbid conditions and consider the whole health of the enrollee.

b. Disease Management programs provided by the Managed Care Plan shall include, but are not limited to, the following components:

(1) Education based on the enrollee assessment of health risks and chronic conditions;

(2) Symptom management including addressing needs such as working with the enrollee on health goals;

(3) Emotional issues of the caregiver;

(4) Behavioral management issues of the enrollee;

(5) Communicating effectively with providers; and

(6) Medication management, including the review of medications that an enrollee is currently taking to ensure that the enrollee does not suffer adverse effects or interactions from contra-indicated medications.

c. The Managed Care Plan shall have policies and procedures regarding disease management programs provided that include the following:

(1) How enrollees are identified for eligibility and stratified by severity and risk level, including details regarding the algorithm and data sources used to identify eligible enrollees;

(2) How eligible enrollees are contacted for outreach and attempts are made to engage enrollees in disease management services. The Managed Care Plan shall maintain documentation that demonstrates that reasonable attempts were made by the Managed Care Plan to contact and engage eligible enrollees into disease management services;

AHCA Contract No. FP020, Attachment II, Page 93 of 214

(3) How the disease management program interfaces with the enrollee’s PCP and/or specialist providers and ensures coordination of care; and

(4) How the Managed Care Plan identifies available community support services and facilitates enrollee referrals to those entities for enrollees with identified community support needs.

d. The Managed Care Plan shall submit a copy of its policies and procedures and program description for each of its disease management programs to the Agency by April 1 of each Contract year. If no changes, the Managed Care Plan shall attest to such.

e. The Managed Care Plan shall develop and use a plan of treatment for each disease management program participant that is tailored to the individual enrollee. The plan of treatment shall be on file for each disease management program participant and shall include measurable goals/outcomes and sufficient information to determine if goals/outcomes are met. The enrollee’s ability to adhere to a treatment regimen shall be monitored in the plan of treatment and include interventions designed to improve the enrollee’s ability to adhere to the plan of treatment. The plan of treatment shall be updated at least annually and as required by changes in an enrollee’s condition.

F. Quality Enhancements

1. In addition to the covered services specified in this section, the Managed Care Plan shall offer and coordinate access to quality enhancements (QEs). Managed Care Plans are not reimbursed by the Agency for these services, nor may the Managed Care Plan offer these services as expanded benefits. The Managed Care Plan must offer QEs to as follows:

(a) MMA Managed Care Plans shall offer additional quality enhancements as specified in the MMA Exhibit.

(b) LTC Managed Care Plans shall offer additional quality enhancements as specified in the LTC Exhibit.

(c) Comprehensive LTC Managed Care Plans shall offer additional quality enhancements as specified in the MMA Exhibit for enrollees with MMA benefits only and the LTC Exhibit for enrollees with LTC benefits.

2. The Managed Care Plan shall develop and maintain written policies and procedures to implement QEs.

3. The Managed Care Plan shall provide information in the enrollee and provider handbooks on the QEs and how to access related services.

4. The Managed Care Plan shall offer QEs in community settings accessible to enrollees.

AHCA Contract No. FP020, Attachment II, Page 94 of 214

5. The Managed Care Plan is encouraged to actively collaborate with community agencies and organizations.

6. If the Managed Care Plan involves the enrollee in an existing community program for purposes of meeting the QE requirements, the Managed Care Plan shall ensure documentation in the enrollee’s medical/case record of referrals to the community program and follow up on the enrollee’s receipt of services from the community program.

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AHCA Contract No. FP020, Attachment II, Page 95 of 214

Section VI. Provider Network

A. Network Adequacy Standards

1. General Provisions

a. The Managed Care Plan shall enter into provider contracts with a sufficient number of providers to provide all covered services to enrollees and ensure that each covered service is provided promptly and is reasonably accessible.

b. The Managed Care Plan shall develop and maintain a provider network that meets the needs of enrollees in accordance with the requirements of this Contract.

c. When establishing and maintaining the provider network or requesting enrollment level increases, the Managed Care Plan shall take the following into consideration as required by 42 CFR 438.206:

(1) The anticipated number of enrollees;

(2) The expected utilization of services, taking into consideration the characteristics and health care needs of specific Medicaid populations represented;

(3) The numbers and types (in terms of training, experience and specialization) of providers required to furnish the covered services;

(4) The numbers of participating providers who are not accepting new enrollees; and

(5) The geographic location of providers and enrollees, considering distance, travel time, the means of transportation ordinarily used by enrollees and whether the location provides physical access for Medicaid enrollees with disabilities.

d. Except as otherwise provided in the Contract, the Managed Care Plan may limit the providers in its network based on credentials, quality indicators, and price.

e. The Managed Care Plan shall allow each enrollee to choose among participating providers in accordance with 42 CFR 431.51.

2. Network Capacity and Geographic Access Standards

a. The Managed Care Plan shall have sufficient facilities, service locations and practitioners to provide the covered services as required by this Contract.

b. The Managed Care Plan shall have the capacity to provide covered services to all enrollees up to the maximum enrollment level, by region, as indicated in this Contract.

AHCA Contract No. FP020, Attachment II, Page 96 of 214

c. Pursuant to s. 409.967(2)(c)(1), F.S., the Managed Care Plan shall maintain a region-wide network of providers in sufficient numbers to meet the network capacity and geographic access standards for services with respect to the applicable SMMC program, as follows:

(1) MMA Managed Care Plans shall meet the network capacity and geographic access standards specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall meet the network capacity and geographic access standards specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall meet the network capacity and geographic access standards specified in the both the MMA Exhibit and the LTC Exhibit.

3. Demonstration of Network Adequacy

The Managed Care Plan shall submit a provider network file of all participating providers to the Agency or its agent(s) as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

4. Timely Access Standards

a. The Managed Care Plan shall contract with and maintain a provider network sufficient to comply with timely and geographic access standards as specified in this Contract with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans and Comprehensive LTC Managed Care Plans shall comply with timely access standards specified in the MMA Exhibit.

b. In accordance with 42 CFR 438.206 (c), the Managed Care Plan shall establish mechanisms to ensure network providers comply with timely access requirements, monitor regularly to determine compliance and take corrective action if there is a failure to comply.

B. Network Development and Management Plan

1. General Provisions

a. The Managed Care Plan shall develop and maintain an annual network development and management plan (annual network plan). The Managed Care Plan shall submit this plan annually to the Agency.

b. The Managed Care Plan shall develop and maintain policies and procedures to evaluate the Managed Care Plan’s provider network to ensure that covered services are:

(1) Available and accessible, at a minimum, in accordance with the access standards in the Contract;

(2) Provided promptly and are reasonably accessible in terms of location and hours of operation; and

AHCA Contract No. FP020, Attachment II, Page 97 of 214

(3) For LTC Managed Care Plans and Comprehensive LTC Managed Care Plans, home and community-based services (HCBS) are available to enrollees with LTC benefits on a seven (7) day a week basis, and for extended hours, as dictated by enrollee needs.

c. The methodology(ies) the Managed Care Plan uses to collect and analyze enrollee, provider and staff feedback about the network designs and performance, and, when specific issues are identified, the protocols for handling them.

2. Annual Network Plan Content

a. The Managed Care Plan’s annual network plan shall include the Managed Care Plan’s processes to develop, maintain and monitor an appropriate provider network that is sufficient to provide adequate access to all services covered under this Contract.

b. The Managed Care Plan’s annual network plan must include a description of network design by region and county for the general population, including details regarding special populations as identified by the Managed Care Plan (e.g., medically complex). The description shall also cover:

(1) How enrollees access the system;

(2) Analysis of timely access to services; and

(3) Relationships among various levels of the system.

c. The Managed Care Plan’s annual network plan must include a description of the evaluation of the prior year’s plan including an explanation of the method used to evaluate the network and reference to the success of proposed interventions and/or the need for re-evaluation.

d. Managed Care Plan’s annual network plan must include a description or explanation of the current status of the network by each covered service at all levels including:

(1) How enrollees access services;

(2) Analysis of timely access to services;

(3) Relationships between the various levels, focusing on provider-to-provider contact and facilitation of such by the Managed Care Plan (e.g., PCP, specialists, hospitals, behavioral health, ALFs, home health agencies); and

(4) For MMA and Comprehensive LTC Managed Care Plans, the assistance and communication tools provided to PCPs when they refer enrollees to specialists and the methods used to communicate the availability of this assistance to the providers.

AHCA Contract No. FP020, Attachment II, Page 98 of 214

e. The Managed Care Plan’s annual network plan must any current barriers and/or network gaps and include the following:

(1) The methodology used to identify barriers and network gaps;

(2) Immediate short-term interventions to address network gaps;

(3) Longer-term interventions to fill network gaps and resolve barriers;

(4) Outcome measures/evaluation of interventions to fill network gaps and resolve barriers;

(5) Projection of changes in future capacity needs, by covered service; and

(6) Ongoing activities for network development based on identified gaps and future needs projection.

f. The Managed Care Plan’s annual network plan must include a description of coordination between internal departments, including a comprehensive listing of all committees and committee membership where this coordination occurs. Identification of members should include the department/area (e.g., quality management, medical management/utilization management, grievances, finance, claims) that they represent on the committee.

g. The Managed Care Plan’s annual network plan must include a description of coordination with outside organizations.

3. Waiver

a. If the Managed Care Plan is able to demonstrate to the Agency’s satisfaction that a region as a whole is unable to meet network requirements, the Agency may waive the requirement at its discretion in writing. As soon as additional service providers become available, however, the Managed Care Plan shall augment its network to include such providers in order to meet the network adequacy requirements. Such a written waiver shall require attestation by the Managed Care Plan that it agrees to modify its network to include such providers as they become available.

b. If the Managed Care Plan is unable to provide medically necessary services to an enrollee through its network, the Managed Care Plan shall cover these services in an adequate and timely manner by using providers and services that are not in the Managed Care Plan’s network for as long as the Managed Care Plan is unable to provide the medically necessary services within its network.

4. Regional Network Changes

a. The Managed Care Plan shall have procedures to address changes in the Managed Care Plan network that negatively affect the ability of enrollees to access services, including access to a culturally diverse provider network.

b. The Managed Care Plan shall provide the Agency with documentation of compliance with access requirements at any time there has been a significant change in the

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Managed Care Plan’s regional operations that would affect adequate capacity and services, including, but not limited to, the following:

(1) Changes in Managed Care Plan services; and

(2) Enrollment of a new population in the Managed Care Plan.

c. The Managed Care Plan shall notify the Agency within seven (7) business days of any adverse changes to its regional provider network. An adverse change is defined as follows:

(1) For MMA Managed Care Plans, adverse changes to the composition of the network that impair access standards as specified in the MMA Exhibit;

(2) For LTC Managed Care Plans, adverse changes to the composition of the network that impair access standards as specified in the LTC Exhibit; or

(3) For Comprehensive LTC Managed Care Plans, adverse changes to the composition of the network that impair access standards as specified in both the MMA Exhibit and the LTC Exhibit.

d. Significant changes in regional network composition that the Agency determines negatively impact enrollee access to services may be grounds for Contract termination or sanctions as determined by the Agency and in accordance with Section XI, Sanctions.

C. Provider Credentialing and Contracting

1. General Provision

The Managed Care Plan shall be responsible for the credentialing and recredentialing of its provider network.

2. Credentialing and Recredentialing

a. The Managed Care Plan’s credentialing and recredentialing policies and procedures shall be in writing and include the following:

(1) Formal delegations and approvals of the credentialing process;

(2) A designated credentialing committee;

(3) Identification of providers who fall under its scope of authority;

(4) A process that provides for the verification of the credentialing and recredentialing criteria required under this Contract;

(5) Approval of new providers and imposition of sanctions, termination, suspension and restrictions on existing providers;

(6) Identification of quality deficiencies that result in the Managed Care Plan’s restriction, suspension, termination or sanctioning of a provider.

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b. The Managed Care Plan shall establish and verify credentialing and recredentialing criteria for all providers that, at a minimum, meet the Agency’s Medicaid participation standards. The Agency’s criteria include:

(1) A copy of each provider’s current medical license for medical providers, or occupational or facility license as applicable to provider type, or authority to do business, including documentation of provider qualifications; if the provider is located in Georgia or Alabama, the provider’s license and permit must be current and applicable to the respective state in which the provider is located;

(2) No revocation, moratorium or suspension of the provider’s state license by the Agency or the Department of Health, if applicable;

(3) Evidence of the provider’s professional liability claims history;

(4) Any sanctions imposed on the provider by Medicare or Medicaid;

(5) Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106); and

(6) A satisfactory level II background check pursuant to s. 409.907, F.S., for all treating providers not currently enrolled in Medicaid’s fee-for-service program, in accordance with the following:

(a) The Managed Care Plan shall verify the provider’s Medicaid eligibility through the Agency’s electronic background screening system; if the provider’s fingerprints are not retained in the Care Provider Background Screening Clearinghouse (Clearinghouse, see s. 435.12, F.S.) and/or eligibility results are not found, the Managed Care Plan shall submit complete sets of the provider’s fingerprints electronically for Medicaid Level II screening following the appropriate process described on the Agency’s background screening website;

(b) The Managed Care Plan shall not contract with any provider who has a record of illegal conduct; i.e., found guilty of, regardless of adjudication, or who entered a plea of nolo contendere or guilty to any of the offenses listed in s. 435.04, F.S.; and

(c) For Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history background screening cannot be documented, the Managed Care Plan must provide fingerprints electronically following the process described on the Agency’s background screening website.

c. The Managed Care Plan’s credentialing and recredentialing files must document the education, experience, prior training and ongoing service training for each staff member or provider rendering services.

d. The Managed Care Plan shall collect and verify each provider’s National Provider Identifier (NPI) and taxonomy as part of the credentialing and recredentialing process, as applicable.

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e. The Managed Care Plan shall establish and verify additional provider credentialing and recredentialing criteria with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall verify the additional criteria specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall verify the additional criteria specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall verify the additional criteria specified in the MMA Exhibit for MMA providers and the LTC Exhibit for LTC providers. Comprehensive LTC Managed Care Plans shall verify the additional criteria for all mixed service providers specified in the MMA Exhibit.

f. The Managed Care Plan must submit disclosures and notifications to the federal Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) and to MPI in accordance with s. 1128, s. 1156, and s. 1892, of the Social Security Act, 42 CFR 455.106, 42 CFR 1002.3, and 42 CFR 1001.1, as described in Section VIII.F.

g. The Managed Care Plan shall not pay, employ or contract with individuals on the state or federal exclusions lists.

h. If the Managed Care Plan declines to include individual providers or groups of providers in its network, it must give the affected providers written notice of the reason for its decision.

3. Provider Registration

a. The Managed Care Plan shall ensure that all providers are eligible for participation in the Medicaid program. If a provider is currently suspended or terminated from the Florida Medicaid program whether by contract or sanction, other than for purposes of inactivity, that provider is not considered an eligible Medicaid provider. Suspension and termination are described further in Rule 59G-9.070, F.A.C.

b. The Managed Care Plan shall require each provider to have a unique Florida Medicaid provider number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form.

c. The Managed Care Plan shall require each provider to have a National Provider Identifier (NPI) in accordance with s. 1173(b) of the Social Security Act, as enacted by s. 4707(a) of the Balanced Budget Act of 1997. The provider contract shall require providers to submit all NPIs to the Managed Care Plan. The Managed Care Plan shall file the providers’ NPIs as part of its provider network file to the Agency or its agent, as set forth in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. The Managed Care Plan need not obtain an NPI from an entity that does not meet the definition of “health care provider” found at 45 CFR 160.103:

(1) Individuals or organizations that furnish atypical or nontraditional services that are only indirectly related to the provision of health care (examples include taxis, home modifications, home delivered meals and homemaker services); and

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(2) Individuals or businesses that only bill or receive payment for, but do not furnish, health care services or supplies (examples include billing services and repricers).

4. Minority Recruitment and Retention Plan

The Managed Care Plan shall implement and maintain a minority recruitment and retention plan in accordance with s. 641.217, F.S. The Managed Care Plan shall have policies and procedures for the implementation and maintenance of such a plan. The minority recruitment and retention plan may be company-wide for all product lines.

5. Prohibition Against Discriminatory Practices

a. The Managed Care Plan shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider, whether participating or nonparticipating, who is acting within the scope of the provider’s license or certification under applicable state law, solely on the basis of such license or certification, in accordance with s. 1932(b) (7) of the Social Security Act (as enacted by s. 4704[a] of the Balanced Budget Act of 1997).

b. The Managed Care Plan shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatments.

6. Provider Contract Requirements

a. The Managed Care Plan shall submit all provider contract templates for Agency review to determine compliance with Contract requirements. The Managed Care Plan shall submit to the Agency, upon request, individual provider contracts as required by the Agency. If the Agency determines, at any time, that a provider contract is not in compliance with a Contract requirement, the Managed Care Plan shall promptly revise the provider contract to bring it into compliance. In addition, the Managed Care Plan may be subject to sanctions pursuant to Section XIV, Sanctions, and/or liquidated damages pursuant to Section XIII, Liquidated Damages.

b. The Managed Care Plan shall ensure all provider contracts comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR 455.105, and 42 CFR 455.106.

c. All provider contracts and amendments executed by the Managed Care Plan shall be in writing, signed and dated by the Managed Care Plan and the provider, and shall meet the following requirements:

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(1) Contain no provision that in any way prohibits or restricts the provider from entering into a commercial contract with any other Managed Care Plan (see s. 641.315, F.S.);

(2) Contain no provision requiring the provider to contract for more than one (1) Managed Care Plan product or otherwise be excluded (see s. 641.315, F.S.);

(3) Not prohibit a provider from acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee for the enrollee’s health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered;

(4) Not prohibit a provider from discussing treatment or non-treatment options with enrollees that may not reflect the Managed Care Plan’s position or may not be covered by the Managed Care Plan;

(5) Not prohibit a provider from advocating on behalf of the enrollee in any grievance system or UM process, or individual authorization process to obtain necessary services;

(6) Require providers to offer hours of operation that are no less than the hours of operation offered to commercial Managed Care Plan members or comparable Medicaid fee-for-service recipients if the provider serves only Medicaid recipients;

(7) Specify covered services and populations to be served under the provider contract;

(8) Require providers to immediately notify the Managed Care Plan of an enrollee’s pregnancy, whether identified through medical history, examination, testing, claims or otherwise;

(9) For nursing facility and hospice, include a bed hold days provision that comports with Medicaid FFS bed hold days policies and procedures;

(10) Require all direct service providers to complete abuse, neglect and exploitation training;

(11) Include provisions for the immediate transfer to another provider if the enrollee’s health or safety is in jeopardy;

(12) Require providers of transitioning enrollees to cooperate in all respects with providers of other Managed Care Plans to assure maximum health outcomes for enrollees;

(13) Provide for continuity of treatment in the event a provider contract terminates during the course of an enrollee’s treatment by that provider;

(14) Prohibit the provider from seeking payment from the enrollee for any covered services provided to the enrollee within the terms of this Contract;

(15) Require the provider to look solely to the Managed Care Plan for compensation for services rendered, with the exception of nominal cost sharing and patient

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responsibility, pursuant to the Medicaid State Plan and the Medicaid Provider General and Coverage and Limitations Handbooks

(16) Specify that any claims payment be accompanied by an itemized accounting of the individual claims included in the payment including, but not limited to, the enrollee’s name, the date of service, the procedure code, the service units, the amount of reimbursement and the identification of the Managed Care Plan;

(17) Require the provider to cooperate with the Managed Care Plan’s peer review, grievance, QI and UM activities, provide for monitoring and oversight, including monitoring of services rendered to enrollees, by the Managed Care Plan (or its subcontractor), and identify the measures that will be used by the Managed Care Plan to monitor the quality and performance of the provider. If the Managed Care Plan has delegated the credentialing to a subcontractor, the agreement must ensure that all providers are credentialed in accordance with the Managed Care Plan’s and the Agency’s credentialing requirements as found in Section VI. C.2.;

(18) Require that providers and subcontractors comply with the Managed Care Plan’s cultural competency plan;

(19) Require that any marketing materials related to this Contract that are displayed by the provider be submitted to the Agency for written approval before use;

(20) Specify that the provider shall comply with the marketing requirements specified in Section III.D.;

(21) Require an adequate record system be maintained for recording services, charges, dates and all other commonly accepted information elements for services rendered to the Managed Care Plan;

(22) Require that records be maintained for a period not less than six (6) years from the close of the Contract, and retained further if the records are under review or audit until the review or audit is complete. Prior approval for the disposition of records must be requested and approved by the Managed Care Plan if the provider contract is continuous;

(23) Specify that DHHS, the Agency, DOEA, MPI and MFCU shall have the right to inspect, evaluate, and audit all of the following related to this Contract:

(a) Pertinent books;

(b) Financial records;

(c) Medical/case records; and

(d) Documents, papers and records of any provider involving financial transactions;

(24) Provide for submission of all reports and clinical information required by the Managed Care Plan, including Child Health Check-Up reporting (if applicable);

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(25) Require providers to submit timely, complete and accurate encounter data to the Managed Care Plan in accordance with the requirements of Section VIII.E.;

(26) Require providers to cooperate fully in any investigation by the Agency, MPI, MFCU or other state or federal entity and in any subsequent legal action that may result from such an investigation involving this Contract;

(27) Require compliance with the background screening requirements of this Contract;

(28) Require safeguarding of information about enrollees according to 42 CFR 438.224;

(29) Require compliance with HIPAA privacy and security provisions;

(30) Require providers to submit notice of withdrawal from the network at least ninety (90) days before the effective date of such withdrawal;

(31) Specify that in addition to any other right to terminate the provider contract, and notwithstanding any other provision of this Contract, the Agency or the Managed Care Plan may request immediate termination of a provider contract if, as determined by the Agency, a provider fails to abide by the terms and conditions of the provider contract, or in the sole discretion of the Agency, the provider fails to come into compliance with the provider contract within fifteen (15) days after receipt of notice from the Managed Care Plan specifying such failure and requesting such provider abide by the terms and conditions thereof;

(32) Specify that any provider whose participation is terminated pursuant to the provider contract for any reason shall utilize the applicable appeals procedures outlined in the provider contract. No additional or separate right of appeal to the Agency or the Managed Care Plan is created as a result of the Managed Care Plan’s act of terminating, or decision to terminate, any provider under this Contract. Notwithstanding the termination of the provider contract with respect to any particular provider, this Contract shall remain in full force and effect with respect to all other providers;

(33) Require an exculpatory clause, which survives provider contract termination, including breach of provider contract due to insolvency, which assures that neither Medicaid recipients nor the Agency shall be held liable for any debts of the provider;

(34) Require that the provider secure and maintain during the life of the provider contract workers’ compensation insurance (complying with the Florida workers’ compensation law) for all of its employees connected with the work under this Contract unless such employees are covered by the protection afforded by the Managed Care Plan;

(35) Require all providers to notify the Managed Care Plan in the event of a lapse in general liability or medical malpractice insurance, or if assets fall below the amount necessary for licensure under Florida statutes;

(36) Contain a clause indemnifying, defending and holding the Agency and the Managed Care Plan’s enrollees harmless from and against all claims, damages,

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causes of action, costs or expenses, including court costs and reasonable attorney fees, to the extent proximately caused by any negligent act or other wrongful conduct arising from the provider contract. This clause must survive the termination of the provider contract, including breach due to insolvency. The Agency may waive this requirement for itself, but not Managed Care Plan enrollees, for damages in excess of the statutory cap on damages for public entities, if the provider is a state agency or subdivision as defined by s. 768.28, F.S., or a public health entity with statutory immunity. All such waivers shall be approved in writing by the Agency;

(37) Make provisions for a waiver of those terms of the provider contract that, as they pertain to Medicaid recipients, are in conflict with the specifications of this Contract; and

(38) Specify that any contracts, agreements or subcontracts entered into by the provider for purposes of carrying out any aspect of this Contract shall include assurances that the individuals who are signing the contract, agreement or subcontract are so authorized and that it includes all the requirements of this Contract.

d. The Managed Care Plan shall include additional provisions in its provider contracts with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall include the additional provisions specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall include the additional provisions specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall include additional provisions specified in the MMA Exhibit for MMA only providers, the LTC Exhibit for LTC only providers and the MMA Exhibit for mixed service providers.

e. No provider contract that the Managed Care Plan enters into with respect to performance under this Contract shall in any way relieve the Managed Care Plan of any responsibility for the provision of services or duties under this Contract. The Managed Care Plan shall assure that all services and tasks related to the provider contract are performed in accordance with the terms of this Contract. The Managed Care Plan shall identify in its provider contract any aspect of service that may be subcontracted by the provider.

f. The Managed Care Plan shall prohibit discrimination with respect to participation, reimbursement or indemnification of any provider who is acting within the scope of his/her license or certification under applicable state law, solely on the basis of such license or certification. This provision shall not be construed as an any willing provider law, as it does not prohibit the Managed Care Plan from limiting provider participation to the extent necessary to meet the needs of the enrollees. This provision does not interfere with measures established by the Managed Care Plan that are designed to maintain quality and control costs;

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7. Network Performance Management

a. The Managed Care Plan shall monitor the quality and performance of each participating provider.

b. The Managed Care Plan shall include using performance measures specified and collected by the Agency, as well as additional measures agreed upon by the provider and the Managed Care Plan.

c. The Managed Care Plan is not prohibited from including providers only to the extent necessary to meet the needs of the Managed Care Plan’s enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the Managed Care Plan.

d. The Managed Care Plan shall have policies and procedures for imposing provider sanctions, restrictions, suspensions and/or terminations.

e. The Managed Care Plan shall develop and implement an appeal procedure for providers against whom the Managed Care Plan has imposed sanctions, restrictions, suspensions and/or terminations.

8. Provider Termination and Continuity of Care

a. The Managed Care Plan shall comply with all state and federal laws regarding provider termination.

b. The Managed Care Plan shall notify enrollees in accordance with the provisions of this Contract and state and federal law regarding provider termination. Additionally, the Managed Care Plan shall provide notice to enrollees as follows:

(1) Pursuant to s. 409.982(1), F.S., if a LTC Managed Care Plan or Comprehensive LTC Managed Care Plan excludes an aging network provider for failure to meet quality or performance criteria specified in s. 409.967, F.S., the Managed Care Plan must provide written notice to all enrollees who have chosen that provider for care, and the notice must be provided at least thirty (30) days before the effective date of the exclusion.

(2) For MMA Managed Care Plans and Comprehensive LTC Managed Care Plans, if a PCP ceases participation in the Managed Care Plan’s network, the Managed Care Plan shall send written notice to the enrollees who have chosen the provider as their PCP. This notice must be provided at least thirty (30) days before the effective date of the termination notice. The requirement to provide notice prior to the effective dates of termination shall be waived in instances where a provider becomes physically unable to care for enrollees due to illness, death or leaving the Managed Care Plan’s region(s) and fails to notify the Managed Care Plan, or when a provider fails credentialing. Under these circumstances, notice shall be issued immediately upon the Managed Care Plan’s becoming aware of the circumstances.

(3) Pursuant to s. 409.975(1)(c), F.S., if a MMA or Comprehensive LTC Managed Care Plan excludes any essential provider from its network for failure to meet

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quality or performance criteria, the Managed Care Plan must provide written notice to all enrollees who have chosen that provider for care. The notice shall be provided at least thirty (30) days before the effective date of the exclusion.

c. The Managed Care Plan shall notify the provider and enrollees in active care at least sixty (60) days before the effective date of the suspension or termination of a provider from the network. If the termination was for "cause," the Managed Care Plan shall provide to the Agency the reasons for termination.

d. If an enrollee is receiving prior authorized care from any provider who becomes unavailable to continue to provide services, the Managed Care Plan shall notify the enrollee in writing within ten (10) days from the date the Managed Care Plan becomes aware of such unavailability. These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a provider becomes physically unable to care for enrollees due to illness, death or leaving the Managed Care Plan’s region(s) and fails to notify the Managed Care Plan, or when a provider fails credentialing. Under these circumstances, notice shall be issued immediately upon the Managed Care Plan’s becoming aware of the circumstances.

e. In a case in which a patient’s health is subject to imminent danger or a provider’s ability to practice medicine or otherwise provide services is effectively impaired by an action by the Board of Medicine or other governmental agency, notice to the provider, the enrollee and the Agency shall be immediate. The Managed Care Plan shall work cooperatively with the Agency to develop and implement a plan for transitioning enrollees to another provider.

f. The Managed Care Plan shall allow enrollees to continue receiving medically necessary services from a not-for-cause terminated provider and shall process provider claims for services rendered to such recipients until the enrollee selects another provider as specified below:

(1) For MMA and LTC services, continuation shall be provided for a minimum of sixty (60) days after the termination of the provider’s contract for the provision of services;

(2) For MMA services, continuation shall not exceed six (6) months after the termination of the provider’s contract for the provision of MMA services; and

(3) For any pregnant enrollees who have initiated a course of prenatal care, regardless of the trimester in which care was initiated, continuation shall be provided until the completion of postpartum care.

g. Notwithstanding the provisions in this section, a terminated provider may refuse to continue to provide care to an enrollee who is abusive or noncompliant.

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h. For continued care under this section, the Managed Care Plan and the terminated provider shall continue to abide by the same terms and conditions as existed in the terminated contract.

i. The requirements set forth in this section, shall not apply to providers who have been terminated from the Managed Care Plan for cause.

j. The Managed Care Plan shall report provider terminations, including documentation of enrollee notification, and additions as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

D. Provider Services

1. General Provisions

a. The Managed Care Plan shall establish and maintain a formal provider relations function to respond timely and adequately to inquiries, questions and concerns from participating providers.

b. The Managed Care Plan shall provide sufficient information to all providers in order to operate in full compliance with this Contract and all applicable federal and state laws and regulations.

c. The Managed Care Plan shall monitor provider compliance with Contract requirements and take corrective action when needed to ensure compliance.

2. Provider Handbook and Bulletin Requirements

a. The Managed Care Plan shall issue a provider handbook to all providers at the time the provider credentialing is complete.

b. The Managed Care Plan may choose not to distribute the provider handbook via surface mail, provided it submits a written notification to all providers that explains how to obtain the handbook from the Managed Care Plan’s website. This notification shall also detail how the provider can request a hard copy from the Managed Care Plan at no charge.

c. The Managed Care Plan shall keep all provider handbooks and bulletins up to date and in compliance with state and federal laws. The provider handbook shall serve as a source of information regarding Managed Care Plan covered services, policies and procedures, statutes, regulations, telephone access and special requirements to ensure all Contract requirements are met.

d. The Managed Care Plan’s provider handbook must, at a minimum, include the following information:

(1) Description of the Medicaid program and the SMMC program;

(2) Listing of covered services;

(3) Emergency service responsibilities;

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(4) Provider or subcontractor responsibilities;

(5) Requirements regarding background screening;

(6) Agency medical necessity standards and practice protocols, including guidelines pertaining to the treatment of chronic and complex conditions;

(7) Prior authorization and referral procedures, including required forms;

(8) Information on the Managed Care Plan’s quality enhancement programs;

(9) Medical/case records standards;

(10) Claims submission protocols and standards, including instructions and all information required for a clean or complete claim;

(11) Protocols for submitting encounter data;

(12) Information notifying providers that the Managed Care Plan is authorized to take whatever steps are necessary to ensure that the provider is recognized by the Agency and its agent(s) as a participating provider of the Managed Care Plan and that the provider’s submission of encounter data is accepted by the Agency;

(13) Requirements regarding community outreach activities and marketing prohibitions;

(14) Policies and procedures that cover the provider complaint system. This information shall include, but not be limited to, specific instructions regarding how to contact the Managed Care Plan to file a provider complaint, including complaints about claims issues, and which individual(s) has authority to review a provider complaint;

(15) A summary of the Managed Care Plan’s cultural competency plan and how to get a full copy at no cost to the provider;

(16) Information on identifying and reporting abuse, neglect and exploitation of enrollees;

(17) Enrollee rights and responsibilities (see 42 CFR 438.100); and

(18) Required procedural steps in the enrollee grievance process, including the address, telephone number and office hours of the grievance staff; the enrollee’s right to request continuation of benefits while utilizing the grievance system; and information about the Beneficiary Assistance Program. The Managed Care Plan shall specify telephone numbers to call to present a complaint, grievance or appeal. Each telephone number shall be toll-free within the caller’s geographic area and provide reasonable access to the Managed Care Plan without undue delays.

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e. The Managed Care Plan shall include information in provider handbooks with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall provide the additional information specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall provide the additional information specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall issue one (1) provider handbook to all network providers and shall provide additional information as specified in the both the MMA Exhibit and the LTC Exhibit.

f. The Managed Care Plan shall disseminate bulletins as needed to incorporate any needed changes to the provider handbook.

3. Provider Education and Training

a. The Managed Care Plan shall offer training to all providers and their staff regarding the requirements of this Contract and special needs of enrollees.

b. The Managed Care Plan shall conduct initial training within thirty (30) days of placing a newly contracted provider, or provider group, on active status. The Managed Care Plan also shall conduct ongoing training, as deemed necessary by the Managed Care Plan or the Agency, in order to ensure compliance with program standards and this Contract.

c. The Managed Care Plan shall provide training and education to providers regarding the Managed Care Plan’s enrollment and credentialing requirements and processes.

d. For a period of at least twelve (12) months following the implementation of this Contract, the Managed Care Plan shall conduct monthly education and training for providers regarding claims submission and payment processes, which shall include, but not be limited to, an explanation of common claims submission errors and how to avoid those errors. Such period may be extended as determined necessary by the Agency.

e. The Managed Care Plan shall ensure all participating and direct service providers required to report abuse, neglect, or exploitation of vulnerable adults under s. 415.1034, F.S., obtain training on these subjects. If the Managed Care Plan provides such training to its participating and direct service providers, training materials must, at minimum, include the Agency’s specified standards.

4. Toll-Free Provider Help Line

a. The Managed Care Plan shall operate a toll-free telephone help line to respond to provider questions, comments and inquiries.

b. The Managed Care Plan shall develop provider help line policies and procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means and compliance with Managed Care Plan standards.

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c. The help line must be staffed twenty-four hours a day, seven days a week (24/7) to respond to prior authorization requests.

d. This help line shall have staff to respond to provider questions in all other areas, including but not limited to the provider complaint system and provider responsibilities, between the hours of 8 a.m. and 7 p.m. in the provider’s time zone, Monday through Friday, excluding state holidays.

e. The Managed Care Plan shall ensure that after regular business hours the provider services line (not the prior authorization line) is answered by an automated system with the capability to provide callers with information about operating hours and instructions about how to verify enrollment for an enrollee with an emergency or urgent medical condition. This requirement shall not be construed to mean that the provider must obtain verification before providing emergency services and care.

f. The Managed Care Plan’s call center systems shall have the capability to track call management metrics identified in Section IV, Enrollee Services and Grievance Procedures.

5. Provider Complaint System

a. The Managed Care Plan shall establish and maintain a provider complaint system that permits a provider to dispute the Managed Care Plan’s policies, procedures, or any aspect of a Managed Care Plan’s administrative functions, including proposed actions, claims, billing disputes, and service authorizations. The Managed Care Plan’s process for provider complaints concerning claims issues shall be in accordance with s. 641.3155, F.S. Disputes between the Managed Care Plan and a provider may be resolved as described in s. 408.7057.

b. The Managed Care Plan shall include its provider complaint system policies and procedures in its provider handbook as described above.

c. The Managed Care Plan shall also distribute the provider complaint system policies and procedures, including claims issues, to non-participating providers upon request. The Managed Care Plan may distribute a summary of these policies and procedures, if the summary includes information about how the provider may access the full policies and procedures on the Managed Care Plan’s website. This summary shall also detail how the provider can request a hard copy from the Managed Care Plan at no charge.

d. As a part of the provider complaint system, the Managed Care Plan shall:

(1) Have dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider complaint and resolve problems;

(2) Identify a staff person specifically designated to receive and process provider complaints;

(3) Allow providers forty-five (45) days to file a written complaint for issues that are not about claims;

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(4) Within three (3) business days of receipt of a complaint, notify the provider (verbally or in writing) that the complaint has been received and the expected date of resolution;

(5) Thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Managed Care Plan’s written policies and procedures;

(6) Document why a complaint is unresolved after fifteen (15) days of receipt and provide written notice of the status to the provider every fifteen (15) days thereafter;

(7) Resolve all complaints within ninety (90) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution; and

(8) Ensure that Managed Care Plan executives with the authority to require corrective action are involved in the provider complaint process.

e. The Managed Care Plan shall report provider complaints as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

E. Medical/Case Records Requirements

1. General Provisions

a. The Managed Care Plan shall ensure maintenance of medical/case records for each enrollee in accordance with this section and with 42 CFR 431 and 42 CFR 456. Medical/case records shall include the quality, quantity, appropriateness and timeliness of services performed under this Contract.

b. The Managed Care Plan shall comply with additional documentation requirements with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall comply with the additional requirements specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall comply with the additional requirements specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall comply with the additional requirement as specified in the both the MMA Exhibit and the LTC Exhibit.

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2. Confidentiality of Medical/Case Records

a. The Managed Care Plan shall have a policy to ensure compliance with the privacy and security provisions of the Health Insurance Portability and Accountability Act (HIPAA).

b. The Managed Care Plan shall have a policy to ensure the confidentiality of medical/case records in accordance with 42 CFR, Part 431, Subpart F.

c. The enrollee or authorized representative shall sign and date a release form before any clinical/case records can be released to another party. Clinical/case record release shall occur consistent with state and federal law.

3. Standards for Medical/Case Records

a. The Managed Care Plan shall follow the medical/case record standards set forth below for each enrollee’s medical/case records, as appropriate:

(1) Include the enrollee’s identifying information, including name, enrollee identification number, date of birth, sex and legal guardianship (if any);

(2) Include a summary of significant surgical procedures, past and current diagnoses or problems, allergies, untoward reactions to drugs and current medications;

(3) Include all services provided. Such services must include, but not necessarily be limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases;

(4) Document referral services in enrollees’ medical/case records;

(5) Each record shall be legible and maintained in detail;

(6) All records shall contain an immunization history;

(7) All records shall contain information relating to the enrollee’s use of tobacco, alcohol, and drugs/substances;

(8) All records shall contain summaries of all emergency services and care and hospital discharges with appropriate, medically indicated follow up;

(9) All records shall reflect the primary language spoken by the enrollee and any translation needs of the enrollee;

(10) All records shall identify enrollees needing communication assistance in the delivery of health care services;

(11) All entries shall be dated and signed by the appropriate party;

(12) All entries shall indicate the chief complaint or purpose of the visit, the objective, diagnoses, medical findings or impression of the provider;

(13) All entries shall indicate studies ordered (e.g., laboratory, x-ray, EKG) and referral reports;

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(14) All entries shall indicate therapies administered and prescribed;

(15) All entries shall include the name and profession of the provider rendering services (e.g., MD, DO, OD), including the signature or initials of the provider;

(16) All entries shall include the disposition, recommendations, instructions to the enrollee, evidence of whether there was follow-up and outcome of services; and

(17) Include copies of any consent or attestation form used or the court order for prescribed psychotherapeutic medication for a child under the age of thirteen (13).

b. The Managed Care Plan shall maintain written policies and procedures for enrollee advance directives which address how the Managed Care Plan will access copies of any advance directives executed by the enrollee. All medical/case records shall contain documentation that the enrollee was provided with written information concerning the enrollee’s rights regarding advance directives (written instructions for living will or power of attorney) and whether or not the enrollee has executed an advance directive. Neither the Managed Care Plan, nor any of its providers shall, as a condition of treatment, require the enrollee to execute or waive an advance directive.

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Section VII. Quality and Utilization Management

A. Quality Improvement

1. General Provisions

a. The Managed Care Plan shall have an ongoing quality improvement program (QI program) that objectively and systematically monitors and evaluates the quality and appropriateness of care and services rendered, thereby promoting quality of care and quality patient outcomes in service performance to its enrollees. (See 42 CFR 438.204 and 438.240.)

b. The Managed Care Plan shall cooperate with the Agency and the external quality review organization (EQRO). The Agency will set methodology and standards for quality improvement (QI) with advice from the EQRO.

c. The Managed Care Plan shall contract with the Florida Medical School Quality Network when the network becomes operational, in accordance with s. 409.975(2), F.S.

d. The Managed Care Plan shall monitor, evaluate and improve the quality and appropriateness of care and service delivery (or the failure to provide care or deliver services) to enrollees through peer review, performance improvement projects (PIP), medical/case record audits, performance measures, surveys and related activities.

e. The Managed Care Plan shall identify and track critical incidents and shall review and analyze critical incidents to identify and address/eliminate potential and actual quality of care and/or health and safety issues.

2. Performance Incentives

The Agency may offer incentives to high-performing Managed Care Plans. The Agency will notify the Managed Care 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 Managed Care 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 Managed Care Plan for any reason the Agency deems appropriate including, but not limited to, Managed Care Plans that received a monetary sanction for performance measures or any other sanctionable offense. In accordance with s. 409.967(3)(g), F.S., as part of the achieved savings rebate process, a Managed Care Plan that exceeds Agency-defined quality measures as specified in Section IX, Method of Payment in the reporting period may retain an additional one percent (1%) of revenue.

3. Accreditation

Pursuant to s. 409.967(2)(e)3., F.S., the Managed Care Plan must be accredited by a nationally recognized accrediting body, or have initiated the accreditation process within one (1) year after this Contract was executed. If the Managed Care Plan is not accredited within eighteen (18) months after executing this Contract the Agency may terminate the

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Contract for failure to comply with the Contract. The Agency shall suspend all assignments until the Managed Care Plan is accredited by a nationally recognized body.

For managed Behavioral Health Organization subcontracts:

a. If the Managed Care Plan subcontracts with a managed behavioral health organization (MBHO) for the provision of behavioral health services, the MBHO must be accredited in the same manner as specified in s. 641.512, F.S., and Rule 59A-12.0072, F.A.C., as follows:

(1) If the MBHO has been in operation for less than two (2) years, it must apply for accreditation from a recognized national accreditation organization within one (1) year of start-up and achieve full accreditation within two (2) years of beginning operations.

(2) If the MBHO has been in operation for at least two (2) years, it must be fully accredited by at least one of the recognized national accreditation organizations.

b. All MBHOs must undergo reaccreditation not less than once every three (3) years.

4. Oversight of Quality Improvement

a. The Managed Care Plan’s governing body shall oversee and evaluate the QI program. The role of the Managed Care Plan’s governing body shall include providing strategic direction to the QI program, as well as ensuring the quality improvement plan (QI plan) is incorporated into operations throughout the Managed Care Plan.

b. The Managed Care Plan shall have a QI program committee. The Managed Care Plan’s medical director shall either chair or co-chair the committee. Other committee representatives shall be selected to meet the needs of the Managed Care Plan but must include: 1) the quality director; 2) the grievance coordinator; 3) the care coordination/case management manager; 4) the utilization review manager; 5) the credentialing manager; 6) the risk manager/infection control nurse; 7) an enrollee advocate representative (the Managed Care Plan is encouraged to include multiple advocate representatives on the QI program committee); and 8) provider representation (either through providers serving on the committee or through a provider liaison position, such as a representative from the network management department). Individual staff members may serve in multiple roles on the committee if they also serve in multiple positions within the Managed Care Plan.

c. Comprehensive LTC Managed Care Plans and LTC Managed Care Plans shall appoint a Geriatrician to the QI program committee. The Geriatrician shall be a qualified geriatrician, with a current active unencumbered Florida license under Chapter 458 or 459, F.S., and further certified in Geriatric Medicine. The Geriatrician shall be responsible for establishing and monitoring the implementation and administration of geriatric management protocols to support long-term care requiring geriatric practice.

d. The committee must meet no less than quarterly. Its responsibilities shall include the development and implementation of a written QI plan, which incorporates the strategic direction provided by the governing body.

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e. The Managed Care Plan shall maintain minutes of all QI committee and sub-committee meetings and make the minutes available for Agency review on request. The minutes shall demonstrate resolution of items or be brought forward to the next meeting.

5. Quality Improvement Plan

a. The Managed Care Plan shall develop and maintain a written quality improvement plan (QI plan) and submit its QI plan to the Agency within thirty (30) days from execution of the initial Contract. The Managed Care Plan shall make the QI Plan available to the Agency as requested.

b. The written QI plan must clearly describe the mechanism within the Managed Care Plan for strategic direction from the governing body to be provided to the QI program and for the QI program committee to communicate with the governing body.

c. The QI plan must describe the QI program and committee structure and the committee’s role in monitoring and evaluation of quality and appropriateness of care provided to enrollees including, but not limited to, review of quality of care and service concerns, grievances, enrollee rights, adverse events, patient safety and utilization review processes, including:

(1) The process for selecting and directing task forces, committees or other Managed Care Plan activities to review areas of concern in the provision of health care services to enrollees;

(2) The role of its providers in giving input to the QI program, whether that is by membership on the committee, its sub-committees or other means;

(3) A description of the Managed Care Plan positions assigned to the QI program, including a description of why each position was chosen to serve on the committee and the roles each position is expected to fulfill. The resumes of QI program committee members shall be made available upon the Agency’s request;

(4) Specific training about quality that will be provided by the Managed Care Plan to staff serving in the QI program. At a minimum, the training shall include protocols developed by CMS regarding quality. CMS protocols may be obtained from:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-External-Quality-Review.html; and www.cms.hhs.gov/MedicaidManagCare

(5) A standard for how the Managed Care Plan shall assure that QI program activities take place throughout the Managed Care Plan and document results of QI program activities for reviewers. Protocols for assigning tasks to individual staff persons and selection of time standards for completion shall be included.

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d. The QI plan must describe Managed Care Plan’s guiding philosophy for quality management. The Managed Care Plan should identify any nationally recognized, standardized approach that is used (e.g., PDCA, Rapid Cycle Improvement, FOCUS-PDCA, Six Sigma). Selection of performance indicators and sources for benchmarking also shall be included in addressing the following specific components of the QI plan:

(1) Methods for assessment of the quality and appropriateness of care provided to enrollees with timely resolution of problems and new or continued improvement activities including, but not limited to:

(a) Service availability and accessibility;

(b) Quality of services;

(c) Network quality;

(d) Care planning and implementation;

(e) Coordination and continuity of care; and

(f) Member safety;

(2) The process to direct and analyze periodic review of enrollee service utilization patterns (including detection of under and over utilization of services);

(3) Monitoring and evaluation of non-clinical aspects of service with timely resolution of problems and improvement in processes;

(4) Monitoring and evaluation of network quality including, but not limited to:

(a) Credentialing and recredentialing processes;

(b) Performance improvement projects;

(c) Performance measurement;

(d) Problem resolution and improvement approach and strategy;

(e) Annual program evaluation; and

(f) Metrics for monitoring the quality and performance of participating providers related to their continued participation in the network.

e. The QI plan must also describe:

(1) The process for selecting evaluation and study design procedures;

(2) A standard describing the process the QI program will use to review and suggest new and/or improved QI activities;

(3) Description of the health management information systems that will be used to support the QI program;

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(4) The process to report findings to appropriate executive authority, staff and departments within the Managed Care Plan as well as relevant stakeholders, such as participating providers. The QI plan also shall include how this communication will be documented for Agency review; and

(5) The process for annual QI program evaluation.

6. EQRO Coordination Requirements

a. The Managed Care Plan shall provide all information requested by the EQRO, including, but not limited to, quality outcomes concerning timeliness of, and enrollee access to, covered services.

b. The Managed Care Plan shall cooperate with the EQRO during the external quality review activities, which may include independent medical/case record review.

c. If the EQRO indicates the Managed Care Plan’s performance is not acceptable, the Agency may require the Managed Care Plan to submit a CAP and may restrict the Managed Care Plan’s enrollment activities.

B. Performance Measures (PMs)

1.    Required Performance Measures (PMs)

a. The Managed Care Plan shall collect statewide data on enrollee PMs, as defined by the Agency and as specified in the SMMC Performance Measure Table below, the Managed Care Plan Report Guide and Performance Measures Specifications Manual.

SMMC Performance Measures Table
1	Call Abandonment (CAB)
2	Call Answer Timeliness (CAT)

b. The Managed Care Plan shall collect and report with additional PMs with respect to the applicable SMMC program as follows:

(1) MMA Managed Care Plans shall collect and report results of additional PMs to the Agency as specified in the MMA Exhibit.

(2) LTC Managed Care Plans shall collect and report results of additional PMs to the Agency as specified in the LTC Exhibit.

(3) Comprehensive LTC Managed Care Plans shall collect and report results of additional PMs to the Agency as specified in both the MMA Exhibit and the LTC Exhibit.

c. The Managed Care Plan shall report results of PMs to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide and Performance Measures Specifications Manual.

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d. The Agency may add or remove PM requirements with sixty (60) days’ advance notice.

2.    Annual Report of Performance

a. By July 1 of each Contract year, the Managed Care Plan shall deliver to the Agency a report on performance measure data and a certification by a National Committee for Quality Assurance (NCQA) certified HEDIS auditor that the performance measure data reported for the previous calendar year are fairly and accurately presented. The report shall be certified by the HEDIS auditor, and the auditor must certify the actual file submitted to the Agency. Extensions to the due date may be granted by the Agency for up to thirty (30) days and require a written request signed by the Managed Care Plan CEO or designee. The request must be received by the Agency before the report due date and the delay must be due to unforeseen and unforeseeable factors beyond the Managed Care Plan’s control. Extensions will not be granted on oral requests.

b. A report, certification or other information required for PM reporting is incomplete when it does not contain all data required by the Agency or when it contains inaccurate data. A report that is incomplete or contains inaccurate data shall be considered deficient and each instance shall be subject to administrative penalties pursuant to Section XI, Sanctions. A report or certification is “false” if done or made with the knowledge, of the preparer or a superior of the preparer, that it contains data or information that is not true or not accurate. A report that contains an “NR” due to bias for any or all measures by the HEDIS auditor, or is “false,” shall be considered deficient and will be subject to administrative penalties pursuant to Section XI Sanctions. The Agency may refer cases of inaccurate or “false” reports to its Bureau of Medicaid Program Integrity.

3.    Publication of Performance Measures

Pursuant to s. 409.967(2)(e)2., F.S., the Managed Care Plan shall publish its results for HEDIS measures on the Managed Care Plan’s website in a manner that allows recipients to reliably compare the performance of Managed Care Plans. The Managed Care Plans may meet this requirement by including information about the comparison of performance measures conducted by the Agency and providing a link to the Agency’s applicable website page.

4. Performance Targets and Penalties

a. The Managed Care Plan shall meet Agency-specified performance targets for all PMs. For HEDIS and Agency-defined measures, the Agency will establish performance targets prior to execution of the Contract. The Agency may change these targets and/or change the timelines associated with meeting the targets. The Agency shall make these changes with sixty (60) days’ advance notice to the Managed Care Plan.

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b. If the Agency determines that the Managed Care Plan performance relative to the performance targets is not acceptable, the Agency may require the Managed Care Plan to submit a performance measure action plan (PMAP) within thirty (30) days after the notice of the determination in the format prescribed by the Agency. If the Managed Care Plan fails to provide a PMAP within the time and format specified by the Agency or fails to adhere to its own PMAP, the Agency may sanction the Managed Care Plan in accordance with the provisions of Section XI, Sanctions, and require the Managed Care Plan to submit reports to the Agency on the progress of all PMAPs.

c. If the Agency-defined or HEDIS PMs indicate that the Managed Care Plan’s performance is not acceptable, the Agency may sanction the Managed Care Plan in accordance with the provisions of Section XI, Sanctions. When considering whether to impose specific sanctions, such as applying civil monetary penalties or limiting enrollment activities or automatic assignments, the Agency may consider the Managed Care Plan’s cumulative performance on all quality and performance measures.

d. If the Managed Care Plan’s performance on Agency-defined and HEDIS performance measures is not acceptable and the Managed Care Plan’s performance measure report is incomplete or contains inaccurate data, the Agency may sanction the Managed Plan in accordance with the provisions of Section XI, Sanctions. Acceptable performance under this section will be determined using the initial performance measure submission, due July 1, with its corresponding attestation of accuracy and completeness. In the event that the Managed Plan later determines the submission contained errors, the Agency may consider using the updated data for public reporting purposes. In that instance, the earliest submission will apply. Likewise, eligibility for incentives and/or pay-for-performance initiatives will be determined based on the initial submission unless subsequent submissions indicate that the July 1 submission had inflated performance ratings.

C.    Performance Improvement Projects (PIPs)

1. General Provisions

a. Annually, by January 1 of each Contract year, the Agency shall determine and notify the Managed Care Plan if there are changes in the number and types of PIPs the Managed Care Plan shall perform for the coming Contract year.

(1) MMA Managed Care Plans shall perform the Agency-approved statewide performance improvement projects as specified in the MMA Exhibit;

(2) LTC Managed Care Plans shall perform the Agency-approved statewide performance improvement projects as specified in the LTC Exhibit; and

(3) Comprehensive LTC Managed Care Plans shall perform the Agency-approved statewide performance improvement projects as specified in both the MMA Exhibit and the LTC Exhibit.

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b. All PIPs shall achieve, through ongoing measurements and intervention, significant improvement to the quality of care and service delivery, sustained over time, in areas that are expected to have a favorable effect on health outcomes and enrollee satisfaction. Improvement must be measured through comparison of a baseline measurement and an initial re-measurement following application of an intervention. Change must be statistically significant at the ninety-five percent (95%) confidence level and must be sustained for a period of two (2) additional re-measurements. Measurement periods and methodologies shall be submitted to the Agency for approval before initiation of the PIP. PIPs that have successfully achieved sustained improvement, as approved by the Agency, shall be considered complete and shall not meet the requirement for one (1) of the number of PIPs required by the Agency, although the Managed Care Plan may wish to continue to monitor the performance indicator as part of its overall QI program. In this event, the Managed Care Plan shall select a new PIP and submit it to the Agency for approval.

c. Each PIP shall include a sample size sufficient to produce a statistically significant result.

d. The Managed Care Plan’s PIP methodology must comply with the most recent protocol set forth by CMS, Conducting Performance Improvement Projects, available from the websites listed above.

e. Populations selected for study under the PIP shall be specific to this Contract and shall not include Medicaid recipients from other states, or enrollees from other lines of business. If the Managed Care Plan contracts with a separate entity for management of particular services, PIPs conducted by the separate entity shall not include enrollees for other Managed Care Plans served by that entity.

2. PIP Proposals

a. Within ninety (90) days after initial Contract execution, the Managed Care Plan shall submit to the Agency in writing, a proposal for each planned PIP.

b. Each initial PIP proposal shall be submitted using the most recent version of the EQRO PIP validation form. Instructions for using the form to submit PIP proposals and updates may be obtained from the Agency.

c. Activities 1 through 6 of the EQRO PIP validation form must be addressed in the PIP proposal.

d. In the event the Managed Care Plan elects to modify a portion of the PIP proposal after initial Agency approval, a written request to do so must be submitted to the Agency.

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3. Annual PIP Submission

a. The Managed Care Plan shall submit ongoing PIPs annually by August 1 to the Agency for review and approval.

b. The Managed Care Plan shall update the EQRO PIP validation form in its annual submission to reflect the Managed Care Plan’s progress. The Managed Care Plan is not required to transfer ongoing PIPs to a new, updated EQRO form.

c. The Managed Care Plan shall submit the Agency-approved EQRO PIP validation form to the EQRO upon its request for validation. The Managed Care Plan shall not make changes to the Agency-approved PIP being submitted to the EQRO unless expressly permitted and approved by the Agency in writing.

4. EQRO Validation

The Managed Care Plan’s PIPs shall be subject to review and validation by the EQRO. The Managed Care Plan shall comply with any recommendations for improvement requested by the EQRO, subject to approval by the Agency.

D.    Satisfaction and Experience Surveys

1. Enrollee Satisfaction Survey

a. The Managed Care Plan shall contract with a qualified, Agency-approved, NCQA-certified vendor to conduct annual enrollee satisfaction surveys required under this Contract.

b. The Agency will specify the survey requirements including survey specifications, applicable supplemental item sets and Agency-defined survey items. Annually, by January 1 of each Contract year, the Agency shall determine and notify the Managed Care Plan if there are changes in survey requirements.

c. The Managed Care Plan shall submit to the Agency, in writing, by the date specified by the Agency of each Contract year, a proposal for survey administration and reporting that includes identification of survey administrator and evidence of NCQA certification as a CAHPS survey vendor; sampling methodology; administration protocol; analysis plan; and reporting description.

d. The Managed Care Plan shall provide the survey results to the Agency, in accordance with the survey results reporting templates and instructions from the Agency, along with an action plan as follows:

(1) MMA Managed Care Plans shall conduct enrollee satisfaction surveys as specified in the MMA Exhibit;

(2) LTC Managed Care Plans shall conduct enrollee satisfaction surveys as specified in the LTC Exhibit; and

(3) Comprehensive LTC Managed Care Plans shall conduct enrollee satisfaction surveys as specified in both the MMA Exhibit and the LTC Exhibit.

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2. Provider Satisfaction Survey

a. The Managed Care Plan shall conduct an annual Provider Satisfaction survey. The Managed Care Plan shall submit a provider satisfaction survey plan (including tool and methodology) to the Agency for written approval within ninety (90) days after initial Contract execution and annually thereafter.

b. The Managed Care Plan shall conduct the survey by the end of the first year of this Contract.

c. The survey tool should utilize a four-point Likert scale and shall include the following domains:

(1) Provider relations and communication;

(2) Clinical management processes;

(3) Authorization processes including denials and appeals;

(4) Timeliness of claims payment and assistance with claims processing;

(5) Complaint resolution process; and

(6) Care coordination/ case management support.

d. The Managed Care Plan shall provide the survey results to the Agency with an action plan to address the results of the Provider Satisfaction survey by July 1 of each Contract year.

E.    Provider-Specific Performance Monitoring

1. General Provision

The Managed Care Plan shall monitor the quality and performance of each participating provider. At the beginning of the Contract period, the Managed Care Plan shall notify all its participating providers of the metrics used by the Managed Care Plan for evaluating the provider’s performance and determining continued participation in the network (see s. 409.975(3), F.S.).

2. Peer Review

a. The Managed Care Plan shall have a peer review process that results in:

(1) Review of a provider’s practice methods and patterns, morbidity/mortality rates, and all grievances filed against the provider relating to medical treatment;

(2) Evaluation of the appropriateness of care rendered by providers;

(3) Implementation of corrective action(s) when the Managed Care Plan deems it necessary to do so;

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(4) Development of policy recommendations to maintain or enhance the quality of care provided to enrollees;

(5) Reviews that include the appropriateness of diagnosis and subsequent treatment, maintenance of a provider’s medical/case records, adherence to standards generally accepted by a provider’s peers and the process and outcome of a provider’s care;

(6) Appointment of a peer review committee, as a sub-committee to the QI program committee, to review provider performance when appropriate. The medical director or a designee shall chair the peer review committee. Its membership shall be drawn from the provider network and include peers of the provider being reviewed;

(7) Receipt and review of all written and oral allegations of inappropriate or aberrant service by a provider; and

(8) Education of enrollees and Managed Care Plan staff about the peer review process, so that enrollees and the Managed Care Plan staff can notify the peer review authority of situations or problems relating to providers.

3. Medical/Case Record Review

a. The Managed Care Plan shall establish and implement a mechanism to ensure provider records meet established medical/case record standards. If the Managed Care Plan is not yet fully accredited by a nationally recognized accrediting body, the Managed Care Plan shall establish processes for medical/case record review that meet or exceed nationally recognized accrediting body medical/case record review standards. The Managed Care Plan shall conduct medical/case record reviews to ensure that enrollees are provided high quality health care that is documented according to established standards below and in Section VI.E, Medical/Case Record Requirements.

b. By June 1 of each Contract year, the Managed Care Plan shall submit a written strategy for conducting medical/case record reviews for Agency approval. The strategy shall include, at a minimum;

(1) Designated staff to perform this duty;

(2) Process for establishing inter-rater reliability;

(3) Sampling methodology for case selection;

(4) The anticipated number of reviews by practice site (non-facility service providers such as home health agencies with multiple offices locations serving the region);

(5) Record confidentiality and security;

(6) The tool that the Managed Care Plan will use to review each site;

(7) Analysis and reporting, and

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(8) How the Managed Care Plan shall link the information compiled during the review to other Managed Care Plan functions (e.g., QI, recredentialing, peer review).

c The Managed Care Plan shall conduct these reviews at all provider and facility provider sites (provider sites refers to service providers such as home health agencies with multiple office locations serving a region and facility provider sites refers to assisted living facilities, adult family care homes and adult foster care facilities sites) that meet the criteria in this subsection.

d. The Managed Care Plan shall conduct medical/case record reviews of all provider sites with a pattern of complaints or poor quality outcomes.

f. The Managed Care Plan shall incorporate additional requirements into the conduct these medical/case record reviews as follows:

(1) MMA Managed Care Plans shall conduct reviews in accordance with standards specified in the MMA Exhibit;

(2) LTC Managed Care Plans shall conduct reviews in accordance with standards specified in the LTC Exhibit; or

(3) Comprehensive LTC Managed Care Plans shall conduct reviews in accordance with standards specified in the MMA Exhibit for enrollees with MMA benefits only and in the LTC Exhibit for enrollees with LTC benefits.

F. Other Quality Management Requirements

1. Critical Incidents

a. The Managed Care Plan shall develop and implement a critical and adverse incident reporting and management system for critical events that negatively impact the health, safety, or welfare of enrollees. Adverse incidents may include events involving abuse, neglect, exploitation, major illness or injury, involvement with law enforcement, elopement/missing, or major medication incidents.

b. The Managed Care Plan shall require participating and direct service providers to report adverse incidents to the Managed Care Plan within twenty-four (24) hours of the incident. The Managed Care Plan must ensure that all participating and direct service providers are required to report adverse incidents to the Agency immediately but not more than twenty-four (24) hours of the incident. Reporting will include information including the enrollee’s identity, description of the incident and outcomes including current status of the enrollee.

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c. The Managed Care Plan shall report suspected abuse, neglect and exploitation of enrollees immediately, in accordance with s.30.201 and Chapter 415, F.S. The Managed Care Plan shall report suspected cases of abuse, neglect and/or exploitation to the appropriate protective services unit/hotline

d. Documentation related to the suspected abuse, neglect or exploitation, including the reporting of such, must be kept in a file, separate from the enrollee’s case file, that is designated as confidential. Such file shall be made available to the Agency upon request.

e. The Managed Care Plan shall implement and maintain a risk-management program.

f. The Managed Care Plan shall provide appropriate training and take corrective action as needed to ensure its staff, participating providers, and direct service providers comply with critical incident requirements.

g. Enrollee quality of care issues must be reported to and a resolution coordinated with the Managed Care Plan’s Quality Management Department.

h. The Managed Care Plan shall report to the Agency, as specified in Section XIV, Reporting Requirements, and in the Managed Care Plan Report Guide, and in the manner and format determined by the Agency, any death and any adverse incident that could impact the health or safety of an enrollee (e.g., physical or sexual abuse) within twenty-four (24) hours of detection or notification.

i. The Managed Care Plan shall report a summary of critical incidents in a report to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, and in the manner and format determined by the Agency.

j. The Managed Care Plan, shall report to the Agency all serious enrollee injuries occurring through health services within fifteen (15) days after the Managed Care Plan received information about the injury. The Managed Care Plan must use the Agency’s Division of Health Quality Assurance’s (HQA’s) online Code 15 report to document and report the incident. The Managed Care Plan can find the Code 15 report at: http://ahca.myflorida.com/SCHS/RiskMgtPubSaftey/on_line.shtml

k. The Managed Care Plan shall report suspected unlicensed ALF’s and AFCH’s to the Agency, and shall require its providers to do the same pursuant to 408.812 F.S..

2. Agency Annual Medical/Case Record Audit and Onsite Monitoring

a. The Managed Care Plan shall furnish specific data requested in order for the Agency to conduct the medical/case record audit, including audit of enrollee plan of care, provider credentialing records, service provider reimbursement records, contractor personnel records, and other documents and files as required under this Contract.

b. If the medical/case record audit and/or other document audits indicate that quality of care is not acceptable within the terms of this Contract, the Managed Care Plan shall correct the problem immediately and may be required to submit a CAP to address the problem. The CAP shall be time limited based upon the nature of the deficiency. Regardless of a CAP, health and safety issues, and problems not corrected, shall result

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in the Agency sanctioning the Managed Care Plan, in accordance with the provisions of Section XI, Sanctions, and may immediately terminate all enrollment activities and mandatory assignments, until the Managed Care Plan attains an acceptable level of quality of care as determined by the Agency.

G.    Utilization Management (UM)

1. General Provisions

a. The UM program shall be consistent with 42 CFR Parts 438 and 456 (as applicable), reflected in a written Utilization Management Program Description and include, but not be limited to:

(1) Procedures for identifying patterns of over-utilization and under-utilization of services and for addressing potential problems identified as a result of these analyses;

(2) Procedures for reporting fraud and abuse information identified through the UM program to the Agency’s MPI as described in Section VIII, Administration and Management, and referenced in 42 CFR 455.1(a)(1);

(3) Procedures for enrollees to obtain a second medical opinion at no expense to the enrollee and for the Managed Care Plan to authorize claims for such services in accordance with 42 CFR 438.206(b)(3) and s. 641.51, F.S.; and

(4) Protocols for prior authorization and denial of services; the process used to evaluate prior and concurrent authorization; objective evidence-based criteria to support authorization decisions; mechanisms to ensure consistent application of review criteria for authorization decisions; consultation with the requesting provider when appropriate; hospital discharge planning; physician profiling; and retrospective review, meeting the predefined criteria below. The Managed Care Plan shall be responsible for ensuring the consistent application of review criteria for authorization decisions and consulting with the requesting provider when appropriate.

b. The Managed Care Plan shall ensure that applicable evidence-based criteria are utilized with consideration given to characteristics of the local delivery systems available for specific members as well as member-specific factors, such as member’s age, co-morbidities, complications, progress in treatment, psychosocial situation and home environment.

c. The Managed Care Plan must provide that compensation to individuals or entities that conduct UM activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee.

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2. Service Authorization System

a. Managed Care Plans shall have automated authorization systems, as required in s. 409.967(2)(c)3., F.S., and may not require paper authorization in addition as a condition for providing treatment.

b. The Managed Care Plan’s service authorization systems shall provide written confirmation of all denials, service limitations and reductions of authorization to providers (See 42 CFR 438.210(c)).

c. The Managed Care Plan’s service authorization systems shall provide the authorization number and effective dates for authorization to providers and non-participating providers.

d. The Managed Care Plan shall not delay service authorization if written documentation is not available in a timely manner. However, the Managed Care Plan is not required to approve claims for which it has received no written documentation.

e. The Managed Care Plan shall comply with the following standards, measured on a monthly basis, for processing authorization requests in a timely manner:

(1) The Managed Care Plan shall process ninety-five percent (95%) of all standard authorizations within fourteen (14) days.

(2) The Managed Care Plan’s average turnaround time for standard authorization requests shall not exceed seven (7) days.

(3) The Managed Care Plan shall process ninety five percent (95%) of all expedited authorization requests within three (3) business days.

(4) The Managed Care Plan’s average turnaround time for expedited authorization requests shall not exceed two (2) business days.

f. The Managed Care Plan may request to be notified, but shall not deny claims payment based solely on lack of notification, for the following:

(1) Inpatient emergency admissions (within ten (10) days);

(2) Obstetrical care (at first visit);

(3) Obstetrical admissions exceeding forty-eight (48) hours for vaginal delivery and ninety-six (96) hours for caesarean section; and

(4) Transplants.

g. The Managed Care Plan shall provide post-authorization to CHDs for emergency shelter medical screenings provided for children being taken into the child welfare system.

h. In accordance with s. 409.967(2)(c)2, F.S., the Managed Care Plan shall assure that the prior authorization process for prescribed drugs is readily accessible to health care providers, including posting appropriate contact information on its website and providing timely responses to providers.

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3. Practice Guidelines

a. The Managed Care Plan shall adopt practice guidelines that meet the following requirements (see 42 CFR 438.236(b)):

(1) Are based on valid and reliable clinical evidence or a consensus of health care professionals in a particular field;

(2) Consider the needs of the enrollees;

(3) Are adopted in consultation with providers; and

(4) Are reviewed and updated periodically, as appropriate.

b. The Managed Care Plan shall disseminate any revised practice guidelines to all affected providers and, upon request, to enrollees and potential enrollees.

c. The Managed Care Plan shall ensure consistency with regard to all decisions relating to UM, enrollee education, covered services and other areas to which the practice guidelines apply.

4. Clinical Decision-Making

a. The Managed Care Plan shall ensure that all decisions to deny a service authorization request, or limit a service in amount, duration or scope that is less than requested, are made by health care professionals who have the appropriate clinical expertise in treating the enrollee’s condition or disease (see 42 CFR 438.210(b)(3)).

b. Only a licensed psychiatrist may authorize a denial for an initial or concurrent authorization of any request for behavioral health services. The psychiatrist’s review shall be part of the UM process and not part of the clinical review, which may be requested by a provider or the enrollee, after the issuance of a denial.

c. Licensed Clinical Social Workers, while classified as Health Care Professionals, are not permitted to make decisions to reduce, deny, suspend, or terminate services, unless it is within the scope of their license to do so according to Chapter 491, F.S. Under no circumstances will Licensed Clinical Social Workers diagnose and treat individuals as defined in Chapter 491, F.S.

5. Notices of Action (See 42 CFR 438.210)

a. The Managed Care Plan shall notify the provider and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested.

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b. For standard authorization decisions, the Managed Care Plan shall provide notice as expeditiously as the enrollee’s health condition requires and within no more than seven (7) days following receipt of the request for service.

c. The timeframe for standard authorization decisions can be extended up to seven (7) additional days if the enrollee or the provider requests extension or the Managed Care Plan justifies the need for additional information and how the extension is in the enrollee’s interest.

d. Expedited authorization is required when a provider indicates, or the Managed Care Plan determines, that following the standard timeline could seriously jeopardize the enrollee’s life or health or ability to attain, maintain or regain maximum function. An expedited decision must be made no later than forty eight (48) hours after receipt of the request for service.

e. The Managed Care Plan may extend the timeframe for expedited authorization decisions by up to two (2) additional business days if the enrollee or the provider requests an extension or if the Managed Care Plan justifies the need for additional information and how the extension is in the enrollee’s interest.

6. Notices of Action to Enrollees (See 42 CFR 438.210)

a. The Managed Care Plan shall provide the enrollee with a written notice of action that includes the following:

(1) The action the Managed Care Plan or its subcontractor has taken or intends to take;

(2) The reasons for the action;

(3) The enrollee or provider’s right to file an appeal with the Managed Care Plan;

(4) The enrollee’s right to request a Medicaid Fair Hearing;

(5) The procedures for exercising the rights specified in the notice;

(6) The circumstances under which expedited resolution is available and how to request it; and

(7) The enrollee’s right to have benefits continue pending resolution of the appeal, how to request that benefits be continued, and the circumstances in which the enrollee must have to pay the cost of those benefits.

b. The Managed Care Plan shall mail the notice of action as follows:

(1) For termination, suspension or reduction of previously authorized Medicaid covered services no later than ten (10) days before the action is to take effect. Certain exceptions apply under 42 CFR 431.213 and 214;

(2) For denial of payment, at the time of any action affecting the claim;

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(3) For standard service authorization decisions that deny or limit services no more than seven (7) days following the request for service or within fourty-eight (48) hours following an expedited service request;

(4) If the Managed Care Plan extends the timeframe for a service authorization decision, in which case it shall:

(a) Notify the enrollee of the reason for extending the timeframe and advising of the right to file a grievance if the enrollee disagrees with the extension of time;

(b) Issue and carry out its determination as expeditiously as possible but no later than the date the extension expires; and

(c) Send notice of the extension to the enrollee within five (5) business days of determining the need for an extension.

(5) For service authorization decisions not reached within required timeframes, on the date the timeframes expire. Such failures constitute a denial and are, therefore, an adverse action; and

(6) For expedited service authorization decisions within the timeframes specified.

7. Changes to Utilization Management Components

a. The Managed Care Plan shall obtain written approval from the Agency for its service authorization protocols and any changes.

b. The Managed Care Plan shall provide no less than thirty (30) days’ written notice to the Agency before making any changes to the administration and/or management procedures and/or authorization, denial or review procedures, including any delegations, as described in this section.

H.    Continuity of Care in Enrollment

1. The Managed Care Plan shall be responsible for coordination of care for new enrollees transitioning into the Managed Care Plan. In the event a new enrollee is receiving prior authorized ongoing course of treatment with any provider, the Managed Care Plan shall be responsible for the costs of continuation of such course of treatment, without any form of authorization and without regard to whether such services are being provided by participating or non-participating providers. The Managed Care Plan shall reimburse non-participating providers at the rate they received for services rendered to the enrollee immediately prior to the enrollee transitioning for a minimum of thirty (30) days, unless said provider agrees to an alternative rate.

2. LTC Managed Care Plans shall provide continuation of LTC services until the enrollee receives an assessment, a plan of care is developed and services are arranged and authorized as required to address the long-term care needs of the enrollee, which shall be no more than sixty (60) days after the effective date of enrollment.

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3. MMA Managed Care Plans shall provide continuation of MMA services until the enrollee’s PCP or behavioral health provider (as applicable to medical or behavioral health services, respectively) reviews the enrollee’s treatment plan, which shall be no more than sixty (60) days after the effective date of enrollment.

4. Comprehensive LTC Managed Care Plans shall provide continuation of LTC services for enrollees with LTC benefits and MMA services for enrollees with MMA benefits as indicated above.

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Section VIII. Administration and Management

A. Organizational Governance and Staffing

1. General Provisions

a. The Managed Care Plan’s governing body shall set forth policy and has overall responsibility for the organization of the Managed Care Plan.

b. The Managed Care Plan shall be responsible for the administration and management of all aspects of this Contract, including, but not limited to, delivery of services, provider network, provider education, claims resolution and assistance, and all subcontracts, employees, agents and services performed by anyone acting for or on behalf of the Managed Care Plan.

c. The Managed Care Plan shall have a centralized executive administration, which shall serve as the contact point for the Agency, except as otherwise specified in this Contract.

d. The Managed Care Plan must ensure adequate staffing and information systems capability to ensure the Managed Care Plan can appropriately manage financial transactions, record keeping, data collection, and other administrative functions, including the ability to submit any financial, programmatic, encounter data or other information required by the Agency, and to comply with the HIPAA and HITECH Acts.

2. Minimum Staffing

The positions described below represent the minimum management staff required for the Managed Care Plan. The Managed Care Plan shall notify the Agency of changes in the staff positions indicated below with one asterisk, within five (5) business days of the changes in staffing, to the Agency.

a. Contract Manager*: The Managed Care Plan shall designate a Contract Manager to work directly with the Agency. The Contract Manager shall be a full-time employee of the Managed Care Plan and shall dedicate one hundred percent (100%) of their time employed with the Managed Care Plan to this Contract. The Contract Manager shall have the authority to administer the day-to-day business activities of this Contract, including revising processes or procedures and assigning additional resources as needed to maximize the efficiency and effectiveness of services required under the Contract. The Contract Manager cannot be designated to any other position in this section, including in other lines of business within the Managed Care Plan. The Managed Care Plan shall meet in person, or by telephone, at the request of Agency representatives to discuss the status of the Contract, Managed Care Plan performance, benefits to the state, necessary revisions, reviews, reports and planning. The Contract Manager shall be located in the State of Florida.

b. Medical Director*: The Medical Director shall be a full-time employee of the Managed Care Plan and shall be a physician with an active unencumbered Florida license in accordance with Chapter 458 or 459, F.S., and shall have experience providing services to the population served under this Contract. The medical director shall oversee and be responsible for the proper provision of covered services to enrollees,

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the quality management program and the grievance system. The medical director cannot be designated to serve in any other position; however, if the Managed Care Plan has both a long-term care Contract and a medical assistance Contract with the Agency, the medical director can serve both Contracts. Under that circumstance, the medical director must then have experience serving both long-term care and medical assistance populations.

c. Compliance Officer*: The Managed Care Plan shall have a designated full-time employee qualified by training and experience in health care or risk management, to oversee the compliance program. The compliance officer shall also be qualified to oversee a fraud and abuse program designed to ensure program integrity through fraud and abuse prevention and detection pursuant to this Contract and state and federal law. If the Managed Care Plan has both a long-term care Contract and a medical assistance Contract with the Agency, the compliance officer can serve both Contracts.

d. Medical/Case Records Review Coordinator: The Managed Care Plan shall have a designated employee, qualified by training and experience, to ensure compliance with the medical/case records requirements as described in this Contract. The medical/case records review coordinator shall maintain medical/case record standards and direct medical/case record reviews according to the terms of this Contract.

e. Data Processing and Data Reporting Coordinator*: The Managed Care Plan shall have a person trained and experienced in data processing, data reporting and claims resolution, as required, to ensure that computer system reports the Managed Care Plan provides to the Agency and its agents are accurate, and that computer systems operate in an accurate and timely manner.

f. Community Outreach Oversight Coordinator: If the Managed Care Plan engages in community outreach, it shall have a designated employee, qualified by training and experience, to ensure the Managed Care Plan adheres to the community outreach and marketing requirements of this Contract.

g. QI Professional: The Managed Care Plan shall have a designated employee, qualified by training and experience in QI and who holds the appropriate clinical certification and/or license.

h. UM Professional*: The Managed Care Plan shall have a designated employee, qualified by training and experience in UM and who holds the appropriate clinical certification and/or license.

i. Grievance System Coordinator*: The Managed Care Plan shall have a designated employee, qualified by training and experience, to process and resolve complaints, grievances and appeals and be responsible for the grievance system.

j. Claims/Encounter Manager*: The Managed Care Plan shall have a designated employee qualified by training and experience to oversee claims and encounter submittal and processing, where applicable, and to ensure the accuracy, timeliness and completeness of processing payment and reporting.

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k. Fraud Investigative Unit (also known as Special Investigative Unit) Manager*: The Managed Care Plan shall have a designated employee qualified by training and experience to oversee the special investigative unit for the investigation of possible fraud, abuse and overpayment and ensures mandatory reporting as required by this Contract, state and federal law.

3. Medical and Professional Support Staff

The Managed Care Plan shall have medical and professional support staff sufficient to conduct daily business in an orderly manner, including having enrollee services staff directly available during business hours for enrollee services consultation, as determined through management and medical reviews. The Managed Care Plan shall maintain sufficient medical and professional support staff, available twenty-four hours a day, seven days a week (24/7), to handle emergency services and care inquiries from enrollees and caregivers.

4. Care Coordination/Case Management Staff

The Managed Care Plan shall have sufficient care coordination/case management staff, qualified by training, experience and certification/licensure to conduct the Managed Care Plan’s care coordination/case management functions. See the LTC Exhibit for required case manager qualifications for enrollees with LTC benefits.

5. Staff Training and Education

The Managed Care Plan shall educate its staff about its policies and procedures and all applicable provisions of this Contract, including advance directives, situations in which advance directives may be of benefit to enrollees, and their responsibility to educate enrollees about this tool and assist them in making use of it.

6. Emergency Management Plan

Before beginning operations and annually by May 31 of each Contract year, the Managed Care Plan shall submit to the Agency for approval an emergency management plan specifying what actions the Managed Care Plan shall conduct to ensure the ongoing provision of covered services in a disaster or man-made emergency including, but not limited to, localized acts of nature, accidents, and technological and/or attack-related emergencies. If the emergency management plan is unchanged from the previous year, and was approved by the Agency, the Managed Care Plan shall submit an electronic certification to the Agency that the prior year’s plan is still in place.

B. Subcontracts

1. General Provisions

a. The Managed Care Plan shall be responsible for all work performed under this Contract, but may, with the prior written approval of the Agency, delegate performance of work required under this Contract to a subcontractor. The Managed Care Plan shall submit any proposed delegation to the Agency for prior written approval. The Managed Care Plan shall submit all subcontracts for Agency review to determine compliance with Contract requirements for subcontracts. If the Agency determines, at any time, that a

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subcontract is not in compliance with a Contract requirement, the Managed Care Plan shall promptly revise the subcontract to bring it into compliance. In addition, the Managed Care Plan may be subject to sanctions pursuant to Section XI, Sanctions, and/or liquidated damages pursuant to Section XIII, Liquidated Damages.

b. All subcontracts must comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR 455.105 and 42 CFR 455.106 and any other applicable state or federal law.

c. No subcontract that the Managed Care Plan enters into with respect to performance under the Contract shall, in any way, relieve the Managed Care Plan of any responsibility for the performance of duties under this Contract. The Managed Care Plan shall assure that all tasks related to the subcontract are performed in accordance with the terms of this Contract and shall provide the Agency with its monitoring schedule annually by December 1 of each Contract year. The Managed Care Plan shall identify in its subcontracts any aspect of service that may be further subcontracted by the subcontractor.

d. All model and executed subcontracts and amendments used by the Managed Care Plan under this Contract shall be in writing, signed, and dated by the Managed Care Plan.

2. Subcontractor Eligibility

a. All subcontractors must be eligible for participation in the Medicaid program; however, the subcontractor is not required to participate in the Medicaid program as a provider.

b. If a subcontractor was involuntarily terminated from the Medicaid program other than for purposes of inactivity, that entity is not considered an eligible subcontractor.

3.    Subcontract Content Requirements

a. The Managed Care Plan agrees to make payment to all subcontractors pursuant to all state and federal laws, rules and regulations, including s. 409.967, F.S., s. 409.975(6), F.S., s. 409.982, F.S., s. 641.3155, F.S., 42 CFR 447.46, and 42 CFR 447.45(d)(2), (3), (5) and (6); All model and executed subcontracts and amendments used by the Managed Care Plan under this Contract shall meet the following requirements with respect to payment:

(1) Identification of conditions and method of payment;

(2) Provide for prompt submission of information needed to make payment;

(3) Provide for full disclosure of the method and amount of compensation or other consideration to be received from the Managed Care Plan;

(4) Require any claims payment to a provider be accompanied by an itemized accounting of the individual claims included in the payment including, but not limited to, the enrollee’s name, the date of service, the procedure code, service units, the amount of reimbursement, and the identification of the Managed Care Plan;

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(5) Require an adequate record system be maintained for recording services, charges, dates and all other commonly accepted information elements for services rendered to the Managed Care Plan;

(6) Specify that the subcontractor may not seek payment from a Medicaid Pending enrollee on behalf of the Managed Care Plan; and

(7) Specify that the Managed Care Plan shall assume responsibility for cost avoidance measures for third party collections in accordance Section X, Financial Requirements.

b. All model and executed subcontracts and amendments used by the Managed Care Plan under this Contract shall meet the following requirements with respect to provisions for monitoring and inspections:

(1) Provide that the Agency and DHHS may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed;

(2) Provide for inspections of any records pertinent to the Contract by the Agency and DHHS;

(3) In addition to record retention requirements for practitioner or provider licensure, require that records be maintained for a period not less than ten (10) years from the close of the Contract and retained further if the records are under review or audit until the review or audit is complete. (Prior approval for the disposition of records must be requested and approved by the Managed Care Plan if the subcontract is continuous.);

(4) Provide for monitoring and oversight by the Managed Care Plan and the subcontractor to provide assurance that all licensed medical professionals are credentialed in accordance with the Managed Care Plan’s and the Agency’s credentialing requirements as found Section VI, Provider Network, if the Managed Care Plan has delegated the credentialing to a subcontractor; and

(5) Provide for monitoring of services rendered to Managed Care Plan enrollees through the subcontractor.

c. All model and executed subcontracts and amendments used by the Managed Care Plan under this Contract shall meet the following requirements with respect to the specification of functions of the subcontractor:

(1) Identify the population covered by the subcontract;

(2) Provide for submission of all reports and clinical information required by the Managed Care Plan, including CHCUP reporting (if applicable); and

(3) Provide for the participation in any internal and external quality improvement, utilization review, peer review and grievance procedures established by the Managed Care Plan.

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d. All model and executed subcontracts and amendments used by the Managed Care Plan under this Contract shall meet the following requirements with respect to protective clauses:

(1) Require safeguarding of information about enrollees according to 42 CFR, Part 438.224.

(2) Require compliance with HIPAA privacy and security provisions.

(3) Require an exculpatory clause, which survives subcontract termination, including breach of subcontract due to insolvency, which assures that Medicaid recipients or the Agency will not be held liable for any debts of the subcontractor.

(4) If there is a Managed Care Plan physician incentive plan, include a statement that the Managed Care Plan shall make no specific payment directly or indirectly under a physician incentive plan to a subcontractor as an inducement to reduce or limit medically necessary services to an enrollee, and affirmatively state that all incentive plans do not provide incentives, monetary or otherwise, for the withholding of medically necessary care;

(5) Require full cooperation in any investigation by the Agency, MPI, MFCU, DOEA, or other state or federal entity or any subsequent legal action that may result from such an investigation;

(6) Contain a clause indemnifying, defending and holding the Agency, its designees and the Managed Care Plan’s enrollees harmless from and against all claims, damages, causes of action, costs or expenses, including court costs and reasonable attorney fees, to the extent proximately caused by any negligent act or other wrongful conduct arising from the subcontract agreement. This clause must survive the termination of the subcontract, including breach due to insolvency. The Agency may waive this requirement for itself, but not Managed Care Plan enrollees, for damages in excess of the statutory cap on damages for public entities, if the subcontractor is a state agency or subdivision as defined by s. 768.28, F.S., or a public health entity with statutory immunity. All such waivers must be approved in writing by the Agency;

(7) Require that the subcontractor secure and maintain, during the life of the subcontract, workers’ compensation insurance for all of its employees connected with the work under this Contract unless such employees are covered by the protection afforded by the Managed Care Plan. Such insurance shall comply with Florida’s Workers’ Compensation Law;

(8) Specify that if the subcontractor delegates or subcontracts any functions of the Managed Care Plan, that the subcontract or delegation includes all the requirements of this Contract;

(9) Make provisions for a waiver of those terms of the subcontract, which, as they pertain to Medicaid recipients, are in conflict with the specifications of this Contract;

(10) Provide for revoking delegation, or imposing other sanctions, if the subcontractor’s performance is inadequate;

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(11) Provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any enrollee; and

(12) Provide details about the following as required by Section 6032 of the federal Deficit Reduction Act of 2005:

(a) The False Claim Act;

(b) The penalties for submitted false claims and statements;

(c) Whistleblower protections; and

(d) The laws role in preventing and detecting fraud, waste and abuse, and each person’s responsibility relating to detection and prevention.

e. In conjunction with the Standard Contract, Section III, B., Termination, all provider contracts and subcontracts shall contain termination procedures.

4.    Other Contract Requirements    

a. Subcontractors are subject to background checks. The Managed Care Plan shall consider the nature of the work a subcontractor or agent will perform in determining the level and scope of the background checks.

b. The Managed Care Plan shall document compliance certification (business-to-business) testing of transaction compliance with HIPAA for any subcontractor receiving enrollee data.

5. Minority Business Enterprises

The Agency encourages use of minority business enterprise subcontractors. See Section VI.C., for provisions and requirements specific to provider contracts and for other minority recruitment and retention plan requirements.

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C. Information Management and Systems

1. General Provisions

a. Systems Functions. The Managed Care Plan shall have information management processes and information systems that enable it to meet Agency and federal reporting requirements, other Contract requirements, and all applicable Agency policies, state and federal laws, rules and regulations, including HIPAA.

b. Systems Capacity. The Managed Care Plan’s system(s) shall possess capacity sufficient to handle the workload projected for the begin date of operations and will be scalable and flexible so to be adapted as needed, within negotiated timeframes, in response to changes in Contract requirements, increases in enrollment estimates, etc.

c. E-Mail System. The Managed Care Plan shall provide a continuously available electronic mail communication link (e-mail system) with the Agency. This system shall be:

(1) Available from the workstations of the designated Managed Care Plan contacts; and

(2) Capable of attaching and sending documents created using software products other than the Managed Care Plan’s systems, including the Agency’s currently installed version of Microsoft Office and any subsequent upgrades as adopted. The electronic mail system should include encryption capabilities compliant with Federal Information Processing Standards Publication (FIPS) 140-2.

d. Participation in Information Systems Work Groups/Committees. The Managed Care Plan shall meet as requested by the Agency, to coordinate activities and develop cohesive systems strategies across vendors and agencies.

e. Connectivity to the Agency/State Network and Systems. The Managed Care Plan shall be responsible for establishing connectivity to the Agency’s/state’s wide area data communications network, and the relevant information systems attached to this network, in accordance with all applicable Agency and/or state policies, standards and guidelines.

2. Data and Document Management Requirements

a. Adherence to Data and Document Management Standards

(1) The Managed Care Plan’s systems shall conform to the standard transaction code sets specified in the Contract.

(2) The Managed Care Plan’s systems shall conform to HIPAA and HITECH standards for data and document management.

(3) The Managed Care Plan shall partner with the Agency in the management of standard transaction code sets specific to the Agency. Furthermore, the Managed Care Plan shall partner with the Agency in the development and implementation planning of future standard code sets not specific to HIPAA or other federal efforts

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and shall conform to these standards as stipulated in the plan to implement the standards.

b. Data Model and Accessibility. Managed Care Plan systems shall be structured query language (SQL) and/or open database connectivity (ODBC) compliant. Alternatively, the Managed Care Plan’s systems shall employ a relational data model in the architecture of its databases in addition to a relational database management system (RDBMS) to operate and maintain them.

c. Data and Document Relationships. The Managed Care Plan shall house indexed images of documents used by enrollees and providers to transact with the Managed Care Plan in the appropriate database(s) and document management systems so as to maintain the logical relationships between certain documents and certain data.

d. Information Retention. Information in the Managed Care Plan’s systems shall be maintained in electronic form for three (3) years in live systems and for six (6) years in live and/or archival systems, or longer for audits or litigation as specified elsewhere in this Contract.

e. Information Ownership. All information, whether data or documents, and reports that contain or make references to said Information, involving or arising out of this Contract is owned by the Agency. The Managed Care Plan is expressly prohibited from sharing or publishing the Agency information and reports without the prior written consent of the Agency. In the event of a dispute regarding the sharing or publishing of information and reports, the Agency’s decision on this matter shall be final and not subject to change.

3. System and Data Integration Requirements

a. Adherence to Standards for Data Exchange

(1) The Managed Care Plan’s systems shall be able to transmit, receive and process data in HIPAA-compliant formats that are in use as of the Contract execution date.

(2) The Managed Care Plan’s systems shall be able to transmit, receive and process data in the Agency-specific formats and/or methods that are in use on the Contract execution date.

(3) The Managed Care Plan’s systems shall conform to future federal and/or Agency-specific standards for data exchange within one-hundred twenty (120) days of the standard’s effective date or, if earlier, the date stipulated by CMS or the Agency. The Managed Care Plan shall partner with the Agency in the management of current and future data exchange formats and methods and in the development and implementation planning of future data exchange methods not specific to HIPAA or other federal effort. Furthermore, the Managed Care Plan shall conform to these standards as stipulated in the Agency agreed-upon plan to implement such standards.

b. HIPAA Compliance Checker. All HIPAA-conforming transactions between the Agency and the Managed Care Plan shall be subjected to the highest level of compliance as measured using an industry-standard HIPAA compliance checker application.

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c. Data and Report Validity and Completeness. The Managed Care Plan shall institute processes to ensure the validity and completeness of the data, including reports, it submits to the Agency. At its discretion, the Agency will conduct general data validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include, but are not limited to: enrollee ID, date of service, assigned Medicaid provider ID, category and subcategory (if applicable) of service, diagnosis codes, procedure codes, revenue codes, date of claim processing, and (if and when applicable) date of claim payment. Control totals shall also be reviewed and verified.

d. State/Agency Website/Portal Integration. Where deemed that the Managed Care Plan’s web presence will be incorporated to any degree to the Agency’s or the state’s web presence (also known as a portal), the Managed Care Plan shall conform to any applicable Agency or state standard for website structure, coding and presentation.

e. Functional Redundancy with FMMIS. The Managed Care Plan’s systems shall be able to transmit and receive transaction data to and from FMMIS as required for the appropriate processing of claims and any other transaction that could be performed by either system.

f. Data Exchange in Support of the Agency’s Program Integrity and Compliance Functions. The Managed Care Plan’s systems shall be capable of generating files in the prescribed formats for upload into Agency systems used specifically for program integrity and compliance purposes.

g. Address Standardization. The Managed Care Plan’s system(s) shall possess mailing address standardization functionality in accordance with US Postal Service conventions.

h. Eligibility and Enrollment Data Exchange Requirements

(1) The Managed Care Plan shall receive process and update enrollment files sent daily by the Agency or its agent(s).

(2) The Managed Care Plan shall update its eligibility/enrollment databases within twenty-four (24) hours after receipt of said files.

(3) The Managed Care Plan shall transmit to the Agency or its agent, in a periodicity schedule, format and data exchange method to be determined by the Agency, specific data it may garner from an enrollee including third party liability data.

(4) The Managed Care Plan shall be capable of uniquely identifying a distinct Medicaid recipient across multiple systems within its span of control.

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4. Systems Availability, Performance and Problem Management Requirements

a. Availability of Critical Systems Functions. The Managed Care Plan shall ensure that critical systems functions available to enrollees and providers, functions that if unavailable would have an immediate detrimental impact on enrollees and providers, are available twenty-four hours a day, seven days a week (24/7), except during periods of scheduled system unavailability agreed upon by the Agency and the Managed Care Plan. Unavailability caused by events outside of a Managed Care Plan’s span of control should be addressed in a business continuity plan. The Managed Care Plan shall make the Agency aware of the nature and availability of these functions prior to extending access to these functions to enrollees and/or providers.

b. Availability of Data Exchange Functions. The Managed Care Plan shall ensure that the systems and processes within its span of control associated with its data exchanges with the Agency and/or its agent(s) are available and operational according to specifications and the data exchange schedule.

c. Availability of Other Systems Functions. The Managed Care Plan shall ensure that at a minimum all other system functions and information are available to the applicable system users between the hours of 7:00 a.m. and 7:00 p.m., in the time zone where the user is located, Monday through Friday.

d. Problem Notification

(1) Upon discovery of any problem within its span of control that may jeopardize or is jeopardizing the availability and performance of all systems functions and the availability of information in said systems, including any problems affecting scheduled exchanges of data between the Managed Care Plan and the Agency and/or its agent(s), the Managed Care Plan shall notify the applicable Agency staff via phone, fax and/or electronic mail within one (1) hour of such discovery. In its notification, the Managed Care Plan shall explain in detail the impact to critical path processes such as enrollment management and claims submission processes.

(2) The Managed Care Plan shall provide to appropriate Agency staff information on system unavailability events, as well as status updates on problem resolution. At a minimum these updates shall be provided on an hourly basis and made available via electronic mail and/or telephone.

e. Recovery from Unscheduled System Unavailability. Unscheduled system unavailability caused by the failure of systems and telecommunications technologies within the Managed Care Plan’s span of control will be resolved, and the restoration of services implemented, within forty-eight (48) hours of the official declaration of system unavailability.

f. Exceptions to System Availability Requirement. The Managed Care Plan shall not be responsible for the availability and performance of systems and IT infrastructure technologies outside of the Managed Care Plan’s span of control.

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g. Information Systems Corrective Action Plan. If at any point there is a problem with a critical systems function, at the request of the Agency, the Managed Care Plan shall provide to the Agency full written documentation that includes a corrective action plan (CAP) that describes how problems with critical systems functions will be prevented from occurring again. The CAP shall be delivered to the Agency within five (5) business days of the problem’s occurrence. Failure to submit a CAP and to show progress in implementing the CAP shall make the Managed Care Plan subject to sanctions, in accordance with Section XI, Sanctions.

h. Business Continuity-Disaster Recovery (BC-DR) Plan

(1) Regardless of the architecture of its systems, the Managed Care Plan shall develop, and be continually ready to invoke, a BC-DR plan that is reviewed and prior-approved by the Agency. If the approved plan is unchanged from the previous year, the Managed Care Plan shall submit a certification to the Agency that the prior year’s plan is still in place annually by April 30th of each Contract year. Changes in the plan are due to the Agency within ten (10) business days after the change.

(2) At a minimum, the Managed Care Plan’s BC-DR plan shall address the following scenarios: (1) the central computer installation and resident software are destroyed or damaged; (2) system interruption or failure resulting from network, operating hardware, software or operational errors that compromise the integrity of transactions that are active in a live system at the time of the outage; (3) system interruption or failure resulting from network, operating hardware, software or operational errors that compromise the integrity of data maintained in a live or archival system; (4) system interruption or failure resulting from network, operating hardware, software or operational errors that do not compromise the integrity of transactions or data maintained in a live or archival system, but do prevent access to the system, i.e., cause unscheduled system unavailability; and (5) Malicious acts, including malware or manipulation.

(3) The Managed Care Plan shall periodically, but no less than annually, by April 30 of each Contract year, perform comprehensive tests of its BC-DR plan through simulated disasters and lower level failures in order to demonstrate to the Agency that it can restore system functions per the standards outlined in the Contract.

(4) In the event that the Managed Care Plan fails to demonstrate in the tests of its BC-DR plan that it can restore system functions per the standards outlined in this Contract, the Managed Care Plan shall be required to submit to the Agency a corrective action plan in accordance with Section XI, Sanctions, that describes how the failure will be resolved. The corrective action plan shall be delivered within ten (10) business days of the conclusion of the test.

5. System Testing and Change Management Requirements

a. Notification and Discussion of Potential System Changes. The Managed Care Plan shall notify the Agency of the following changes to systems within its span of control at least ninety (90) days before the projected date of the change. If so directed by the Agency, the Managed Care Plan shall discuss the proposed change with the applicable

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Agency staff. This includes: (1) software release updates of core transaction systems: claims processing, eligibility and enrollment processing, service authorization management, provider enrollment and data management; and (2) conversions of core transaction management systems.

b. Response to Agency Reports of Systems Problems not Resulting in System Unavailability

(1) The Managed Care Plan shall respond to Agency reports of system problems not resulting in system unavailability according to the following timeframes:

(a) Within seven (7) days of receipt, the Managed Care Plan shall respond in writing to notices of system problems.

(b) Within twenty (20) days, the correction shall be made or a requirements analysis and specifications document will be due.

(2) The Managed Care Plan shall correct the deficiency by an effective date to be determined by the Agency.

c. Valid Window for Certain System Changes. Unless otherwise agreed to in advance by the Agency as part of the activities described in this section, scheduled system unavailability to perform system maintenance, repair and/or upgrade activities shall not take place during hours that could compromise or prevent critical business operations.

d. Testing

(1) The Managed Care Plan shall work with the Agency pertaining to any testing initiative as required by the Agency.

(2) Upon the Agency’s written request, the Managed Care Plan shall provide details of the test regions and environments of its core production information systems, including a live demonstration, to enable the Agency to corroborate the readiness of the Managed Care Plan’s information systems.

6. Information Systems Documentation Requirements

a. Types of Documentation. The Managed Care Plan shall develop, prepare, print, maintain, produce and distribute distinct system process and procedure manuals, user manuals and quick-reference guides, and any updates thereafter, for the Agency and other applicable Agency staff.

b. Content of System Process and Procedure Manuals. The Managed Care Plan shall ensure that written system process and procedure manuals document and describe all manual and automated system procedures for its information management processes and information systems.

c. Content of System User Manuals. The system user manuals shall contain information about, and instructions for, using applicable system functions and accessing applicable system data.

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d. Changes to Manuals

(1) When a system change is subject to the Agency’s written approval, the Managed Care Plan shall draft revisions to the appropriate manuals prior to Agency approval of the change.

(2) Updates to the electronic version of these manuals shall occur in real time; updates to the printed version of these manuals shall occur within ten (10) business days of the update’s taking effect.

e. Availability of/Access to Documentation. All of the aforementioned manuals and reference guides shall be available in printed form and/or online. If so prescribed, the manuals will be published in accordance with the appropriate Agency and/or state standard.

7. Reporting Requirements

The Managed Care Plan shall extract and upload data sets, upon request, to an Agency-hosted secure FTP site to enable authorized Agency personnel, or the Agency’s agent, on a secure and read-only basis, to build and generate reports for management use. The Agency and the Managed Care Plan shall arrange technical specifications for each data set as required for completion of the request.

8. Community Health Record/Continuity of Care Document/Electronic Medical/Case Record and Related Efforts

a. At such times that the Agency requires, the Managed Care Plan shall participate and cooperate with the Agency to implement, within a reasonable timeframe, secure, web-accessible, community health records for enrollees.

b. The design of the vehicle(s) for accessing the community health record/continuity of care document, the health record format and design shall comply with all HIPAA and related regulations.

c. The Managed Care Plan shall also cooperate with the Agency in the continuing development of the state’s health care data site (www.FloridaHealthFinder.com).

d. The Managed Care Plan shall provide to its staff and volunteers, initial and ongoing/periodic training on this Contract including, but not limited to, HIPAA and the HITECH Act regarding the use and safeguarding of PHI.

9. Compliance with Standard Coding Schemes

a. Compliance with HIPAA-Based Code Sets. Managed Care Plan systems that are required to or otherwise contain the applicable data type shall conform to the following HIPAA-based standard code sets; the processes through which the data are generated should conform to the same standards as needed:

(1) Logical Observation Identifiers Names and Codes (LOINC);

(2) Healthcare Common Procedure Coding System (HCPCS);

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(3) Home Infusion EDI Coalition (HEIC) Product Codes;

(4) National Drug Code (NDC);

(5) National Council for Prescription Drug Programs (NCPDP);

(6) International Classification of Diseases (ICD);

(7) Diagnosis Related Group (DRG);

(8) Claim Adjustment Reason Codes (CARC); and

(9) Remittance Advice Remarks Codes (RARC).

b. Compliance with Other Code Sets. Managed Care Plan systems that are required to or otherwise contain the applicable data type shall conform to the following non-HIPAA-based standard code sets:

(1) As described in all Agency Medicaid reimbursement handbooks, for all "covered entities," as defined under HIPAA, and which submit transactions in paper format (non-electronic format).

(2) As described in all Agency Medicaid reimbursement handbooks for all "non-covered entities," as defined under HIPAA.

10. Transition to ICD-10 Coding

The Managed Care Plan shall be responsible for ensuring its ability to transition from ICD-9 codes to the new ICD-10 codes upon Agency implementation and shall modify its policies, procedures and operations to reflect the coding changes brought about by the transition to ICD-10.

11. Data Exchange and Formats and Methods Applicable to Managed Care Plans

a. HIPAA-Based Formatting Standards. Managed Care Plan systems shall conform to the following HIPAA-compliant standards for Electronic Data Interchange (EDI) of health care data effective the first day of operations in the applicable region. The Managed Care Plan shall submit and receive transactions, ASC X12N or NCPDP (for certain pharmacy transactions), including claims and encounter information, payment and remittance advice, claims status, eligibility, enrollment and disenrollment, referrals and authorizations, coordination of benefits and premium payment. The implementation specifications for ASC X12N standards may be obtained from the Washington Publishing Company on the Internet at http://www.wpc-edi.com/. Florida specifications may be obtained on the Florida Medicaid provider portal at:

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_CompanionGuides/tabld/62/Default.aspx

Transaction types include, but are not limited to:

(1) ASC X12N 820 Payroll Deducted & Other Premium Payment

(2) ASC X12N 834 Enrollment and Audit Transaction

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(3) ASC X12N 835 Claims Payment Remittance Advice Transaction

(4) ASC X12N 837I Institutional Claim/Encounter Transaction

(5) ASC X12N 837P Professional Claim/Encounter Transaction

(6) ASC X12N 837D Dental Claim/Encounter Transaction

(7) ASC X12N 270/271 Eligibility/Benefit Inquiry/Response

(8) ASC X12N 276 Claims Status Inquiry

(9) ASC X12N 277 Claims Status Response

(10) ASC X12N 278/279 Utilization Review Inquiry/Response

(11) NCPDP D.0 Pharmacy Claim/Encounter Transaction

b. Methods for Data Exchange

(1) The Managed Care Plan and the Agency and/or its agent shall make predominant use of secure file transfer protocol (SFTP) and electronic data interchange (EDI) in their exchanges of data.

(2) The Managed Care Plan shall encourage network providers to participate in the Agency’s Direct Secure Messaging (DSM) service when it is implemented.

c. Agency-Based Formatting Standards and Methods. Managed Care Plan systems shall exchange the following data with the Agency and/or its agent in formats specified by the Agency:

(1) Provider network data;

(2) Case management fees, if applicable; and

(3) Payments.

12. Social Networking

a. If the Managed Care Plan uses social networking or smartphone applications (apps), the Managed Care Plan must develop and maintain policies and procedures.

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b. If the Managed Care Plan uses smartphone applications (apps) to allow enrollees direct access to Agency-approved member materials, the Managed Care Plan shall comply with the following:

(1) The smartphone application shall disclaim that the app being used is not private and that no PHI or personally identifying information should be published on this application by the Managed Care Plan or end user; and

(2) The Managed Care Plan shall ensure that software applications obtained, purchased, leased, or developed are based on secure coding guidelines; for example:

(a) OWASP [Open Web Application Security Project] Secure Coding Principles —

http://www.owasp.org/index.php/Secure_Coding_Principles;

(b) CERT Security Coding - http://www.cert.org/secure-coding/; and

(c) Top 10 Security Coding Practices —

https://www.securecoding.cert.org/confluence/display/seccode/Top+10+Secure+Coding+Practices

D. Claims and Provider Payment

1. General Claims Provisions

a. Pursuant to s. 409.967(2)(i), F.S., the Managed Care Plan shall comply with ss. 641.315, 641.3155, and 641.513., F.S.

b. The Managed Care Plan shall have performance metrics, including those for quality, accuracy and timeliness, and include a process for measurement and monitoring, and for the development and implementation of interventions for improvement in regards to claims processing and claims payment. The Managed Care Plan shall keep documentation of the above and have these available for Agency review.

c. The Managed Care Plan shall be able to accept electronically transmitted claims from providers in HIPAA compliant formats.

d. For purposes of this subsection, electronic transmission of claims, transactions, notices, documents, forms and payments shall be used to the greatest extent possible by the Managed Care Plan and shall be HIPAA compliant.

e. The Managed Care Plan shall ensure that claims are processed and comply with the federal and state requirements set forth in 42 CFR 447.45 and 447.46 and Chapter 641, F.S., whichever is more stringent.

f. Pursuant to s. 409.967(2)(l), F.S., any claims payment to a provider by the Managed Care Plan must be accompanied by an itemized accounting of the individual claims included in the payment including, but not limited to, the enrollee’s name, the date of service, the procedure code, service units, the amount of reimbursement and the identification of the Managed Care Plan.

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g. Pursuant to s. 409.967(2)(k), F.S., MMA and LTC PSNs must ensure that no entity licensed under Chapter 395, F.S., with a controlling interest in the PSN charges a Medicaid Managed Care Plan more than the amount paid to that provider by the PSN for the same service.

h. The Managed Care Plan is responsible for Medicare co-insurance and deductibles for covered services. The Managed Care Plan shall reimburse providers or enrollees for Medicare deductibles and co-insurance payments made by the providers or enrollees, according to Medicaid guidelines referenced in the Florida Medicaid Provider General Handbook.

i. The Managed Care Plan shall not deny Medicare crossover claims solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three (3) years.

j. The Managed Care Plan shall have a process for handling and addressing the resolution of provider complaints concerning claims issues. The process shall be in compliance with s. 641.3155 F.S. Pursuant to s. 409.967(2)(m), F.S., disputes between the Managed Care Plan and a provider may be resolved as described in s. 408.7057, F.S.

k. The Managed Care Plan shall not deny claims submitted by a non-participating provider solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred sixty-five (365) days.

2. Claims Provisions

a. The Managed Care Plan shall submit an aging claims summary as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, and in the manner and format determined by the Agency.

b. The Managed Care Plan shall comply with the following requirements:

(1) For Medicaid-only enrollees residing in a nursing facility and receiving hospice services, the Managed Care Plan shall pay the hospice provider the per diem rate set by the Agency for hospice services.

(2) For dually eligible enrollees residing in a nursing facility and receiving hospice services, the hospice provider shall bill Medicare for the per diem rate for hospice services.

c. Pursuant to s. 409.975(6), F.S., a MMA Plan and hospitals shall negotiate mutually acceptable rates, methods, and terms of payment. For rates, methods, and terms of payment negotiated after this Contract is executed, the MMA shall pay hospitals, at a minimum, the rate the Agency would have paid on the first day of the contract between the provider and the Managed Care Plan. Such payments to hospitals may not exceed one-hundred and twenty percent (120%) of the rate the Agency would have paid on the first day of the contract between the provider and the Managed Care Plan, unless specifically approved by the Agency. Payment rates may be updated periodically.

d. Pursuant to s. 409.975(1)(a) and (b), F.S., a MMA Plan shall make payments to essential providers as specified in the MMA Exhibit. In accordance with s. 409.976(2), F.S., a

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MMA Plan shall pay statewide inpatient psychiatric programs (SIPPs) the payment rates established by the Agency.

e. For claims for services:

(1) The date of claim receipt is the date the Managed Care Plan receives the claim at its designated claims receipt location.

(2) The date of Managed Care Plan claim payment is the date of the check or other form of payment.

(3) For all electronically submitted claims for services, the Managed Care Plan shall:

(a) Within twenty-four (24) hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgement of the receipt of the claim to the electronic source submitting the claim.

(b) Pursuant to s. 409.982(5), F.S., within ten (10) business days of receipt of nursing facility and hospice clean claims, pay or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.

(c) Within fifteen (15) days after receipt of a non-nursing facility/non-hospice claim, pay the claim or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.

(d) Pay or deny the claim within ninety (90) days after receipt of the non-nursing-facility/non-hospice claim. Failure to pay or deny the claim within one hundred twenty (120) days after receipt of the claim creates an uncontestable obligation for the Managed Care Plan to pay the claim. (See s. 641.3155, F.S.)

(4) For all non-electronically submitted claims for services, the Managed Care Plan shall:

(a) Within fifteen (15) days after receipt of the claim, provide acknowledgment of receipt of the claim to the provider or designee or provide the provider or designee with electronic access to the status of a submitted claim.

(b) Within twenty (20) days after receipt of the claim, pay the claim or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.

(c) Pay or deny the claim within one hundred twenty (120) days after receipt of the claim. Failure to pay or deny the claim within one hundred forty (140) days after receipt of the claim creates an uncontestable obligation for the Managed Care Plan to pay the claim.

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(5) The Managed Care Plan shall comply with the following standards regarding timely claims processing:

(a) The Managed Care Plan shall pay or deny fifty percent (50%) of all clean claims submitted within seven (7) days.

(b) The Managed Care Plan shall pay or deny seventy percent (70%) of all clean claims submitted within ten (10) days.

(c) The Managed Care Plan shall pay or deny ninety percent (90%) of all clean claims submitted within twenty (20) days.

f. The Managed Care Plan shall reimburse providers for the delivery of authorized services as described in s. 641.3155, F.S., including, but not limited to:

(1) The provider must mail or electronically transfer (submit) the claim to the Managed Care Plan within six (6) months after:

(a) The date of service or discharge from an inpatient setting; or

(b) The date that the provider was furnished with the correct name and address of the Managed Care Plan.

(2) When the Managed Care Plan is the secondary payer, the provider must submit the claim to the Managed Care Plan within ninety (90) days after the final determination of the primary payer, in accordance with the Medicaid Provider General Handbook.

E. Encounter Data Requirements

1. General Provisions

a. Encounter data collection and submission is required from the Managed Care Plan for all services, including expanded benefits, rendered to its enrollees (excluding services paid directly by the Agency on a fee-for-service basis). The Managed Care Plan shall submit encounter data that meets established Agency data quality standards as defined herein. These standards are defined by the Agency to ensure receipt of complete and accurate data for program administration and are closely monitored and enforced.

b. The Agency will revise and amend these standards with sixty (60) days’ advance notice to the Managed Care Plan to ensure continuous quality improvement. The Managed Care Plan shall make changes or corrections to any systems, processes or data transmission formats as needed to comply with Agency data quality standards as originally defined or subsequently amended.

The Managed Care Plan must be capable of sending and receiving any claims information directly to the Agency in standards and timeframes specified by the Agency within sixty (60) days’ notice.

c. The Managed Care Plan must certify all data to the extent required in 42 CFR 438.606. Such certification must be submitted to the Agency with the certified data and must be

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based on the knowledge, information and belief of the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Medical Officer (CMO) or an individual who has written delegated authority to sign for, and directly reports to the CEO or CFO that all data submitted in conjunction with the encounter data and all documents requested by the Agency are accurate, truthful, and complete. The Managed Care Plan shall provide the certification at the same time it submits the certified data in the format and within the timeframe required by the Agency.

d. The Managed Care Plan shall have the capacity to identify encounter data anomalies and shall provide a description of that process to the Agency for review and approval.

e. The Managed Care Plan shall designate sufficient information technology (IT) and staffing resources to perform these encounter functions as determined by generally accepted best industry practices.

f. The Managed Care Plan shall participate in Agency-sponsored workgroups directed at continuous improvements in encounter data quality and operations.

2. Requirements for Complete and Accurate Encounters

a. The Managed Care Plan shall have a comprehensive automated and integrated encounter data system capable of meeting the requirements below:

(1) All Managed Care Plan encounters shall be submitted to the Agency in the standard HIPAA transaction formats, namely the ANSI X12N 837 transaction formats (P — Professional; I — Institutional; D — Dental), and, for pharmacy services, in the National Council for Prescription Drug Programs (NCPDP) format. The Managed Care Plan’s encounters shall also follow the standards in the Agency’s 5010 Companion Guides, the Florida D.0 Payer Specification - Encounters and in this section. Encounters must include Managed Care Plan amounts paid to the providers and shall be submitted for all providers (capitated and non-capitated).

(2) The Managed Care Plan shall follow the instructions in the User Guide and Report Guide regarding the reporting of pharmacy encounter data using the National Council for Prescription Drug Program (NCPDP) standard D.0. format and field definitions. Additionally the Managed Care Plan shall submit all denied pharmacy claims data and the reason code(s) for denial.

(3) The Managed Care Plan shall convert all information that enters its claims system via hard copy paper claims or other proprietary formats to encounter data to be submitted in the appropriate HIPAA-compliant formats.

(4) For any services in which a Managed Care Plan has entered into capitation reimbursement arrangements with providers, the Managed Care Plan shall comply with all encounter data submission requirements in this section. The Managed Care Plan shall require timely submissions from its providers as a condition of the capitation payment.

b. The Managed Care Plan shall implement and maintain review procedures to validate encounter data submitted by providers.

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c. The Managed Care Plan shall submit complete, accurate and timely encounter data to the Agency as defined below.

(1) For all services rendered to its enrollees (excluding services paid directly by the Agency on a fee-for-service basis), the Managed Care Plan shall submit encounter data no later than seven (7) days following the date on which the Managed Care Plan adjudicated the claims.

(2) Pharmacy Encounters (NCPDP)

(a) Complete: The Managed Care Plan shall submit encounters for ninety-five percent (95%) of the covered services provided by participating and non-participating providers, as defined in E.1. of this subsection.

(b) Accurate: Ninety-five percent (95%) of the Managed Care Plan’s encounter lines submissions shall pass NCPDP edits and the pharmacy benefits system edits as specified by the Agency. The NCPDP edits are described in the National Council for Prescription Drug Programs Telecommunications Standard Guides. Pharmacy benefits system edits are defined on the following website:

http://portal.flmmis.com/FLPublic/Provider_Pharmacy/tabId/52/Default.aspx.

(3) Non-Pharmacy Encounters (X12)

(a) Complete: The Managed Care Plan shall submit encounters for ninety-five percent (95%) of the covered services provided by participating and non-participating providers, as defined in D.1. of this subsection.

(b) Accurate: No less than ninety-five percent (95%) of the Managed Care Plan’s encounter lines submission shall pass FMMIS system edits as specified by the Agency.

d. Encounter Resubmission - Adjustments, Reversals or Corrections

(1) Within thirty (30) days after encounters fail NCPDP edits, X12 (EDI) edits or FMMIS system edits, the Managed Care Plan shall correct and resubmit all encounters for which errors can be remedied.

(2) The Managed Care Plan shall correct and resubmit one-hundred percent (100%) of previously submitted X12 and NCPDP encounter data transactions to reflect the most current and accurate payment adjustments or reversals that resulted in a recoupment or additional payment within thirty (30) days of the respective action.

e. For encounter data acceptance purposes the Managed Care Plan must ensure the provider information it supplies to the Agency is sufficient to ensure providers are recognized in FMMIS as either actively enrolled Medicaid providers or as Managed Care Plan registered providers. The Managed Care Plan is responsible for ensuring information is sufficient for accurate identification of participating network providers and non-participating providers who render services to Managed Care Plan enrollees.

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3. Check Run Summary File Submission

a. The Managed Care Plan must submit a Check Run Summary File for each provider payment adjudication cycle no later than seven (7) days following each respective adjudication cycle and in a format specified by the Agency.

b. The Managed Care Plan must submit a Check Run Summary File reporting how total provider payment amounts reconcile with the encounter data submissions for each provider payment adjudication cycle. The Check Run Summary File must be submitted along with the encounter claims data submissions. The Check Run Summary file must be submitted in a format and in timeframes specified by the Agency.

4. Encounter Data Submission

a. The Managed Care Plan shall collect, and submit encounter data to the Agency’s fiscal agent. The Managed Care Plan shall be held responsible for errors or noncompliance resulting from their own actions or the actions of an agent authorized to act on its behalf.

b. The encounter data submission standards required to support encounter data collection and submission are defined by the Agency in the Medicaid Companion Guides, Pharmacy Payer Specifications and this section. In addition, the Agency will post encounter data reporting requirements on the following websites:

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_CompanionGuides/tabId/62/Default.aspx

and

http://portal.flmmis.com/FLPublic/Provider_Pharmacy/tabId/52/Default.aspx.

c. The Managed Care Plan shall adhere to the following requirements for the encounter data submission process:

(1) Within thirty (30) days after notice by the Agency or its fiscal agent of encounters getting a denied or rejected payment status (failing fiscal agent edits), the Managed Care Plan shall accurately resubmit one-hundred percent (100%) of all encounters for which errors can be remedied.

(2) The Managed Care Plan shall retain submitted historical encounter data for a period not less than six (6) years as specified in the Standard Contract, Section I., Item D., Retention of Records.

d. The Managed Care Plan shall implement and maintain review procedures to validate the successful loading of encounter files by the Agency’s fiscal agent’s electronic data interface (EDI) clearinghouse. The Managed Care Plan shall use the EDI response (acknowledgement) files to determine if files were successfully loaded. Within seven (7) days of the original submission attempt, the Managed Care Plan shall correct and resubmit files that fail to load

e. If the Managed Care Plan fails to comply with the encounter data reporting requirements of this Contract, the Agency will impose sanctions pursuant to Section XI, Sanctions.

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F. Fraud and Abuse Prevention

1. General Provisions

a. The Managed Care Plan shall establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall comply with all state and federal program integrity requirements, including but not limited to, the applicable provisions of the Social Security Act, ss. 1128, 1902, 1903, and 1932; 42 CFR 431, 433, 434, 435, 438, 441, 447, 455; 45 CFR Part 74; Chapters 409, 414, 458, 459, 460, 461, 626, 641 and 932, F.S., and 59A-12.0073, 59G and 69D-2, F.A.C.

b. The Managed Care Plan shall have adequate Florida-based staffing and resources to enable the compliance officer to investigate indicia of fraud and abuse and develop and implement corrective action plans relating to fraud and abuse and overpayment.

c. The Managed Care Plan’s written fraud and abuse prevention program shall have internal controls and policies and procedures in place that are designed to prevent, reduce, detect, correct and report known or suspected fraud and abuse activities. This shall include reporting instances of fraud and abuse pursuant to ss. 409.91212, F.S., 626.989, F.S., and 641.3915, F.S.

d. In accordance with s. 6032 of the federal Deficit Reduction Act of 2005, the Managed Care Plan shall make available written fraud and abuse policies to all employees. If the Managed Care Plan has an employee handbook, the Managed Care Plan shall include specific information about s. 6032, the Managed Care Plan’s policies, and the rights of employees to be protected as whistleblowers.

e. The Managed Care Plan shall meet with the Agency periodically, at the Agency’s request, to discuss fraud, abuse, neglect and overpayment issues.

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2. Compliance Officer

The Managed Care Plan’s compliance officer as described in Section VIII, Administration and Management, shall have unrestricted access to the Managed Care Plan’s governing body for compliance reporting, including fraud and abuse and overpayment.

3. Fraud Investigation Unit

a. The Managed Care Plan shall establish and maintain a fraud investigative unit to investigate possible acts of fraud, abuse or overpayment, or may subcontract such functions.

b. If a Managed Care Plan subcontracts for the investigation of fraudulent claims and other types of program abuse by enrollees or service providers, the Managed Care Plan shall file the following with the Bureau of Medicaid Program Integrity (MPI) for approval at least sixty (60) days before subcontract execution:

(1) The names, addresses, telephone numbers, e-mail addresses and fax numbers of the principals of the entity with which the Managed Care Plan wishes to subcontract;

(2) A description of the qualifications of the principals of the entity with which the Managed Care Plan wishes to subcontract; and

(3) The proposed subcontract.

c. The Managed Care Plan shall submit to MPI such executed subcontracts, attachments, exhibits, addendums or amendments thereto, within thirty (30) days after execution.

4. Compliance Plan and Anti-Fraud Plan

a. The Managed Care Plan shall submit its compliance plan and anti-fraud plan, including its fraud and abuse policies and procedures, and any changes to these items, to MPI for written approval at least forty-five (45) days before those plans and procedures are implemented. (See ss. 409.91212, F.S. and 409.967(2)(f), F.S.) The Managed Care Plan shall submit these documents via the MPI-MC secure file transfer protocol (SFTP) site. Failure to implement an MPI approved anti-fraud plan within ninety (90) days may result in liquidated damages. MPI may reassess the implementation of the anti-fraud plan every ninety (90) days until MPI deems the Managed Care Plan to be in compliance. (See Section XIII, Liquidated Damages.)

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b. At a minimum the compliance plan must include:

(1) Written policies, procedures and standards of conduct that articulate the Managed Care Plan’s commitment to comply with all applicable federal and state standards;

(2) The designation of a compliance officer and a compliance committee accountable to senior management;

(3) Effective training and education of the compliance officer and the Managed Care Plan’s employees;

(4) Effective lines of communication between the compliance officer and the Managed Care Plan’s employees;

(5) Enforcement of standards through well-publicized statutory and contractual requirements and related disciplinary guidelines;

(6) Provision for internal monitoring and auditing; and

(7) Provisions for prompt response to detected offenses and for development of corrective action initiatives.

c. At a minimum, the Managed Care Plan shall submit its anti-fraud plan to MPI annually by September 1. The anti-fraud plan shall comply with s. 409.91212, F.S., and, at a minimum, must include:

(1) A written description or chart outlining the organizational arrangement of the Managed Care Plan’s personnel who are responsible for the investigation and reporting of possible overpayment, abuse or fraud;

(2) A description of the Managed Care Plan’s procedures for detecting and investigating possible acts of fraud, abuse and overpayment;

(3) A description of the Managed Care Plan’s procedures for the mandatory reporting of possible overpayment, abuse or fraud to MPI;

(4) A description of the Managed Care Plan’s program and procedures for educating and training personnel on how to detect and prevent fraud, abuse and overpayment;

(a) At a minimum, training shall be conducted within thirty (30) days of new hire and annually thereafter;

(b) The Managed Care Plan shall have a methodology to verify training occurs as required; and

(c) The Managed Care Plan shall also include Deficit Reduction Act requirements in the training curriculum.

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(5) The name, address, telephone number, e-mail address and fax number of the individual responsible for carrying out the anti-fraud plan; and

(6) A summary of the results of the investigations of fraud, abuse, or overpayment which were conducted during the previous fiscal year by the Managed Care Plan’s fraud investigative unit.

d. At a minimum, the Managed Care Plan’s compliance plan, anti-fraud plan, and fraud and abuse policies and procedures shall comply with s. 409.91212, F.S., and with the following:

(1) Ensure that all officers, directors, managers and employees know and understand the provisions;

(2) Include procedures designed to prevent and detect potential or suspected fraud and abuse in the administration and delivery of services under this Contract. Nothing in this Contract shall require that the Managed Care Plan assure that non-participating providers are compliant with this Contract, but the Managed Care Plan is responsible for reporting suspected fraud and abuse by non-participating providers when detected;

(3) Describe the Managed Care Plan’s organizational arrangement of anti-fraud personnel, their roles and responsibilities, including a description of the internal investigational methodology and reporting protocols. Such internal investigational methodology and reporting protocols shall ensure the unit’s primary purpose is for the investigation (or supervision of the investigation) of suspected insurance/Medicaid fraud and fraudulent claims;

(4) Incorporate a description of the specific controls in place for prevention and detection of potential or suspected fraud and abuse, including, but not limited to:

(a) An effective pre-payment and post-payment review process, including but not limited to data analysis, claims and other system edits, and auditing of participating providers (see s. 409.967(2)(f), F.S.);

(b) A description of the method(s), including detailed policies and procedures, for verifying enrollees’ identity and if services billed by providers were actually received. Such methods must be either the use of electronic verification or biometric technology but may also include sending enrollee explanations of Medicaid benefits (EOMB), contacting enrollees by telephone, mailing enrollees a questionnaire, contacting a representative sample of enrollees, or sampling enrollees based on business analyses;

(c) Provider profiling, credentialing, and recredentialing, and ongoing provider monitoring including a review process for claims and encounters that shall include providers and non-participating providers who:

(i) Demonstrate a pattern of submitting falsified encounter data or service reports;

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(ii) Demonstrate a pattern of overstated reports or up-coded levels of service;

(iii) Alter, falsify or destroy clinical record documentation;

(iv) Make false statements relating to credentials;

(v) Misrepresent medical information to justify enrollee referrals;

(vi) Fail to render medically necessary covered services they are obligated to provide according to their provider contracts;

(vii) Charge enrollees for covered services; and

(viii) Bill for services not rendered;

(d) Prior authorization;

(e) Utilization management;

(f) Subcontract and provider contract provisions;

(g) Provisions from the provider and the enrollee handbooks; and

(h) Standards for a code of conduct.

(5) Contain provisions pursuant to this section for the confidential reporting of Managed Care Plan violations to MPI and other agencies as required by law;

(6) Include provisions for the investigation and follow-up of any reports;

(7) Ensure that the identities are protected for individuals reporting in good faith alleged acts of fraud and abuse;

(8) Require all suspected or confirmed instances of internal and external fraud and abuse relating to the provision of, and payment for, Medicaid services including, but not limited to, Managed Care Plan employees/management, providers, subcontractors, vendors, delegated entities, or enrollees under state and/or federal law be reported to MPI within fifteen (15) days of detection, as specified in s. 409.91212, F.S. and in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. Additionally, any final resolution reached by the Managed Care Plan shall include a written statement that provides notice to the provider or enrollee that the resolution in no way binds the State of Florida nor precludes the State of Florida from taking further action for the circumstances that brought rise to the matter;

(9) Ensure that the Managed Care Plan and all providers and subcontractors, upon request and as required by state and/or federal law, shall:

(a) Make available to all authorized federal and state oversight agencies and their agents, including but not limited to, the Agency, the Florida Attorney General, and DFS any and all administrative, financial and medical/case

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records and data relating to the delivery of items or services for which Medicaid monies are expended; and

(b) Allow access to all authorized federal and state oversight agencies and their agents, including but not limited to, the Agency, the Florida Attorney General, and DFS to any place of business and all medical/case records and data, as required by state and/or federal law. Access shall be during Normal Business Hours, except under special circumstances when the Agency, the Florida Attorney General, and DFS shall have After Hours admission. The Agency and the Florida Attorney General shall determine the need for special circumstances.

(10) Ensure that the Managed Care Plan shall cooperate fully in any investigation by federal and state oversight agencies and any subsequent legal action that may result from such an investigation;

(11) Ensure that the Managed Care Plan does not retaliate against any individual who reports violations of the Managed Care Plan’s fraud and abuse policies and procedures or suspected fraud and abuse;

(12) Not knowingly have affiliations with individuals debarred or excluded by federal agencies under ss. 1128 and 1128A of the Social Security Act and 42 CFR 438.610 or subcontractors on the discriminatory vendor list maintained by the Department of Management Services in accordance with s. 287.134, F.S.;

(13) On at least a monthly basis check current staff, subcontractors and providers against the federal List of Excluded Individuals and Entities (LEIE) and the federal System for Award Management (SAM) (includes the former Excluded Parties List System (EPLS) or their equivalent, to identify excluded parties. The Managed Care Plan shall also check monthly the Agency’s listing of suspended and terminated providers at the Agency website below, to ensure the Managed Care Plan does not include any non-Medicaid eligible providers in its network: http://apps.ahca.myflorida.com/dm_web.

The Managed Care Plan shall also conduct these checks during the process of engaging the services of new employees, subcontractors and providers and during renewal of agreements and recredentialing. The Managed Care Plan shall not engage the services of an entity that is in nonpayment status or is excluded from participation in federal health care programs under ss. 1128 and 1128A of the Social Security Act;

(14) Provide details and educate employees, subcontractors and providers about the following as required by s. 6032 of the federal Deficit Reduction Act of 2005:

(a) The Federal False Claim Act;

(b) The penalties and administrative remedies for submitting false claims and statements;

(c) Whistleblower protections under federal and state law;

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(d) The entity’s role in preventing and detecting fraud, waste and abuse;

(e) Each person’s responsibility relating to detection and prevention; and

(f) The toll-free state telephone numbers for reporting fraud and abuse.

(15) If the Managed Care Plan is approved to provide telemedicine, the Managed Care Plan shall include a review of telemedicine in its fraud and abuse detection activities.

5. Reporting and Disclosure Requirements

a. The Managed Care Plan shall comply with all reporting requirements as set forth below and in s. 409.91212, F.S.

b. The Managed Care Plan shall report on a quarterly basis a comprehensive fraud and abuse prevention activity report regarding its investigative, preventive and detective activity efforts, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide

c. The Managed Care Plan shall, by September 1 of each year, report to MPI its experience in implementing an anti-fraud plan, and on conducting or subcontracting for investigations of possible fraudulent or abusive acts during the prior state fiscal year, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. The report must include, at a minimum:

(1) The dollar amount of Managed Care Plan losses and recoveries attributable to overpayment, abuse and fraud; and

(2) The number of Managed Care Plan referrals to MPI.

d. The Managed Care Plan shall notify DHHS OIG and MPI within ten (10) business days of discovery of individuals who have met the conditions giving rise to mandatory or permissive exclusions per s. 1128, s. 1156, and s.1892 of the Social Security Act, 42 CFR 455.106, 42 CFR 1002.3, and 42 CFR 1001.1.

e. In accordance with 42 CFR 455.106, the Managed Care Plan shall disclose to DHHS OIG, with a copy to MPI within ten (10) business days after discovery, the identity of any person who:

(1) Has ownership or control interest in the Managed Care Plan, or is an agent or managing employee of the Managed Care Plan; and

(2) Has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs.

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f. In addition to the disclosure required under 42 CFR 455.106, the Managed Care Plan shall also disclose to DHHS OIG with a copy to MPI within ten (10) business days after discovery, the identity of any person described in 42 CFR 1002.3 and 42 CFR 1001.1001(a)(1), and to the extent not already disclosed, to additionally disclose any person who has ownership or control interest in a Managed Care Plan participating provider, or subcontractor, or is an agent or managing employee of a Managed Care Plan participating provider or subcontractor, and meets at least one of the following requirements:

(1) Has been convicted of a crime as identified in s. 1128 of the Social Security Act and/or conviction of a crime related to that person’s involvement in any program under Medicare, Medicaid, or the Title XX services program since the inception of those programs;

(2) Has been denied entry into the Managed Care Plan’s network for program integrity-related reasons; or

(3) Is a provider against whom the Managed Care Plan has taken any action to limit the ability of the provider to participate in the Managed Care Plan’s provider network, regardless of what such an action is called. This includes, but is not limited to, suspension actions, settlement agreements and situations where an individual or entity voluntarily withdraws from the program or Managed Care Plan provider network to avoid a formal sanction.

g. The Managed Care Plan shall submit the written notification referenced above to DHHS OIG via email to: floridaexclusions@oig.hhs.gov and copy MPI via email to: mpifo@ahca.myflorida.com. Document information examples include, but are not limited to, court records such as indictments, plea agreements, judgments and conviction/sentencing documents.

h. In lieu of an e-mail notification, a hard copy notification is acceptable to DHHS OIG at:

Attention: Florida Exclusions

Office of the Inspector General

Office of Investigations

7175 Security Boulevard, Suite 210

Baltimore, MD 21244

With a copy to MPI at:

Attention: Florida Exclusions

Office of the Inspector General

Medicaid Program Integrity

2727 Mahan Drive, M.S. #6

Tallahassee, FL 32308-5403

i. The Managed Care Plan shall notify MPI and provide a copy of any corporate integrity or corporate compliance agreements within thirty (30) days after execution of such agreements.

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j. The Managed Care Plan shall notify MPI and provide a copy of any corrective action plans required by the Department of Financial Services (DFS) and/or federal governmental entities, excluding AHCA, within thirty (30) days after execution of such plans.

k. The Managed Care Plan shall query its potential non-provider subcontractors before contracting to determine whether the subcontractor has any existing or pending contract(s) with the Agency and, if any, notify MPI.

6. Sanctions

a. Notwithstanding any other provisions related to the imposition of sanctions or fines in this Contract, including any attachments, exhibits, addendums or amendments hereto, the following sanctions will be applied:

b. If the Managed Care Plan fails to timely submit an acceptable anti-fraud plan or fails to timely submit the reports referenced in Section XIV, Reporting Requirements, and specified in the Managed Care Plan Report Guide, a sanction of $2,000 per calendar day, from the date the report is due to the Agency, shall be imposed under this Contract until MPI deems the Managed Care Plan to be in compliance.

c. If the Managed Care Plan fails to implement an anti-fraud plan or investigative unit, a sanction of $10,000 shall be imposed under this Contract.

d. If the Managed Care Plan fails to timely report, or report all required information for all suspected or confirmed instances of provider or recipient fraud or abuse within fifteen (15) days after detection to MPI, as specified in s. 409.91212, F.S., a sanction of $1,000 per calendar day will be imposed under this Contract, until MPI deems the Managed Care Plan to be in compliance.

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Section IX. Method of Payment

A. Fixed Price Unit Contract

This is a fixed price (unit cost) Contract awarded through procurement. The Agency, through its fiscal agent, shall make payment to the Managed Care Plan on a monthly basis for the Managed Care Plan’s satisfactory performance of its duties and responsibilities as set forth in this Contract.

B. Payment Provisions

1. Capitation Rates

a. The Agency shall pay the applicable capitation rate for each eligible enrollee whose name appears on the HIPAA-compliant X12 820 file for each month, except that the Agency shall not pay for, and shall recoup, any part of the total payment for enrollment that exceeds the maximum authorized enrollment level(s) expressed in Attachment I, as applicable. The total payment amount to the Managed Care Plan shall depend upon the number of enrollees in each eligibility category and each rate group, as provided for by this Contract, or as adjusted pursuant to the Contract when necessary. The Managed Care Plan is obligated to provide services pursuant to the terms of this Contract for all enrollees for whom the Managed Care Plan has received capitation payment or for whom the Agency has assured the Managed Care Plan that capitation payment is forthcoming.

b. In accordance with ss. 409.968, 409.976 and 409.983, F.S., the capitation rates reflect historical utilization and spending for covered services projected forward and will be adjusted to reflect the level of care profile (risk) for enrollees in each Managed Care Plan.

c. The rates shall be actuarially sound in accordance with 42 CFR 438.6(c).

d. Pursuant to s. 409.966(3)(d), F.S., for the first year of the first Contract term, the Agency shall negotiate capitation rates in order to guarantee savings of at least five percent (5%). Determination of the amount of savings shall be calculated by comparison to the Medicaid rates that the Agency paid Managed Care Plans for similar populations in the same areas in the prior year. In a region without any capitated plans in the prior year, savings shall be calculated by comparison to the Medicaid rates established and certified for those regions in the prior year. After the first year no further rate negotiations will be conducted.

e. The base capitation rates prior to risk adjustment are included in Attachment I, titled “ESTIMATED MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

f. The Agency may use, or may amend and use these rates, only after certification by its actuary and approval by the Centers for Medicare and Medicaid Services. Inclusion of these rates is not intended to convey or imply any rights, duties or obligations of either party, nor is it intended to restrict, restrain or control the rights of either party that may have existed independently of this section of the Contract.

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g. By signature on this Contract, the parties explicitly agree that this section shall not independently convey any inherent rights, responsibilities or obligations of either party, relative to these rates, and shall not itself be the basis for any cause of administrative, legal or equitable action brought by either party. In the event that the rates certified by the actuary and approved by CMS are different from the rates included in this Contract, the Managed Care Plan agrees to accept a reconciliation performed by the Agency to bring payments to the Managed Care Plan in line with the approved rates. The Agency may amend and use the CMS-approved rates by notice to the Managed Care Plan through an amendment to the Contract.

h. Unless otherwise specified in this Contract, the Managed Care Plan shall accept the capitation payment received each month as payment in full by the Agency for all services provided to enrollees covered under this Contract and the administrative costs incurred by the Managed Care Plan in providing or arranging for such services. Any and all costs incurred by the Managed Care Plan in excess of the capitation payment shall be borne in total by the Managed Care Plan.

i. The Agency shall pay a retroactive capitation rate for each newborn enrolled in a MMA or Comprehensive LTC Managed Care Plan retroactive to the month of birth. (see s. 409.977(3), F.S.) The Managed Care Plan is responsible for payment of all covered services provided to newborns.

j. The Agency shall pay a MMA or Comprehensive LTC Managed Care Plan one kick payment for each covered transplant for enrollees who are not also eligible for Medicare. The Agency shall make kick payments for transplants in the amounts indicated in the MMA Exhibit.

k. The Agency shall pay an MMA or Comprehensive LTC Managed Care Plan a supplemental payment for eligible primary care services provided between January 1, 2013 and December 31, 2014 as provided in the MMA Exhibit.

l. The Agency shall prospectively adjust the base capitation rates for LTC and Comprehensive LTC Managed Care Plans in accordance with the LTC Exhibit.

2. Rate Adjustments and Reconciliations

a. The Managed Care Plan and the Agency acknowledge that the capitation rates paid under this Contract are subject to approval by the federal government.

b. The Managed Care Plan and the Agency acknowledge that adjustments to funds previously paid, and to funds yet to be paid, may be required. Funds previously paid shall be adjusted when capitation rate calculations are determined to have been in error, or when capitation rate payments have been made for enrollees who are determined not to have been eligible for Managed Care Plan membership during the period for which the capitation rate payments were made. In such events, the Managed Care Plan agrees to refund any overpayment and the Agency agrees to pay any underpayment.

c. Pursuant to ss. 409.983(6) and 409.983(7), F.S., the Agency shall reconcile a Managed Care Plan’s actual payments to nursing facilities, including patient responsibility, and hospices for enrollees with LTC benefits as specified in the LTC exhibit.

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d. Pursuant to s. 409.976(2), F.S., the Agency shall reconcile a Managed Care Plan’s actual payments to SIPPs for enrollees with MMA benefits to ensure actual claim payments are, at a minimum, the same as Medicaid FFS claim payments. Any Managed Care Plan provider payments to SIPPs in excess of FFS claim payments will not be reimbursed by the Agency or in any way increase per member per month payment to the Managed Care Plan in any current or future capitation rate setting period. The Managed Care Plan accepts and assumes all risks of excess payments as a cost of doing business and cannot seek additional Medicaid payments for such business decisions. Any inadvertent payments made by the Agency to a Managed Care Plan in excess of the FFS amount shall be overpayments and shall be recouped.

e. The Agency shall adjust capitation rates to reflect budgetary changes in the Medicaid program. The rate of payment and total dollar amount may be adjusted with a properly executed amendment when Medicaid expenditure changes have been established through the appropriations process and subsequently identified in the Agency’s operating budget. Legislatively-mandated changes shall take effect on the dates specified in the legislation. The Agency may not approve any Managed Care Plan request for a rate increase unless sufficient funds to support the increase have been authorized in the General Appropriations Act. (See s. 409.968(3), F.S.).

f. In accordance with s. 409.967(3), F.S., the Agency shall verify the Managed Care Plan’s achieved savings rebate specified in this Contract.

3. Errors

The Managed Care Plan shall carefully prepare all reports and monthly payment requests for submission to the Agency. If after preparation and electronic submission, the Managed Care Plan discovers an error, including, but not limited to, errors resulting in capitated payments above the Managed Care Plan’s authorized levels, either by the Managed Care Plan or the Agency, the Managed Care Plan has thirty (30) days from its discovery of the error, or thirty (30) days after receipt of notice by the Agency, to correct the error and re-submit accurate reports and/or invoices. Failure to respond within the thirty- (30) calendar-day period shall result in a loss of any money due to the Managed Care Plan for such errors and/or sanctions against the Managed Care Plan pursuant to Section XI, Sanctions.

4. Enrollee Payment Liability Protection

a. Pursuant to s. 1932(b)(6), Social Security Act (as enacted by section 4704 of the Balanced Budget Act of 1997), the Managed Care Plan shall not hold enrollees liable for debts of the Managed Care Plan, in the event of the Managed Care Plan’s insolvency;

b. Managed Care Plan shall not hold enrollees liable for payment of covered services provided by the Managed Care Plan if the Managed Care Plan has not received payment from the Agency for the covered services (excluding Medicaid Pending LTC enrollees who are determined ineligible for Medicaid as specified in this Contract), or if the provider, under contract or other arrangement with the Managed Care Plan, fails to receive payment from the Agency or the Managed Care Plan; and/or

c. Managed Care Plan shall not hold enrollees liable for payments to a provider, including referral providers, that furnished covered services under a contract or other

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arrangements with the Managed Care Plan, that are in excess of the amount that normally would be paid by the enrollee if the covered services had been received directly from the Managed Care Plan.

5. Achieved Savings Rebate

a. In accordance with s. 409.967(3), F.S. and as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, the Managed Care Plan shall submit:

(1) Quarterly unaudited financial statements including the Achieved Savings Rebate exhibits, and an annual financial audit conducted by an independent certified public accountant (CPA) in accordance with generally accepted accounting principles (GAAP);

(2) If the Managed Care Plan is regulated by the Office of Insurance Regulation (OIR) annual statements prepared in accordance with statutory accounting principles; and

b. The Managed Care Plan shall pay to the Agency the expenses of the Agency’s achieved savings rebate audit at the rates established by the Agency. Expenses shall include actual travel expenses, reasonable living expense allowances, compensation of the CPA and necessary attendant administrative costs of the Agency directly related to the audit/examination. The Managed Care Plan shall pay the Agency within twenty-one (21) days after presentation by the Agency of the detailed account of the charges and expenses.

c. At a Florida location by the date specified by the Agency’s contracted CPA, the Managed Care Plan shall make available all books, accounts, documents, files and information that relate to the Managed Care Plan’s Medicaid transactions.

(1) The Managed Care Plan shall cooperate in good faith with the Agency and the CPA.

(2) Records not in the Managed Care Plan’s immediate possession must be made available to the Agency or the CPA in the Florida location specified by the Agency or the CPA within three (3) days after a request is made by the Agency or the CPA. If original records are required, and they cannot be made available in a Florida location as specified herein, the Managed Care Plan shall make the records available for the CPA to review at the applicable location and shall pay any expenses related to the CPA’s review at that location.

(3) Failure to comply with such record requests shall be deemed a breach of Contract, and the Managed Care Plan shall be subject to sanctions as specified in Section XI, Sanctions.

d. In accordance with s. 409.967(3)(g), F.S. and as specified below, if the Managed Care Plan exceeds the Agency-defined quality measures as specified below, the Managed Care Plan may retain up to an additional one percent (1%) of its revenue.

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(1) For MMA and Comprehensive LTC managed care plans, the following shall apply:

(a) The Agency shall assign the HEDIS performance measures listed in d.(1)(c) 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

(b) In order to be eligible to retain up to an additional one percent (1%) of revenue, the Managed Care Plan shall achieve a group score of four (4) or higher for each of the six performance measure groups in the first year of reporting performance measures. To be eligible to retain up to an additional one percent (1%) of revenue based on the second year and subsequent years of reporting performance measures, the Managed Care Plan shall achieve a group score of five (5) or higher for each of the six (6) performance measure groups.

(c) Performance measure groups are as follows:

(i) Mental Health and Substance Abuse

• Antidepressant Medication Management

• Follow-up Care for Children Prescribed ADHD Medication

• Follow-up after Hospitalization for Mental Illness (7 day)

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

(ii) Well-Child

• Adolescent Well Care Visits

• Childhood Immunization Status – Combo 3

• Immunizations for Adolescents

• Well-Child Visits in the First 15 Months of Life (6 or more)

• Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life

• Lead Screening in Children

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(iii) Other Preventive Care

• Adults’ Access to Preventive/Ambulatory Health Services

• Annual Dental Visits

• BMI Assessment

• Breast Cancer Screening

• Cervical Cancer Screening

• Children and Adolescents’ Access to Primary Care

• Chlamydia Screening for Women

(iv) Prenatal/Perinatal

• Prenatal and Postpartum Care (includes two (2) measures)

• Prenatal Care Frequency

(v) Diabetes – Comprehensive Diabetes Care Measure Components

• HbA1c Testing

• HbA1c Control (< 8%)

• Eye Exam

• LDL-C Screening

• LDL-C Control

• Medical Attention for Nephropathy

(vi) Other Chronic and Acute Care

• Controlling High Blood Pressure

• Pharyngitis – Appropriate Testing related to Antibiotic Dispensing

• Use of Appropriate Medications for People with Asthma

• Annual Monitoring for Patients on Persistent Medications

(2) In order to eligible to retain up to an additional one percent (1%) of revenue in the first year, a LTC or Comprehensive LTC managed care plan shall exceed the specified threshold for each and all performance measures as listed below:

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Measure	Threshold
HEDIS Measures
Care for Older Adults	90th percentile
Call Answer Timeliness	90th percentile
Agency-Defined
Required Record Documentation
•701B Assessment	95%
•Freedom of Choice Form	95%
•Plan of Care/Enrollee Participation	95%
•Plan of Care/PCP Notification	95%
•Plan of Care/PCP Participation	75%
Face-To-Face Encounters	95%
Case Manager Training	95%
Timeliness of Services	98%

(3) Comprehensive LTC plans that meet the quality standards for only one program component (LTC or MMA), may retain up to one percent (1%) of ASR-allowed revenue associated with the component for which they meet the quality standards.

(4) The Agency may amend the performance measure groups and the group scores required for an MMA managed care plan or Comprehensive LTC plan to retain up to an additional one percent (1%) of revenue with sixty (60) days’ advance notice.

(5) The Agency may amend the performance measures and thresholds required for an LTC or Comprehensive LTC plan to retain up to an additional one percent (1%) of revenue with sixty (60) days’ advance notice.

e. The Agency CPA will validate the achieved savings rebate, and the results will be provided to the Agency. If the CPA validates the achieved savings rebate submitted by the Managed Care Plan in accordance with the Managed Care Plan Report Guide, these results shall be final and dispositive. If the CPA fails to validate the achieved savings rebate submitted by the Managed Care Plan, the Agency will provide written notice of the CPA’s findings to the Managed Care Plan and allow the Managed Care Plan the opportunity to review and respond to the CPA’s findings in writing within the timeframe specified by the Agency. The CPA will review the Managed Care Plan’s response and issue final results. These results are dispositive.

f. The Agency will provide the final results of the audit to the Managed Care Plan, and the Managed Care Plan shall pay the rebate to the Agency within thirty (30) days after the results are provided.

g. The achieved savings rebate is established by determining pretax income as a percentage of revenues and applying the following income ratios:

(1) One hundred percent (100%) of income up to and including five (5) percent of revenue shall be retained by the Managed Care Plan.

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(2) Fifty percent (50%) of income above five (5) percent and up to ten percent (10%) shall be retained by the Managed Care Plan, and the other fifty percent (50%) refunded to the state.

(3) One hundred percent (100%) of income above ten percent (10%) of revenue shall be refunded to the state

h. As further specified in the Managed Care Plan Report Guide, for purposes of the achieved savings rebate:

(1) Pretax income is defined as pre-tax revenue minus those expenses permitted in the Managed Care Plan Report Guide.

(2) Revenue includes but is not limited to all capitation premium payments made by the State to the Managed Care Plan. Revenue does not include additions to, or components of, premium payments made to provide funds for payment of the ACA Section 9010 Health Insurance Providers Fee, or the additional amounts to provide for the payment of state premium taxes or federal income tax on such amounts. Revenue is to be reduced by the state premium tax or other state assessments based on the premium.

(3) Expenses generally include reasonable and appropriate medical expenses and general and administrative expenses, other than interest expense, of operating the Managed Care Plan in accordance with the requirements of this Contract. Any state premium tax or other state assessment based on premium that is treated as a reduction to premium revenue cannot be included in the allowable expenses. In accordance with s. 409.967(3)(h), F.S., the following expenses are not allowable expenses for purposes of determining the pre-tax income subject to the achieved savings rebate;

(a) Payment of achieved savings rebates;

(b) Any financial incentive payments made to the Managed Care Plan outside of the capitation rate;

(c) Expenses associated with any lobbying or political activities;

(d) Cash value or equivalent cash value of bonuses of any type paid or awarded to the Managed Care Plan’s executive staff other than base salary;

(e) Reserves and reserve accounts other than those expressly permitted by the Managed Care Plan Report Guide; and

(f) Administrative costs in excess of actuarially sound maximum amounts set by the Agency.

i. The actuarially sound maximum amount for administrative costs will be calculated by the actuary developing the capitation rates as part of the ratesetting process.

j. In accordance with s. 409.967(3)(i), F.S., if the Managed Care Plan incurs a loss in the first calendar year of operation subject to the achieved saving rebate, it may apply the

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full amount of such loss as an offset to income in the second year. If the Managed Care Plan elects to carry forward such a loss, then the life-years of coverage for the first calendar year of coverage will also carry over to the second year.

k. In accordance with s. 409.967(3)(i), F.S., if the Agency later determines that the Managed Care Plan owes an additional rebate, the Managed Care Plan shall have thirty (30) days after notification by the Agency to make payment. If the Managed Care Plan fails to pay the rebate, the Agency will withhold future payments until the entire amount of the rebate is recouped. If the Agency determines that the Managed Care Plan made an overpayment, the Agency will return the overpayment within thirty (30) days of such determination.

l. If the Managed Care Plan purchases part or all of the business of another managed care plan, the Managed Care Plan’s information and reports regarding its achieved savings rebate shall include information for the purchased business, including for that part of the reporting period that was prior to the purchase.

m. If the Managed Care Plan’s enrollment in the reporting period is greater than or equal to five-thousand (5,000) life-years but fewer than seventy-five thousand (75,000) life-years, the Agency will make a credibility-based adjustment to the amount of pre-tax income that is fully retained by the Managed Care Plan. If the Managed Care Plan’s enrollment in a reporting period is fewer than five thousand (5,000) life-years, the Managed Care Plan shall not owe a rebate for the reporting period. However, the information from that reporting period shall be carried over and included with information for the next reporting period. When the cumulative life-years of such combined reporting periods equals or exceeds five-thousand (5,000) life-years, the achieved saving rebate calculation will be performed subject to the credibility-based adjustment using the combined life-years.

n. If the Agency determines that payment of an achieved savings rebate by the Managed Care Plan would result in the Managed Care Plan being put at significant risk of insolvency, the Agency may defer all or a portion of the rebate payment owed by the Managed Care Plan.

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AHCA Contract No. FP020, Attachment II, Page 176 of 214

The Achieved Savings Rebate shall be calculated in accordance with s. 409.967(3)(f), F.S., as illustrated below.

Note: The following three (3) increments shall be applied to the Managed Care Plan’s (Plan’s) pre-tax income (AKA: net operating income [NOI])

Achieved Savings Rebates Table – Effective 1/1/2014 – 12/31/2018
	NOI Range Category	Amount Managed Care Plans will retain	Amount Managed Care Plans will be required to refund to the Agency
I	NOI ranging from Zero (0) up to and including five (5) percent of the Plan’s premium revenue:	Managed Care Plans will retain 100% of NOI within this range.	Managed Care Plans will not be required to refund any of their NOI within this range.
II	NOI above five (5) percent and up to and including ten (10) percent of the Plan’s premium revenue:	Managed Care Plans will retain 50% of NOI within this range.	Managed Care Plans will be required to refund 50% of the NOI within this range.
III	NOI above ten (10) percent of the Plan’s premium revenue:	Managed Care Plans will not be allowed to retain any of the NOI within this range.	Managed Care Plans will have to refund to the Agency 100% of the NOI within this range.

Example: If the Plan’s premium revenues are $1,000,000 and allowed expenses are $850,000, the Plan has a pre-tax net operating income (NOI) of $150,000. The NOI is calculated to be 15% of premium revenue (NOI/Revenue):

NOI Range as Percent of Revenue		Plan retains		Plan refunds to the State
0.00% to 5.00% =	$50,000.00	100% of NOI within this range	$50,000.00	0% of NOI within this range:	$0.00
5.00% to 10.00% =	$50,000.00	50% of NOI within this range	$25,000.00	50% of NOI within this range:	$25,000.00
above 10.00% =	$50,000.00	0% of NOI within this range	$0.00	100% of NOI within this range:	$50,000.00
TOTAL =	$150,000.00		$75,000.00		$75,000.00

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Section X. Financial Requirements

A. Insolvency Protection

1. Insolvency Protection Requirements

a. The Managed Care Plan shall establish a restricted insolvency protection account with a federally guaranteed financial institution licensed to do business in Florida in accordance with s. 1903(m)(1) of the Social Security Act (amended by s. 4706 of the Balanced Budget Act of 1997), and s. 409.912, F.S. The Managed Care Plan shall deposit into that account five percent (5%) of the capitation payments made by the Agency each month until a maximum total of two percent (2%) of the annualized total current Contract amount is reached and maintained. No interest may be withdrawn from this account until the maximum Contract amount is reached and withdrawal of the interest will not cause the balance to fall below the required maximum amount. This provision shall remain in effect as long as the Managed Care Plan continues to contract with the Agency.

b. The restricted insolvency protection account may be drawn upon with the authorized signatures of two (2) persons designated by the Managed Care Plan and two (2) representatives of the Agency. The Multiple Signature Verification Agreement Form shall be resubmitted to the Agency within thirty (30) days of Contract execution and resubmitted within thirty (30) days after a change in authorized Managed Care Plan personnel occurs. If the authorized persons remain the same, the Managed Care Plan shall submit an attestation to this effect annually by April 1 of each Contract year to the Agency along with a copy of the latest bank statement. The Managed Care Plan may obtain a sample Multiple Signature Verification Agreement form from the Agency or its agent or download from the Agency website at:

http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/med_prov_0912.shtml.

All such agreements or other signature cards shall be approved in advance by the Agency.

c. In the event that a determination is made by the Agency that the Managed Care Plan is insolvent, as defined in Section I, Definitions and Acronyms, the Agency may draw upon the amount solely with the two (2) authorized signatures of representatives of the Agency and funds may be disbursed to meet financial obligations incurred by the Managed Care Plan under this Contract. A statement of account balance shall be provided by the Managed Care Plan within fifteen (15) days of request of the Agency.

d. If the Contract is terminated, expired, or not continued, the account balance shall be released by the Agency to the Managed Care Plan upon receipt of proof of satisfaction of all outstanding obligations incurred under this Contract.

e. In the event the Contract is terminated or not renewed and the Managed Care Plan is insolvent, the Agency may draw upon the insolvency protection account to pay any outstanding debts the Managed Care Plan owes the Agency including, but not limited to, overpayments made to the Managed Care Plan, and fines imposed under the

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Contract or, for HMOs, s. 641.52, F.S., for EPOs, s. 627, F.S., and for health insurers, s. 624, F.S., for which a final order has been issued. In addition, if the Contract is terminated or not renewed and the Managed Care Plan is unable to pay all of its outstanding debts to health care providers, the Agency and the Managed Care Plan agree to the court appointment of an impartial receiver for the purpose of administering and distributing the funds contained in the insolvency protection account. An appointed receiver shall give outstanding debts owed to the Agency priority over other claims.

f. In the event the Contract is terminated or not renewed and the Managed Care Plan is insolvent, the Agency may draw upon the insolvency protection account to pay any outstanding debts the Managed Care Plan owes the Agency including, but not limited to, overpayments made to the Managed Care Plan, and fines imposed under the Contract, for which a final order has been issued. In addition, if the Contract is terminated or not renewed and the Managed Care Plan is unable to pay all of its outstanding debts to health care providers, the Agency and the Managed Care Plan agree to the court appointment of an impartial receiver for the purpose of administering and distributing the funds contained in the insolvency protection account. An appointed receiver shall give outstanding debts owed to the Agency priority over other claims.

2. Insolvency Protection Account Waiver

Pursuant to s. 409.912, F.S., the Agency may waive the insolvency protection account in writing when evidence of adequate insolvency insurance and reinsurance are on file with the Agency to protect enrollees in the event the Managed Care Plan is unable to meet its obligations.

B. Surplus

1. Surplus Start Up Account

All new Managed Care Plans (excluding public entities that are organized as political subdivisions) at Contract execution, shall submit to the Agency proof of working capital in the form of cash or liquid assets excluding revenues from Medicaid payments equal to at least the first three (3) months of operating expenses or $200,000, whichever is greater. This provision shall not apply to Managed Care Plans that have been providing services to enrollees for a period exceeding three (3) continuous months.

2. Surplus Requirement

a. The Managed Care Plan shall maintain at all times in the form of cash and investments allowable as admitted assets by the Department of Financial Services, and restricted funds of deposits controlled by the Agency (including the Managed Care 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 Managed Care Plan’s prepaid revenues. In the event that the Managed Care Plan’s surplus (as defined in Section I, Definitions and Acronyms) falls below the amount specified in this paragraph, the Agency shall prohibit the Managed Care Plan from engaging in community outreach activities, shall cease to process new enrollments until the required balance is achieved, or may terminate the Managed Care Plan’s Contract statewide..

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b. In lieu of the surplus requirements under Section X.B., Surplus Requirements, the Agency may consider the following:

(1) If the organization is a public entity, the Agency may take under advisement a statement from the public entity that a county supports the Managed Care Plan with the county’s full faith and credit. In order to qualify for the Agency’s consideration, the county must own, operate, manage, administer or oversee the Managed Care Plan, either partly or wholly, through a county department or agency;

(2) The state guarantees the solvency of the organization;

(3) The organization is a federally qualified health center (FQHC) or is controlled by one (1) or more FQHCs and meets the solvency standards established by the state for such organization pursuant to s. 409.912(4)(c), F.S.; or

(4) The entity meets the financial standards for federally approved provider-sponsored organizations as defined in 42 CFR 422.380 through 422.390 and the solvency requirements established in approved federal waivers or Florida’s Medicaid State Plan.

C. Interest

Interest generated through investments made by the Managed Care Plan under this Contract shall be the property of the Managed Care Plan and shall be used at the Managed Care Plan’s discretion.

D. Third Party Resources

1. Covered Third Party Collections

a. The Managed Care Plan shall determine the legal liability of third parties to pay for services rendered to enrollees under this Contract and notify the Agency of any third party liability discovered.

b. The Managed Care Plan shall assume full responsibility for covered third party collections in accordance with this section. Covered third party collections include only recoveries initiated within one year after the Managed Care Plan’s claims payment date for the cost of covered services incurred by the Managed Care Plan on behalf of an enrollee for services that should have been paid through a third party. The Managed Care Plan shall be considered to have initiated a recovery by filing a claim of lien in a court of law or filing a claim for reimbursement with the liable third party for the full amount of medical assistance provided. The Managed Care Plan shall have the sole right to subrogation for one (1) year from the when the plan incurred the cost to recovery of any third party resource. All recoveries outside this period that were not initiated by the Managed Care Plan will be pursued by the Agency. Covered third party collections exclude all estate, trust and annuity recoveries.

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c. The following standards govern recovery of covered third party collections:

(1) If the Managed Care Plan has determined that third party liability exists for part or all of the services provided directly by the Managed Care Plan to an enrollee, the Managed Care Plan shall make reasonable efforts to recover from third party liable sources the value of services rendered.

(2) If the Managed Care Plan has determined that third party liability exists for part or all of the services provided to an enrollee by a subcontractor or referral provider, and the third party is reasonably expected to make payment within one-hundred twenty (120) days, the Managed Care Plan may pay the subcontractor or referral provider only the amount, if any, by which the subcontractor’s allowable claim exceeds the amount of the anticipated third party payment; or, the Managed Care Plan may assume full responsibility for third party collections for service provided through the subcontractor or referral provider.

(3) The Managed Care Plan may not withhold payment for services provided to an enrollee if third party liability or the amount of liability cannot be determined, or if payment shall not be available within a reasonable time, beyond one-hundred twenty (120) days from the date of receipt.

d. When the Agency has a fee-for-service lien against a third party resource and the Managed Care Plan has also extended services potentially reimbursable from the same third party resource, the Agency’s lien shall be entitled to priority.

e. The Managed Care Plan shall provide necessary data for recoveries in a format prescribed by the Agency.

2. Optional Third Party Recovery Services

a. The Agency may, at its sole discretion, offer to provide third party recovery services to the Managed Care Plan for covered third party collections.

b. If the Managed Care Plan elects to authorize the Agency to recover covered third party collections on its behalf, the Managed Care Plan shall be required to provide the necessary data for recovery in the format prescribed by the Agency.

c. If the Managed Care Plan elects to authorize the Agency to recover covered third party collections on its behalf, all recoveries, less the Agency’s cost to recover, shall be income to the Managed Care Plan. The cost to recover shall be expressed as a percentage of recoveries and shall be fixed at the time the Managed Care Plan elects to authorize the Agency to recover on its behalf.

d. All funds recovered from third parties shall be treated as income for the Managed Care Plan.

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3. Patient Responsibility

LTC Managed Care Plans and Comprehensive LTC Managed Care Plans shall comply with the requirements regarding patient responsibility in the LTC Exhibit.

E. Assignment

Except as provided below, or with the prior written approval of the Agency, this Contract and the monies which may become due are not to be assigned, transferred, pledged or hypothecated in any way by the Managed Care Plan, including by way of an asset or stock purchase of the Managed Care Plan, and shall not be subject to execution, attachment or similar process by the Managed Care Plan.

1. No plan subject to this procurement or any entity outside this procurement shall be allowed to be merged with or acquire all the Managed Care Plans within the region. When a merger or acquisition of a Managed Care Plan has been approved, the Agency shall approve the assignment or transfer of the appropriate Medicaid Managed Care Plan Contract upon the request of the surviving entity of the merger or acquisition if the Managed Care Plan and the surviving entity have been in good standing with the Agency for the most recent twelve (12) month period, unless the Agency determines that the assignment or transfer would be detrimental to Medicaid recipients or the Medicaid program (see s. 409.912, F.S.). The entity requesting the assignment or transfer shall notify the Agency of the request ninety (90) days before the anticipated effective date.

2. Entities regulated by the Department of Financial Services, Office of Insurance Regulation (OIR), must comply with provisions of s. 628.4615, F.S., and receive OIR approval before a merger or acquisition can occur.

3. For the purposes of this section, a merger or acquisition means a change in controlling interest of a Managed Care Plan, including an asset or stock purchase.

4. To be in good standing, a Managed Care Plan shall not have failed accreditation or committed any material violation of the requirements of s. 641.52, F.S., and shall meet the Medicaid Contract requirements.

5. The Managed Care Plan requesting the assignment or transfer of its enrollees and the acquiring/merging entity must work with the Agency to develop and implement an Agency-approved transition plan, to include a timeline and appropriate notices to all enrollees and all providers as required by the Agency and to ensure a seamless transition for enrollees, as required by the Agency and to ensure a seamless transition for enrollees, particularly those hospitalized, those requiring care coordination/case management and those with complex medication needs. The Managed Care Plan requesting assignment or transfer of its enrollees shall perform as follows:

a. Notice its enrollees, providers and subcontractors of the change in accordance with this Contract; and

b. Provide to the Agency the data needed, including encounter data, by the Agency to maintain existing case relationships.

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6. The notice to enrollees shall contain the same information as required for a notice of termination according to Section XII.F.

F. Financial Reporting

1. Financial Statements

a. The Managed Care Plan shall submit to the Agency an annual audited financial report and quarterly unaudited financial statements in accordance with Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide, as applicable.

b. The Managed Care Plan shall submit to the Agency the audited financial statements no later than three (3) calendar months after the end of the calendar year, and submit the quarterly statements no later than forty-five (45) days after each calendar quarter and shall use generally accepted accounting principles in preparing the statements.

c. The Managed Care Plan shall submit annual and quarterly financial statements that are specific to the operations of the Managed Care Plan rather than to a parent or umbrella organization.

2. Medical Loss Ratio (MLR)

MMA Managed Care Plans shall comply with Medical Loss Ratio requirements as specified in the MMA Exhibit.

G. Inspection and Audit of Financial Records

The state, CMS and DHHS may inspect and audit any financial records of the Managed Care Plan or its subcontractors. Pursuant to s. 1903(m)(4)(A) of the Social Security Act and state Medicaid Manual 2087.6(A-B), non-federally qualified Managed Care Plans shall report to the state, upon request, and to the Secretary and the Inspector General of DHHS, a description of certain transactions with parties of interest as defined in s. 1318(b) of the Social Security Act.

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Section XI. Sanctions

A. Contract Violations and Non-Compliance

1. The Managed Care Plan shall comply with all requirements and performance standards set forth in this Contract.

2. In the event the Agency identifies a violation of or other non-compliance with this Contract (to include the failure to meet performance standards), the Agency may sanction the Managed Care Plan pursuant to any of the following: s. 409.912 (21), F.S., s. 409.91212, F.S.; Rule 59A-12.0073, F.A.C.; s. 409.967; F.S., 42 CFR part 438 subpart I (Sanctions) and s.1932 of the Social Security Act or s.1903(m) of the Social Security Act. The Agency may impose sanctions in addition to any liquidated damages imposed pursuant to Section XIII.

3. For purposes of this section, violations involving individual, unrelated acts shall not be considered arising out of the same action.

4. In addition to imposing sanctions for a Contract violation or other non-compliance, the Agency may require the Managed Care Plan to submit to the Agency a performance measure action plan (PMAP) within a timeframe specified by the Agency. The Agency may also require the Managed Care Plan to submit a corrective action plan (CAP) for a violation of or any other non-compliance with this Contract.

5. If the Agency imposes monetary sanctions, the Managed Care Plan must pay the monetary sanctions to the Agency within thirty (30) days from receipt of the notice of sanction. If the Managed Care Plan fails to pay, the Agency reserves the right to recover the money by any legal means, including but not limited to the withholding of any payments due to the Managed Care Plan. If the Deputy Secretary determines that the Agency should reduce or eliminate the amount imposed, the Agency will return the appropriate amount to the Managed Care Plan within sixty (60) days from the date of a final decision rendered.

B. Performance Measure Action Plans (PMAP) and Corrective Action Plans (CAP)

1. If a PMAP or CAP is required as determined by the Agency, the Agency will either approve or disapprove a proposed PMAP or CAP from the Managed Care Plan. If the Agency disapproves the PMAP or CAP, the Managed Care Plan shall submit a new PMAP or CAP within ten (10) business days, or an expedited timeframe if required by the Agency, that addresses the concerns identified by the Agency. The Managed Care Plan shall accept and implement an Agency defined CAP if required by the Agency.

2. The Agency may impose a monetary sanction of $200 per calendar day on the Managed Care Plan for each calendar day that the Managed Care Plan does not implement, to the satisfaction of the Agency, the approved PMAP or CAP.

C. Performance Measure Sanctions

1. The Agency may sanction the Managed Care Plan for failure to achieve minimum performance scores on performance measures specified by the Agency after the first year of poor performance, as specified in the MMA Exhibit or the LTC Exhibit, as applicable. The

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Agency will develop performance measures and may impose monetary sanctions for some or all of performance measures. The Agency will develop performance targets for each performance measure with a methodology for application of sanction specified by the Agency.

2. The Agency shall sanction the Managed Care Plan for failure to achieve minimum scores on performance measures after the first year of poor performance on any measure as specified in the table below. The Agency may impose monetary sanctions and Performance Measure Action Plans (PMAPs) or PMAPs alone as described above.

3. Two (2) HEDIS measures will be compared to the National Committee for Quality Assurance HEDIS National Means and Percentiles. The HEDIS Call Abandonment measure and the HEDIS Call Answer Timeliness measure have threshold rates (percentages) that may trigger a sanction, as indicated in the Performance Measure Sanction Table below.

Performance Measure Sanction Table – Effective 8/01/2014 – 8/31/2019
HEDIS Measures	Rate and applicable sanction
Call Answer Timeliness	Rate < 25th percentile - immediate monetary sanction
	and PMAP may be imposed Rate < 50th percentile - PMAP may be required
Call Abandonment	Rate > 5% - immediate monetary sanction and PMAP may be imposed

4. The Agency shall sanction MMA Managed Care Plans for failure to achieve minimum scores on additional performance measures after the first year of poor performance on any measure as specified in the MMA Exhibit.

5. The Agency shall sanction LTC Managed Care Plans for failure to achieve minimum scores on additional performance measures after the first year of poor performance on any measure as specified in the LTC Exhibit.

6. The Agency shall sanction Comprehensive LTC Managed Care Plans for failure to achieve minimum scores on additional performance measures after the first year of poor performance on any measure as specified in both the MMA Exhibit and the LTC Exhibit.

D. Other Sanctions

1. Pursuant to s. 409.967(2)(h)2., F.S., if the Managed Care Plan fails to comply with the encounter data reporting requirements as specified in this Contract for thirty (30) days, the Agency shall assess the Managed Care Plan a fine of five thousand dollars ($5,000) per day for each day of noncompliance beginning on the thirty-first (31st) calendar day. On the thirty-first (31st) calendar day, the Agency must notify the Managed Care Plan that the Agency will initiate Contract termination procedures on the ninetieth (90th) calendar day unless the Managed Care Plan comes into compliance before that date.

2. Fraud and Abuse – See Section VIII.F.

3. Pursuant to s. 409.967(2)(a), F.S, after two (2) years of continuous operation under this Contract, the Managed Care Plan’s physician payment rates shall equal or exceed Medicare

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rates for similar services. The Agency may impose fines or other sanctions if the Managed Care Plan fails to meet this performance standard.

4. Pursuant to s. 409.967(2)(h)1., F.S., if the Managed Care Plan reduces its enrollment level or leaves a region before the end of the Contract term, the Managed Care Plan shall reimburse the Agency for the cost of enrollment changes and other transition activities. If more than one (1) MMA or LTC Managed Care Plan leaves a region at the same time, the exiting Managed Care Plans will share the costs in a manner proportionate to their enrollments. In addition to the payment of costs, departing PSNs shall pay a per-enrollee penalty of up to three (3) months’ payment and continue to provide services to enrollees for ninety (90) days or until the enrollee is enrolled in another Managed Care Plan, whichever occurs first. In addition to payment of costs, all other departing Managed Care Plans must pay a penalty of twenty-five percent (25%) of that portion of the minimum surplus maintained pursuant to s. 641.225(1), F.S., which is attributable to the provision of coverage to Medicaid enrollees. The Managed Care Plan will provide at least one hundred eighty (180) days’ notice to the Agency before withdrawing from a region. If the Managed Care Plan leaves a region before the end of the Contract term, the Agency shall terminate all Contracts with the Managed Care Plan in other regions.

E. Notice of Sanctions    

1. Except as noted in 42 CFR part 438, subpart I (Sanctions), before imposing any of the sanctions specified in this section, the Agency will give the Managed Care Plan written notice that explains the basis and nature of the sanction, cites the specific contract section(s) and/or provision of law and the methodology for calculation of any fine.

2. If the Agency decides to terminate the Managed Care Plan’s Contract for cause, the Agency will provide advance written notice of intent to terminate including the reason for termination and the effective date of termination. The Agency will also notify Managed Care Plan enrollees of the termination along with information on their options for receiving services following Contract termination.

3. Unless the Agency specifies the duration of a sanction, a sanction will remain in effect until the Agency is satisfied that the basis for imposing the sanction has been corrected and is not likely to recur.

F. Dispute of Sanctions    

1. To dispute a sanction, the Managed Care Plan must request that the Agency’s Deputy Secretary for Medicaid or designee, hear and decide the dispute.

a. The Managed Care Plan must submit, within twenty-one (21) days after the issuance of a sanction, a written dispute of the sanction directly to the Deputy Secretary or designee; this submission shall include all arguments, materials, data, and information necessary to resolve the dispute (including all evidence, documentation and exhibits). A Managed Care Plan submitting such written requests for appeal or dispute as allowed under the Contract, shall submit such appeal or dispute to the following mailing address:

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Deputy Secretary for Medicaid

Agency for Health Care Administration

Managed Care Appeals/Disputes, MS 70

2727 Mahan Drive

Tallahassee, FL 32308

b. The Managed Care Plan waives any dispute not raised within twenty-one (21) days of receiving the sanction. It also waives any arguments it fails to raise in writing within twenty-one (21) days of receiving the sanction, and waives the right to use any materials, data, and/or information not contained in or accompanying the Managed Care Plan’s submission submitted within the twenty-one (21) days following its receipt of the sanction in any subsequent legal, equitable, or administrative proceeding (to include circuit court, federal court and any possible administrative venue).

2. The Deputy Secretary or his/her designee will decide the dispute under the reasonableness standard, reduce the decision to writing and serve a copy to the Managed Care Plan. This written decision will be final.

3. The exclusive venue of any legal or equitable action that arises out of or relating to the Contract, including an appeal of the final decision of the Deputy Secretary or his/her designee, will be Circuit Court in Leon County, Florida; in any such action, the Managed Care Plan agrees that the Circuit Court can only review the final decision for reasonableness, and Florida law shall apply. In the event the Agency issues any action under Florida Statutes or Florida Administrative Code apart from this Contract, the Agency will notice the Managed Care Plan of the appropriate administrative remedy.

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Section XII. Special Terms and Conditions

A. Applicable Laws and Regulations

1. The Managed Care Plan shall comply with all applicable federal and state laws, rules and regulations including but not limited to: Title 42 CFR Chapter IV, Subchapter C; Title 45 CFR Part 74, General Grants Administration Requirements; Chapters 409 and 641, F.S.; all applicable standards, orders, or regulations issued pursuant to the Clean Air Act of 1970 as amended (42 USC 1857, et seq.); Title VI of the Civil Rights Act of 1964 (42 USC 2000d) in regard to persons served; Title IX of the education amendments of 1972 (regarding education programs and activities); 42 CFR 431, Subpart F; s. 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C. in regard to the Contractor safeguarding information about enrollees; Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or applicants for employment; Rule 59G-8.100, F.A.C.; Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794 (which prohibits discrimination on the basis of handicap in programs and activities receiving or benefiting from federal financial assistance); the Age Discrimination Act of 1975, as amended, 42 USC 6101 et. seq. (which prohibits discrimination on the basis of age in programs or activities receiving or benefiting from federal financial assistance); the Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits discrimination on the basis of sex and religion in programs and activities receiving or benefiting from federal financial assistance; Medicare - Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget Reconciliation Acts; Americans with Disabilities Act (42 USC 12101, et seq.); the Newborns’ and Mothers’ Health Protection Act of 1996, the Balanced Budget Act of 1997, the Health Insurance Portability and Accountability Act of 1996; 45 CFR 74 relating to uniform administrative requirements; 45 CFR 92 providing for cooperative agreements with state, local and tribal governments; s. 508 of the Federal Water Pollution Control Act as amended (33 U.S.C. 1251, et seq.); Executive Order 11738 as amended; where applicable, Environmental Protection Agency regulations 40.CFR 30; 2 CFR 215 and Executive Order 11246, Equal Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in Department of Labor regulation 41 CFR 60 and 45 CFR 92, if applicable; the Pro-Children Act of 1994 (20 U.S.C. 6081; 2 CFR 180 and Executive Orders 12549 and 12689 “Debarment and Suspension; the Immigration and Nationality Act (8 U.S.C. 1324a); Immigration Reform and Control Act of 1986 (8 U.S.C. 1101); 2 CFR 175 relating to trafficking in persons; 2 CFR 170.110(b) relating to the Transparency Act; and 45 CFR 92.36(i)(10) regarding examination of records.

2. The Managed Care Plan is subject to any changes in federal and state law, rules or regulations and federal Centers for Medicare and Medicaid Services waivers applicable to this Contract and shall implement such changes in accordance with the required effective dates upon notice from the Agency without waiting for an amendment to this Contract. However, an amendment to the Contract will be processed to incorporate the changes.

B. Entire Agreement

This Contract, including all attachments and exhibits, represents the entire agreement between the Managed Care Plan and the Agency and supersedes all other contracts between the parties when it is executed by duly authorized signatures of the Managed Care Plan and the Agency. Correspondence and memoranda of understanding do not constitute part of this

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Contract. In the event of a conflict of language between the Contract and the attachments (which includes the ITN), the provisions of the Contract shall govern, unless otherwise noted. The Agency reserves the right to clarify any contractual relationship in writing and such clarification shall govern. Pending final determination of any dispute over any Agency decision, the Managed Care Plan shall proceed diligently with the performance of its duties as specified under the Contract and in accordance with the direction of the Agency’s Division of Medicaid.

C. Licensing

In accordance with s. 409.962, F.S., the Managed Care Plan shall be one of the following:

1. A health insurer licensed in accordance with Chapter 624, F.S., that meets the requirements of a PSN (MMA only or an LTC PSN).

2. An exclusive provider organization (EPO) licensed in accordance with Chapter 627, F.S.

3. An HMO licensed in accordance with the provisions of Part I and Part III of Chapter 641, F.S.

4. A PSN (MMA only or an LTC PSN) that is licensed as, or contracts with, a licensed third party administrator (TPA) or health insurer in order to adjudicate claims. A PSN (MMA only or an LTC PSN) shall operate in accordance with s. 409.912(4)(d), and s. 409.962(13), F.S., and LTC PSNs shall operate in accordance with s. 409.962(8) and s. 409.981(1), F.S. PSNs (MMA only or LTC PSNs) are exempt from licensure under Chapter 641, F.S.; however, they shall be responsible for meeting certain standards in Chapter 641, F.S., as required in this Contract.

5. An Accountable Care Organization (ACO) that meets the requirements of an MMA or LTC PSN as applicable determined by the Agency.

D. Ownership and Management Disclosure

1. The Managed Care Plan shall fully disclose any business relationships, ownership, management and control of disclosing entities in accordance with state and federal law. The Agency will not contract with Managed Care Plans to operate as Standard MMA Plans that have a business relationship with another Managed Care Plan operating as a Standard MMA Plan in the same region. (See s. 409.966(3)(b), F.S.). The Agency may contract with a Managed Care Plan to operate as a Specialty Plan which has a business relationship with another managed care plan operating as a Standard MMA Plan in the same region.

2. Pursuant to s. 409.966(3)(b), F.S., as part of the SMMC procurement, the Managed Care Plan was required to disclose any business relationship, as defined in s. 409.966(3)(b), F.S., that it had with any other eligible plan that responded to the invitation to negotiate. If the Managed Care Plan failed to disclose a business relationship or is considering a business relationship with a Managed Care Plan that has a contract with the Agency under the SMMC program, the Managed Care Plan shall immediately disclose such business relationship to the Agency within five (5) days after discovery. The disclosure shall include but not be limited to the identifying information for each Managed Care Plan, the nature of the business relationship, the regions served by each Managed Care Plan, and the

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signature of the authorized representative for each Managed Care Plan. In addition, PSNs must disclose changes in the percentages of provider ownership interest and changes in the provider make-up of the board of directors or members and/or managers if structured as a limited liability company.

3. Disclosure shall be made on forms prescribed by the Agency for the areas of ownership and control interest (42 CFR 455.104, Form CMS 1513); business transactions (42 CFR 455.105); conviction of crimes (42 CFR 455.106); public entity crimes (s. 287.133(2)(a), F.S.); disbarment and suspension (52 Fed. Reg., pages 20360-20369, and Section 4707 of the Balanced Budget Act of 1997); and, for PSNs, an attestation disclosing any changes in the percentages of provider ownership interest and changes in the provider make-up of the board of directors or members and/or managers if structured as a limited liability company. The forms are available through the Agency and are to be submitted to the Agency by September 1 of each Contract year. In addition, the Managed Care Plan shall submit to the Agency full disclosure of ownership and control of the Managed Care Plan and any changes in management within five (5) days of knowing the change will occur and at least sixty (60) days before any change in the Managed Care Plan’s ownership or control takes effect.

4. The following definitions apply to ownership disclosure:

a. A person with an ownership interest or control interest means a person or corporation that:

(1) Owns, indirectly or directly, five percent (5%) or more of the Managed Care Plan’s capital or stock, or receives five percent (5%) or more of its profits;

(2) Has an interest in any mortgage, deed of trust, note or other obligation secured in whole or in part by the Managed Care Plan or by its property or assets and that interest is equal to or exceeds five percent of the total property or assets; or

(3) Is an officer or director of the Managed Care Plan, if organized as a corporation, or is a partner in the Managed Care Plan, if organized as a partnership.

b. The percentage of direct ownership or control is calculated by multiplying the percent of interest that a person owns by the percent of the Managed Care Plan’s assets used to secure the obligation. Thus, if a person owns ten percent (10%) of a note secured by sixty percent (60%) of the Managed Care Plan’s assets, the person owns six percent (6%) of the Managed Care Plan.

c. The percent of indirect ownership or control is calculated by multiplying the percentage of ownership in each organization. Thus, if a person owns ten percent (10%) of the stock in a corporation, which owns eighty percent (80%) of the Managed Care Plan’s stock, the person owns eight percent (8%) of the Managed Care Plan.

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5. The following definitions apply to management disclosure:

a. Changes in management are defined as any change in the management control of the Managed Care Plan. Examples of such changes are those listed below and in Section VIII, Administration and Management, or equivalent positions by another title.

b. Changes in the board of directors or officers of the Managed Care Plan, medical director, chief executive officer, administrator and chief financial officer.

c. Changes in the management of the Managed Care Plan where the Managed Care Plan has decided to contract out the operation of the Managed Care Plan to a management corporation. The Managed Care Plan shall disclose such changes in management control and provide a copy of the contract to the Agency for approval at least sixty (60) days prior to the management contract start date.

6. By September 1 of each Contract Year, the Managed Care Plan shall conduct an annual background check with the Florida Department of Law Enforcement on all persons with five percent (5%) or more ownership interest in the Managed Care Plan, or who have executive management responsibility for the Managed Care Plan, or have the ability to exercise effective control of the Managed Care Plan (see ss. 409.912 and 435.04, F.S.). The Managed Care Plan shall conduct this verification as follows:

a. By requesting screening results through the Agency’s background screening system (see the Agency’s background screening website). If the person’s fingerprints are not retained in the Care Provider Background Screening Clearinghouse (Clearinghouse, see s. 435.12, F.S.) and/or eligibility results are not found, the Managed Care Plan shall submit complete sets of the person’s fingerprints electronically for Medicaid Level II screening following the process described on the Agency’s background screening website and provide the Agency with the results.

(1) The Managed Care Plan shall complete and email a Background Screening (BGS) Managed Care User Registration Agreement to the Agency at: MGDCAREBGS@ahca.myflorida.com;

(2) In accordance with s. 435.12(2)(c), F.S., the Managed Care Plan shall register with the Clearinghouse and maintain the employment status of all employees within the Clearinghouse. The Managed Care Plan shall report initial employment status and changes to the Clearinghouse within ten (10) business days after the initial employment or change.

7. The Managed Care Plan shall submit, as required by the Agency, complete sets of fingerprints of principals of the Managed Care Plan to the Agency for the purpose of conducting a criminal history record check

a. Principals of the Managed Care Plan shall be as defined in s. 409.907, F.S.

b. The Managed Care Plan shall submit to the Agency complete sets of fingerprints of newly hired principals (officers, directors, agents, and managing employees) within thirty (30) days of the hire date.

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8. The Managed Care Plan shall submit to the Agency, within five (5) business days, any information on any officer, director, agent, managing employee, or owner of stock or beneficial interest in excess of five percent (5%) of the Managed Care Plan who has been found guilty of, regardless of adjudication, or who entered a plea of nolo contendere or guilty to, any of the offenses listed in s. 435.04, F.S. The Managed Care Plan shall submit information to the Agency for such persons who have a record of illegal conduct according to the background check. The Managed Care Plan shall keep a record of all background checks to be available for Agency review upon request.

9. The Agency shall not contract with a Managed Care Plan that has an officer, director, agent, managing employee, or owner of stock or beneficial interest in excess of five percent (5%) of the Managed Care Plan, who has committed any of the above listed offenses (see ss. 409.912 and 435.04, F.S.). In order to avoid termination, pursuant to a timeline as determined by the Agency, the Managed Care Plan shall submit a corrective action plan, acceptable to the Agency, which ensures that such person is divested of all interest and/or control and has no role in the operation and/or management of the Managed Care Plan.

10. The Managed Care Plan shall submit to the Agency reports regarding current administrative subcontractors and affiliates as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

E. Conflict of Interest

This Contract is subject to the provisions of Chapter 112, F.S. Within ten (10) business days of discovery, the Managed Care Plan shall disclose to the Agency the name of any officer, director or agent who is an employee of the State of Florida, or any of its agencies. Further, within this same timeframe, the Managed Care Plan shall disclose the name of any state employee who owns, directly or indirectly, an interest of five percent (5%) or more in the Managed Care Plan or any of its affiliates. The Managed Care Plan shall disclose the name of any Agency or DOEA employee who owns, directly or indirectly, an interest of one percent (1%) or more in the Managed Care Plan or any of its affiliates. The Managed Care Plan covenants that it presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance of the services hereunder. The Managed Care Plan further covenants that in the performance of the Contract, no person having any such known interest shall be employed. No official or employee of the Agency and no other public official of the State of Florida or the federal government who exercises any functions or responsibilities in the review or approval of the undertaking of carrying out the Contract shall, prior to completion of this Contract, voluntarily acquire any personal interest, direct or indirect, in this Contract or proposed Contract.

F. Withdrawing Services from a Region

1. If the Managed Care Plan intends to withdraw services from a region, the Managed Care Plan shall provide the Agency with one-hundred eighty (180) days’ notice. Once the Agency receives the request for withdrawal, the Agency will remove the Managed Care Plan from receipt of new voluntary enrollments, mandatory assignments and reinstatements going forward.

2. The Managed Care Plan shall work with the Agency to develop a transition plan for enrollees, particularly those in the hospital, those under care coordination/case

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management and those with complex medication needs. The Managed Care Plan withdrawing from a Region shall perform as follows:

a. Notice its enrollees, providers and subcontractors of the change at least sixty (60) days before the last day of service; and

b. Provide to the Agency the data, including encounter data, needed by the Agency to maintain existing case relationships.

3. The notice to enrollees shall contain the same information as required for a notice of termination according to Section XII.F.

4. If the Managed Care Plan withdraws from a region before the end of the term of this Contract, the Managed Care Plan shall pay the costs and penalties specified in s. 409.967(2)(h)1, F.S., and Section XI, Sanctions, and the Contract through which the Managed Care Plan operates in any other region will be terminated in accordance with the termination procedures in s. 409.967(2)(h)3, F.S., this section and Section XI, Sanctions.

5. As specified in s. 409.967(2)(h)1. F.S., if the Managed Care Plan intends to withdraw services from a region, the Managed Care Plan shall provide the Agency with one-hundred eighty (180) days’ notice and work with the Agency to develop a transition plan for enrollees, particularly those under case management and those with complex medication needs, and provide data needed to maintain existing case relationships.

6. As specified in s. 409.967 (2)(h)1., F.S., Managed Care Plans that reduce enrollment levels or leave a region before the end of the Contract term must continue to provide services to the enrollee for ninety (90) days or until the enrollee is enrolled in another Managed Care Plan, whichever occurs first.

G. Termination Procedures

1. In conjunction with the Standard Contract, Section III, Item A., Termination, all provider contracts and subcontracts shall contain termination procedures. The Managed Care Plan agrees to extend the thirty (30) calendar-day termination notice found in the Standard Contract, Section III., Item A.1., Termination at Will, to one-hundred eighty (180) days’ notice. Depending on the volume of Managed Care Plan enrollees affected, the Agency may require an extension of the termination date. Once the Agency receives the request for termination, the Agency will remove the Managed Care Plan from receipt of new voluntary enrollments, mandatory assignments and reinstatements going forward.

2. The Managed Care Plan will work with the Agency to create a transition plan that shall ensure the orderly and reasonable transfer of enrollee care and progress whether or not the enrollees are hospitalized, under care coordination/case management, and/or have complex medication needs. The Managed Care Plan shall perform as follows:

a. Notice its enrollees, providers and subcontractors of the change in accordance with this Contract; and

b. Provide to the Agency the data needed by the Agency to maintain existing case/care relationships.

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3. The party initiating the termination shall render written notice of termination to the other party by certified mail, return receipt requested, or in person with proof of delivery, or by facsimile letter followed by certified mail, return receipt requested. The notice of termination shall specify the nature of termination, the extent to which performance of work under the Contract is terminated, and the date on which such termination shall become effective. In accordance with s. 1932(e)(4), Social Security Act, the Agency shall provide the Managed Care Plan with an opportunity for a hearing prior to termination for cause. This does not preclude the Agency from terminating without cause.

4. Upon receipt of final notice of termination, on the date and to the extent specified in the notice of termination, the Managed Care Plan shall:

a. Continue work under the Contract until the termination date unless otherwise required by the Agency;

b. Cease enrollment of new enrollees under the Contract;

c. Terminate all community outreach activities and subcontracts relating to community outreach;

d. Assign to the state those subcontracts as directed by the Agency’s contracting officer including all the rights, title and interest of the Managed Care Plan for performance of those subcontracts;

e. In the event the Agency has terminated the Managed Care Plan’s Medicaid participation in one region, complete the performance of this Contract in all other regions in which the Managed Care Plan’s participation was not terminated;

f. Take such action as may be necessary, or as the Agency’s contracting officer may direct, for the protection of property related to the Contract that is in the possession of the Managed Care Plan and in which the Agency has been granted or may acquire an interest;

g. Not accept any payment after the Contract ends, unless the payment is for the time period covered under the Contract. Any payments due under the terms of this Contract may be withheld until the Agency receives from the Managed Care Plan all written and properly executed documents as required by the written instructions of the Agency; and

h. At least sixty (60) days before the termination effective date, provide written notification to all enrollees of the following information: the date on which the Managed Care Plan will no longer participate in the state’s Medicaid program and instructions on contacting the Agency’s enrollment broker help line to obtain information on enrollment options and to request a change in Managed Care Plans.

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5. If the Managed Care Plan fails to disclose any business relationship, as defined in s. 409.966(3)(b), F.S., with another Managed Care Plan in the same region during the procurement process, the Agency shall terminate this Contract and all other SMMC contracts with the Managed Care Plan.

6. In the event the Agency terminates the Managed Care Plan’s participation in more than one region due to non-compliance with Contract requirements, the Agency shall also terminate all of the Managed Care Plan’s participation in other regions by terminating this entire Contract, in accordance with s. 409.967(2)(h)3., F.S.

7. If the Managed Care Plan received an additional award pursuant to s. 409.966(3)(e), F.S., and is subject to penalties pursuant to s. 409.967(2)(h), F.S., for activities in Region 1 or Region 2, the additional awarded regions shall automatically be terminated from this Contract one-hundred eighty (180) days after the imposition of the penalties. The Managed Care Plan shall reimburse the Agency for the cost of enrollment changes and other transition activities.

8. If the Managed Care Plan fails to meet regional plan readiness criteria by the Agency’s specified monthly enrollment calculation date prior to the region becoming operational in SMMC, the Agency shall terminate the Managed Care Plan from participation in that region. In addition the following requirements apply to the Managed Care Plan:

a. If the Managed Care Plan received an additional award pursuant to s. 409.966(3)(e), F.S., and fails to meet plan readiness criteria in Region 1 or Region 2, the Agency shall terminate the additional awarded region(s) within one-hundred eighty (180) days after the respective Region 1 and/or Region 2 termination from the Contract.

b. If the Managed Care Plan has been terminated from participation in all regions of its Contract, the Agency shall terminate this entire Contract with thirty (30) days’ notice, as specified in the Standard Contract, Section III, Item B., Termination at Will.

9. If the Managed Care Plan Contract is terminated by either the Managed Care Plan or the Agency (with cause) prior to the end of the Contract period, the Agency will assess the performance bond required under this Contract to cover the costs of issuing a solicitation and selecting a new Managed Care Plan. The Agency’s damages in the event of termination shall be considered to be the full amount of the bond. The Agency need not prove the damage amount in exercising its right of recourse against the bond.

H. Agency Contract Management

1. The Agency shall be responsible for management of the Contract. Contract management shall be conducted in good faith, with the best interest of the state and the Medicaid recipients it serves being the prime consideration. The Agency shall make all statewide policy decisions or Contract interpretationsThe Managed Care Plan may seek an interpretation from the Agency of any Contract requirement or Medicaid policy. When an interpretation of the contract is sought, the Managed Care Plan shall submit a written request to the Agency’s Deputy Secretary for Medicaid.

2. The terms of this Contract do not limit or waive the ability, authority or obligation of the Office of Inspector General, MPI, its contractors, DOEA, or other duly constituted

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government units (state or federal) to audit or investigate matters related to, or arising out of this Contract.

3. The Contract shall be amended only as follows (unless specified elsewhere in this Contract):

a. The parties cannot amend or alter the terms of this Contract without a written amendment and/or change order to the Contract.

b. The Agency and the Managed Care Plan understand that any such written amendment to amend or alter the terms of this Contract shall be executed by an officer of each party, who is duly authorized to bind the Agency and the Managed Care Plan.

c. The Agency reserves the right to amend this Contract within the scope set forth in the procurement (to include original Contract and all attachments) in order to clarify requirements or if it is determined by the Agency that modifications are necessary to better serve or provide covered services to the eligible population.

I. Disputes

1. To dispute an interpretation of the Contract, the Managed Care Plan must request that the Agency’s Deputy Secretary for Medicaid hear and decide the dispute. The Managed Care Plan must submit, within twenty-one (21) days after the interpretation of the Contract, a written dispute of the Contract interpretation directly to the Deputy Secretary; this submission shall include all arguments, materials, data, and information necessary to resolve the dispute (to include all evidence, documentation and exhibits). The Managed Care Plan waives any dispute not raised within twenty-one (21) days of receiving a notice of the Contract interpretation. It also waives any arguments it fails to raise in writing within twenty-one (21) days of receiving a Contract interpretation, and waives the right to use any materials, data, and/or information not contained in or accompanying the Managed Care Plan’s submission submitted within the twenty-one (21) days following its receipt of the notice of the Contract interpretation in any subsequent legal, equitable, or administrative proceeding (to include circuit court, federal court and any possible administrative venue).

2. The Deputy Secretary or his/her designee will decide the dispute under the reasonableness standard, reduce the decision to writing and serve a copy to the Managed Care Plan. This written decision will be final.

3. The exclusive venue of any legal or equitable action that arises out of or relating to the Contract, including an appeal of the final decision of the Deputy Secretary or his/her designee, will be Circuit Court in Leon County, Florida; in any such action, the Managed Care Plan agrees that the Circuit Court can only review the final decision for reasonableness, and Florida law shall apply. In the event the Agency issues any action under Florida Statutes or Florida Administrative Code apart from this Contract, the Agency will notice the Managed Care Plan of the appropriate administrative remedy.

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J. Indemnification

1. The Managed Care Plan, agrees to indemnify, defend, and hold harmless the Agency, as provided in this Clause.

2. Scope. The Duty to Indemnify and the Duty to Defend, as described herein (collectively known as the “Duty to Indemnify and Defend”), extend to any completed, actual, pending, or threatened action, suit, claim, or proceeding, whether civil, criminal, administrative, or investigative (including any action by or in the right of the Managed Care Plan), and whether formal or informal, in which the Agency is, was, or becomes involved and which in any way arises from, relates to, or concerns the Managed Care Plan’s acts or omissions related to this contract (inclusive of all attachments, etc.) (collectively “Proceeding”).

a. Duty to Indemnify. The Managed Care Plan agrees to hold harmless and indemnify the Agency to the full extent permitted by law against any and all liability, claims, actions, suits, judgments, damages, and costs of whatsoever name and description, including attorneys’ fees, arising from or relating to any Proceeding.

b. Duty to Defend. With respect to any Proceeding, the Managed Care Plan agrees to fully defend the Agency and shall timely reimburse all of the Agency’s legal fees and costs; provided, however, that the amount of such payment for attorneys’ fees and costs is reasonable pursuant to rule 4–1.5, Rules Regulating The Florida Bar. The Agency retains the exclusive right to select, retain, and direct its defense through defense counsel funded by the Managed Care Plan pursuant to the Duty to Indemnify and Defend the Agency.

3. Expense Advance. The presumptive right to indemnification of damages shall include the right to have the Managed Care Plan pay the Agency’s expenses in any Proceeding as such expenses are incurred and in advance of the final disposition of such Proceeding.

4. Enforcement Action. In the event that any claim for indemnity, whether an Expense Advance or otherwise, is made hereunder and is not paid in full within sixty (60) calendar days after written notice of such claim is delivered to the Managed Care Plan, the Agency may, but need not, at any time thereafter, bring suit against the Managed Care Plan to recover the unpaid amount of the claim (hereinafter “Enforcement Action”). In the event the Agency brings an Enforcement Action, the Managed Care Plan shall pay all of the Agency’s attorneys’ fees and expenses incurred in bringing and pursuing the Enforcement Action.

5. Contribution. In any Proceeding in which the Managed Care Plan is held to be jointly liable with the Agency for payment of any claim of any kind (whether for damages, attorneys’ fees, costs, or otherwise), if the Duty to Indemnify provision is for any reason deemed to be inapplicable, the Managed Care Plan shall contribute toward satisfaction of the claim whatever portion is or would be payable by the Agency in addition to that portion which is or would be payable by the Managed Care Plan, including payment of damages, attorneys’ fees, and costs, without recourse against the Agency. No provision of this part, or of any other section of this contract (inclusive of all attachments, etc.), whether read separately or in conjunction with any other provision, shall be construed to: (i) waive the state or the Agency’s immunity to suit or limitations on liability; (ii) obligate the state or the Agency to indemnify the Managed Care Plan for the Managed Care Plan’s own negligence, or otherwise assume any liability for the Managed Care Plan’s own negligence; or (iii) create

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any rights enforceable by third parties, as third party beneficiaries or otherwise, in law or in equity.

K. Public Records Requests

1. In accordance with s.119.0701, F.S., and notwithstanding Standard Contract, Section I, Item M., Requirements of Section 287.058, Florida Statutes, in addition to other contract requirements provided by law, the Managed Care Plan shall comply with public records laws, as follows:

a. The Managed Care Plan shall keep and maintain public records that ordinarily and necessarily would be required in order to perform services under the Contract;

b. The Managed Care Plan shall provide the public with access to public records on the same terms and conditions that the Agency would provide the records and at a cost that does not exceed the cost provided in s. 119.0701, F.S., or as otherwise provided by law;

c. The Managed Care Plan shall ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law;

d. The Managed Care Plan shall meet all requirements for retaining public records and transfer, at no cost, to the Agency all public records in possession of the Managed Care Plan upon termination of the Contract and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to the Agency in a format that is compatible with the information technology systems of the Agency.

e. If the Managed Care Plan does not comply with a public records request, the Agency shall enforce the Contract provisions in accordance with the Contract.

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Section XIII. Liquidated Damages

A. Damages

1. If the Managed Care Plan breaches this Contract, the Agency will be entitled to monetary damages in the form of actual, consequential, direct, indirect, special, and/or liquidated damages. In some cases, the actual damage to the Agency as a result of the Managed Care Plan’s failure to meet any aspect of the responsibilities of the Contract and/or to meet specific performance standards set forth in the Contract will be difficult or impossible to determine with precise accuracy. Therefore, in the event of a breach of this Contract, the Agency will impose liquidated damages in writing against the Managed Care Plan. The Agency will assess liquidated damages against the Managed Care Plan regardless of whether the breach is the fault of the Managed Care Plan (including the Plan’s subcontractors, agents and/or consultants), provided the Agency has not materially caused or contributed to the breach.

2. The liquidated damages prescribed in this section are not intended to be in the nature of a penalty, but are intended to be reasonable estimates of the Agency’s projected financial loss and damage resulting from the Managed Care Plan’s nonperformance, including financial loss as a result of project delays. Accordingly, in the event the Managed Care Plan fails to perform in accordance with the Contract, the Agency may assess liquidated damages as provided in this section.

3. If the Managed Care Plan fails to perform any of the services described in the Contract, the Agency may assess liquidated damages for each occurrence listed in the table in Section XIII.B. Any liquidated damages assessed by the Agency shall be due and payable to the Agency within thirty (30) days after the Managed Care Plan’s receipt of the notice of damages, regardless of any dispute in the amount or interpretation which led to the notice. All interpretations of the Contract are handled by Deputy Secretary for Medicaid or his/her delegate.

4. The Agency may elect to collect liquidated damages:

a. Through direct assessment and demand for payment delivered to the Managed Care Plan; or

b. By deduction of amounts assessed as liquidated damages from, and as set-off against payments then due to the Managed Care Plan or that become due at any time after assessment of the liquidated damages. The Agency will make deductions until it has collected the full amount payable by the Managed Care Plan.

5. The Managed Care Plan will not pass through liquidated damages imposed under this Contract to a provider and/or subcontractor, unless the provider and/or subcontractor caused the damage through its own action or inaction. Nothing described herein shall prohibit a provider and/or a subcontractor from seeking judgment before an appropriate court in situations where it is unclear that the provider and/or the subcontractor caused the damage by an action or inaction.

6. All liquidated damages imposed pursuant to this Contract, whether paid or due, shall be paid by the Managed Care Plan out of administrative costs and profits.

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7. To dispute the imposition of liquidated damages, the Managed Care Plan must request that the Agency’s Deputy Secretary for Medicaid or designee, hear and decide the dispute.

a. The Managed Care Plan must submit, within twenty-one (21) days after receiving notice of the imposition of liquidated damages, a written dispute of the liquidated damages directly to the Deputy Secretary or designee; this submission shall include all arguments, materials, data, and information necessary to resolve the dispute (including all evidence, documentation and exhibits). A Managed Care Plan submitting such written requests for appeal or dispute as allowed under the Contract, shall submit such appeal or dispute to the following mailing address:

Deputy Secretary for Medicaid

Agency for Health Care Administration

Managed Care Appeals/Disputes, MS 70

2727 Mahan Drive

Tallahassee, FL 32308

b. The Managed Care Plan waives any dispute not raised within twenty-one (21) days of receiving notice of the imposition of liquidated damages. It also waives any arguments it fails to raise in writing within twenty-one (21) days of receiving said notice, and waives the right to use any materials, data, and/or information not contained in or accompanying the Managed Care Plan’s submission within the twenty-one (21) days following its receipt of the notice in any subsequent legal, equitable, or administrative proceeding (to include circuit court, federal court and any possible administrative venue).

8. The Deputy Secretary or his/her designee will decide the dispute under the reasonableness standard, reduce the decision to writing and serve a copy to the Managed Care Plan. This written decision will be final.

9. The exclusive venue of any legal or equitable action that arises out of or relating to the Contract, including an appeal of the final decision of the Deputy Secretary or his/her designee, will be Circuit Court in Leon County, Florida; in any such action, the Managed Care Plan agrees that the Circuit Court can only review the final decision for reasonableness, and Florida law shall apply. In the event the Agency issues any action under Florida Statutes or Florida Administrative Code apart from this Contract, the Agency will notice the Managed Care Plan of the appropriate administrative remedy.

B. Issues and Amounts

The Managed Care Plan shall pay the Agency the amount for each issue as specified below.

MMA Managed Care Plans shall also pay the Agency the amount for each issue as specified in the MMA Exhibit.

LTC Managed Care Plans shall also pay the Agency the amount for each issue as specified in the LTC Exhibit.

AHCA Contract No. FP020, Attachment II, Page 200 of 214

Comprehensive LTC Managed Care Plans shall also pay the Agency the amount for each issue as specified in both the MMA Exhibit and LTC Exhibit as applicable.

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Liquidated Damages Issues and Amounts
#	CORE PROGRAM ISSUES	DAMAGES
1.	Failure to comply in any way with Managed Care Plan staffing requirements as specified in the Contract.	$250 per calendar day for each day that staffing requirements are not met.
2.	Failure to submit a Provider Network File that meets the Agency’s specifications as described in the Contract.	$250 per day after the due date that the Provider Enrollment File fails to meet the Agency’s specifications.
3.	Failure to submit audited HEDIS, CAHPS, and Agency-defined measures results annually by July 1 as described in the Contract.	$250 per day for every calendar day reports are late.
4.	Failure to timely report termination or suspension of providers for “for cause” as described in the Contract.	$250 per occurrence.
5.	Submission of inappropriate report certifications and/or failure to submit report attestations as described in the Contract.	$250 per occurrence.
6.	Failure to timely report staff or marketing or community outreach representative violations as described in the Contract.	$250 per occurrence.
7.	Failure to maintain and/or provide proof of required insurance as described in the Contract.	$500 per calendar day.
8.	Failure to terminate providers who become ineligible for Medicaid participation.	$500 per occurrence, in addition to $250 per day until the provider is terminated.
9.	Failure to timely submit any complete plan as described in this Contract, including, but not limited to a cultural competency plan. Note: The Anti-Fraud plan liquidated damages listed in this table is separate and not included in this program issue.	$250 per day for every calendar day plans are late.
10.	Failure to achieve and/or maintain insolvency requirements in accordance with the Contract.	$500 per calendar day for each day that insolvency requirements are not met.
11.	Failure to timely submit audited annual and quarterly unaudited financial statements as described in the Contract.	$500 per calendar day for each day that reporting requirements are not met.

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12.	Failure to comply with fraud and abuse provisions as described in the Contract.	$500 per calendar day per occurrence/issue.
13.	Failure to address or resolve problems with individual encounter records in a timely manner as required by the Agency and described in the Contract.	$500 per calendar day, per occurrence.
14.	Failure to provide continuity of care and a seamless transition consistent with the services in place prior to the new enrollee’s enrollment in the Managed Care Plan as described in the Contract.	$500 per day beginning on the next calendar day after default by the Managed Care Plan in addition to the cost of the services not provided. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in this Contract.
15.	Failure to timely file required reports as described in the Contract.	$500 per day beyond the due date until submitted.
16.	Failure to respond to an Agency request or ad-hoc report for documentation (such as medical records, complaint logs, or Contract checklists) within the time prescribed by the Agency as described in the Contract.	$500 per day for each calendar day beyond the due date until provided to the Agency. However, after three (3) instances during the Contract period, the liquidated damages amount is increased by $1,000 per day.
17.	Failure to obtain approval of enrollee and provider materials, as required by the Contract.	$500 per day for each calendar day that the Agency determines the Managed Care Plan has provided enrollee or provider material that had not been approved by the Agency.
18.	Failure to complete a comprehensive assessment, develop a treatment or service plan or plan of care, or authorize and initiate all services specified in the plan for an enrollee within specified timelines as described in the Contract.	$500 per day for each service not initiated timely beginning on the next calendar day after default by the Managed Care Plan in addition to the cost of the services not provided. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in this Contract.

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19.	Failure to obtain and/or maintain national accreditation as described in the Contract.	$500 per day for every calendar day beyond the day accreditation status must be in place as described in this Contract.
20.	Failure to provide covered services within the timely access standards in the Contract.	$500 per day, per occurrence.
21.	Failure to provide covered services within the geographic access standards in the Contract.	$500 per day, per occurrence.
22.	Failure to report notice of provider termination of participation in the Managed Care Plan as described in of the Contract.	$500 per day, per occurrence.
23.	Failure by the Managed Care Plan to timely report violations in the access, use and disclosure of PHI or timely report a security incident or timely make a notification of breach or notification of provisional breach (see also ancillary business associate agreement between the parties) as described in the Contract.	$500 per enrollee per occurrence, not to exceed $10,000,000.
24.	Failure by the Managed Care Plan to execute the appropriate agreements to effectuate transfer and exchange of enrollee PHI confidential information including, but not limited to, a data use agreement, trading partner agreement, business associate agreement or qualified protective order prior to the use or disclosure of PHI to a third party (see ancillary business associate agreement between the parties) pursuant to the Contract.	$500 per enrollee per occurrence.
25.	Failure to cooperate fully with the Agency and/or state during an investigation of fraud or abuse, complaint, or grievances as described in the Contract.	$500 per incident for failure to fully cooperate during an investigation.

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26.	Failure to comply with the notice requirements described in the Contract, the Agency rules and regulations, and all court orders governing appeal procedures, as they become effective.	$500 per occurrence in addition to $500 per calendar day for each calendar day required notices are late or deficient or for each calendar day beyond the required time frame that the appeal is unanswered in each and every aspect and/or day beyond the required time frame that the appeal is unanswered in each and every aspect and/or each day the appeal is not handled according to the provisions set forth by this Contract or required by the Agency. $1,000 per occurrence if the Agency notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective.
27.	Failure to timely report changes in Managed Care Plan staffing as described in the Contract.	$500 per occurrence.
28.	Failure to timely report information about offenses listed in s. 435.04, F.S., as described in the Contract.	$500 per occurrence.
29.	Failure to comply with community outreach or marketing requirements as described in the Contract.	$500 per recipient, per verified incident of promotion or marketing of Managed Care Plan.
30.	Failure to timely submit appropriate performance improvement projects (PIPs) as described in this Contract.	$1,000 per day for every calendar day PIPs are late.
31.	Failure to achieve and/or maintain financial surplus requirements as described in the Contract.	$1,000 per calendar day for each day Contract requirements are not met.

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32.	Failure by the Managed Care Plan to ensure that all data containing protected health information (PHI), as defined by HIPAA, is secured through commercially reasonable methodology in compliance with the HITECH Act, such that it is rendered unusable, unreadable and indecipherable to unauthorized individuals through encryption or destruction, that compromises the security or privacy of the Agency enrollee’s PHI (see also ancillary business associate agreement requirements between the parties) as specified in the Contract.	$1,000 per enrollee per occurrence. If the State determines credit monitoring and/or identity theft safeguards are needed to protect those enrollees whose PHI was placed at risk by Managed Care Plan’s failure to comply with the terms of this Contract, the Managed Care Plan shall also be liable for all costs associated with the provision of such monitoring and/or safeguard services.
33.	Failure to comply with enrollee notice requirements as described in the Contract.	$1,000 per occurrence if the enrollee notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective.
34.	Failure to notify enrollees of denials, reductions, or terminations of services within the timeframes specified in the Contract as described in the Contract.	$1,000 per occurrence plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late.
35.	Failure to acknowledge or act timely upon a request for prior authorization in accordance the Contract.	$1,000 per occurrence, in addition to $1,000 for each day that it is determined the Managed Care Plan failed to acknowledge or act timely upon a request for prior authorization.
36.	Failure to update online and printed provider directory in accordance with Contract requirements as described in the Contract.	$1,000 per occurrence.
37.	Failure to file accurate reports as described in this Contract.	$1,000 per occurrence.

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38.	Failure to facilitate transfers between health care settings as described in the Contract.	$1,000 per occurrence. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the case management requirements as described in the Contract.
39.	Failure to allow an enrollee to obtain a second medical opinion at no expense and regardless of whether the provider is participating or not, as described in this Contract.	$5,000 per occurrence.
40.	Failure to cooperate with the Agency’s contracted external quality review organization (EQRO) as described in this Contract.	$5,000 per occurrence.
41.	Failure to honor any written documentation of prior authorization of ongoing covered services for a period of sixty (60) days after the effective date of enrollment, as specified in this Contract.	$5,000 per occurrence, in addition to $5,000 per day services are not authorized.
42.	Failure to comply with time frames for providing Enrollee Handbooks, I.D. cards and Provider Directories, as required in the Contract.	$5,000 for each occurrence.
43.	Failure to comply with licensure or background screening requirements for Managed Care Plan principals in the Contract.	$5,000 per calendar day that owner/staff is not licensed or qualified as required by applicable state or local law plus the amount paid to the owner/staff during that period.
44.	Failure to comply with licensure or background screening requirements for subcontractors in the Contract.	$5,000 per calendar day that subcontractor/driver/agent is not licensed or qualified as required by applicable state or local law plus the amount paid to the subcontractor/driver/agent during that period.
45.	Failure to timely report notice of terminated providers due to imminent danger/impairment as described in the Contract.	$5,000 per occurrence.
46.	Failure to meet provider credentialing requirements, including background screening requirements, specified in the Contract.	$5,000 per occurrence.
47.	Failure to timely report, or provide notice for, significant network changes as described in the Contract.	$5,000 per occurrence.

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48.	Failure to timely report changes in ownership and control as described in the Contract.	$5,000 per occurrence.
49.	Failure to comply with claims processing as described in the Contract.	$10,000 per month, for each month that the Agency determines that the Managed Care Plan is not in compliance.
50.	Failure to establish an investigative unit as required in this Contract, by the time the Managed Care Plan has enrolled its first recipient. Failure to implement an anti-fraud plan as required by this Contract, within ninety (90) calendar days of its approval by the Agency. Failure to timely submit an acceptable anti-fraud plan, quarterly fraud and abuse report or the annual report required by this Contract. Failure to timely report, or report all required information for, all suspected or confirmed instances of provider or recipient fraud or abuse as required by this Contract.	$10,000 for each occurrence. $10,000 for each occurrence. $2,000 per calendar day, until MPI deems the Managed Care Plan to be in compliance. $1,000 per calendar day, until MPI deems the Managed Care Plan to be in compliance.
51.	Failure to develop and/or implement a transition plan for recipients including the provision of data to the Agency, as specified in the Contract.	$10,000 per occurrence.
52.	Failure to comply with conflict of interest or lobbying requirements as described in the Contract.	$10,000 per occurrence.
53.	Failure to disclose lobbying activities and/or conflict of interest as required by the Contract.	$1,000 per day that disclosure is late.
54.	Failure to provide no less than thirty (30) days’ written notice before making any changes to the administration and/or management procedures and/or authorization, denial or review procedures, including any delegations, as described in this Contract.	$25,000 per occurrence.
55.	Failure to comply with encounter data submission requirements as described in the Contract (excluding the failure to address or resolve problems with individual encounter records in a timely manner as required by the Agency).	$25,000 per occurrence.

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56.	Imposition of arbitrary utilization guidelines or other quantitative coverage limits as prohibited in the Contract.	$25,000 per occurrence.
57.	Failure to provide continuation of services during the pendency of a Medicaid fair hearing and/or the Managed Care Plan’s appeal process where the enrollee has challenged a reduction or elimination of services as required by the Contract, applicable state or federal law, and all court orders governing appeal procedures as they become effective.	The value of the reduced or eliminated services as determined by the Agency for the timeframe specified by the Agency and $500 per day for each calendar day the Managed Care Plan fails to provide continuation or restoration as required by the Agency.
58.	Failure to provide restoration of services after the Managed Care Plan receives an adverse determination as a result of a Medicaid fair hearing or the Managed Care Plan’s appeal process as required by the Contract, applicable state or federal law and all court orders governing appeal procedures as they become effective.	The value of the reduced or eliminated services as determined by the Agency and $500 per day for each calendar day the Managed Care Plan fails to provide continuation or restoration as required by the Agency.
59.	Failure to comply with provider network requirements specified in this Contract.	$500 per day, per occurrence.
60.	Failure to comply with the quality requirements specified in this Contract under Section VII of Attachment II and its Exhibits.	$1,000 per occurrence.
61.	Failure to provide notice of noncompliance to the Agency within five (5) calendar days or other Contract-specified period of time in accordance with the Contract.	$500 per day beginning on the next calendar day after default by the Managed Care Plan.
62.	Failure to staff the Compliance Officer position with a qualified individual in accordance with the Contract.	$500 per calendar day starting ninety (90) calendar days from the date of the position vacancy.
63.	Failure to maintain and/or provide proof of the Managed Care Plan’s fidelity bond as required in the Contract.	$500 per calendar day.
64.	Failure to comply with public records laws, in accordance with s. 119.0701, F.S.	$5,000 for each occurrence.
65.	Failure to develop and document a treatment or service plan for an enrollee, that shall be documented in writing as described in the Contract.	$500 per deficient/missing treatment or service plan.

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66.	Failure to provide proof of compliance to the Agency within five (5) days of a directive from the Agency or within a longer period of time that has been approved by the Agency	$500 per day beginning on the next calendar day after default by the Managed Care Plan.
67.	Failure to require and ensure compliance with ownership and disclosure requirements as required in the Contract.	$5,000 per provider disclosure/attestation for each disclosure/attestation that is not received timely or is not in compliance with the requirements outlined in 42 CFR 455, Subpart B.
68.	Failure to respond to an Agency communication within the time prescribed by the Agency as described in the Contract.	$500 for each calendar day beyond the due date until provided to the Agency. However, after three (3) instances during the Contract period, the liquidated damages amount is increased by $1,000 per day.
69.	Failure to submit a timely notice of involuntary disenrollment to the enrollee as described in the Contract.	$1,000 per occurrence if the enrollee notice remains defective plus a per calendar day assessment in increasing increments of $500 ($500 for the first day, $1,000 for the second day, $1,500 for the third day, etc.) for each day the notice is late and/or remains defective.
70.	Failure to timely submit fingerprints of newly hired principals as described in the Contract.	$500 per occurrence.
71.	Failure to complete or comply with corrective action plans as described in the Contract.	$500 per calendar day for each day the corrective action is not completed or complied with as required.
72,	Failure to have a rate at or above the 25th percentile for the HEDIS measures as described in the Contract.	$500 per each case in the denominator not present in the numerator for the measure.
73.	Failure to comply in any way with the toll-free enrollee help line requirements as described in the Contract (excluding the failure to respond to individual messages on the automated system of the toll-free enrollee help line in a timely manner as required by the Agency).	$10,000 per month, for each month that the Agency determines that the Managed Care Plan is not in compliance.
74.	Failure to respond to individual messages on the automated system of the toll-free enrollee help line in a timely manner as described the Contract.	$500 per calendar day, per occurrence

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75.	Failure to comply with any of the standards for timely service authorization decisions as specified in the Contract.	$5,000 per month, for each month that the Agency determines that the Managed Care Plan is not in compliance, per standard
76.	Failure of a provider contract to comply with a requirement of this Contract.	$1,000 per failure per provider contract
77.	Failure to receive prior written Agency approval of delegation to a subcontractor.	$25,000 per occurrence
78.	Failure of a subcontract to comply with a requirement of this Contract.	$5,000 per failure per subcontract
79.	Failure to meet plan readiness review deadlines set by the Agency	$2,000 per calendar day per occurrence
80.	Failure to meet plan readiness goals set by the Agency	$2,000 per occurence

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Section XIV. Reporting Requirements

A. Managed Care Plan Reporting Requirements

1. General Provisions

a. The Managed Care Plan shall comply with all reporting requirements set forth in this Contract.

b. The Managed Care Plan shall comply with the Managed Care Plan Report Guide in submitting required reports, including the report formats, templates, instructions, data specifications, submission timetables and locations, and other materials contained in the guide. The Managed Care Plan Report Guide will be posted on the Agency’s website. The Agency shall furnish the Managed Care Plan with appropriate technical assistance in using the Managed Care Plan Report Guide.

c. Unless otherwise specified, all reports shall be submitted electronically, as prescribed in the reporting guidelines. PHI information shall be submitted to the Agency SFTP sites.

2. Submission Deadlines

a. Deadlines for report submission referred to in this Contract specify the actual time of receipt at the Agency bureau or location, not the date the file was postmarked or transmitted.

b. If a reporting due date falls on a weekend or state holiday, the report shall be due to the Agency on the following business day.

c. All reports filed on a quarterly basis shall be filed on a calendar year quarter.

3. Required Reports

a. The Managed Care Plan shall comply with reports required by the Agency as specified in the Managed Care Plan Report Guide. All reports shall be submitted to the Agency Contract Manager unless otherwise indicated in the Managed Care Report Guide

Summary of Reporting Requirements
Report Name	Plan Type	Frequency
Marketing Agent Termination	All Plans	Monthly
Marketing/Educational Events Report	All Plans	Monthly
Enrollee Help Line Statistics	All Plans	Monthly
Enrollee Complaints, Grievance and Appeals Report	All Plans	Monthly
Nursing Facility Transfer Report	LTC Plans	Monthly
Provider Network File	All Plans	Weekly

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Summary of Reporting Requirements
Provider Termination and New ProviderNotification Report	All Plans	Weekly
Provider Complaint Report	All Plans	Monthly
Performance Measure Report	All Plans	Annually
Critical Incident Summary Report	All Plans	Monthly
Critical Incident Report	All Plans	Immediately upon occurrence and no less than within twenty-four (24) hours of detection or notification
Claims Aging Report and Supplemental Filing Report	All Plans	Quarterly Optional supplemental filing — due within one-hundred five (105) days after the end of the reporting quarter
Suspected/ Confirmed Fraud & Abuse Reporting	All Plans	Within fifteen (15) days of detection
Quarterly Fraud and Abuse Activity Report	All Plans	Quarterly
Annual Fraud and Abuse Activity Report	All Plans	Annually
Achieved Savings Rebate Financial Reports	All Plans	Annually Quarterly
Annual Financial Statements Filed with OIR	All Plans	Annually Quarterly
Audited Annual and Unaudited Quarterly Financial Reports	All Plans	Annually Quarterly
Administrative Subcontractors and Affiliates Report	All Plans	Quarterly

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b. MMA Managed Care Plans shall comply with the additional reporting requirements specified in the MMA Exhibit.

c. LTC Managed Care Plans shall comply with the additional reporting requirements as specified in the LTC Exhibit.

d. Comprehensive LTC Managed Care Plans shall comply with the additional reporting requirements as specified in both the MMA Exhibit and the LTC Exhibit.

4. Modifications to Reporting Requirements

a. The Agency reserves the right to modify the reporting requirements, with a ninety (90) calendar day notice to allow the Managed Care Plan to complete implementation, unless otherwise required by law.

b. The Agency shall provide the Managed Care Plan with written notification of any modifications to the reporting requirements.

5. Certification of Timely, Complete and Accurate Submission

a. The Managed Care Plan shall assure the accuracy, completeness and timely submission of each report.

b. The Managed Care Plan’s chief executive officer (CEO), chief financial officer (CFO) or an individual who reports to the CEO or CFO and who has delegated authority to certify the Managed Care Plan’s reports, shall attest, based on his/her best knowledge, information and belief, that all data submitted in conjunction with the reports and all documents requested by the Agency are accurate, truthful and complete (see 42 CFR 438.606(a) and (b)).

c. The Managed Care Plan shall submit its certification at the same time it submits the certified data reports (see 42 CFR 438.606(c)). The certification page shall be scanned and submitted electronically.

d. If the Managed Care Plan fails to submit the required reports accurately or within the timeframes specified, the Agency shall fine or otherwise sanction the Managed Care Plan in accordance with Section XI, Sanctions, and 59A-12.0073, F.A.C.

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ATTACHMENT II

EXHIBIT II-A

MANAGED MEDICAL ASSISTANCE (MMA) PROGRAM

Section I. Definitions and Acronyms

The definitions and acronyms in Core Provisions Section I, Definitions and Acronyms apply to all MMA Managed Care Plans and Comprehensive LTC Managed Care Plans unless specifically noted otherwise in this Exhibit.

Section II. General Overview

The provisions in this Exhibit apply to all MMA Managed Care Plans and Comprehensive LTC Managed Care Plans. The provisions in this Exhibit also apply to all Specialty Plans unless provisions unique to a specific type of Specialty Plan are codified in the resulting Contract and its Exhibits.

In accord with the order of precedence listed in Attachment I, any additional items or enhancements listed in the Managed Care Plan’s response to the Invitation to Negotiate are included in this Exhibit by this reference.

Section III. Eligibility and Enrollment

A. Eligibility

1. Mandatory Populations

a. In addition to the programs and eligibility categories specified in Core Provisions, Section III, Eligibility and Enrollment, the Agency may enroll recipients in Medically Needy program eligibility categories pursuant to s. 409.972, F.S., subject to required federal approval byt the Centers for Medicare and Medicaid Services.

b. In addition to the programs and eligibility categories specified in Section III, Eligibility and Enrollment, recipients in the following eligibility categories are required to enroll in a managed care plan:

(1) Title XXI MediKids; and

(2) Children between 100 - 133% of federal poverty level (FPL) who transfer from the state’s Children’s Health Insurance Program (CHIP) to Medicaid.

2. Voluntary Populations

In addition to the programs and eligibility categories specified in Section III, Eligibility and Enrollment, recipients in any of the following eligibility categories may, but are not required to, enroll in a Managed Care Plan:

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a. SSI (enrolled in developmental disabilities home and community based waiver)

b. MEDS (SOBRA) for children under one (1) year old and income between one-hundred eighty-five percent (185%) and two-hundred percent (200%) FPL;

c. MEDS AD – (SOBRA) for aged and disabled – enrolled in DD home and community based waiver

d. Recipients with other creditable coverage excluding Medicare;.

e. Recipients residing in residential community facilities operated through DJJ or mental health treatment facilities as defined in s. 394.455(32), F.S.;

f. Residents of DD centers including Sunland and Tachacale; and

g. Refugee assistance.

B. Enrollment

1. Notification of Enrollee Pregnancy

a. The Managed Care Plan shall be responsible for newborns of pregnant enrollees from the date of their birth. The Managed Care Plan shall comply with all requirements set forth by the Agency or its agent related to unborn activation and newborn enrollment.

b. Unborn activation shall occur through the following procedures:

(1) Upon identification of an enrollee’s pregnancy through medical history, examination, testing, claims, or otherwise, the Managed Care Plan shall immediately notify DCF of the pregnancy and any relevant information known (for example, due date and gender). The Managed Care Plan must provide this notification by completing the DCF Excel spreadsheet and submitting it, via electronic mail, to the appropriate DCF Customer Call Center address and copied to MPI at email: mcobaby@ahca.myflorida.com. The Managed Care Plan shall indicate its name and number as the entity initiating the referral. The DCF Excel spreadsheet and directions for completion are located on the Medicaid web site: http://ahca.myflorida.com/Medicaid/Newborn/index.shtml.

(2) DCF will generate a Medicaid ID number for the unborn child. This information will be transmitted to the Medicaid fiscal agent. The Medicaid ID number will remain inactive until the child is born and DCF is notified of the birth.

(3) Upon notification that a pregnant enrollee has presented to the hospital for delivery, the Managed Care Plan shall inform the hospital, the pregnant enrollee’s attending physician and the newborn’s attending and consulting physicians that the newborn is an enrollee. At this time the Managed Care Plan or its designee shall complete and submit the Excel spreadsheet for unborn activation to DCF, and to MPI for its information.

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(4) E-mail submissions shall include the password-protected spreadsheet as an attachment, and the spreadsheet shall contain all pregnancy notifications and newborn births for that Managed Care Plan (or that Managed Care Plan’s designated subcontractor). Each Managed Care Plan (or Managed Care Plan-designated subcontractor) shall send no more than one (1) e-mail submission, per day, to each DCF customer call center region based on the enrollee’s region of residence. (Refer to the Medicaid website referenced above for DCF customer call center information.)

(5) When the baby’s Medicaid ID has been activated the newborn will be enrolled in the Managed Care Plan retroactive to birth.

c. If a pregnant enrollee presents for delivery without having an unborn eligibility record that is awaiting activation, the Managed Care Plan or designee shall submit the spreadsheet to DCF immediately upon birth of the child. The newborn will automatically become a Managed Care Plan enrollee retroactive to birth.

d. Failure to use the unborn activation process for reporting pregnancies as specified by his Contract may result in sanctions as described in Section XI, Sanctions.

C. Disenrollment

There are no additional disenrollment provisions unique to the MMA managed care program.

D. Marketing

There are no additional marketing provisions unique to the MMA managed care program.

Section IV. Enrollee Services and Grievance Procedures

A. Enrollee Materials

1. Enrollee Handbook Requirements

a. The Managed Care Plan shall include additional information in its handbook applicable to the MMA program, as follows:

(1) Information on the importance of selecting a PCP and the procedure for selecting a PCP; (see s. 409.973(4)(a), F.S.)

(2) How to change PCPs;

(3) Information about how to select a newborn’s PCP;

(4) An explanation to all potential enrollees that an enrolled family may choose to have all family members served by the same PCP or they may choose different PCPs based on each family member’s needs;

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(5) Emergency services and procedures for obtaining services both in and out of the Managed Care Plan’s region, including explanation that prior authorization is not required for emergency or post-stabilization services, the locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization care services, use of the 911-telephone system or its local equivalent, and other post-stabilization requirements in s. 1932(b)(2)(A)(ii)) of the Social Security Act and 42 CFR 438.114; and

(6) The right to obtain family planning services from any participating Medicaid provider without prior authorization;

b. The Managed Care Plan, subject to Agency approval, may include a separate section for behavioral health services. In such cases, its handbook shall provide the following information:

(1) The extent to which and how after-hours and emergency coverage are provided and that the enrollee has a right to use any hospital or other setting for emergency care;

(2) Information that post-stabilization services are provided without prior authorization and other post-stabilization care services rules set forth in s. 1932(b)(2)(A)(ii)) of the Social Security Act and 42 CFR 438.114;

(3) A clear statement that the enrollee may select an alternative behavioral health case manager or direct service provider within the Managed Care Plan, if one is available;

(4) A description of behavioral health services provided, including limitations, exclusions and out-of-network use;

(5) A description of emergency behavioral health services procedures both in and out of the Managed Care Plan’s region;

(6) Information to help the enrollee assess a potential behavioral health problem;

(7) A clear statement that prior authorization or referral by a PCP is not required for behavioral health services;

(8) Information on the Managed Care Plan’s healthy behavior programs, including how to participate, that incentives/rewards are non-transferrable, and that members will lose access to earned incentives/rewards if they voluntarily disenroll from the Managed Care Plan or lose Medicaid eligibility for more than one-hundred eighty (180) days (and thus are not automatically reinstated in the Managed Care Plan); and

(9) The Managed Care Plan’s psychotropic drug informed consent requirements for enrollees under age thirteen (13) as provided for in s. 409.912(51), F.S.

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B. Enrollee Services

1. Medicaid Redetermination Assistance

a. The Agency will provide Medicaid recipient redetermination date information to the Managed Care Plan. This information shall be used by the Managed Care Plan only as indicated in this subsection.

b. The Managed Care Plan shall notify the Agency, in writing, if it wants to participate in using this information. The Managed Care Plan’s participation in using this information is voluntary.

c. If the Managed Care Plan chooses to participate in the use of this information, it shall provide its policies and procedures regarding this subsection to the Agency for its approval along with its notification indicating it will participate.

d. A Managed Care Plan that chooses to participate in the use of this information may decide to discontinue using it at any time and must so notify the Agency in writing thirty (30) days prior to the date it will discontinue such use.

e. Regardless of whether the Managed Care Plan participates in the use of this information, the Managed Care Plan is subject to the sanctioning indicated in this subsection if the Managed Care Plan misuses the information at any time.

f. A Managed Care Plan that chooses to participate in using this information shall use the redetermination date information only in the methods listed below and shall use either or both methods to communicate this information.

(1) The Managed Care Plan may use redetermination date information in written notices to be sent to their enrollees reminding them that their Medicaid eligibility may end soon and to reapply for Medicaid if needed. A Managed Care Plan that chooses to use this method to provide this information to its enrollees must adhere to the following requirements:

(a) The Managed Care Plan shall mail the redetermination date notice to each enrollee for whom it has received a redetermination date. The Managed Care Plan may send one (1) notice to the enrollee’s household when there are multiple enrollees within a family who have the same Medicaid redetermination date, provided that these enrollees share the same mailing address.

(b) The Managed Care Plan shall use the Agency-provided template for its redetermination date notices. The Managed Care Plan may put this template on its letterhead for mailing; however, the Managed Care Plan shall make no other changes, additions or deletions to the letter text; and

(c) The Managed Care Plan shall mail the redetermination date notice to each enrollee no more than sixty (60) days and no less than thirty (30) days before the redetermination date occurs.

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(2) The Managed Care Plan may use redetermination date information in automated voice response (AVR) or integrated voice response (IVR) automated messages sent to enrollees reminding them that their Medicaid eligibility may end soon and to reapply for Medicaid if needed. A Managed Care Plan that chooses to use this method to provide this information to its enrollees must adhere to the following requirements:

(a) The Managed Care Plan shall send the redetermination date messages to each enrollee for whom that Managed Care Plan has received a redetermination date and for whom the Managed Care Plan has a telephone number. The Managed Care Plan may send an automated message to the enrollee’s household when there are multiple enrollees within a family who have the same Medicaid redetermination date provided that these enrollees share the same mailing address/phone number;

(b) For the voice messages, the Managed Care Plan shall use only the language in the Agency’s redetermination date notice template provided to the Managed Care Plan. The Managed Care Plan may add its name to the message but shall make no other changes, additions or deletions to the message text; and

(c) The Managed Care Plan shall make such automated calls to each enrollee no more than sixty (60) days and no less than thirty (30) days before the redetermination date occurs.

g. The Managed Care Plan shall not include the redetermination date information in any file viewable by enrollee service or community outreach staff. This information shall be used only in the letter templates and automated scripts provided by the Agency and cannot be referenced or discussed by the Managed Care Plan with the enrollees, unless in response to an enrollee inquiry about the letter received, nor shall it be used at a future time by the Managed Care Plan. If the Managed Care Plan receives enrollee inquiries about the notices, such inquiries must be referred to the Department of Children and Families.

h. Should any complaint or investigation by the Agency result in a finding that the Managed Care Plan has violated this subsection, the Managed Care Plan will be sanctioned in accordance with Section XI, Sanctions. In addition to any other sanctions available in Section XI, Sanctions, the first such violation will result in a thirty (30) day suspension of use of Medicaid redetermination dates; any subsequent violations will result in thirty-day (30-day) incremental increases in the suspension of use of Medicaid redetermination dates. In the event of any subsequent violations, additional penalties may be imposed in accordance with Section XI, Sanctions. Additional or subsequent violations may result in the Agency’s rescinding provision of redetermination date information to the Managed Care Plan.

C. Grievance System

There are no additional grievance system provisions unique to the MMA managed care program.

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Section V. Covered Services

A. Required MMA Benefits

1. Specific MMA Services to be Provided

a. The Managed Care Plan shall provide the services listed below in accordance with the Florida Medicaid State Plan, the Florida Medicaid Coverage and Limitations Handbooks, the Florida Medicaid fee schedules, and the provisions herein, unless specified elsewhere in this Contract. The Managed Care Plan shall comply with all state and federal laws pertaining to the provision of such services. The following provisions highlight key requirements for certain covered services, including requirements specific to the MMA program:

(1) Advanced Registered Nurse Practitioner

(a) The Managed Care Plan shall provide Advanced Registered Nurse Practitioner Services. Advanced Registered Nurse Practitioners (ARNPs) are licensed advanced practice registered nurses who work in collaboration with practitioners pursuant to Chapter 464, F.S., according to protocol, to provide diagnostic and interventional patient care.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Practitioner Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Practitioner Services Coverage and Limitations Handbook.

(2) Ambulatory Surgical Center Services

(a) The Managed Care Plan shall provide Ambulatory Surgical Center Services. Ambulatory surgical centers (ASCs) provide scheduled, elective, medically necessary surgical care to patients who do not require hospitalization. Medicaid reimburses surgical procedures that have been approved by the federal Centers for Medicare and Medicaid Services and Florida Medicaid, provided in a licensed Medicare-approved, Medicaid-participating ASC entity that is separate and distinguishable from any other entity or type of facility, and is not part of a hospital. The reimbursed facility fee is all-inclusive of the following:

(i) Administrative, record keeping, and housekeeping items and services;

(ii) Blood, blood plasma, and components;

(iii) Diagnostic or therapeutic services or items directly related to providing surgical procedures;

(iv) Drugs, biologicals, intraocular lenses, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to providing surgical procedures;

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(v) Materials for anesthesia;

(vi) Nursing, technical, and related services; and

(vii) Use of ASC facilities.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Ambulatory Surgical Center Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Ambulatory Surgical Center Services Coverage and Limitations Handbook.

(3) Assistive Care Services

(a) The Managed Care Plan shall provide Assistive Care Services. Assistive Care Services are an integrated set of 24-hour services only for Medicaid-eligible residents in assisted living facilities, adult family care homes and residential treatment facilities. Assistive Care Services require a health assessment by a licensed practitioner establishing medical necessity for at least two of the four service components and the need for at least one specific service each day. Components are health support, assistance with activities of daily living (ADL), assistance with instrumental activities of daily living (IADL), and assistance with self-administration of medication.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Assistive Care Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Assistive Care Services Coverage and Limitations Handbook.

(4) Behavioral Health Services

(a) The Managed Care Plan shall provide a full range of medically necessary behavioral health services authorized under the State Plan and specified in the Florida Medicaid Mental Health Targeted Case Management Coverage and Limitations Handbook and the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook (the Handbooks) and by this Contract to all enrollees.

(b) The Managed Care Plan shall provide the following services as described in the Handbooks and applicable fee schedules. The amount, duration and scope of such services shall not be more restrictive than that specified in the Handbooks. The Managed Care Plan shall not establish service limitations that are lower than, or inconsistent with, the Handbooks.

(i) Inpatient hospital services for behavioral health conditions;

(ii) Outpatient hospital services for behavioral health conditions;

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(iii) Psychiatric physician services for behavioral health conditions and psychiatric specialty codes 42, 43, and 44;

(iv) Community behavioral health services for mental health conditions;

(v) Community behavioral health services for substance abuse conditions;

(vi) Mental Health Targeted Case Management ;

(vii) Mental Health Intensive Targeted Case Management;

(viii) Specialized therapeutic foster care;

(ix) Therapeutic group care services;

(x) Comprehensive behavioral health assessment;

(xi) Behavioral health overlay services in child welfare settings;

(xii) Residential care; and

(xiii) Statewide Inpatient Psychiatric Program (SIPP) services for individuals under age twenty-one (21).

(c) The Managed Care Plan may provide substitute services to its enrollees as specified in this subsection. The Managed Care Plan is encouraged to provide substitute services that will enhance covered services. To the degree possible, the Managed Care Plan shall use existing community resources. Substitute services represent a downward substitution for services in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook and are not an expansion of behavioral health benefits. The Managed Care Plan shall make information on substitute services available to enrollees and require documentation of enrollee agreement before implementing such services. Managed Care Plans shall ensure providers use clinical rationale for determining the benefit of the service for the enrollee. The Managed Care Plan shall not require an enrollee to choose a substitute service over a Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook service. Substitute services must be prior approved by the Agency.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
912	Psychiatric/ Psychological Svcs: Partial Hosp - less intensive	Partial Hospitalization - Less intensive	Master's Level Practitioner, or Licensed Practitioner of the Healing Arts	Documentation must be sufficient to indicate that this Partial Hospitalization Service is clinically appropriate for the enrollee.	Face to Face in a Hospital	All inclusive Daily Per Diem	1 unit per day; 90 days annual limit for adults ages 21+; No annual limit for children under age 21.
1001	Residential treatment-psychiatric	Short Term Residential Treatment - Level I - (SRT when utilized as a medically necessary downward substitution for acute CSU). Services should be provided with the goal of giving the enrollee additional time to stabilize, recover and rehabilitate. These services are intended to Increase enrollees’ ability to successful re-integrate into an independent community setting at the time of discharge.	Licensed SRTs	Documentation must be sufficient to indicate that the enrollee meets clinical criteria for this level of care. The enrollee must meet criteria for acute crisis stabilization services and documentation must indicate that this level of care is being utilized as a downward substitution.	Face-to-Face in a licensed SRT program	Per diem	I unit per day. This benefit like CSU is flexed against the inpatient day limit of 45 days per fiscal year for adults over age 21. Note: 2 SRT days = 1 Inpatient day. No annual limit for children under age 21.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
H0038	SELF-HELP/PEER SERVICES, PER 15 MINUTES	Services may include: peer specialist activities, peer mentoring, peer education, recovery coach services and mental health services provided by peers. Does not include: paperwork for consumers, attendance at NAMI or other consumer support meetings, offering meeting space for consumer meetings, travel time or transportation of consumers, peer specialist time that is not spent on education or self-help activities, or other administrative services.	Those qualified by training & certification to perform this service under the supervision of a licensed master's level clinician	Services must provide a documented support and/or treatment benefit to PMHP enrollees. Services must be individualized and demonstrate a recovery and resiliency focus.	Face- to-Face with Client Present	15 minutes	16 units per day.
H0046 HE	MENTAL HEALTH SERVICES, NOT OTHERWISE SPECIFIED; MENTAL HEALTH PROGRAM	Respite care services	Those qualified by 2 years of experience with the mental health population and have completed 30 hours of training which includes psychopathology, medication management, family dynamics, and crisis intervention or those licensed as a regular foster care home and certified as a specialized therapeutic foster home.	Enrollee must be in active treatment and there must be documentation to support that respite services will assist family or caregivers while providing an option to de-escalate a situation while avoiding hospitalization.	Services may be provided in the home, school, or community and must be provided face-to-face.	Daily rate	Minimum of 8 hours per day.
H2011 HO	PSYCHIATRIC HEALTH FACILITY SERVICE, PER DIEM; MASTERS DEGREE LEVEL	Mobile Crisis Assessment and Intervention for enrollees in the community	Provided by a master degree level clinician under the supervision of a licensed master's level clinician	Documentation of clinical intervention and outcome of intervention	Intervention by referral from MCO	15 minutes	96 units per year; maximum of 8 units per day.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
H2015 HE	COMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER 15 MINUTES; MENTAL HEALTH PROGRAM	Outreach Services; Services may include: activities designed to keep individuals out of the jail and juvenile justice system. Applies to both Children and Adults. Does not include: paperwork, travel time, transportation of consumers, phone calls, or other administrative services.	Bachelor's level practitioner or LPN	Services must provide a beneficial diversion from jail or juvenile justice system. Services must be targeted towards a specific recipient and encourage engagement in the treatment process to prevent involvement in the criminal justice system.	Face- to-Face; Client Present	15 minutes	16 units per day.
H2019 HB	THERAPEUTIC BEHAVIORAL SERVICES, PER 15 MINUTES; ADULT PROGRAM	In-Home Counseling Adult - Therapy, rehabilitative and supportive counseling in the client's home	minimum of master’s degree	documentation of services	Face-to-Face	encounter	No limit.
H2020 HB	Therapeutic Behavioral Services, per diem, adult program	A service that covers the medically necessary clinical support services of enrollees while residing in an SRT level of care. The goal of these services would be to provide stabilization, recovery, and rehabilitation services to enrollees to allow them to discharged to a community setting and increase their capacity for independent living.	Services must be provided by the appropriate level clinician. In a SRT setting. There must be a clinical supervisor and master's level clinician. Physicians and bachelor's level clinicians would be able to provide this service as well.	Enrollees must meet criteria for admission to SRT – Residential Level Treatment I. The program must also be licensed by SAMH as a short term residential treatment unit.	Services are face to face delivered in a residential level I (SRT) setting.	Per Diem	1 unit per day.
S5102 HE	DAY CARE SERVICES, ADULT; PER DIEM; MENTAL HEALTH PROGRAM	Drop-In Center - A social club offering peer support and flexible schedule of activities: may operate on weekdays, evenings and/ or weekends. Activities focus on support, social and behavioral skills.	BA level practitioner	Plan of care, activities and documented records	Face- to-Face	One day	365 days per year.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
T1023 HA	SCREENING TO DETERMINE THE APPROPRIATENESS OF CONSIDERATION OF AN INDIVIDUAL FOR PARTICIPATION IN A SPECIFIED PROGRAM, PROJECT OR TREATMENT PROTOCOL, PER ENCOUNTER; CHILD/ADOLESCENT PROGRAM	Infant Mental Health Pre and Post Testing Services - Tests, inventories, questionnaires, structured interviews, structured observations, and systematic assessments that are administered to help assess the caregiver-child relationship and to help aid in the development of the treatment plan	Masters level or above with 2 years’ experience working with infant mental health OR MA level and under the supervision of a MA level or above with at least 2 years’ experience working IMH. Individuals administering the tests are to be operating within the scope of their professional licensure, training, test protocols, and competencies, and in accordance with applicable statutes.	A written report of evaluation and testing results must be done by the individual rendering services and must be included in the child's medical record for all evaluation and testing services listed in the evaluation and testing section	Face-to-Face	15 minutes	For children ages 0 through 5 years, 40 units per year.
T1027	Family Training & Counseling for Child Development, per 15 minutes	Services may include: support groups for family members which provide education regarding SED, family education, psychosocial activities, and other education and support activities related to SED. Does not include paperwork or case management services, does not include telephone calls to families, travel time, transportation of consumers, services to support appointment coordination, or other administrative services.	BA level practitioner	Services must support the family and child in treatment. They must be resiliency focused and provide meaningful supports to allow the family and caregivers, and child to participate fully in the treatment process.	Face- to-Face; Client Present	15 minutes.	16 units per day.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
H0046 HK	MENTAL HEALTH SERVICES, NOT OTHERWISE SPECIFIED; SPECIALIZED MENTAL HEALTH PROGRAMS FOR HIGH-RISK POPULATIONS	Specialized therapeutic in-home service is a flexible in-home support service designed for children in the child welfare system, ages 5 through 17, who are stepping down from or at high risk for residential care and institutional services. Providing therapeutic support in addition to helping parents in developing parenting skills, specialized therapeutic in-home services are designed to aid in the transition to community-based outpatient services by providing intensive therapeutic services plus 24 hour crisis response services for an anticipated length of stay of up to 120 days.	The specialized therapeutic in-home services team is led by a licensed clinician who coordinates the services of the treatment team, which includes a mental health targeted case manager, master’s level therapist and psychiatrist.	Individualized treatment plans within 14 days of admission, treatment plan reviews biweekly by the treatment team with the youth and family and updated as needed. Weekly written progress updates are provided in addition to a weekly face-to-face or telephonic staffing with the Community Based Care agency responsible for the child's care.	Specialized therapeutic in-home services will be reimbursed on a weekly basis. A minimum of four face-to-face contacts per week are required and must include both individual and family therapy. A minimum of three contacts per week are to be made in the home by the primary clinician.	1 unit per week	1 unit per week.
S9475	AMBULATORY SETTING SUBSTANCE ABUSE TREATMENT OR DETOXIFICATION SERVICES	The ambulatory detoxification service includes clinical and medical management of the physical and psychological process of withdrawal from alcohol and other drugs on an outpatient basis in a community based setting. This service is intended to stabilize the recipient physically and psychologically using accepted detox protocols.	Licensed ambulatory detoxification facility.	Documentation must be sufficient to indicate that the enrollee meets clinical criteria for this level of care. The enrollee must meet criteria for detoxification and documentation must indicate that this level of care is being utilized as a downward substitution.	Face-to-face in a licensed ambulatory detoxification facility.	Per diem	3 hours per day for up to 30 days.

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HCPCS Or Revenue Code	HCPCS Level II or Revenue Code Service Description	Service Description	Provider Qualifications	Documentation Required	Service Setting	Unit of Service	Reimbursement /Service Limits
H2022	Community-Based Wrap-Around Services	Wraparound is an intensive level of community-based services in order to prevent residential treatment. The wraparound service delivery model is built around family team planning. Wraparound services include frequent assessment and treatment plan progress reviews, and treatment team meetings must include the full complement of professionals working with the family. Meeting frequency of child and family teams is guided by the family’s needs and level of risk. Included in the wraparound services include intensive targeted case management, in-home intervention, crisis intervention, parenting, peer support, psychiatric services, and behavior analytical services.	Provider type 91 and certified to provide children’s mental health targeted case management; Provider type 05—Community Behavioral Health Provider	All Wraparound team meetings shall be documented in the form of formal meeting minutes. All collateral contacts shall be documented in the form of contact/progress notes. Treatment and TCM services documented according to handbook standards for PT-05 and PT-91.	Services may be provided in the home, school, or community and must be provided face-to-face.	Per diem	No annual limit for children under age 21.

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(d) The Managed Care Plan shall adhere to the following requirements regarding evaluation and treatment services for enrolled children/adolescents:

(i) The Managed Care Plan shall provide all medically necessary evaluations, psychological testing and treatment services for children/adolescents referred to the Managed Care Plan by DCF, DJJ and schools (elementary, middle, and secondary schools);

(ii) The Managed Care Plan shall provide court-ordered evaluation and treatment required for children/adolescents who are enrollees. See specifications in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook; and

(iii) The Managed Care Plan or designee shall develop a process to participate in interagency staffings (for example, DCF and DJJ) or school staffings that may result in the provision of behavioral health services to an enrolled child/adolescent. The Managed Care Plan or designee shall participate in such staffings upon request.

(5) Birth Center and Licensed Midwife Services

(a) The Managed Care Plan shall provide Birth Center and Licensed Midwife Services. Birth centers and licensed midwifes provide services appropriate to the care of Medicaid recipients during low-risk pregnancies, deliveries and the postpartum period. Birth center birth center must meet all state licensure requirements pursuant to the guidelines set forth in Chapter 59A-11, F.A.C. and Chapter 383, F.S. to provide obstetrical, postpartum, gynecological, and family planning services and Child Health Check-Up screenings (newborn evaluations only). Licensed midwives must meet all state licensure requirements pursuant to the guidelines set forth in Chapter 467, F.S. to provide obstetrical and postpartum care and Child Health Check-Up screenings (newborn evaluations only).

(b) The Managed Care Plan shall comply with provisions of the Medicaid Birth Center and Licensed Midwife Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Birth Center and Licensed Midwife Services Coverage and Limitations Handbook.

(6) Clinic Services

(a) The Managed Care Plan shall provide Rural Health Clinic Services. Rural Health Clinics provide ambulatory primary care to a medically underserved population in a rural geographical area. A Rural Health Clinic provides primary health care and related diagnostic services. In addition, Rural Health Clinics may provide Adult Health Screening Services, Child Health Check-Up Screenings, Chiropractic Services, Family Planning Services, Family

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Planning Waiver Services, Immunization Services, Medical Primary Care Services, Mental Health Services, Optometric Services, Podiatry Services.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Rural Health Clinic Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Rural Health Clinic Services Coverage and Limitations Handbook.

(c) The Managed Care Plan shall provide Federally Qualified Health Center Services. A Federally Qualified Health Center provides primary health care and related diagnostic services. In addition, an Federally Qualified Health Center may provide Adult health screening services, Child Health Check-Up, Chiropractic services, Dental services, Family planning services, Medical primary care, Mental health services, Optometric services, and Podiatric services.

(d) The Managed Care Plan shall comply with provisions of the Medicaid Federally Qualified Health Center Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Federally Qualified Health Center Services Coverage and Limitations Handbook.

(e) The Managed Care Plan shall provide County Health Department Services. County Health Departments provide public health services in accordance with Chapter 154, F.S. Medicaid County Health Department services consist of primary and preventive health care, related diagnostic services, and dental services.

(f) The Managed Care Plan shall comply with provisions of the Medicaid County Health Department Program Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid County Health Department Program Coverage and Limitations Handbook.

(7) Chiropractic Services

(a) The Managed Care Plan shall provide Chiropractic Services. Chiropractic services include evaluation and medically necessary treatment performed on one or more areas of the body. Treatment consists of manual manipulation or adjustment with application of controlled force to re-establish normal articular function. Manual manipulation is used to restore optimum mobility and range of motion to the spine. A doctor of chiropractics (D.C.) is an individual who is licensed to engage in the practice of chiropractic medicine, as defined in Chapter 460, F.S.

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(b) The Managed Care Plan shall comply with provisions of the Medicaid Chiropractic Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Chiropractic Services Coverage and Limitations Handbook.

(8) Dental Services

(a) The Managed Care Plan shall provide Dental Services to enrollees under the age of 21 years, emergency dental services to enrollees age 21 and older, and denture and denture-related services and oral and maxillofacial surgery services to all enrollees. The Managed Care Plan shall provide medically-necessary, emergency dental procedures to alleviate pain or infection to enrollees age 21 and older. Emergency dental care for enrollees 21 years of age and older is limited to a problem focused oral evaluation, necessary radiographs in order to make a diagnosis, extractions, and incision and drainage of an abscess. Full and removable partial dentures and denture-related services are also covered services for enrollees 21 years of age and older. The Managed Care Plan shall provide full dental services for all enrollees age 20 and below. The Managed Care Plan shall provide medically necessary oral and maxillofacial surgery for all eligible Medicaid recipients regardless of age.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Dental Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Dental Services Coverage and Limitations Handbook.

(9) Child Health Check Up

(a) The Managed Care Plan shall provide Child Health Check-Up Services. The Managed Care Plan shall provide a health screening evaluation that shall consist of: comprehensive health and developmental history (including assessment of past medical history, developmental history and behavioral health status); comprehensive unclothed physical examination; developmental assessment; nutritional assessment; appropriate immunizations according to the appropriate Recommended Childhood Immunization Schedule for the United States; laboratory testing (including blood lead testing); health education (including anticipatory guidance); dental screening (including a direct referral to a dentist for enrollees beginning at age three or earlier as indicated); vision screening, including objective testing as required; hearing screening, including objective testing as required; diagnosis and treatment; and referral and follow-up as appropriate. A Child Health Check-Up is a comprehensive, preventive health screening service. Child Health Check-Ups are performed according to a periodicity schedule that ensures that children have a health screening on

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a routine basis. In addition, a child may receive a Child Health Check-Up whenever it is medically necessary or requested by the child or the child’s parent or caregiver. If a child is diagnosed as having a medical problem, the child is treated for that problem through the applicable Medicaid program, such as physician, dental and therapy services.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Child Health Check-Up Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Child Health Check-Up Coverage and Limitations Handbook.

(c) For children/adolescents whom the Managed Care Plan identifies through blood lead screenings as having abnormal levels of lead, the Managed Care Plan shall provide care coordination/case management follow-up services as required in Chapter Two of the Child Health Check-Up Services Coverage and Limitations Handbook. Screening for lead poisoning is a required component of this Contract. The Managed Care Plan shall require all providers to screen all enrolled children for lead poisoning at ages 12 months and 24 months. In addition, children between the ages of 12 months and 72 months must receive a screening blood lead test if there is no record of a previous test. The Managed Care Plan shall provide additional diagnostic and treatment services determined to be medically necessary to a child/adolescent diagnosed with an elevated blood lead level. The Managed Care Plan shall recommend, but shall not require, the use of paper filter tests as part of the lead screening requirement.

(d) The Managed Care Plan shall inform enrollees of all testing/screenings due in accordance with the periodicity schedule specified in the Medicaid Child Health Check-Up Services Coverage and Limitations Handbook. The Managed Care Plan shall contact enrollees to encourage them to obtain health assessment and preventive care.

(e) The Managed Care Plan shall authorize enrollee referrals to appropriate providers within four (4) weeks of these examinations for further assessment and treatment of conditions found during the examination. The Managed Care Plan shall ensure that the referral appointment is scheduled for a date within six (6) months of the initial examination, or within the time periods set forth in Section VI, Provider Network, as applicable.

(f) The Managed Care Plan shall cover fluoride treatment by a physician or a dentist for children/adolescents. Fluoride varnish application in a physician’s office is limited to children up four (4) years of age.

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(g) The Managed Care Plan shall offer transportation to enrollees in order to assist them to keep, and travel to, medical appointments.

(h) The CHCUP program includes the maintenance of a coordinated system to follow the enrollee through the entire range of screening and treatment, as well as supplying CHCUP training to medical care providers.

(i) Pursuant to s. 409.975(5), F.S., the Managed Care Plan shall achieve a CHCUP screening rate of at least eighty percent (80%) for those enrollees who are continuously enrolled for at least eight (8) months during the federal fiscal year (October 1 – September 30). This screening compliance rate shall be based on the CHCUP data reported by the Managed Care Plan in its CHCUP (CMS-416) and FL 80% Screening Report and due to the Agency as specified in Section XIV, Reporting Requirements. The data shall be monitored by the Agency for accuracy, and, if the Managed Care Plan does not achieve the eighty percent (80%) screening rate, the Agency may require the Managed Care Plan to submit a corrective action plan (CAP). Failure to meet the eighty percent (80%) screening requirement may result in sanctions (see Section XI, Sanctions). Any data reported by the Managed Care Plan that is found to be inaccurate shall be disallowed by the Agency, and the Agency shall consider such findings as being in violation of the Contract and may sanction the Managed Care Plan accordingly.

(j) The Managed Care Plan shall adopt annual participation goals to achieve at least an eighty percent (80%) CHCUP participation rate, as required by the Centers for Medicare & Medicaid Services. This participation compliance rate shall be based on the CHCUP data reported by the Managed Care Plan in its CHCUP (CMS-416) and FL 80% Screening Report (see sub-item H.2.h. above) and/or supporting encounter data. Upon implementation and notice by the Agency, the Managed Care Plan shall submit additional data, as required by the Agency for its submission of the CMS-416, to the Centers for Medicare & Medicaid Services, within the schedule determined by the Agency. For each federal fiscal year that the Managed Care Plan does not meet the eighty percent (80%) participation rate, the Agency may require the Managed Care Plan to submit a CAP. Any data reported by the Managed Care Plan that is found to be inaccurate shall be disallowed by the Agency, and the Agency shall consider such findings as being in violation of the Contract and shall sanction the Managed Care Plan accordingly. (See s. 1902(a)(43)(D)(iv) of the Social Security Act.)

(k) The Managed Care Plan shall achieve a preventive dental services rate of at least twenty-eight percent (28%) for those enrollees who are continuously eligible for CHCUP for ninety (90) continuous days. This rate shall be based on the CHCUP data reported by the Managed Care Plan in its CHCUP (CMS-416) audited report and/or supporting encounter data. Beginning with the report for federal fiscal year 2015, failure to meet the 28% preventive dental services rate may result in a corrective action plan and liquidated damages (see Section XIII, Liquidated Damages).

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(10) Immunizations

(a) The Managed Care Plan shall provide immunizations in accordance with the Recommended Childhood Immunization Schedule for the United States, or when medically necessary for the enrollee's health.

(b) The Managed Care Plan shall provide for the simultaneous administration of all vaccines for which an enrollee under the age of 21 is eligible at the time of each visit.

(c) The Managed Care Plan shall follow only contraindications established by the Advisory Committee on Immunization Practices (ACIP), unless:

(i) In making a medical judgment in accordance with accepted medical practices, such compliance is deemed medically inappropriate; or

(ii) The particular requirement is not in compliance with Florida law, including Florida law relating to religious or other exemptions.

(d) The Managed Care Plan shall participate, or direct its providers to participate, in the Vaccines For Children Program ("VFC"). See s. 1905(r)(1)(B)(iii) of the Social Security Act. The VFC is administered by the Department of Health, Bureau of Immunizations. The VFC provides vaccines at no charge to physicians and eliminates the need to refer children to CHDs for immunizations. Title XXI MediKids enrollees do not qualify for the VFC program. The Managed Care Plan shall advise providers to bill Medicaid fee-for-service directly for immunizations provided to Title XXI MediKids participants.

(e) The Managed Care Plan shall submit an attestation with accompanying documentation annually, by October 1 of each Contract year, to the Agency that the Managed Care Plan has advised its providers to enroll in the VFC program. The Agency may waive this requirement in writing if the Managed Care Plan provides documentation to the Agency that the Managed Care Plan is enrolled in the VFC program.

(f) The Managed Care Plan shall provide coverage and reimbursement to the participating provider for immunizations covered by Medicaid, but not provided through VFC.

(g) The Managed Care Plan shall ensure that providers have a sufficient supply of vaccines if the Managed Care Plan is enrolled in the VFC program. The Managed Care Plan shall direct those providers that are directly enrolled in the VFC program to maintain adequate vaccine supplies.

(h) The Managed Care Plan shall pay no more than the Medicaid program vaccine administration fee. For dates of service through December 31, 2014, the Managed Care Plan, in accordance with the Patient Protection and Affordable Care Act (ACA), shall pay no more than the Medicaid program vaccine product code and administration fee, per administration, as specified in the Florida Medicaid Physician Primary Care Rate Increase Fee Schedule

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at: http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/FEE%20SCHEDULES/2013_07_01_Phys_Primary_Care_Rates.pdf, and Section V, Covered Services, unless another rate is negotiated with the participating provider.

(i) The Managed Care Plan shall pay no less than the Medicaid program vaccine administration fee when an enrollee receives immunizations from a non-participating provider so long as:

(i) The non-participating provider contacts the Managed Care Plan at the time of service delivery;

(ii) The Managed Care Plan is unable to provide documentation to the non-participating provider that the enrollee has already received the immunization; and

(iii) The non-participating provider submits a claim for the administration of immunization services and provides medical records documenting the immunization to the Managed Care Plan.

(j) The Managed Care Plan shall encourage PCPs to provide immunization information about enrollees requesting temporary cash assistance from DCF, upon request by DCF and receipt of the enrollee’s written permission. This information is necessary in order to document that the enrollee has met the immunization requirements for enrollees receiving temporary cash assistance.

(11) Emergency Services

(a) The Managed Care Plan shall provide pre-hospital and hospital-based trauma services and emergency services and care to enrollees. See ss. 395.1041, 395.4045 and 401.45, F.S.

(b) When an enrollee presents at a hospital seeking emergency services and care, the determination that an emergency medical condition exists shall be made, for the purposes of treatment, by a physician of the hospital or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a hospital physician. See ss. 409.9128, 409.901, F.S. and 641.513, F.S.

(i) The physician, or the appropriate personnel, shall indicate on the enrollee's chart the results of all screenings, examinations and evaluations.

(ii) The Managed Care Plan shall cover all screenings, evaluations and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the enrollee's condition is an emergency medical condition.

(iii) If the provider determines that an emergency medical condition does not exist, the Managed Care Plan is not required to cover services

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rendered subsequent to the provider's determination unless authorized by the Managed Care Plan.

(c) If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of the Managed Care Plan, the hospital must make a reasonable attempt to notify:

(i) The enrollee's PCP, if known,; or

(ii) The Managed Care Plan, if the Managed Care Plan has previously requested in writing that it be notified directly of the existence of the emergency medical condition.

(d) If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must:

(i) Notify the Managed Care Plan as soon as possible before discharging the enrollee from the emergency care area; or

(ii) Notify the Managed Care Plan within twenty-four (24) hours or on the next business day after the enrollee’s inpatient admission.

(e) If the hospital is unable to notify the Managed Care Plan, the hospital must document its attempts to notify the Managed Care Plan, or the circumstances that precluded the hospital's attempts to notify the Managed Care Plan. The Managed Care Plan shall not deny coverage for emergency services and care based on a hospital's failure to comply with the notification requirements of this section.

(f) If the enrollee's PCP responds to the hospital's notification, and the hospital physician and the PCP discuss the appropriate care and treatment of the enrollee, the Managed Care Plan may have a member of the hospital staff with whom it has a participating provider contract participate in the treatment of the enrollee within the scope of the physician's hospital staff privileges.

(g) The Managed Care Plan shall advise all enrollees of the provisions governing emergency services and care. The Managed Care Plan shall not deny claims for emergency services and care received at a hospital due to lack of parental consent. In addition, the Managed Care Plan shall not deny payment for treatment obtained when a representative of the Managed Care Plan instructs the enrollee to seek emergency services and care in accordance with s. 743.064, F.S.

(h) The Managed Care Plan shall not:

(i) Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;

(ii) Specify or imply that emergency services and care are covered by the Managed Care Plan only if secured within a certain period of time;

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(iii) Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or

(iv) Deny payment based on a failure by the enrollee or the hospital to notify the Managed Care Plan before, or within a certain period of time after, emergency services and care were given.

(i) Notwithstanding any other state law, a hospital may request and collect from an enrollee any insurance or financial information necessary to determine if the patient is an enrollee of the Managed Care Plan, in accordance with federal law, so long as emergency services and care are not delayed in the process.

(j) The Managed Care Plan shall cover any medically necessary duration of stay in a non-contracted facility, which results from a medical emergency, until such time as the Managed Care Plan can safely transport the enrollee to a participating facility. The Managed Care Plan may transfer the enrollee, in accordance with state and federal law, to a participating hospital that has the service capability to treat the enrollee's emergency medical condition. The attending emergency physician, or the provider actually treating the enrollee, is responsible for determining when the enrollee is sufficiently stabilized for transfer discharge, and that determination is binding on the entities identified in 42 CFR 438.114(b) as responsible for coverage and payment.

(k) In accordance with 42 CFR 438.114 and s. 1932(b)(2)(A)(ii) of the Social Security Act, the Managed Care Plan shall cover post-stabilization care services without authorization, regardless of whether the enrollee obtains a service within or outside the Managed Care Plan's network for the following situations:

(i) Post-stabilization care services that were pre-approved by the Managed Care Plan;

(ii) Post-stabilization care services that were not pre-approved by the Managed Care Plan because the Managed Care Plan did not respond to the treating provider's request for pre-approval within one (1) hour after the treating provider sent the request;

(iii) The treating provider could not contact the Managed Care Plan for pre-approval; and

(iv) Those post-stabilization care services that a treating physician viewed as medically necessary after stabilizing an emergency medical condition are non-emergency services. The Managed Care Plan can choose not to cover them if they are provided by a non-participating provider, except in those circumstances detailed above.

(l) The Managed Care Plan shall not deny claims for the provision of emergency services and care submitted by a non-participating provider solely based on the period between the date of service and the date of clean claim

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submission, unless that period exceeds three-hundred and sixty-five (365) days.

(m) Pursuant to s. 409.967(2)(b), F.S., the Managed Care Plan shall pay for services required by ss. 395.1041 and 401.45, F.S. provided to an enrollee under this section by a non-participating provider. The Managed Care Plan must comply with s. 641.3155, F.S. Reimbursement for services under this paragraph is the lesser of:

(i) The non-participating provider's charges;

(ii) The usual and customary provider charges for similar services in the community where the services were provided;

(iii) The charge mutually agreed to by the Managed Care Plan and the non-participating provider within sixty (60) days after the non-participating provider submits a claim; or

(iv) The rate the Agency would have paid on the most recent October 1.

(n) Notwithstanding the requirements set forth in this section, the Managed Care Plan shall approve all claims for emergency services and care by non-participating providers pursuant to the requirements set forth in s. 641.3155, F.S., and 42 CFR 438.114.

(o) The Managed Care Plan shall provide timely approval or denial of authorization of out-of-network use of non-emergency services through the assignment of a prior authorization number, which refers to and documents the approval. The Managed Care Plan may not require paper authorization as a condition of receiving treatment Managed Care Plan. Written follow-up documentation of the approval must be provided to the non-participating provider within one (1) business day after the approval. Enrollees shall be liable for the cost of such unauthorized use of covered services from non-participating providers.

(p) In accordance with ss. 409.912(18) and 409.967(2), F.S., the Managed Care Plan shall reimburse any hospital or physician that is outside the Managed Care Plan’s authorized service area for Managed Care Plan-authorized services at a rate negotiated with the hospital or physician or according to the lesser of the following:

(i) The usual and customary charge made to the general public by the hospital or provider; or

(ii) The Florida Medicaid reimbursement rate established for the hospital or provider.

(q) The Managed Care Plan shall reimburse all non-participating providers as described in s. 641.3155, F.S.

(r) Unless otherwise specified in this Contract, where an enrollee uses non-emergency services available under the Managed Care Plan from a non-

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participating provider, the Managed Care Plan shall not be liable for the cost of such services unless the Managed Care Plan referred the enrollee to the non-participating provider or authorized the out-of-network service.

(12) Emergency Behavioral Health Services

(a) The Managed Care Plans shall provide emergency behavioral health services pursuant, but not limited, to s. 394.463, F.S.; s. 641.513, F.S.; and Title 42 CFR Chapter IV. Emergency service providers shall make a reasonable attempt to notify the Managed Care Plan within twenty-four (24) hours of the enrollee’s presenting for emergency behavioral health services. In cases in which the enrollee has no identification, or is unable to orally identify himself/herself when presenting for behavioral health services, the provider shall notify the Managed Care Plan within twenty-four (24) hours of learning the enrollee’s identity.

(b) In addition to the requirements outlined in s. 641.513, F.S., the Managed Care Plan will ensure:

(i) The enrollee has a follow-up appointment scheduled within seven (7) days after discharge; and

(ii) All required prescriptions are authorized at the time of discharge.

(c) The Managed Care Plan shall operate, as part of its crisis support/emergency services, a crisis emergency hotline available to all enrollees twenty-four hours a day, seven days a week (24/7).

(d) For each county it serves, the Managed Care Plan shall designate an emergency service facility that operates twenty-four hours a day, seven days a week, (24/7) with Registered Nurse coverage and on-call coverage by a behavioral health specialist.

(13) Family Planning Services and Supplies

(a) The Managed Care Plan shall provide family planning services to help enrollees make comprehensive and informed decisions about family size and/or spacing of births. The Managed Care Plan shall provide the following services: planning and referral, education and counseling, initial examination, diagnostic procedures and routine laboratory studies, contraceptive drugs and supplies, and follow-up care in accordance with the Medicaid Practitioner Services Coverage and Limitations Handbook. Policy requirements include:

(i) The Managed Care Plan shall furnish services on a voluntary and confidential basis.

(ii) The Managed Care Plan shall allow enrollees freedom of choice of family planning methods covered under the Medicaid program, including Medicaid-covered implants, where there are no medical contra-indications.

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(ii) The Managed Care Plan shall render the services to enrollees under the age of 18 provided the enrollee is married, a parent, pregnant, has written consent by a parent or legal guardian, or, in the opinion of a physician, the enrollee may suffer health hazards if the services are not provided. See s. 390.01114, F.S.

(iv) The Managed Care Plan shall allow each enrollee to obtain family planning services from any provider and require no prior authorization for such services. If the enrollee receives services from a non-participating Medicaid provider, then the Managed Care Plan shall reimburse at the Medicaid reimbursement rate, unless another payment rate is negotiated.

(v) The Managed Care Plan shall make available and encourage all pregnant women and mothers with infants to receive postpartum visits for the purpose of voluntary family planning, including discussion of all appropriate methods of contraception, counseling and services for family planning to all women and their partners. The Managed Care Plan shall direct providers to maintain documentation in the enrollee's medical records to reflect this provision. See ss. 409.912(34) and 409.967(2), F.S.

(b) The provisions of this subsection shall not be interpreted so as to prevent a health care provider or other person from refusing to furnish any contraceptive or family planning service, supplies or information for medical or religious reasons. A health care provider or other person shall not be held liable for such refusal.

(c) Pursuant to s. 409.973(1)(h), F.S., and 42 CFR 438.102, the Managed Care Plan may elect to not provide these services due to an objection on moral or religious grounds, and must have notified the Agency of that election as specified in, Section V.C., Excluded Services

(14) Healthy Start Services

(a) Pursuant to s. 409.975(4)(b), F.S., the Managed Care Plan shall establish specific programs and procedures to improve pregnancy outcomes and infant health, including, but not limited to, coordination with the Healthy Start program, immunization programs, and referral to the Special Supplemental Nutrition Program for Women, Infants, and Children, and the Children's Medical Services program for children with special health care needs. In addition, the program for pregnant women and infants must be aimed at promoting early prenatal care to decrease infant mortality and low birth weight and to enhance healthy birth outcomes. The Managed Care Plan shall provide the most appropriate and highest level of quality care for pregnant enrollees.

(b) Florida's Healthy Start Prenatal Risk Screening – The Managed Care Plan shall ensure that the provider offers Florida's Healthy Start prenatal risk screening to each pregnant enrollee as part of her first prenatal visit, as required by s. 383.14, F.S., s. 381.004, F.S., and 64C-7.009, F.A.C.

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(i) The Managed Care Plan shall ensure that the provider uses the Agency approved Healthy Start (Prenatal) Risk Screening Instrument.

(ii) The Managed Care Plan shall ensure that the provider keeps a copy of the completed screening instrument in the enrollee's medical record and provides a copy to the enrollee.

(iii) The Managed Care Plan shall ensure that the provider submits the Healthy Start (Prenatal) Risk Screening Instrument to the CHD in the county where the prenatal screen was completed within ten (10) business days of completion of the screening.

(iv) The Managed Care Plan shall collaborate with the Healthy Start care coordinator within the enrollee's county of residence to assure delivery of risk-appropriate care.

(c) Florida's Healthy Start Infant (Postnatal) Risk Screening Instrument – Florida hospitals electronically file the Healthy Start (Prenatal) Risk Screening Instrument Certificate of Live Birth with the CHD in the county where the infant was born within five (5) business days of the birth. If the Managed Care Plan contracts with birthing facilities not participating in the Department of Health electronic birth registration system, the Managed Care Plan shall ensure that the provider files required birth information with the CHD within five (5) business days of the birth, keeps a copy of the completed Healthy Start (Prenatal) Risk Screening Instrument in the enrollee's medical record and mails a copy to the enrollee.

(d) Pursuant to s. 409.975(4)(b), F.S., the Managed Care Plan shall establish specific programs and procedures to improve pregnancy outcomes and infant health, including, but not limited to, coordination with the Healthy Start program, immunization programs, and referral to the Special Supplemental Nutrition Program for Women, Infants, and Children, and the Children's Medical Services program for children with special health care needs. The programs and procedures shall include agreements with each local Healthy Start Coalition in the region to provide risk-appropriate care coordination/case management for pregnant women and infants, consistent with Agency policies in accordance with Agency policies and the MomCare Network.

(e) Pregnant enrollees or infants who do not score high enough to be eligible for Healthy Start case management may be referred for services, regardless of their score on the Healthy Start risk screen, in the following ways:

(i) If the referral is to be made at the same time the Healthy Start risk screen is administered, the provider may indicate on the risk screening form that the enrollee or infant is invited to participate based on factors other than score; or

(ii) If the determination is made subsequent to risk screening, the provider may refer the enrollee or infant directly to the Healthy Start care coordinator based on assessment of actual or potential factors

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associated with high risk, such as HIV, Hepatitis B, substance abuse or domestic violence.

(f) The Managed Care Plan shall refer all infants, children up to age five (5), and pregnant, breast-feeding and postpartum women to the local WIC office. The Managed Care Plan shall ensure providers provide:

(i) A completed Florida WIC program medical referral form with the current height or length and weight (taken within sixty (60) days of the WIC appointment);

(ii) Hemoglobin or hematocrit; and

(iii) Any identified medical/nutritional problems.

For subsequent WIC certifications, the Managed Care Plan shall ensure that providers coordinate with the local WIC office to provide the above referral data from the most recent CHCUP.

Each time the provider completes a WIC referral form, the Managed Care Plan shall ensure that the provider gives a copy of the form to the enrollee and keeps a copy in the enrollee's medical record.

(g) The Managed Care Plan shall ensure that providers give all women of childbearing age HIV counseling and offer them HIV testing. See Chapter 381, F.S.

(i) The Managed Care Plan shall ensure that its providers offer all pregnant women counseling and HIV testing at the initial prenatal care visit and again at twenty-eight (28) and thirty-two (32) weeks.

(ii) The Managed Care Plan shall ensure that its providers attempt to obtain a signed objection if a pregnant woman declines an HIV test. See s. 384.31, F.S. and 64D-3.019, F.A.C.

(iii) The Managed Care Plan shall ensure that all pregnant women who are infected with HIV are counseled about and offered the latest antiretroviral regimen recommended by the U.S. Department of Health & Human Services (Public Health Service Task Force Report entitled Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States).

(h) The Managed Care Plan shall ensure that its providers screen all pregnant enrollees receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during the first prenatal visit.

(i) The Managed Care Plan shall ensure that its providers perform a second HBsAg test between twenty-eight (28) and thirty-two (32) weeks of pregnancy for all pregnant enrollees who tested negative at the first prenatal visit and are considered high-risk for Hepatitis B

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infection. This test shall be performed at the same time that other routine prenatal screening is ordered.

(ii) All HBsAg-positive women shall be reported to the local CHD and to Healthy Start, regardless of their Healthy Start screening score.

(i) The Managed Care Plan shall ensure that infants born to HBsAg-positive enrollees receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once they are physiologically stable, preferably within twelve (12) hours of birth, and shall complete the Hepatitis B vaccine series according to the vaccine schedule established by the Recommended Childhood Immunization Schedule for the United States.

(i) The Managed Care Plan shall ensure that its providers test infants born to HBsAg-positive enrollees for HBsAg and Hepatitis B surface antibodies (anti-HBs) six (6) months after the completion of the vaccine series to monitor the success or failure of the therapy.

(ii) The Managed Care Plan shall ensure that providers report to the local CHD a positive HBsAg result in any child age 24 months or less within twenty-four (24) hours of receipt of the positive test results.

(iii) The Managed Care Plan shall ensure that infants born to enrollees who are HBsAg-positive are referred to Healthy Start regardless of their Healthy Start screening score.

(j) The Managed Care Plan shall report to the Perinatal Hepatitis B Prevention Coordinator at the local CHD all prenatal or postpartum enrollees who test HBsAg-positive. The Managed Care Plan also shall report said enrollees’ infants and contacts to the Perinatal Hepatitis B Prevention Coordinator.

(i) The Managed Care Plan shall report the following information – name, date of birth, race, ethnicity, address, infants, contacts, laboratory test performed, date the sample was collected, the due date or estimated date of confinement, whether the enrollee received prenatal care, and immunization dates for infants and contacts.

(ii) The Managed Care Plan shall use the Practitioner Disease Report Form (DH Form 2136) for reporting purposes.

(k) The Managed Care Plan shall ensure that the PCP maintains all documentation of Healthy Start screenings, assessments, findings and referrals in the enrollees’ medical records.

(l) Prenatal Care – The Managed Care Plan shall:

(i) Require a pregnancy test and a nursing assessment with referrals to a physician, PA or ARNP for comprehensive evaluation;

(ii) Require care coordination/case management through the gestational period according to the needs of the enrollee;

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(iii) Require any necessary referrals and follow-up;

(iv) Schedule return prenatal visits at least every four (4) weeks until week thirty-two (32), every two (2) weeks until week thirty-six (36), and every week thereafter until delivery, unless the enrollee’s condition requires more frequent visits;

(v) Contact those enrollees who fail to keep their prenatal appointments as soon as possible, and arrange for their continued prenatal care;

(vi) Assist enrollees in making delivery arrangements, if necessary; and

(vii) Ensure that all providers screen all pregnant enrollees for tobacco use and make certain that the providers make available to pregnant enrollees smoking cessation counseling and appropriate treatment as needed.

(m) Nutritional Assessment/Counseling – The Managed Care Plan shall ensure that its providers supply nutritional assessment and counseling to all pregnant enrollees. The Managed Care Plan shall:

(i) Ensure the provision of safe and adequate nutrition for infants by promoting breast-feeding and the use of breast milk substitutes;

(ii) Offer a mid-level nutrition assessment;

(iii) Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a nurse or physician following the nutrition assessment; and

(iv) Ensure documentation of the nutrition care plan in the medical record by the person providing counseling.

(n) Obstetrical Delivery – The Managed Care Plan shall develop and use generally accepted and approved protocols for both low-risk and high-risk deliveries reflecting the highest standards of the medical profession, including Healthy Start and prenatal screening, and ensure that all providers use these protocols.

(i) The Managed Care Plan shall ensure that all providers document preterm delivery risk assessments in the enrollee’s medical record by week twenty-eight (28).

(ii) If the provider determines that the enrollee’s pregnancy is high risk, the Managed Care Plan shall ensure that the provider’s obstetrical care during labor and delivery includes preparation by all attendants for symptomatic evaluation and that the enrollee progresses through the final stages of labor and immediate postpartum care.

(o) Newborn Care – The Managed Care Plan shall make certain that its providers supply the highest level of care for the newborn beginning

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immediately after birth. Such level of care shall include, but not be limited to, the following:

(i) Instilling of prophylactic eye medications into each eye of the newborn;

(ii) When the mother is Rh negative, securing a cord blood sample for type Rh determination and direct Coombs test;

(iii) Weighing and measuring of the newborn;

(iv) Inspecting the newborn for abnormalities and/or complications;

(v) Administering one half (.5) milligram of vitamin K;

(vi) APGAR scoring;

(vii) Any other necessary and immediate need for referral in consultation from a specialty physician, such as the Healthy Start (postnatal) infant screen; and

(viii) Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a physician licensed under Chapters 458 or 459, F.S., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist).

(p) Postpartum Care – The Managed Care Plan shall:

(i) Provide a postpartum examination for the enrollee within six (6) weeks after delivery;

(ii) Ensure that its providers supply voluntary family planning, including a discussion of all methods of contraception, as appropriate; and

(iii) Ensure that continuing care of the newborn is provided through the CHCUP program component and documented in the child’s medical record.

(15) Hearing Services

(a) The Managed Care Plan shall provide Hearing Services. Hearing services include mandatory newborn hearing screenings; medically-necessary hearing evaluations, diagnostic testing, hearing aids, hearing aid fitting and dispensing, hearing aid repairs and accessories; and medically-necessary cochlear implant services including provision of the device, post-operative tuning of the headset, replacement and repairs furnished by physicians, audiologists and hearing aid specialists.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Hearing Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract

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prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Hearing Services Coverage and Limitations Handbook.

(16) Home Health Services and Nursing Care

(a) The Managed Care Plan shall provide Home Health Services. Home health services are medically necessary services, which can be effectively and efficiently provided in the place of residence of a recipient. Services include home health visits (nurse and home health aide), private duty nursing and personal care services for children, therapy services, medical supplies, and durable medical equipment.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Home Health Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Home Health Services Coverage and Limitations Handbook.

(17) Hospice Services

(a) The Managed Care Plan shall provide Hospice Services. Hospice services are forms of palliative medical care and services designed to meet the physical, social, psychological, emotional, and spiritual needs of terminally ill recipients and their families. Hospice care is an approach that focuses on palliative care rather than curative care.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Hospice Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Hospice Services Coverage and Limitations Handbook.

(18) Hospital Services

(a) The Managed Care Plan shall provide Inpatient Hospital Services. Inpatient services are medically necessary services ordinarily furnished by a state-licensed acute care hospital for the medical care and treatment of inpatients provided under the direction of a physician or dentist in a hospital maintained primarily for the care and treatment of patients with disorders other than mental diseases.

(b) Inpatient services include, but are not limited to, rehabilitation hospital care (which are counted as inpatient hospital days), medical supplies, diagnostic and therapeutic services, use of facilities, drugs and biologicals, room and board, nursing care and all supplies and equipment necessary to provide adequate care. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than the Medicaid Hospital Services Coverage & Limitations Handbook.

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(c) Inpatient services also include inpatient care for any diagnosis including tuberculosis and renal failure when provided by general acute care hospitals in both emergent and non-emergent conditions.

(d) The Managed Care Plan shall cover physical therapy services when medically necessary and when provided during an enrollee's inpatient stay.

(e) The Managed Care Plan shall provide up to twenty-eight (28) inpatient hospital days (calendar) in an inpatient hospital substance abuse treatment program for pregnant substance abusers who meet ISD (intensity, severity, discharge screens) Criteria with Florida Medicaid modifications, as specified in InterQual Level of Care Acute Criteria-Pediatric and/or InterQual Level of Care Acute Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”), the most current edition, for use in screening cases admitted to rehabilitative hospitals and CON-approved rehabilitative units in acute care hospitals.

(f) In addition, the Managed Care Plan shall provide inpatient hospital treatment for severe withdrawal cases exhibiting medical complications that meet the severity of illness criteria under the alcohol/substance abuse system-specific set which generally requires treatment on a medical unit where complex medical equipment is available. Withdrawal cases (not meeting the severity of illness criteria under the alcohol/substance abuse criteria) and substance abuse rehabilitation (other than for pregnant women), including court ordered services, are not covered in the inpatient hospital setting.

(g) The Managed Care Plan shall coordinate hospital and institutional discharge planning for substance abuse detoxification to ensure inclusion of appropriate post-discharge care.

(h) The Managed Care Plan shall adhere to the provisions of the Newborns and Mothers Health Protection Act (NMHPA) of 1996 regarding postpartum coverage for mothers and their newborns. Therefore, the Managed Care Plan shall provide for no less than a forty-eight (48) hour hospital length of stay following a normal vaginal delivery, and at least a ninety-six (96) hour hospital length of stay following a Cesarean section. In connection with coverage for maternity care, the hospital length of stay is required to be decided by the attending physician in consultation with the mother.

(i) The Managed Care Plan shall prohibit the following practices:

(i) Denying the mother or newborn child eligibility, or continued eligibility, to enroll or renew coverage under the terms of the Managed Care Plan, solely for the purpose of avoiding the NMHPA requirements;

(ii) Providing monetary payments or rebates to mothers to encourage them to accept less than the minimum protections available under NMHPA;

(iii) Penalizing or otherwise reducing or limiting the reimbursement of an attending physician because the physician provided care in a manner consistent with NMHPA;

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(iv) Providing incentives (monetary or otherwise) to an attending physician to induce the physician to provide care in a manner inconsistent with NMHPA; and

(v) Restricting any portion of the forty-eight (48) hour, or ninety-six (96) hour, period prescribed by NMHPA in a manner that is less favorable than the benefits provided for any preceding portion of the hospital stay.

(j) The Managed Care Plan shall cover any medically necessary duration of stay in a non-contracted facility that results from a medical emergency until such time as the Managed Care Plan can safely transport the enrollee to a Managed Care Plan participating facility.

(k) For all child/adolescent enrollees (up to age 21) and pregnant adults, the Managed Care Plan shall be responsible for providing up to three-hundred and sixty-five (365) days of health-related inpatient care, including behavioral health, for each state fiscal year. For all non-pregnant adults, the Managed Care Plan shall be responsible for up to forty-five (45) days of inpatient coverage and up to three-hundred sixty-five (365) days of emergency inpatient care, including behavioral health, in accordance with the Medicaid Hospital Services Coverage and Limitations Handbook, for each state fiscal year.

(i) The Managed Care Plan shall count inpatient days based on the lesser of the actual number of covered days in the inpatient hospital stay and the average length of stay for the relevant All Patient Refined Diagnosis Related Group (APR-DRG or DRG). This requirement applies whether or not the Managed Care Plans uses DRGs to pay the provider. DRGs can be found at the following website: http://ahca.myflorida.com/Medicaid/cost_reim/index.shtml.

(ii) If an enrollee has not yet met his/her forty-five day (45-day) hospital inpatient limit per state fiscal year for non-pregnant adults, at the start of a new hospital admission, the entire new stay must be covered by the Managed Care Plan in which the enrollee was enrolled on the date of admission. This requirement applies even if the actual or average length of stay for the DRG puts the person over the inpatient limit. There is no proration of inpatient days.

(l) Pursuant to section 2702 of the Patient Protection and Affordable Care Act (ACA), the Florida Medicaid State Plan and 42 CFR 434.6(12) and 447.26, the Managed Care Plan shall comply with the following requirements:

(i) Require providers to identify Provider-Preventable Conditions (PPCs) in their claims;

(ii) Deny reimbursement for PPCs occurring after admission in any inpatient hospital or inpatient psychiatric hospital setting, including CSUs, as listed under Forms at http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/med_prov_0912.shtml;

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(iii) Ensure that non-payment for PPCs does not prevent enrollee access to services;

(iv) Ensure that documentation of PPC identification is kept and accessible for reporting to the Agency;

(v) Ensure encounter data submissions include PPC information in order to meet the PPC identification requirements;

(vi) Amend all hospital provider contracts to include PPC reporting requirements; and

(vii) Relative to all above requirements, not:

(a) Limit inpatient days for services that are unrelated to the PPC diagnosis present on admission (POA);

(b) Reduce authorization to a provider when the PPC existed prior to admission;

(c) Deny reimbursement to inpatient hospitals and inpatient psychiatric hospitals, including CSUs, for services occurring prior to the PPC event;

(d) Deny reimbursement to surgeons, ancillary and other providers that bill separately through the CMS 1500;

(e) Deny reimbursement for health care settings other than inpatient hospital and inpatient psychiatric hospital, including CSUs; or

(f) Deny reimbursement for clinic services provided in clinics owned by hospitals.

(m) The Managed Care Plan shall provide medically necessary transplants and related services as outlined in the chart below. For transplant services specified with one (1) asterisk, Managed Care Plans are paid by the Agency through kick payments. See Section IX, Method of Payment, for payment details. Transplant services specified with two (2) asterisks, as well as pre- and post-transplant follow-up care, are covered through fee-for-service Medicaid and not by the Managed Care Plan.

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SUMMARY OF RESPONSIBILITY
Transplant Service	Adult (21 and Over)	Pediatric (20 and Under)
Evaluation	Managed Care Plan	Managed Care Plan
Bone Marrow	Managed Care Plan	Managed Care Plan
Cornea	Managed Care Plan	Managed Care Plan
Heart	Managed Care Plan*	Managed Care Plan*
Intestinal/ Multivisceral	Medicaid**	Medicaid**
Kidney	Managed Care Plan	Managed Care Plan
Liver	Managed Care Plan*	Managed Care Plan*
Lung	Managed Care Plan*	Managed Care Plan*
Pancreas	Managed Care Plan	Managed Care Plan
Pre- and Post-Transplant Care, including Transplants Not Covered by Medicaid	Managed Care Plan	Managed Care Plan
Other Transplants Not Covered by Medicaid	Not Covered	Not Covered

(n) The Managed Care Plans shall be responsible for the reimbursement of care for enrollees who have been diagnosed with Tuberculosis disease, or show symptoms of having Tuberculosis and have been designated a threat to the public health by the FDOH Tuberculosis Program and shall observe the following:

(i) Said enrollees shall be hospitalized and treated in a hospital licensed under Chapter 395 F.S. and under contract with the FDOH pursuant to 392.62, Florida Statutes;

(ii) Treatment plans and discharge determinations shall be made solely by FDOH and the treating hospital;

(iii) For enrollees determined to be a threat to public health and receiving Tuberculosis treatment at an FDOH contracted hospital, the Managed Care Plan shall pay the Medicaid per diem rate for hospitalization and treatment as negotiated between Florida Medicaid and FDOH, and shall also pay any wrap-around costs not included in the per-diem rate; and

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(iv) Reimbursement shall not be denied for failure to prior authorize admission, or for services rendered pursuant to 392.62 F.S.

(o) With the exception of hospitalization pursuant to section (n) above, the Managed Care Plan may provide services in a nursing facility as downward substitution for inpatient services. Such services shall not be counted as inpatient hospital days.

(p) The Managed Care Plan shall provide Outpatient Hospital Services. Outpatient hospital services consist of medically necessary preventive, diagnostic, therapeutic or palliative care under the direction of a physician or dentist at a licensed acute care hospital. Outpatient hospital services include medically necessary emergency room services, dressings, splints, oxygen and physician-ordered services and supplies for the clinical treatment of a specific diagnosis or treatment.

(i) The Managed Care Plan shall provide emergency services and care without any specified dollar limitations.

(ii) The Managed Care Plan shall have a procedure for the authorization of dental care and associated ancillary medical services provided in an outpatient hospital setting if that is provided under the direction of a dentist at a licensed hospital and, although not usually considered medically necessary, is considered medically necessary to the extent that the outpatient hospital services must be provided in a hospital due to the enrollee’s disability, behavioral health condition or abnormal behavior due to emotional instability or a developmental disability.

(q) The Managed Care Plan shall provide medically necessary ancillary medical services at the hospital without limitation. Ancillary hospital services include, but are not limited to, radiology, pathology, neurology, neonatology, and anesthesiology.

(i) When the Managed Care Plan or its authorized physician authorizes these services (either inpatient or outpatient), the Managed Care Plan shall reimburse the provider of the service at the Medicaid line item rate, unless the Managed Care Plan and the hospital have negotiated another reimbursement rate.

(ii) The Managed Care Plan shall authorize payment for non-participating physicians for emergency ancillary services provided in a hospital setting.

(r) The Managed Care Plan shall cover medically necessary dental care and associated ancillary services provided in licensed ambulatory surgical center settings if that care is provided under the direction of a dentist as described in the Florida Medicaid State Plan.

(s) Crisis stabilization units (CSU) may be used as a substitute service for inpatient psychiatric hospital care when determined medically appropriate. Notwithstanding network adequacy standards, when reporting inpatient days used, these bed days are calculated on a one-to-one basis. If CSU beds are at capacity, and some of the beds are occupied by enrollees, and a non-funded client presents in need of

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services, the enrollees must be transferred to an appropriate facility to allow the admission of the non-funded client. Therefore, the Managed Care Plan shall demonstrate adequate capacity for psychiatric inpatient hospital care in anticipation of such transfers.

(19) Laboratory and Imaging Services

(a) The Managed Care Plan shall provide laboratory, portable x-ray, and advanced diagnostic imaging services as medically necessary.

(b) Laboratory services are clinical laboratory procedures provided in freestanding laboratory facilities. A clinical laboratory is defined as a facility that examines materials taken from the human body for the purpose of providing information to assist in the diagnosis, prevention, or treatment of disease or assessment of health. A freestanding or independent facility is one that is not controlled, managed or supervised by a hospital or a hospital’s organized medical staff, or the treating health care practitioner.

(c) Portable x-ray services are diagnostic x-ray services provided at the residence of a recipient who is unable to travel to a physician’s office or outpatient hospital’s radiology facility. The recipient’s residence must be one of the following: recipient’s private home, assisted living facility (ALF), nursing facility, or intermediate care facility for the developmentally disabled (ICF/DD).

(d) Advanced diagnostic imaging services include magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) studies.

(e) The Managed Care Plan shall comply with provisions of the Medicaid Independent Laboratory Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Independent Laboratory Services Coverage and Limitations Handbook and the Portable X-Ray Services Coverage and Limitations Handbook.

(20) Medical Supplies, Equipment, Protheses and Orthoses

(a) The Managed Care Plan shall provide medical supplies, equipment, protheses and orthoses. Medical supplies are defined as medically-necessary medical or surgical items that are consumable, expendable, disposable, or non-durable and appropriate for use in the recipient’s home. Durable medical equipment (DME) is defined as medically-necessary equipment that can withstand repeated use, serves a medical purpose, and is appropriate for use in the recipient’s home as determined by the Agency for Health Care Administration (AHCA). DME also includes respiratory equipment Ventilator, oxygen, oxygen-related and respiratory equipment used to support the respiratory system. Orthotic devices are defined as medically-necessary devices or appliances that support or correct a weak or deformed body part, or restrict or eliminate motion in a diseased or injured body part. Prosthetic devices are defined as medically-necessary artificial devices or

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appliances that replace all or part of a permanently inoperative or missing body part.

(b) The Managed Care Plan shall comply with provisions of the Medicaid DME and Medical Supply Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid DME and Medical Supply Services Coverage and Limitations Handbook.

(c) In the same manner as specified in s. 641.31, F.S., the Managed Care Plan shall provide coverage for medically necessary diabetes equipment, supplies, and services used to treat diabetes, including outpatient self-management training and educational services, if the enrollee’s PCP, or the physician to whom the enrollee has been referred who specializes in treating diabetes, certifies that the equipment, supplies and services are medically necessary. Outpatient self-management training and educational services shall be in accordance with American Diabetes Association standards for such services.

(21) Optometric and Vision Services

(a) The Managed Care Plan shall provide Optometric and Vision Services. Optometric services are medically-necessary services that provide for examination, diagnosis, treatment and management of ocular and adnexal pathology. Visual examinations to determine the need for eyeglasses are also covered. Optometric services must be furnished by or under the direct supervision of a licensed optometrist or ophthalmologist. Visual services include the medically necessary provision of optical services and supplies such as eyeglasses, prosthetic eyes, and contact lenses; the fitting, dispensing, and adjusting of eyeglasses; and eyeglass repair services.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Optometric Services Coverage and Limitations Handbook and Medicaid Vision Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Optometric Services Coverage and Limitations Handbook and Medicaid Vision Services Coverage and Limitations Handbook.

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(22) Physician Assistant Services

(a) The Managed Care Plan shall provide Physician Assistant Services. Physician Assistant Services are services provided by a Physician Assistant (PA) certified to provide diagnostic and therapeutic patient care and fully licensed as a PA as defined in Chapter 458 or Chapter 459, Florida Statutes. The services must be provided in collaboration with a practitioner licensed pursuant to Chapter 458 or 459, Florida Statutes.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Practitioner Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Practitioner Services Coverage and Limitations Handbook.

(23) Podiatric Services

(a) The Managed Care Plan shall provide Podiatric Services. Podiatry is the specialty concerned with the diagnosis and or the medical, surgical, mechanical, physical, and adjunctive treatment of the diseases, injuries, and defects of the human foot. Podiatry services may include routine care of the foot as well as care related to underlying systemic conditions such as metabolic, neurologic or peripheral vascular disease, or injury, ulcers, wounds and infections.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Podiatry Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Podiatry Services Coverage and Limitations Handbook.

(24) Physician Services

(a) The Managed Care Plan shall provide Physician Services. Physician Services are those services rendered by licensed doctors of allopathic or osteopathic medicine. Services may be rendered in the practitioner’s office, the patient’s home, a hospital, a nursing facility, or other approved place of service as necessary to treat a particular injury, illness, or disease.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Practitioner Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Practitioner Services Coverage and Limitations Handbook.

(c) The Managed Care Plan shall maintain a log of all hysterectomy, sterilization and abortion procedures performed for its enrollees. The log shall include, at a minimum, the enrollee’s name and identifying information, date of procedure, and type of procedure. The Managed Care Plan shall provide abortions only in the following situations:

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(i) If the pregnancy is a result of an act of rape or incest; or

(ii) The physician certifies that the woman is in danger of death unless an abortion is performed.

(d) Primary Care Services

(i) The Managed Care Plan shall process claims for and pay certain physicians who provide Florida Medicaid-covered eligible primary care services in accordance with sections 1902(a)(13), 1902(jj), 1932(f), and 1905(dd) of the Social Security Act, as amended by the Affordable Care Act and 42 CFR sections 438, 441 and 447, for dates of service on or after January 1, 2013, through December 31, 2014. This provision also applies to any payments made through subcapitation arrangements. For Managed Care Plans with subcapitation arrangements, the Agency recommends that the Managed Care Plan shall implement a physician payment increase methodology similar to the Agency’s payment methodology approved by CMS.

(ii) The Managed Care Plan shall ensure the physician payment specified in this section applies to such primary care services provided by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine or related subspecialists. Physicians affected include the following:

(a) A physician as defined in 42 CFR 440.50; or provider under the personal supervision of a physician who self-attests to a specialty designation of family medicine, general internal medicine or pediatric medicine; or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA); and

(b) A physician who self-attests that he/she is board certified with such a specialty or subspecialty and/or has furnished evaluation and management services and vaccine administration services under the codes listed below that equal at least sixty percent (60%) of the Medicaid codes he or she has billed during the most recently completed calendar year or, for newly eligible physicians, the prior month.

(iii) The Managed Care Plan shall ensure that increased payments specified in this provision are not provided to physicians delivering primary care services at FQHCs, RHCs or CHDs.

(iv) The Managed Care Plan shall make increased physician payments according to this provision. The Managed Care Plan shall ensure that the full benefit of the payment increase is paid to eligible providers, regardless of the payment amount received by the Managed Care Plan from the Agency.

(v) The Managed Care Plan shall document physician eligibility for any increased payments made under this subsection for each calendar year as

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part of its credentialing information or by the use of a physician self-attestation form as follows:

(a) Enrolled Medicaid providers may use the Agency’s online attestation form and certification process for the Affordable Care Act Primary Care Increase, as specified at http://portal.flmmis.com/FLpublic/default. The Managed Care Plan may not require additional documentation to be submitted to the Managed Care Plan for Medicaid-enrolled physicians who have already self-attested using the Agency’s web-portal process for each calendar year.

(b) For the January 1, 2014, through December 31, 2014, calendar year, the Managed Care Plan shall ensure written notification of the Managed Care Plan’s attestation/eligibility process is given to eligible providers by June 15, 2014, in order to allow physicians time to complete the process. The capitated Managed Care Plan may direct its providers to print out and submit the Agency’s online attestation form, use its own attestation form or use its credentialing information to document Medicaid-registered providers’ eligibility for the increased physician payments.

i. If the Managed Care Plan uses the notification language supplied by the Agency verbatim (except for specified insertions), the Managed Care Plan does not need Agency approval for this notice. If the Managed Care Plan uses the supplied notice language verbatim, the Managed Care Plan shall email AHCA of its intent to do so.

ii. The Managed Care Plan shall complete its initial review of credentialing information from eligible physicians by August 15, 2014.

iii. The Managed Care Plan shall ensure that physicians who complete the Managed Care Plan’s eligibility process or the Agency’s attestation process as specified above by August 15, 2014, will be eligible for the rate increase retroactively up to January 1, 2014. The Managed Care Plan shall ensure that physicians who complete the Managed Care Plan’s eligibility process or the Agency’s attestation process as specified above after August 15, 2014, are eligible for the fee increase on the first day of the month of documented eligibility.

(c) The Managed Care Plan shall retain documentation of how its affected providers met the physician self-attestation and payment eligibility requirements, and make the documentation available to the Agency upon request.

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(vi) The Managed Care Plan shall ensure that payments to eligible providers are limited to the following primary care services, in accordance with the Florida Medicaid Affordable Care Act Fee Schedule:

(a) Evaluation and Management (E&M) codes 99201 through 99499; and

(b) Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474, and their successor codes.

(vii) Notwithstanding the claims payment requirements in Section VIII.D, Claims and Provider Payment, the Managed Care Plan shall ensure physician payments related to this fee increase are made as follows: For dates of service in calendar year 2014, the Managed Care Plan shall ensure payments are paid within sixty (60) days of receipt of the Agency’s supplemental payment to the Managed Care Plan.

(viii) In order to provide accurate data reports of utilization and encounter data for physicians eligible for provider payments, including vaccination administration payments, made to the physician relative to this subsection, the Managed Care Plan shall report utilization of eligible services to the Agency’s Medicaid Program Analysis (MPA) secure file transfer protocol (SFTP) site as follows:

(a) For calendar year 2014, the Managed Care Plan shall submit to the Agency quarterly reports that document the physician’s eligibility and provider payments, including vaccination administration payments, made to the physician relative to this subsection, and as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. The Managed Care Plan shall not include PCP fee increases (differential) in its regular, ongoing encounter data submissions to the Agency (see Section VIII.E., Encounter Data Requirements); and

(b) The Agency will review and evaluate all submissions, and provide feedback to the Managed Care Plan. Evaluation will consider: (1) adherence of submitted data to the format and content requirements as specified by the Agency; (2) consistency between the summary report and the supporting encounter data; (3) the number of submissions required for acceptability of data; and (4) adherence to reporting deadlines. If the Managed Care Plan’s data is unacceptable, the Managed Care Plan shall make corrections and resubmit, potentially resulting in payment delays for eligible physicians and resulting in sanctions and/or liquidated damages to the Managed Care Plan.

(ix) The Managed Care Plan shall submit any documentation as required by the Agency, by the date specified by the Agency, in order to ensure that increased provider payments are made as required by 42 CFR 438.6(c)(5)(vi)(A), to adequately document expenditures eligible for 100% FFP and to support all audit or reconciliation processes.

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(x) The Managed Care Plan shall provide its physicians that have received an increased payment pursuant to this subsection with an explanation of benefits (EOB).

(xi) In accordance with the ACA PCP fee increase provisions of this Attachment, primary care services provided to MediKids are not eligible for this fee increase. Managed Care Plans shall not include such payments in the summary reports and encounter data supporting documentation submissions for the ACA PCP fee increase payments.

(25) Prescribed Drug Services

(a) The Managed Care Plan shall provide those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed drug services shall include all prescription drugs listed in the Agency’s Medicaid Preferred Drug List (PDL). For prescribed drug services under this Contract, the Managed Care Plan shall not negotiate any drug rebates with pharmaceutical manufacturers during the time that the Managed Care Plan is utilizing the Agency’s Medicaid PDL. The Agency will be the sole negotiator of pharmaceutical rebates, and all rebate payments will be made to the Agency. No sooner than the end of the first year of operation the Managed Care Plan may develop a Managed Care Plan-specific PDL for the Agency’s consideration, if requested by the Agency at that time. See s. 409.91195, F.S. and s. 409.912(37), F.S.

(b) The Managed Care Plan shall make available those drugs and dosage forms listed on the Agency’s Medicaid PDL, and shall comply with the following requirements listed in s. 409.912(37)(a), F.S.:

(i) The requirements of s. 409.912(37)(a)1.a. and b., F.S., regarding responding to requests for prior authorization and 72-hour drug supplies;

(ii) The requirements of s. 409.912(37)(a)4., F.S., regarding limiting pharmacy networks;

(iii) The requirements of s. 409.912(37)(a)5., F.S., regarding the use of counterfeit-proof prescription pads;

(iv) The requirements of s. 409.912(37)(a)13., F.S., regarding promoting best practices and ensuring cost-effective prescribing practices; and

(v) The requirements of s. 409.912(37)(a)14., 15., and 16., F.S., regarding prior authorization.

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(c) The Managed Care Plan shall not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the enrollee’s diagnosis, type of illness or condition. The Managed Care Plan may place appropriate limits on prescriptions based on criteria such as medical necessity, or for the purpose of utilization control, provided the Managed Care Plan reasonably expects said limits to achieve the purpose of the prescribed drug services set forth in the Medicaid State Plan.

(d) The Managed Care Plan shall make available those drugs not on the PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other medical documentation is provided. The Managed Care Plan may adopt the Medicaid prior authorization criteria posted on the Agency website, or develop its own criteria. Prior authorization, step-edit therapy protocols for PDL drugs may not be more restrictive than that used by the Agency as indicated in the Florida Statutes, the Florida Administrative Code, the Medicaid State Plan, and those posted on the Agency website.

(e) The Managed Care Plan shall participate in the Medicaid Pharmaceutical and Therapeutics Committee by asking qualified plan administrators (MDs, DOs or pharmacists) to volunteer for committee appointment by the Governor’s Office.

(f) The Managed Care Plan shall ensure that antiretroviral agents and contraceptive drugs and items are not subject to the PDL.

(g) The Managed Care Plan shall notify providers who may prescribe or are currently prescribing a drug that is being deleted from the PDL within thirty (30) days of the effective date of the change.

(h) The Managed Care Plan may delegate any or all functions to one (1) or more PBMs. Before entering into a subcontract, the Managed Care Plan shall obtain the Agency’s prior written approval of the delegation in accordance with Section VIII.B, Subcontracts. In addition, the Managed Care Plan shall work with the Agency’s fiscal agent to ensure that the transfer of accurate and complete Managed Care Plan encounter prescription data is initiated within forty-five (45) days of PBM implementation. The Managed Care Plan acknowledges that the transfer of prescription data is required by federal law (Affordable Care Act) and that the Agency will invoice pharmaceutical manufacturers for federal rebates mandated under federal law, and for supplemental rebates negotiated by the Agency according to s. 409.912(37)(a)(7), F.S. The Managed Care Plan also acknowledges that failure to provide the necessary data to the Agency will result in immediate action by the Agency that may include (but not be limited to) sanctions, application of liquidated damages, or reduction of capitation payments in the amount of estimated combined federal and supplemental rebates. If there is a dispute between the Agency and a drug manufacturer regarding federal drug rebates, the Managed Care Plan shall assist the Agency in dispute resolution by providing information regarding claims and provider details. Failure to collect drug rebates due to the Managed Care Plan’s failure to assist the Agency will result in the Agency’s recouping from the Managed Care Plan any determined uncollected rebates.

(i) The Managed Care Plan shall continue the medication prescribed to the enrollee in a state mental health treatment facility for at least ninety (90) days after the

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facility discharges the enrollee, unless the Managed Care Plan's prescribing psychiatrist, in consultation and agreement with the facility's prescribing physician, determines that the medications:

(i) Are not medically necessary; or

(ii) Are potentially harmful to the enrollee.

(j) The Managed Care Plan shall provide smoking cessation medications consistent with the Agency PDL to enrollees who want to quit smoking.

(i) The Managed Care Plan shall not cover barbiturates and benzodiazepines for dually eligible Medicare and Medicaid enrollees.

(k) If the Managed Care Plan has authorization requirements for prescribed drug services, the Managed Care Plan shall comply with all aspects of the Settlement Agreement to Hernandez, et al v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA). An HSA situation arises when an enrollee attempts to fill a prescription at a participating pharmacy location and is unable to receive the prescription as a result of:

(i) An unreasonable delay in filling the prescription;

(ii) A denial of the prescription;

(iii) The reduction of a prescribed good or service; and/or

(iv) The expiration of a prescription.

(l) The Managed Care Plan shall ensure that its enrollees are receiving the functional equivalent of those goods and services received by fee-for-service Medicaid recipients in accordance with the HSA..

(m) The Managed Care Plan shall maintain a log of all correspondence and communications from enrollees relating to the HSA ombudsman process. The ombudsman log shall contain, at a minimum, the enrollee’s name, address and telephone number and any other contact information, the reason for the participating pharmacy location’s denial (an unreasonable delay in filling a prescription, a denial of a prescription and/or the termination of a prescription), the pharmacy’s name (and store number, if applicable), the date of the call, a detailed explanation of the final resolution, and the name of the prescribed good or service. The ombudsman log report shall be submitted quarterly to the Agency, as required in Section XIV, Reporting Requirements, and specified in the Managed Care Plan Report Guide.

(n) The Managed Care Plan’s enrollees are third party beneficiaries for this section of the Contract.

(o) The Managed Care Plan shall conduct annual HSA surveys of no less than five percent (5%) of all participating pharmacy locations to ensure compliance with the HSA.

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(i) The Managed Care Plan may survey less than five percent (5%), with written approval from the Agency, if the Managed Care Plan can show that the number of participating pharmacies it surveys is a statistically significant sample that adequately represents the pharmacies that have contracted with the Managed Care Plan to provide pharmacy services.

(ii) The Managed Care Plan shall not include in the HSA survey any participating pharmacy location that the Managed Care Plan found to be in complete compliance with the HSA requirements within the past twelve (12) months.

(iii) The Managed Care Plan shall require all participating pharmacy locations that fail any aspect of the HSA survey to undergo mandatory training within six (6) months and then be re-evaluated within one (1) month of the training to ensure that the pharmacy location is in compliance with the HSA.

(iv) The Managed Care Plan shall ensure that it complies with all aspects and surveying requirements set forth in Policy Transmittal 06-01, Hernandez Settlement Requirements, an electronic copy of which can be found at:

http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/med_prov_0912.shtml

(v) The Managed Care Plan shall submit a report annually, by August 1 of each Contract year to the Agency, providing survey results following requirements in Section XIV, Reporting Requirements and the Managed Care Plan Report Guide.

(p) The Managed Care Plan shall offer training to all new and existing participating pharmacy locations about the HSA requirements.

(q) The Managed Care Plan shall ensure its PBM provides the following electronic message alerting the pharmacist to provide Medicaid recipients with the Hernandez notice/pamphlet when coverage is rejected due to the drug not being on the PDL:

Non-preferred drug; Contact provider for change to preferred drug or to obtain prior authorization. Give Medicaid pamphlet if not corrected.

(r) The Managed Care Plan shall cover a brand-name drug if the prescriber:

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(i) Writes in his/her own handwriting on the valid prescription that the “Brand Name is Medically Necessary” (pursuant to s. 465.025, F.S.); and

(ii) Submits a completed “Multisource Drug and Miscellaneous Prior Authorization” form to the Managed Care Plan indicating that the enrollee has had an adverse reaction to a generic drug or has had, in the prescriber’s medical opinion, better results when taking the brand-name drug.

(s) Hemophilia factor-related drugs identified by the Agency for distribution through the Comprehensive Hemophilia Disease Management Program are reimbursed on a fee-for-service basis. During operation of the Comprehensive Hemophilia Disease Management Program, the Managed Care Plan shall coordinate the care of its enrollees with Agency-approved organizations and shall not be responsible for the distribution of hemophilia-related drugs.

(t) The Managed Care Plan may have a pharmacy lock-in program that conforms to the requirements in the Medicaid Prescribed Drug Services Coverage, Limitations and Reimbursement Handbook, provided it is submitted in writing and approved by the Agency in advance of implementation.

(u) The Managed Care Plan shall require that prescriptions for psychotropic medication prescribed for an enrollee under the age of thirteen (13) be accompanied by the express written and informed consent of the enrollee’s parent or legal guardian. Psychotropic (psychotherapeutic) medications include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity disorder (ADHDS) medications (stimulants and non-stimulants) are not included at this time. In accordance with s. 409.912(51), F.S., the Managed Care Plan shall ensure the following requirements are met:

(i) The prescriber must document the consent in the child’s medical record and provide the pharmacy with a signed attestation of the consent with the prescription.

(ii) The prescriber must ensure completion of an appropriate attestation form.

(iii) Sample consent/attestation forms that may be used and pharmacies may receive are located at the following link:

http://ahca.myflorida.com/Medicaid/Prescribed_Drug/med_resource.shtml

(iv) The completed form must be filed with the prescription (hardcopy of imaged) in the pharmacy and held for audit purposes for a minimum of six (6) years.

(v) Pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.

(vi) Every new prescription will require a new informed consent form.

(vii) The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from birth through age seventeen (17).

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(v) The Managed Care Plan shall design and implement a drug utilization review (DUR) program designed to encourage coordination between an enrollee’s primary care provider and a prescriber of a psychotropic or similar prescription drug for behavioral health problems. The Managed Care Plan’s DUR program shall identify those medications for other serious medical conditions (such as hypertension, diabetes, neurological disorders, or cardiac problems), where this is a significant risk to the enrollee posed by potential drug interactions between drugs for these conditions and behavioral-related drugs. After the Managed Care Plan identifies the potential for such problems, the Managed Care Plan’s DUR program shall notify all related prescribers that certain drugs may be contra-indicated due to the potential for drug interactions and shall encourage the prescribers to coordinate their care. Notice may be provided electronically or via mail, or by telephonic or direct consultation, as the Managed Care Plan deems appropriate.

(26) Renal Dialysis Services

(a) The Managed Care Plan shall provide renal dialysis services. The services include in-center hemodialysis, in-center administration of the injectable medication Erythropoietin (Epogen or EPO), other Agency approved drugs, and home peritoneal dialysis. Dialysis is a process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. There are two types of renal dialysis procedures in common clinical usage: hemodialysis and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are acceptable modes of treatment for ESRD under Medicaid. Hemodialysis is a process by which blood passes through an artificial kidney machine and the waste products diffuse across a manmade membrane into a bath solution known as dialysate, after which the cleansed blood is returned to the patient’s body. Hemodialysis is accomplished usually in three to four hour sessions, three times a week. Peritoneal dialysis is a process by which waste products pass from the patient’s body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically. The dialysis treatment includes routine laboratory tests, dialysis-related supplies, and ancillary and parenteral items. These services must be provided under the supervision of a physician licensed to practice allopathic or osteopathic medicine in Florida.

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(b) The Managed Care Plan shall comply with provisions of the Medicaid Freestanding Dialysis Center Coverage and Limitations Handbook and Medicaid Hospital Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Freestanding Dialysis Center Coverage and Limitations Handbook and Medicaid Hospital Services Coverage and Limitations Handbook.

(27) Therapy Services

(a) The Managed Care Plan shall provide physical therapy services. Physical therapy (PT) is a specifically prescribed program to develop, improve or restore neuro-muscular or sensory-motor function, relieve pain, or control postural deviations to attain maximum performance. PT services include evaluation and treatment of range-of motion, muscle strength, functional abilities and the use of adaptive and therapeutic equipment. Examples are rehabilitation through exercise, massage, the use of equipment and habilitation through therapeutic activities.

(b) The Managed Care Plan shall provide occupational therapy services. Occupational therapy (OT) is the provision of services that addresses the developmental or functional needs of a child related to the performance of self-help skills; adaptive behavior; and sensory, motor and postural development. OT services include evaluation and treatment to prevent or correct physical and emotional deficits or to minimize the disabling effect of these deficits. Examples are perceptual motor activities, exercises to enhance functional performance, kinetic movement activities, guidance in the use of adaptive equipment and other techniques related to improving motor development.

(c) The Managed Care Plan shall provide speech-language pathology services. Speech-language pathology (SLP) services involve the evaluation and treatment of speech-language disorders. Services include the evaluation and treatment of disorders of verbal and written language, articulation, voice, fluency, phonology, mastication, deglutition, cognition, communication (including the pragmatics of verbal communication), auditory processing, visual processing, memory, comprehension and interactive communication as well as the use of instrumentation, techniques, and strategies to remediate and enhance the recipient’s communication needs, when appropriate. Services also include the evaluation and treatment of oral pharyngeal and laryngeal sensorimotor competencies. Examples are techniques and instrumentation to evaluate the recipient’s condition, remedial procedures to maximize the recipient’s oral motor functions and communication via augmentative and alternative communication (AAC) systems.

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(d) The Managed Care Plan shall provide respiratory therapy services. respiratory therapy (RT) is treatment of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system. RT services include evaluation and treatment related to pulmonary dysfunction. Examples are ventilatory support; therapeutic and diagnostic use of medical gases; respiratory rehabilitation; management of life support systems and bronchopulmonary drainage; breathing exercises and chest physiotherapy.

(e) The Managed Care Plan shall comply with provisions of the Medicaid Therapy Services Coverage and Limitations Handbook and Medicaid Hospital Services Coverage and Limitations Handbook. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Therapy Services Coverage and Limitations Handbook and Medicaid Hospital Services Coverage and Limitations Handbook.

(28) Transportation Services

(a) The Managed Care Plan shall provide transportation services, including emergency transportation, for its enrollees who have no other means of transportation available to any covered service, including enhanced benefits.

(b) The Managed Care Plan shall comply with provisions of the Medicaid Transportation Services Coverage and Limitations Handbooks. In any instance when compliance conflicts with the terms of this Contract, the Contract prevails. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those in the Medicaid Transportation Services Coverage and Limitations Handbooks.

(c) The Managed Care Plan is not obligated to follow the requirements of the Commission for the Transportation Disadvantaged (CTD) or the Transportation Coordinating Boards as set forth in Chapter 427, F.S., unless the Managed Care Plan has chosen to coordinate services with the CTD.

(d) The Managed Care Plan may provide transportation services directly through its own network of transportation providers or through a provider contract relationship, which may include the Commission for the Transportation Disadvantaged. In either case, the Managed Care Plan is responsible for monitoring provision of services to its enrollees.

(e) The Managed Care Plan shall:

(i) Ensure that all transportation providers comply with standards set forth in Chapter 427, F.S., and Rules 41-2 and 14-90, F.A.C. These standards include drug and alcohol testing, safety standards, driver accountability, and driver conduct;

(ii) Ensure that all transportation providers maintain vehicles and equipment in accordance with State and federal safety standards and the manufacturers’

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mechanical operating and maintenance standards for any and all vehicles used for transportation of Medicaid recipients;

(iii) Ensure that all transportation providers comply with applicable state and federal laws, including, but not limited to, the Americans with Disabilities Act (ADA) and the Federal Transit Administration (FTA) regulations;

(iv) Ensure that transportation providers immediately remove from service any vehicle that does not meet the Florida Department of Highway Safety and Motor Vehicles licensing requirements, safety standards, ADA regulations, or Contract requirements and re-inspect the vehicle before it is eligible to provide transportation services for Medicaid recipients under this Contract. Vehicles shall not carry more passengers than the vehicle was designed to carry. All lift-equipped vehicles must comply with ADA regulations;

(v) Ensure transportation services meet the needs of its enrollees including use of multiload vehicles, public transportation, wheelchair vehicles, stretcher vehicles, private volunteer transport, over-the-road bus service, or, where applicable, commercial air carrier transport;

(vi) Collect and submit encounter data, as required elsewhere in this Contract;

(vii) Ensure a transportation network of sufficient size so that failure of any one component will not impede the ability to provide the services required in this Contract;

(viii) Ensure that any subcontracts for transportation services meet the subcontracting requirements detailed in Section VIII.B., Subcontracts;

(ix) Maintain policies and procedures, consistent with 42 CFR 438.12 to ensure there is no discrimination in serving high-risk populations or people with conditions that require costly transportation; and

(x) Ensure all transportation providers maintain sufficient liability insurance to meet requirements of Florida law.

(f) The Managed Care Plan shall be responsible for the cost of transporting an enrollee from a non-participating facility or hospital to a participating facility or hospital if the reason for transport is solely for the Managed Care Plan's convenience.

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(g) The Managed Care Plan shall approve and process claims for transportation services in accordance with the requirements set forth in this Contract.

(h) If the Managed Care Plan subcontracts for transportation services, it shall provide a copy of the model subcontract to the Agency for approval before use.

(i) Before providing transportation services, the Managed Care Plan shall provide the Agency a copy of its policies and procedures for approval relating to the following:

(i) How the Managed Care Plan will determine eligibility for each enrollee and what type of transportation to provide that enrollee;

(ii) The Managed Care Plan's procedure for providing prior authorization to enrollees requesting transportation services;

(iii) How the Managed Care Plan will review transportation providers to prevent and/or identify those who falsify encounter or service reports, overstate reports or upcode service levels, or commit any form of fraud or abuse as defined in s. 409.913, F.S.;

(iv) How the Managed Care Plan will deal with providers who alter, falsify or destroy records before the end of the retention period; make false statements about credentials; misrepresent medical information to justify referrals; fail to provide scheduled transportation; or charge enrollees for covered services; and

(v) How the Managed Care Plan will provide transportation services outside its region.

(j) The Managed Care Plan shall report within two (2) business days of the occurrence, in writing to the Agency, any transportation-related adverse or untoward incident (see s. 641.55, F.S.). The Managed Care Plan shall also report, immediately upon identification, in writing to MPI, all instances of suspected enrollee or transportation services provider fraud or abuse as defined in s. 409.913, F.S. See also Section VIII.F., Fraud and Abuse Prevention.

(k) The Managed Care Plan shall ensure compliance with the minimum liability insurance requirement of $200,000 per person and $300,000 per incident for all transportation services purchased or provided for the transportation disadvantaged through the Managed Care Plan. (See s. 768.28(5), F.S.) The Managed Care Plan shall indemnify and hold harmless the local, state, and federal governments and their entities and the Agency from any liabilities arising out of or due to an accident or negligence on the part of the Managed Care Plan and/or all transportation providers under contract to the Managed Care Plan.

(l) The Managed Care Plan shall ensure adequate seating for paratransit services for each enrollee and escort, child, or personal care attendant, and shall ensure that the vehicle meets the following requirements and does not transport more passengers than the registered passenger seating capacity in a vehicle at any time:

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(i) Enrollee property that can be carried by the passenger and/or driver, and can be stowed safely on the vehicle, shall be transported with the passenger at no additional charge. The driver shall provide transportation of the following items, as applicable, within the capabilities of the vehicle:

(a) Wheelchairs;

(b) Child seats;

(c) Stretchers;

(d) Secured oxygen;

(e) Personal assistive devices; and/or

(f) Intravenous devices.

(ii) Each vehicle shall have posted inside the Managed Care Plan’s toll-free telephone number for enrollee complaints.

(iii) The interior of all vehicles shall be free from dirt, grime, oil, trash, torn upholstery, damaged or broken seats, protruding metal or other objects or materials which could soil items placed in the vehicle or cause discomfort to enrollees.

(iv) The transportation provider shall provide the enrollee with boarding assistance, if necessary or requested, to the seating portion of the vehicle. Such assistance shall include, but not be limited to, opening the vehicle door, fastening the seat belt or wheelchair securing devices, storage of mobility assistive devices and closing the vehicle door. In the door-through-door paratransit service category, the driver shall open and close doors to buildings, except in situations in which assistance in opening and/or closing building doors would not be safe for passengers remaining in the vehicle. The driver shall provide assisted access in a dignified manner.

(v) Smoking, eating and drinking are prohibited in any vehicle, except in cases in which, as a medical necessity, the enrollee requires fluids or sustenance during transport.

(vi) All vehicles must be equipped with two-way communications, in good working order and audible to the driver at all times, by which to communicate with the transportation services hub or base of operations.

(vii) All vehicles must have working air conditioners and heaters.

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(m) Vehicle transfer points shall provide shelter, security, and safety of enrollees.

(n) The transportation provider shall maintain a passenger/trip database for each enrollee it transports.

(o) The Managed Care Plan shall establish a minimum twenty-four (24) hour advance notification policy to obtain transportation services, and the Managed Care Plan shall communicate that policy to its enrollees and transportation providers.

(p) The Managed Care Plan shall establish enrollee pick-up windows and communicate those timeframes to enrollees and transportation providers.

(q) The Managed Care Plan shall submit data on transportation performance measures as defined by the Agency and as specified in the Agency’s Performance Measures Specifications Manual. The Managed Care Plan shall report on those measures to the Agency as specified in Section VII, Quality and Utilization Management, Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

(r) The Managed Care Plan shall provide an annual attestation to the Agency by January 1 of each Contract year that it is in full compliance with the policies and procedures relating to transportation services, and that all vehicles used for transportation services have received annual safety inspections.

(s) The Managed Care Plan shall provide an annual attestation to the Agency by January 1 of each Contract Year that all drivers providing transportation services have passed background checks and meet all qualifications specified in law and in rule.

2. Customized Benefits

a. The Managed Care Plan may customize benefit packages for non-pregnant adults, vary cost-sharing provisions, and provide coverage for additional services.

b. Submitted PETs must comply with instructions available from the Agency. The Agency shall evaluate the Managed Care Plan’s CBP for actuarial equivalency and sufficiency of benefits before approving the CBP. Actuarial equivalency is tested by using a PET that:

(1) Compares the value of the level of benefits in the proposed package to the value of the contracted benefit package for the average member of the covered population;

(2) Ensures that the overall level of benefits is appropriate; and

(3) Compares the proposed CBP to state-established standards. The standards are based on the covered population’s historical use of Medicaid State Plan services. These standards are used to ensure that the proposed CBP is adequate to cover the needs of the vast majority of the enrollees.

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c. If, in its CBP, the Managed Care Plan limits a service to a maximum annual dollar value, the Managed Care Plan must calculate the dollar value of the service using the Medicaid fee schedule.

d. The CBPs may change on a Contract year basis and only if approved by the Agency in writing. The Managed Care Plan shall submit to the Agency a PET for its proposed CBP for evaluation of actuarial equivalency and sufficiency standards no later than the date established by the Agency each year.

e. The Managed Care Plan shall send letters of notification to enrollees regarding exhaustion of benefits for services restricted by unit amount if the amount is more restrictive than Medicaid. The Managed Care Plan shall send an exhaustion of benefits letter for any service restricted by a dollar amount. The Managed Care Plan shall implement said letters upon the written approval of the Agency. The letters of notification include the following:

(1) A letter notifying an enrollee when he/she has reached fifty percent (50%) of any maximum annual dollar limit established by the Managed Care Plan for a benefit;

(2) A follow-up letter notifying the enrollee when he/she has reached seventy-five (75%) of any maximum annual dollar limit established by the Managed Care Plan for a benefit; and

(3) A final letter notifying the enrollee that he/she has reached the maximum dollar limit established by the Managed Care Plan for a benefit.

f. The Managed Care Plan shall submit the Customized Benefit Notifications Report to the Agency in accordance with Section XIV, Reporting Requirements and the Managed Care Plan Report Guide.

B. Expanded Benefits

There are no additional expanded benefits provisions unique to the MMA managed care program.

C. Excluded Services

There are no additional excluded services provisions unique to the MMA managed care program.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

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D. Coverage Provisions

1. Primary Care Provider Initiatives

a. Pursuant to s. 409.973(4), F.S., the Managed Care Plan shall establish a program to encourage enrollees to establish a relationship with their PCP.

b. This program shall provide information to each enrollee on the importance of selecting a PCP and the procedure for selecting a PCP (see s. 409.973(4), F.S.).

c. The Managed Care Plan shall offer each enrollee a choice of PCPs. After making a choice, each enrollee shall have a single or group PCP.

d. The Managed Care Plan shall allow pregnant enrollees to choose Managed Care Plan obstetricians as their PCPs to the extent that the obstetrician is willing to participate as a PCP, as specified in Section VI, Provider Network.

e. If the enrollee has not selected a provider for a newborn, the Managed Care Plan shall assign a pediatrician or other appropriate PCP to all pregnant enrollees for the care of their newborn babies no later than the beginning of the last trimester of gestation.

f. The Managed Care Plan shall assign a PCP to those enrollees who did not choose a PCP at the time of managed care plan selection. The Managed Care Plan shall take into consideration the enrollee's last PCP (if the PCP is known and available in the Managed Care Plan's network), closest PCP to the enrollee's ZIP code location, keeping children/adolescents within the same family together, enrollee’s age (adults versus children/adolescents), and PCP performance measures. If the language and/or cultural needs of the enrollee are known to the Managed Care Plan, the Managed Care Plan shall assign the enrollee to a PCP who is or has office staff who are linguistically and culturally competent to communicate with the enrollee.

g. The Managed Care Plan shall permit enrollees to request to change PCPs at any time. If the enrollee request is not received by the Managed Care Plan’s established monthly cut-off date for system processing, the PCP change will be effective the first day of the next month.

h. The Managed Care Plan shall assign all enrollees that are reinstated after a temporary loss of eligibility to the PCP who was treating them prior to loss of eligibility, unless the enrollee specifically requests another PCP, the PCP no longer participates in the Managed Care Plan or is at capacity.

i. Pursuant to s. 409.973(4), F.S., the Managed Care Plan shall report on the number of enrollees assigned to each participating PCP and the number of enrollees who have not had an appointment with their PCP within their first year of enrollment as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

j. Pursuant to s. 409.973(4), F.S., the Managed Care Plan shall report on the number of emergency room visits by enrollees who have not had at least one appointment

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with their PCP as specified in the Managed Care Plan Report Guide and as referenced in Section, XIV, Reporting Requirements.

2. Enrollee Screening and Education

a. Within thirty (30) days of enrollment, the Managed Care Plan shall notify enrollees of, and ensure the availability of, a screening for all enrollees known to be pregnant or who advise the Managed Care Plan that they may be pregnant. The Managed Care Plan shall refer enrollees who are, or may be, pregnant to a provider to obtain appropriate care.

b. The Managed Care Plan shall use the enrollee’s health risk assessment and/or released medical/case records to identify enrollees who have not received CHCUP screenings in accordance with the Agency-approved periodicity schedule.

c. The Managed Care Plan shall develop and implement an education and outreach program to increase the number of eligible enrollees receiving CHCUP screenings. This program shall include, at a minimum, the following:

(1) The Managed Care Plan shall have a tracking system to identify enrollees for whom a screening is due or overdue;

(2) The Managed Care Plan shall systematically send reminder notices to enrollees before a screening is due. The notice shall include an offer to assist with scheduling and transportation;

(3) If the Managed Care Plan’s CHCUP screening rate is below eighty percent (80%), the Managed Care Plan shall call (which may include automated calls) all new enrollees under the age of twenty-one (21) to inform them of CHCUP services and offer to assist with scheduling and transportation;

(4) The Managed Care Plan shall have a process for following up with enrollees who do not get timely screenings. This shall include contacting, twice if necessary, any enrollee more than two (2) months behind in the Agency-approved periodicity screening schedule to urge those enrollees, or their legal representatives, to make an appointment with the enrollee’s PCP for a screening visit and offering to assist with scheduling and transportation. The Managed Care Plan shall document all outreach education attempts. For this subsection “contact” is defined as mailing a notice to or calling an enrollee at the most recent address or telephone number available; and

(5) The Managed Care Plan shall provide enrollee education and outreach in community settings.

d. The Managed Care Plan shall develop and implement an education outreach program to encourage wellness visits to prevent illness or exacerbations of chronic illness.

e. The Managed Care Plan shall take immediate action to address any identified urgent medical needs. “Urgent medical needs” means any sudden or unforeseen situation that requires immediate action to prevent hospitalization or nursing facility placement. Examples include hospitalization of spouse or caregiver or increased impairment of

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an enrollee living alone who suddenly cannot manage basic needs without immediate help, hospitalization or nursing home placement.

(1) Pursuant to s. 409.966(3)(c)2, F.S., the Managed Care Plan may have program for recognizing patient centered medical homes (PCMHs) and providing increased compensation for recognized PCMHs, as defined by the Managed Care Plan. If the Managed Care Plan has a patient centered medical home program, it shall submit its policies and procedures for such program to the Agency, which shall include recognition standards and increased compensation protocols developed by the Managed Care Plan for the program.

(2) The Managed Care Plan shall report to the Agency regarding providers that are recognized by the Managed Care Plan as PCMHs in accordance with Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

3. New Enrollee Procedures

a. The Managed Care Plan shall contact each new enrollee at least twice, if necessary, within ninety (90) days of the enrollee’s enrollment to offer to schedule the enrollee’s initial appointment with the PCP Pursuant to s. 409.973(4)(a), F.S., for enrollees who enroll before December 31, 2015, the appointment should be scheduled within six (6) months after enrollment in the Managed Care Plan. For enrollees who enroll after December 31, 2015, the appointment should be scheduled within thirty (30) days of enrollment. This appointment is to obtain an initial health assessment including a CHCUP screening, if applicable. For this subsection “contact” is defined as mailing a notice to or telephoning an enrollee at the most recent address or telephone number available.

b. Within thirty (30) days of enrollment, the Managed Care Plan shall ask the enrollee to authorize release of the medical/case and behavioral health clinical records to the new PCP or other appropriate provider and shall assist by requesting those records from the enrollee’s previous provider(s).

c. The Managed Care Plan shall honor any written documentation of prior authorization of ongoing covered services for a period of sixty (60) days after the effective date of enrollment, or until the enrollee's PCP or behavioral health provider (as applicable to medical care or behavioral health care services, respectively) reviews the enrollee's treatment plan, whichever comes first.

d. For all enrollees, written documentation of prior authorization of ongoing medical and behavioral health services includes the following, provided that the services were prearranged prior to enrollment with the Managed Care Plan:

(1) Prior existing orders;

(2) Provider appointments, e.g., dental appointments, surgeries, etc.;

(3) Prescriptions (including prescriptions at non-participating pharmacies); and

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(4) Behavioral health services.

e. The Managed Care Plan shall not delay service authorization if written documentation is not available in a timely manner. However, the Managed Care Plan is not required to approve claims for which it has received no written documentation.

4. Telemedicine Coverage Provisions

a. The Managed Care Plan may use telemedicine as specified in this Contract and as specified in the Medicaid State Plan for the following services:

(1) Behavioral Health Services;

(2) Dental Services; and

(3) Physician Services.

b. The Managed Care Plan may utilize telemedicine for other covered services, as approved by the Agency.

c. When providing services through telemedicine, the Managed Care Plan shall ensure:

(1) The equipment used meets the definition of telecommunication equipment as defined in this Contract. See hub site, spoke site and telecommunication equipment definitio

ns in Section I, Definitions and Acronyms;

(2) The telecommunication equipment and telemedicine operations meet the technical safeguards required by 45 CFR 164.312, where applicable;

(3) Telemedicine services are provided only to enrollees in a provider office setting;

(4) The Managed Care Plan’s providers using telemedicine comply with HIPAA and other state and federal laws pertaining to patient privacy;

(5) The Managed Care Plan’s telemedicine policies and procedures comply with the requirements in this Contract; and

(6) Provider training regarding the telemedicine requirements in this Contract.

d. When telemedicine services are provided, the Managed Care Plan shall ensure that the enrollee’s medical/case record includes documentation, as applicable.

e. The following interactions are not Medicaid reimbursable telemedicine services:

(1) Telephone conversations;

(2) Video cell phone interactions;

(3) Electronic mail messages;

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(4) Facsimile transmissions;

(5) Telecommunication with the enrollee at a location other than the spoke site; and

(6) “Store and forward” visits and consultations that are transmitted after the enrollee or provider is no longer available.

f. Medicaid does not reimburse for the costs or fees of any of the equipment necessary to provide services through telemedicine, including telecommunication equipment and services.

g. Only certain providers that meet the requirements in Section VI, Provider Network, are eligible to provide services through telemedicine at the spoke and hub sites.

h. The Managed Care Plan shall ensure the enrollee has a choice of whether to access services through a face-to-face or telemedicine encounter, and shall document such choice in the enrollee’s medical/case record.

5. Protective Custody Coverage Provisions

a. The Managed Care Plan shall provide a physical screening within seventy-two (72) hours, or immediately if required, for all enrolled children/adolescents taken into protective custody, emergency shelter or the foster care program by DCF. See 65C-29.008, F.A.C.

b. The Managed Care Plan shall provide these required examinations without requiring prior authorization, or, if a non-participating provider is utilized by DCF, approve and process the out-of-network claim.

c. For all CHCUP screenings for children/adolescents whose enrollment and Medicaid eligibility are undetermined at the time of entry into the care and custody of DCF, and who are later determined to be enrollees at the time the examinations took place, the Managed Care Plan shall approve and process the claims.

E. Care Coordination/Case Management

1. Behavioral Health Coverage and Coordination in Long-Term Care Settings

a. The Managed Care Plan shall retain responsibility for provision of medically necessary behavioral health evaluation and treatment services to enrollees, regardless of setting, including in the community, a medical facility, an assisted-living facility, or a nursing facility. Provision of services in long-term care settings will require coordination with other entities including LTC Managed Care Plans and providers, Medicare plans and providers, and state-funded programs and services.

b. In cooperation with the administration and/or treatment providers associated with the other plans, settings or agencies, the Managed Care Plan shall coordinate behavioral health services consistent with the care coordination requirements established in Section V.D.2. Specific responsibilities of the Managed Care Plan as it relates to coordinating with other entities include:

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(1) Psychiatric Evaluations and Treatment for Enrollees Applying for Nursing Facility Admission: The Managed Care Plan shall, upon request from the DCF offices, promptly arrange for and authorize psychiatric evaluations for enrollees who are applying for admission to a nursing facility pursuant to OBRA 1987, and who, on the basis of a screening conducted by Comprehensive Assessment and Review for Long-Term Care Services (CARES) workers, are thought to need behavioral health treatment. The examination shall be adequate to determine the need for “specialized treatment” under OBRA. Evaluations must be completed within five (5) business days from the time the request from the DCF office is received. Regulations have been interpreted by the state to permit any of the mental health professionals listed in s. 394.455, F.S., to make the observations preparatory to the evaluation, although a psychiatrist must sign such evaluations. The Managed Care Plan will not be responsible for resident reviews as a result of a pre-admission screening and resident review (PASRR) evaluation. If the psychiatric evaluation of an enrollee indicates covered behavioral health services are medically necessary, and the enrollee is subsequently admitted to a nursing facility, the Managed Care Plan will retain responsibility for provision or those behavioral health services to enrollee in the nursing facility.

(2) Assessment and Treatment of Mental Health Residents Who Reside in Assisted Living Facilities (ALFs) That Hold a Limited Mental Health License: The Managed Care Plan shall develop and implement a plan to ensure compliance with s, 394.4574, F.S., related to behavioral health services provided to residents of licensed assisted living facilities that hold a limited mental health license.

c. The Managed Care Plan shall ensure that a cooperative agreement, as defined in s. 429.02, F.S., is developed by the ALF administrator and the Managed Care Plan’s designated care coordinator/case manager for enrollees that are residents of an ALF and qualify as a mental health resident. The Managed Care Plan must ensure that appropriate assessment services are provided to enrollees and that medically necessary behavioral health services, including psychiatric medication and access to drop-in centers and clubhouses, are available to all enrollees who meet criteria as a mental health resident and reside in this type of setting.

d. A community living support plan, as defined in Section I, Definitions and Acronyms, shall be developed for each enrollee who is a resident of an ALF, and it must be updated annually. The Managed Care Plan shall ensure that its designated care coordinator/case manager is responsible for ensuring that the community living support plan is implemented as written.

e. Upon request from an ALF, the Managed Care Plan shall provide procedures for the ALF to follow should an emergent condition arise with an enrollee that resides at the ALF (see s. 409.912(35), F.S.).

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2. Enhanced Care Coordination for Enrollees under Age 21 Receiving Skilled Nursing facility or Private Duty Nursing Services

a. The Managed Care Plan shall implement enhanced care coordination processes for medically complex and medically fragile enrollees under the age of 21 who are receiving services in a skilled nursing facility or are receiving private duty nursing services in their family home or other community based setting.

b. The Managed Care Plan shall maintain written protocols for the care coordination of medically complex and medically fragile enrollees, as described in sub-item a., above, which shall include:

(1) The Managed Care Plan shall assign a care coordinator to all enrollees meeting the criteria described in sub-item a., above. The Managed Care Plan shall maintain documentation of an enrollee or their parent or legal guardian’s rejection of care coordination services.

(2) The Managed Care Plan shall utilize care coordinators who possess the following qualifications:

(a) State of Florida licensed registered nurse with at least two (2) years of pediatric experience;

(b) State of Florida licensed practical nurse with four (4) years of pediatric experience; or

(c) Master’s degree in social work with at least one (1) year of related professional experience.

(3) The Managed Care Plan shall ensure that care coordinator caseloads do not exceed a ratio of forty (40) enrollees to one care coordinator for enrollees receiving private duty nursing services in their family home or other community based setting and no more than a ratio of fifteen (15) enrollees to one (1) care coordinator for enrollees who are receiving services in a skilled nursing facility.

(4) The Managed Care Plan shall ensure that the care coordinator maintains monthly (or more frequently, if needed) contact with the enrollee and the enrollee's parent or legal guardian. The contact shall be face-to-face or telephonic. The Managed Care Plan shall maintain documentation in the enrollee’s record of any contacts made, including whether such attempts were successful in reaching the enrollee or the parent or legal guardian.

(5) The Managed Care Plan shall convene a multidisciplinary team (MDT) every six (6) months to provide a comprehensive review of the services and supports that the enrollee needs and to authorize any Medicaid reimbursable services that are prescribed for the enrollee (e.g., private duty nursing, therapy services, etc.). The MDT shall meet more frequently, if needed, based on any changes in the enrollee’s medical condition. The MDT meeting shall include at a minimum: the enrollee’s care coordinator, the enrollee (if able), the enrollee’s parent or legal guardian, and other health care professionals involved in that enrollee’s care. The MDT shall

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also develop a person centered individualized service plan that reflects the services and supports that the enrollee needs.

(6) The Managed Care Plan shall convene an MDT meeting one year prior to an enrollee turning the age of twenty-one (21) to discuss the services and supports that the enrollee will need after turning twenty-one (21). If the services are not covered by Medicaid, the Managed Care Plan shall inform the enrollee or their representative of any community programs or home and community based waiver options that may be able to meet the needs and make the necessary referrals, as needed.

c. The Managed Care Plan shall maintain written protocols that address the transition/discharge planning process for medically complex and medically fragile enrollees who are receiving services in a skilled nursing facility. The Managed Care Plan shall:

(1) Ensure that transition planning begins upon admission to a skilled nursing facility. In those cases where the enrollee has been residing a skilled nursing facility prior to enrollment in the Managed Care Plan, the Managed Care Plan shall begin the transition planning process upon enrollment in the Managed Care Plan.

(2) Convene an MDT meeting focused specifically on transition planning to proactively consider placement alternatives and offer such opportunities to the enrollee and his or her parent or legal guardian. This transition planning meeting shall occur every three (3) months until the enrollee is transitioned home or to another community based setting.

(3) Develop a final written transition plan within thirty (30) days prior to discharge that includes all of the services and supports that the enrollee needs to successfully reside in the community.

(4) Maintain contact with the enrollee and his or her parent or legal guardian at least two (2) times a month during the first six (6) months after discharge from the skilled nursing facility. If agreed to by the parent or legal guardian, at least one of these contacts must be face-to-face. After this six (6) month transition period, the Managed Care Plan shall continue to maintain monthly contact with the enrollee and his or her parent or legal guardian.

3. Healthy Behaviors Program

a. Pursuant to s. 409.973(3), F.S., the Managed Care Plan shall establish and maintain programs to encourage and reward healthy behaviors. At a minimum, the Managed Care Plan must establish a medically approved smoking cessation program, a medically directed weight loss program, and a medically approved alcohol or substance abuse recovery program. The Managed Care Plan must identify enrollees who smoke, are morbidly obese, or are diagnosed with alcohol or substance abuse in order to establish written agreements to secure the enrollees' commitment to participation in these programs.

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b. The Managed Care Plan shall receive written approval of its healthy behavior program from the Agency before implementing the program. The Managed Care Plan’s program shall include a detailed description of the program, including the goals of the program, how targeted enrollees will be identified, the interventions, rewards for or incentives to participate, research to support the effectiveness of the program, and evidence that the program is medically approved or directed, as applicable. Programs administered by the Managed Care Plan must comply with all applicable laws, including fraud and abuse laws that fall within the purview of the United States Department of Health and Human Services, Office of Inspector General (OIG). The Managed Care Plan is encouraged to seek an advisory opinion from OIG once the specifics of its Healthy Behaviors programs are determined.

c. The Managed Care Plan shall make all programs, including incentives and rewards available to all enrollees and shall not use incentives or rewards to direct individuals to select a particular provider.

d. The Managed Care Plan may inform enrollees, once they are enrolled, about its healthy behavior programs, including incentives and rewards.

e. The Managed Care Plan shall not include the provision of gambling, alcohol, tobacco or drugs (except for over-the-counter drugs) in any of its incentives or rewards and shall state on the incentive or reward that it may not be used for such purposes.

f. Incentives or rewards may have some health- or child development-related function (e.g., clothing, food, books, safety devices, infant care items, subscriptions to publications that include health-related subjects, membership in clubs advocating educational advancement and healthy lifestyles, etc.). Incentive or reward dollar values shall be in proportion to the importance of the healthy behavior being encouraged or rewarded (e.g., a tee-shirt for attending one (1) smoking cessation class, but a gift card for completion of a series of classes).

g. Incentives and rewards shall be limited to a value of twenty dollars ($20), except in the case of incentives or rewards for the completion of a series of services, health education classes or other educational activities, in which case the incentive or reward shall be limited to a value of fifty dollars ($50). The Agency will allow a special exception to the dollar value relating to infant car seats, strollers, and cloth baby carriers/ slings.

h. The Managed Care Plan shall not include in the dollar limits on incentives or rewards any money spent on the transportation of enrollees to services or child care provided during the delivery of services.

i. Healthy Behavior incentives/rewards are non-transferable from one managed care plan to another.

j. As part of its smoking cessation program, the Managed Care Plan shall provide participating PCPs with the Quick Reference Guide to assist in identifying tobacco users and supporting and delivering effective smoking cessation interventions. (The Managed Care Plan can obtain copies of the guide by contacting the DHHS, Agency for Health Care Research & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O. Box 8547, Silver Spring, MD 20907.)

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k. As part of its medically approved alcohol or substance abuse recovery program, the Managed Care Plan shall offer annual alcohol or substance abuse screening training to its providers. The Managed Care Plan shall have all PCPs screen enrollees for signs of alcohol or substance abuse as part of prevention evaluation at the following times:

(1) Initial contact with a new enrollee;

(2) Routine physical examinations;

(3) Initial prenatal contact;

(4) When the enrollee evidences serious over-utilization of medical, surgical, trauma or emergency services; and

(5) When documentation of emergency room visits suggests the need.

l. The Managed Care Plan shall report on its healthy behavior programs in accordance with Section XIV, Reporting Requirements and the Managed Care Plan Report Guide. This shall include submitting data related to each healthy behavior program, caseloads (new and ongoing) for each healthy behavior program, and the amount and type of rewards/incentives provided for each healthy behavior program.

4. Additional Care Coordination / Case Management Requirements

a. The Managed Care Plan shall be responsible for the management and continuity of medical and behavioral health care for all enrollees.

b. The Managed Care Plan shall maintain written care coordination/case management and continuity of care protocols that include the following minimum functions:

(1) Appropriate referral and scheduling assistance for enrollees needing specialty health care or transportation services, including those identified through CHCUP screenings;

(2) 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 Medicaid Area Office;

(3) Care coordination/case management follow-up services for children/adolescents whom the Managed Care Plan identifies through blood screenings as having abnormal levels of lead;

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(4) A mechanism for direct access to specialists for enrollees identified as having special health care needs, as appropriate for their conditions and identified needs;

(5) An outreach program and other strategies for identifying every pregnant enrollee. This shall include care coordination/case management, claims analysis, and use of health risk assessment, etc. The Managed Care Plan shall require its participating providers to notify the plan of any enrollee who is identified as being pregnant;

(6) Documentation of referral services in enrollee medical/case records, including reports resulting from the referral;

(7) Documentation of emergency care encounters in enrollee medical/case records with appropriate medically indicated follow-up;

(8) Coordination of hospital/institutional discharge planning that includes post-discharge care, including residential services, day treatment programs, outpatient appointments, skilled short-term rehabilitation, and skilled nursing facility care, as appropriate;

(9) Sharing with other Managed Care 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; and

(10) Ensuring that in the process of coordinating care/case management, 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.

c. The Managed Care Plan shall maintain written protocols for identifying, assessing and implementing interventions for enrollees with complex medical issues, high service utilization, intensive health care needs, or who consistently access services at the highest level of care. This shall include, at a minimum, the following:

(1) Identifying eligible enrollees and stratifying enrollees by severity and risk level including developing an algorithm to identify and stratify eligible enrollees;

(2) Developing different types of interventions and specifying minimum touch frequency for each severity and/or risk level;

(3) Determining maximum caseloads for each case manager and support staff and managing and monitoring caseloads;

(4) Specifying experience and educational requirements for case managers and case management support staff;

(5) Providing training and continuing education for case management staff;

(6) Using evidence based guidelines;

(7) Conducting comprehensive assessments that identify enrollee needs across multiple domains, including current health conditions, current providers, caregiver

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or other supports available, transportation barriers, medications, behavioral health conditions, and preferences for treatment;

(8) Developing treatment plans that incorporate the health risk issues identified during the assessment and incorporate the treatment preferences of the enrollee. The treatment plan shall contain goals that are outcomes based and measurable and include the interventions and services to be provided to obtain goals. Interventions should include community service linkage, improving support services and lifestyle management as appropriate based on the enrollee’s identified issues. Treatment plans shall be updated at least every six (6) months when there are significant changes in enrollee’s condition;

(9) Identifying enrollees with co-morbid mental health and substance abuse disorders, including a depression screening, and addressing those disorders;

(10) Identifying enrollees with co-morbid medical conditions and addressing the co-morbid medical conditions;

(11) Interfacing with the enrollee’s PCP and/or specialists;

(12) Assessing enrollees for literacy levels and other hearing, vision or cognitive functions that may impact an enrollee’s ability to participate in his/her care and implementing interventions to address the limitations;

(13) Assessing enrollees for community, environmental or other supportive services needs and referring enrollees to get needed assistance;

(14) Facilitating enrollee preferences for treatment, including cultural preferences, and enrollee participation in treatment planning;

(15) Using best practices to increase enrollee engagement;

(16) Documentation of emergency care encounters in enrollee medical/case records with appropriate medically indicated follow-up;

(17) Coordination of hospital/institutional discharge planning that includes post-discharge care, including residential services, day treatment programs, outpatient appointments, skilled short-term rehabilitation, and skilled nursing facility care, as appropriate;

(18) Ensure a linkage to pre-booking sites for assessment, screening or diversion related to behavioral health services for enrollees who have justice system involvement;

(19) Sharing with other managed care 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; and

(20) Ensuring that in the process of coordinating care/case management, 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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d. Pursuant to 42 CFR 438.208(c)(4), for enrollees with special health care needs determined through an assessment by appropriate behavioral health professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular care monitoring, the Managed Care Plan shall have a mechanism in place to allow enrollees to directly access a behavioral health care specialist (for example, through a standing referral or an approved number of visits) as appropriate for the enrollee's condition and identified needs.

e. The Managed Care Plan shall maintain written protocols for discharge planning through the evaluation of an enrollee's medical care needs, mental health service needs, and substance use service needs and coordination of appropriate care after discharge from one level of care to another. The Managed Care Plan shall:

(1) Monitor all enrollee discharge plans from behavioral health inpatient admissions to ensure that they incorporate the enrollee’s needs for continuity in existing behavioral health therapeutic relationships;

(2) Ensure enrollees' family members, guardians, outpatient individual practitioners and other identified supports are given the opportunity to participate in enrollee treatment to the maximum extent practicable and appropriate, including behavioral health treatment team meetings and discharge plan development. For adult enrollees, family members and other identified supports may be involved in the development of the discharge plan only if the enrollee consents to their involvement;

(3) Designate care coordination/case management staff who are responsible for identifying and providing care coordination/case management to enrollees who remain in the hospital for non-clinical reasons (i.e., absence of appropriate treatment setting availability, high demand for appropriate treatment setting, high-risk enrollees and enrollees with multiple agency involvement);

(4) Develop and implement a plan that monitors and ensures that clinically indicated behavioral health services are offered and available to enrollees within seven (7) days of discharge from an inpatient setting;

(5) Ensure that a behavioral health program clinician provides medication management to enrollees requiring medication monitoring within seven (7) days of discharge from a behavioral health program inpatient setting. The Managed Care Plan shall ensure that the behavioral health program clinician is duly qualified and licensed to provide medication management; and

(6) Upon the admission of an enrollee, the Managed Care Plan shall make its best efforts to ensure the enrollee’s smooth transition to the next service or to the community and shall require that behavioral health care providers:

(a) Assign a mental health case manager to oversee the care given to the enrollee;

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(b) Develop an individualized discharge plan, in collaboration with the enrollee where appropriate, for the next service or program or the enrollee's discharge, anticipating the enrollee's movement along a continuum of services; and

(c) Document all significant efforts related to these activities, including the enrollee's active participation in discharge planning.

f. The Managed Care Plan and its QI plan shall demonstrate specific interventions in its behavioral health care coordination/case management to better manage behavioral health services and promote positive enrollee outcomes. The Managed Care Plan‘s written policies and procedures shall address components of effective behavioral health care coordination/case management including, but not limited to, anticipation, identification, monitoring, measurement, evaluation of enrollee‘s behavioral health needs, and effective action to promote quality of care. Participation in the DCF planning process, where such exists (see s. 394.75, F.S.). The provision of enhanced care coordination and management for high-risk populations. Such populations shall include, at a minimum, enrollees that meet any of the following conditions:

(1) Have resided in a state mental health facility for at least six (6) of the past thirty-six (36) months;

(2) Reside in the community and have had two (2) or more admissions to a state mental health facility in the past thirty-six (36) months;

(3) Reside in the community and have had three (3) or more admissions to a crisis stabilization unit, short-term treatment facility, inpatient psychiatric unit, or any combination of these facilities within the past twelve (12) months;

(4) Have been diagnosed with a mental health disorder in conjunction with a complex medical condition and have been prescribed numerous prescription medications; or

(5) Have been identified as exceeding the Managed Care Plan’s prescription limits as permitted under Section V, Covered Services.

If an enrollee makes a request for behavioral health services to the Managed Care Plan, the Managed Care Plan shall provide the enrollee with the name (or names) of qualified behavioral health care providers, and if requested, assist the enrollee with making an appointment with the provider that is within the required access times indicated in Section VI, Provider Network.

The Managed Care Plan shall be responsible for the management and continuity of medical and behavioral health care for all enrollees.

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g. The Managed Care Plan shall ensure that appropriate resources are available to address the treatment of complex conditions that reflect both behavioral health and physical health involvement. The following conditions must be addressed:

(1) Mental health disorders due to or involving a general medical condition, and

(2) Eating disorders.

The Managed Care Plan shall develop a plan of care that includes all appropriate collateral providers necessary to address the complex medical issues involved. Clinical care criteria shall address modalities of treatment that are effective for each diagnosis. The Managed Care Plan’s provider network must include appropriate treatment resources necessary for effective treatment of each diagnosis within the required access time periods.

F. Quality Enhancements

The Managed Care Plan shall offer quality enhancements (QE) to enrollees as specified below:

1. Children's Programs

a. The Managed Care Plan shall provide regular general wellness programs targeted specifically toward enrollees from birth to age of five (5), or the Managed Care Plan shall make a good faith effort to involve enrollees in existing community children's programs.

b. Children's programs shall promote increased use of prevention and early intervention services for at-risk enrollees. The Managed Care Plan shall approve claims for services recommended by the Early Intervention Program when they are covered services and medically necessary.

c. The Managed Care Plan shall offer its providers annual training that promote proper nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and early intervention services.

2. Domestic Violence

The Managed Care Plan shall ensure that PCPs screen enrollees for signs of domestic violence and shall offer referral services to applicable domestic violence prevention community agencies.

3. Pregnancy Prevention

The Managed Care Plan shall conduct regularly scheduled pregnancy prevention programs, or shall make a good faith effort to involve enrollees in existing community pregnancy prevention programs, such as the Abstinence Education Program. The programs shall be targeted towards teen enrollees, but shall be open to all enrollees, regardless of age, gender, pregnancy status or parental consent.

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4. Prenatal/Postpartum Pregnancy Programs

The Managed Care Plan shall provide regular home visits, conducted by a home health nurse or aide, and counseling and educational materials to pregnant and postpartum enrollees who are not in compliance with the Managed Care Plan's prenatal and postpartum programs. The Managed Care Plan shall coordinate its efforts with the local Healthy Start care coordinator/case manager to prevent duplication of services.

5. Behavioral Health Programs

The Managed Care Plan shall provide outreach to homeless and other populations of enrollees at risk of justice system involvement, as well as those enrollees currently involved in this system, to assure that services are accessible and provided when necessary. This activity shall be oriented toward preventive measures to assess behavioral health needs and provide services that can potentially prevent the need for future inpatient services or possible deeper involvement in the forensic or justice system;

6. Other Programs and Services

The Managed Care Plan is encouraged to actively collaborate with community agencies and organizations, including CHDs, local Early Intervention Programs and local school districts in offering these services.

Section VI. Provider Network

A. Network Adequacy Standards

1. Network Capacity and Geographic Access Standards

Pursuant to s. 409.967(2)(c)(1), Managed Care Plans must maintain a region wide network of providers in sufficient numbers to meet the access standards for specific medical services for all recipients enrolled in the plan. At a minimum, Managed Care Plans shall contract with the providers specified in the MMA Provider Network Standards Table (table) below. Managed Care Plans shall ensure regional provider ratios and provider-specific geographic access standards for recipients in urban or rural counties are met and maintained throughout the life of this Contract, as specified in the table.

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Managed Medical Assistance Provider Network Standards Table
	Urban County		Rural County		Regional Provider Ratios
Required Providers	Maximum Time (minutes)	Maximum Distance (miles)	Maximum Time (minutes)	Maximum Distance (miles)	Providers per Recipient
Primary Care Providers	30	20	30	20	1:1,500 enrollees
Specialists
Adolescent Medicine	100	75	110	90	1:31,200 enrollees
Allergy	80	60	90	75	1:20,000 enrollees
Anesthesiology	n/a	n/a	n/a	n/a	1:1,500 enrollees
Cardiology	50	35	75	60	1:3,700 enrollees
Cardiology (PEDS)	100	75	110	90	1:16,667 enrollees
Cardiovascular Surgery	100	75	110	90	1:10,000 enrollees
Chiropractic	80	60	90	75	1:10,000 enrollees
Dermatology	60	45	75	60	1:7,900 enrollees
Endocrinology	100	75	110	90	1:25,000 enrollees
Endocrinology (PEDS)	100	75	110	90	1:20,000 enrollees
Gastroenterology	60	45	75	60	1:8,333 enrollees
General Dentist	50	35	75	60	1:1,500 enrollees
General Surgery	50	35	75	60	1:3,500 enrollees
Infectious Diseases	100	75	110	90	1:6,250 enrollees
Midwife	100	75	110	90	1:33,400 enrollees
Nephrology	80	60	90	75	1:11,100 enrollees
Nephrology (PEDS)	100	75	110	90	1:39,600 enrollees
Neurology	60	45	75	60	1:8,300 enrollees
Neurology (PEDS)	100	75	110	90	1:22,800 enrollees
Neurosurgery	100	75	110	90	1:10,000 enrollees
Obstetrics/Gynecology	50	35	75	60	1:1,500 enrollees
Oncology	80	60	90	75	1:5,200 enrollees
Ophthalmology	50	35	75	60	1:4,100 enrollees
Optometry	50	35	75	60	1:1,700 enrollees
Oral Surgery	100	75	110	90	1:20,600 enrollees
Orthodontist	100	75	110	90	1:38,500 enrollees
Orthopaedic Surgery	50	35	75	60	1:5,000 enrollees
Otolaryngology	80	60	90	75	1:3,500 enrollees
Pathology	n/a	n/a	n/a	n/a	1:3,700 enrollees
Pediatrics	50	35	75	60	1:1,500 enrollees
Pharmacy	30	20	60	45	1:2,500 enrollees
24-hour Pharmacy	60	45	60	45	n/a
Pulmonology	60	45	75	60	1:7,600 enrollees
Rheumatology	100	75	110	90	1:14,400 enrollees
Therapist (Occupational)	50	35	75	60	1:1,500 enrollees
Therapist (Speech)	50	35	75	60	1:1,500 enrollees
Therapist (Physical)	50	35	75	60	1:1,500 enrollees
Therapist (Respiratory)	100	75	110	90	1:8,600 enrollees

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Managed Medical Assistance Provider Network Standards Table
	Urban County		Rural County		Regional Provider Ratios
Required Providers	Maximum Time (minutes)	Maximum Distance (miles)	Maximum Time (minutes)	Maximum Distance (miles)	Providers per Recipient
Urology	60	45	75	60	1:10,000 enrollees
Facility/ Group/ Organization
Hospitals (acute care)	30	20	30	20	1 bed: 275 enrollees
Hospital or Facility with Birth/Delivery Services	30	20	30	20	2: County
24/7 Emergency Service Facility	30	20	30	20	2: County
Home Health Agency	n/a	n/a	n/a	n/a	2: County
Adult Family Care Home	n/a	n/a	n/a	n/a	2: County
ALF	n/a	n/a	n/a	n/a	2: County
Birthing Center	n/a	n/a	n/a	n/a	1: County
Hospice	n/a	n/a	n/a	n/a	2: County
DME/HME	n/a	n/a	n/a	n/a	As required in s. 409.975(1)(d), F.S.
Behavioral Health
Board Certified or Board Eligible Adult Psychiatrists	30	20	60	45	1:1,500 enrollees
Board Certified or Board Eligible Child Psychiatrists	30	20	60	45	1:7,100 enrollees
Licensed Practitioners of the Healing Arts	30	20	60	45	1:1,500 enrollees
Licensed Community Substance Abuse Treatment Centers	30	20	60	45	2: county
Inpatient Substance Abuse Detoxification Units	n/a	n/a	n/a	n/a	1 bed:4,000 enrollees
Fully Accredited Psychiatric Community Hospital (Adult) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital	n/a	n/a	n/a	n/a	1 bed:2,000 enrollees
Fully Accredited Psychiatric Community Hospital (Child) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital	n/a	n/a	n/a	n/a	1 bed:4,000 enrollees

2. Primary Care Providers

a. The Managed Care Plan shall enter into provider contracts with at least one (1) FTE PCP per one-thousand five-hundred (1,500) enrollees. The Managed Care Plan may

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increase the ratio by seven-hundred fifty (750) enrollees for each FTE advanced registered nurse practitioner (ARNP) or physician’s assistant (PA) affiliated with a PCP. The Managed Care plan shall have at least one (1) FTE PCP in each of the

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following four (4) specialty areas within the geographic access standards indicated above:

(1) Family Practice;

(2) General Practice;

(3) Pediatrics; and

(4) Internal Medicine.

b. The Managed Care Plan shall ensure the following:

(1) The PCP provides, or arranges for coverage of services, consultation or approval for referrals twenty-four hours per day, seven days per week (24/7) by Medicaid-enrolled providers who will accept Medicaid reimbursement. This coverage shall consist of an answering service, call forwarding, provider call coverage or other customary means approved by the Agency. The chosen method of 24/7 coverage must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. The after-hours coverage must be accessible using the medical office’s daytime telephone number;

(2) The PCP arranges for coverage of primary care services during absences due to vacation, illness or other situations that require the PCP to be unable to provide services. A Medicaid-eligible PCP must provide coverage; and

(3) Pregnant enrollees are allowed to choose Managed Care Plan obstetricians as their PCPs to the extent that the obstetrician is willing to participate as a PCP.

3. Primary Dental Providers

a. The Managed Care Plan shall enter into provider contracts with a sufficient number of Primary Dental Providers (PDPs) providing dental services to ensure adequate accessibility for enrollees of all ages. The Managed Care Plan shall ensure that PDPs provide services in accordance with this Contract and the Medicaid Dental Services Coverage and Limitations Handbooks.

b. The Managed Care Plan shall provide the following:

(1) At least one (1) FTE PDP per service area including, but not limited to, the following broad specialty areas:

(a) General dentist; and

(b) Pediatric dentist.

(2) At least one (1) FTE PDP per 1,500 enrollees. The Managed Care Plan may increase the ratio by 500 enrollees for each FTE licensed dental hygienist affiliated with a PDP providing dental services. However, this increase is limited to two (2) FTE licensed dental hygienists per FTE dentist.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 77 of 102

c. The Managed Care Plan shall ensure that PDP services and referrals to participating specialists are available on a timely basis, as follows:

(1) Urgent Care — within one (1) day;

(2) Routine Sick Patient Care — within one (1) week;

(3) Well Care Visit — within one (1) month; and

(4) Follow-up dental services — within one (1) month after assessment.

4. Specialists and Other Providers

a. The Managed Care Plan shall enter into provider contracts with a sufficient number of specialists to ensure adequate accessibility for enrollees of all ages. The Managed Care Plan shall ensure the following:

(1) At least one (1) of the network infectious disease specialists have expertise in HIV/AIDS and its treatment and care;

(2) Female enrollees have direct access to a women's health specialist within the network for covered services necessary to provide women's routine and preventive health care services. This is in addition to an enrollee's designated PCP, if that provider is not a women's health specialist; and

(3) In accordance with s. 641.31, F.S., low-risk enrollees have access to certified nurse midwife services or licensed midwife services, licensed in accordance with Chapter 467, F.S.

b. For pediatric specialists not listed the Managed Medical Assistance Provider Network Standards Table, the Managed Care Plan may assure access by providing telemedicine consultations with participating pediatric specialists, at a location or via a PCP within sixty (60) minutes travel time or forty-five (45) miles from the enrollee’s residence zip code. Alternatively, for pediatric specialists not listed in the Managed Medical Assistance Provider Network Standards Table, for which there is no pediatric specialist located within sixty (60) minutes travel time or forty-five (45) miles from the enrollee's residence zip code, the Managed Care Plan may assure access to that specialist in another location in Florida through a transportation arrangement with willing participating pediatric provider(s) who have such capability.

c. The Managed Care Plan shall ensure the availability of providers in the following dental specialty areas, as appropriate for both adults and pediatric enrollees, on at least a referral basis. The Managed Care Plan shall use participating specialists with pediatric expertise for children/adolescents when the need for pediatric specialty care is significantly different from the need for adult specialty care (for example a pediatric endodontist). Specialties below marked with an asterisk (*) require the Managed Care Plan to assure the availability of both adult and pediatric participating providers.

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(1) Endodontics,

(2) Oral and maxillofacial surgery*,

(3) Orthodontics,

(4) Periodontics, and

(5) Prosthodontics*.

d. The Managed Care Plan shall determine when exceptional referrals to non-participating specialty-qualified providers are needed to address any unique dental needs of an enrollee (for example, when an enrollee’s dental condition requires the placement of a maxillofacial prosthesis for the correction of an anatomical deficiency). Financial arrangements for the provision of such services shall be agreed to prior to the provision of services. The Managed Care Plan shall develop and maintain policies and procedures for such referrals.

5. Public Health Providers

a. The Managed Care Plan shall make a good faith effort to execute memoranda of agreement with the local County Health Departments (CHDs) to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, foster care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Managed Care Plan shall provide documentation of its good faith effort upon the Agency’s request.

b. The Managed Care Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. The Managed Care Plan shall reimburse the CHD when the CHD notifies the Managed Care Plan and provides the Managed Care Plan with copies of the appropriate medical/case records and provides the enrollee's PCP with the results of any tests and associated office visits.

c. The Managed Care Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Managed Care Plan before providing health care services to enrollees and shall provide the Managed Care Plan with the results of the office visit, including test results. The Managed Care Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred sixty-five (365) days, and shall be reimbursed by the Managed Care Plan at the rate negotiated between the Managed Care Plan and the public provider or the applicable Medicaid fee-for-service rate. The Medicaid FFS rate is the standard Medicaid fee schedule rate or the CHD cost-based rate as specified by the County Health Department Clinic Services Coverage and Limitations Handbook for applicable rates.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 79 of 102

(1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV;

(2) The provision of immunizations;

(3) Family planning services and related pharmaceuticals;

(4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and

(5) In the event that a vaccine-preventable disease emergency is declared, the Managed Care Plan shall authorize claims from the CHD for the cost of the administration of vaccines.

d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Managed Care Plan in order to receive reimbursement. If prior authorization is provided, the Managed Care Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Managed Care Plan shall reimburse the entity at Medicaid’s standard pharmacy rate.

e. The Managed Care Plan shall make a good faith effort to execute a contract with a Rural Health Clinic (RHC).

f. The Managed Care Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community.

g. The Managed Care Plan shall report quarterly to the Agency as part of its quarterly financial reports (as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide), the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities.

h. The Managed Care Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70, 409.9071, F.S. and 409.908(21), F.S.

6. Facilities and Ancillary Providers

The Managed Care Plan shall enter into provider contracts with a sufficient number of facilities and ancillary providers to ensure adequate accessibility for enrollees of all ages. The Managed Care Plan shall ensure the following:

a. Network emergency service facilities have one (1) or more physicians and one (1) or more nurses on duty in the facility at all times;

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 80 of 102

b. Network facilities are licensed, as required by law and rule, accessible to the handicapped, in compliance with federal Americans with Disabilities Act guidelines, and have adequate space, supplies, good sanitation, and fire, safety, and disaster preparedness and recovery procedures in operation;

c. Care for medically high-risk perinatal enrollees is provided in a facility with a NICU sufficient to meet the appropriate level of need for the enrollee;

d. Pursuant to s. 409.967(2)(c)1, F.S., the Managed Care Plan may use mail-order pharmacies; however mail-order pharmacies shall not count towards the Managed Care Plan’s pharmacy network access standards; and

e. In accordance with s. 409. 975(1)(d), F.S., a provider contract is offered to each licensed home medical equipment and supplies provider and to each Medicaid enrolled durable medical equipment (DME) provider in the region, as specified by the Agency, that meets quality and fraud prevention and detection standards established by the Managed Care Plan and that agrees to accept the lowest price previously negotiated between the Managed Care Plan and another such provider.

f. The Managed Care Plan’s provider network includes:

(1) Independent laboratories to conduct medically necessary clinical laboratory procedures in freestanding facilities;

(2) Freestanding dialysis centers to conduct medically necessary hemodialysis and peritoneal dialysis performed in the center and related injectable medications, including Erythropoietin (Epogen or EPO) administered in the freestanding dialysis center;

(3) Portable x-ray providers to provide diagnostic x-ray services at the residence of an enrollee who is unable to travel to a physician’s office or an outpatient hospital’s radiology facility;

(4) Ambulatory surgical centers to provide scheduled, elective, medically necessary surgical care to patients who do not require hospitalization; and

(5) Audiologists to provide medically necessary hearing related services.

7. Essential Providers

a. Pursuant to s. 409.975(1)(b), F.S., certain providers are statewide resources and essential providers for all managed care plans in all regions. The Managed Care Plan shall include these essential providers in its network, even if the provider is located outside of the region served by the Managed Care Plan.

b. Statewide essential providers include:

(1) Faculty plans of Florida medical schools, which include University of Florida College of Medicine, University of Miami School of Medicine, University of South Florida College of Medicine, University of Central Florida College of Medicine, Nova Southeastern University College of Osteopathic Medicine, Florida State

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 81 of 102

University College of Medicine, and Florida International University College of Medicine;

(2) Regional perinatal intensive care centers (RPICCs) as defined in s. 383.16(2), F.S., including All Children's Hospital, Arnold Palmer Hospital, Bayfront Medical Center, Broward General Medical Center, Jackson Memorial Hospital, Lee Memorial Hospital at HealthPark, Memorial Regional Hospital, Sacred Heart Hospital, Shands – Jacksonville, Shands Teaching Hospital, St. Mary's Hospital and Tampa General Hospital;

(3) Hospitals licensed as specialty children's hospitals as defined in s. 395.002(28), F.S., including All Children’s Hospital, Miami Children’s Hospital, Nemours; and Shriners Hospitals for Children; and

(4) Accredited and integrated systems serving medically complex children that are comprised of separately licensed, but commonly owned, health care providers delivering at least the following services: medical group home, in-home and outpatient nursing care and therapies, pharmacy services, durable medical equipment, and Prescribed Pediatric Extended Care.

c. If the Managed Care Plan has not contracted with all statewide essential providers in all regions as of the first date of recipient enrollment, the Managed Care Plan must continue to negotiate in good faith.

(1) The Managed Care Plan shall make payments to physicians on the faculty of non-participating Florida medical schools at the applicable Medicaid rate.

(2) The Managed Care Plan shall make payments for services rendered by a regional perinatal intensive care center at the applicable Medicaid rate as of the first day of this Contract.

(3) The Managed Care Plan shall make payments to a non-participating specialty children's hospital equal to the highest rate established by contract between that provider and any other Medicaid managed care plan.

d. Pursuant to s. 409.975(1)(c), F.S., after twelve (12) months of active participation in the Managed Care Plan’s network, the Managed Care Plan may exclude any essential provider from the network for failure to meet quality or performance criteria.

e. Pursuant to s. 409.975(1)(a), F.S., the Managed Care Plan must include all providers in the region that are classified by the Agency as essential Medicaid providers, unless the Agency approves, in writing, an alternative arrangement for securing the types of services offered by the essential providers.

f. The Agency may determine that the following providers are essential Medicaid providers:

(1) Federally qualified health centers;

(2) Statutory teaching hospitals as defined in s. 408.07(45), F.S.

(3) Hospitals that are trauma centers as defined in s. 395.4001(14), F.S.; and

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 82 of 102

(4) Hospitals located at least twenty-five (25) miles from any other hospital with similar services.

8. Timely Access Standards

a. The Managed Care Plan must assure that PCP services and referrals to specialists for medical and behavioral health services are available on a timely basis, as follows:

(1) Urgent Care — within one (1) day of the request;

(2) Sick Care — within one (1) week of the request; and

(3) Well Care Visit — within one (1) month of the request.

b. Annually the Managed Care Plan shall review a statistically valid sample of PCP and specialist offices’ average appointment wait times to ensure services are in compliance with this subsection, and report the results to the Agency as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. (See 42 CFR 438.206(c)(1)(iv),(v) and (vi).)

9. Network Adequacy Measures

a. The Managed Care Plan shall collect regional data on the following measures in order to evaluate the Managed Care Plan’s provider network and to ensure that covered services are reasonably accessible.

b. The Managed Care Plan shall comply with the regional standards for each measure as specified in the Provider Network Adequacy Standards Table below.

c. The Managed Care Plan shall submit the results of the network adequacy standards specified in the table below to the Agency quarterly as specified in Section XIV, Reporting Requirements and the Managed Care Plan Report Guide.

d. The Agency reserves the right to require Managed Care Plans to collect data and report results on additional network adequacy standards.

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AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 83 of 102

Provider Network Adequacy Measures Table
Measure	Standard	Region
		1	2	3	4	5	6	7	8	9	10	11
The Managed Care Plan agrees that at least ___ percent of required participating primary care providers (as required by the Managed Medical Assistance Provider Network Standards Table in Exhibit II-A), by region, are accepting new Medicaid enrollees.		90	85	90	85	85	90	85	90	85	85	85
The Managed Care Plan agrees that at least ___ percent of required participating specialist providers, (as required by the Managed Medical Assistance Provider Network Standards Table in Exhibit II-A), by region, are accepting new Medicaid enrollees.		90	90	85	90	90	90	90	90	90	90	90
The Managed Care Plan agrees that at least ___ percent of required participating primary care providers (as required by the Managed Medical Assistance Provider Network Standards Table in Exhibit II-A), by region, offer after hours appointment availability to Medicaid enrollees.		30	40	35	40	35	35	40	30	40	40	40
The Managed Care Plan agrees that no more than ___ percent of enrollee hospital admissions, by region, shall occur in non-participating facilities, excluding continuity of care periods, as defined in Subsection VII. H., Continuity of Care in Enrollment. Admissions through the emergency department are not included in this standard.		5	5	8	5	3	5	5	5	5	10	8
The Managed Care Plan agrees that no more than ___ percent of enrollee specialty care (physician specialists) utilization, by region, shall occur with non-participating providers, excluding continuity of care periods, as defined in Subsection VII. H., Continuity of Care in Enrollment. Hospital based specialists are not included in this standard.		8	10	10	10	8	8	8	8	10	10	8

10. Electronic Health Record Measures

a. The Managed Care Plan shall collect regional data on the regional standards specified in the Electronic Health records Standards Table below in order to evaluate the Managed Care Plan’s provider’s EHR capabilities.

b. The Managed Care Plan shall comply with the regional standards specified in the Electronic Health Record Standards Table below.

c. The Managed Care Plan shall submit the results of the electronic health record standards specified above to the Agency quarterly as specified in Section XIV, Reporting Requirements and the Managed Care Plan Report Guide.

d. The Agency reserves the right to require Managed Care Plans to collect data and report results on additional network adequacy standards.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 84 of 102

Electronic Health Records Standards Table
Measure	Standard	Region
		1	2	3	4	5	6	7	8	9	10	11
By the end of the second Contract year, the Managed Care Plan agrees at least ___ percent of eligible professionals and hospitals, as defined under the HITECH Act, are: (1) Using certified electronic health records in a meaningful manner; (2) Using certified electronic health exchange of health information to improve quality of health care; and, (3) Using certified electronic health record technology to submit clinical quality measures and other such measures selected by the Secretary of DHHS under the HITECH Act.		55	55	60	65	50	60	60	50	60	50	45
By the end of the second Contract year, the Managed Care Plan agrees at least ___ percent of enrollees are assigned to primary care providers meeting meaningful use requirements defined above.		65	65	65	75	70	75	70	70	70	70	70

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AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 85 of 102

B. Network Development and Management Plan

1. Regional Network Changes

a. The Managed Care Plan shall notify the Agency within seven (7) business days of any significant changes to its regional provider network. A significant change is defined as follows:

(1) Any change that would cause more than five percent (5%) of enrollees in the region to change the location where services are received or rendered; or

(2) For MMA Managed Care Plans, a decrease in the total number of PCPs by more than five percent (5%).

C. Provider Credentialing and Contracting

1. Credentialing and Recredentialing

a. Managed Care Plan credentialing and recredentialing processes must include verification of the following additional requirements for physicians and must ensure compliance with 42 CFR 438.214:

(1) Good standing of privileges at the hospital designated as the primary admitting facility by the physician or if the physician does not have admitting privileges, good standing of privileges at the hospital by another provider with whom the physician has entered into an arrangement for hospital coverage.

(2) Valid Drug Enforcement Administration (DEA) certificates, where applicable.

(3) Attestation that the total active patient load (all populations, including but not limited to, Medicaid FFS; Children’s Medical Services Network; SMMC plans; Medicare; KidCare and commercial coverage) is no more than three-thousand (3,000) patients per PCP. An active patient is one that is seen by the provider a minimum of three (3) times per year.

(4) A good standing report on a site visit survey. For each PCP, documentation in the Managed Care Plan’s credentialing files regarding the site survey shall include the following:

(a) Evidence that the Managed Care Plan has evaluated the provider's facilities using the Managed Care Plan's organizational standards;

(b) Evidence that the provider’s office meets criteria for access for persons with disabilities and that adequate space, supplies, proper sanitation, smoke-free facilities, and proper fire and safety procedures are in place;

(c) Evidence that the Managed Care Plan has evaluated the provider's medical/case record keeping practices at each site to ensure conformity with the Managed Care Plan's organizational standards; and

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(d) Evidence that the Managed Care Plan has determined that the following documents are posted in the provider's waiting room/reception area: the Agency’s statewide consumer call center telephone number, including hours of operation, and a copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities, in accordance with s. 381.026, F.S. The provider must have a complete copy of the Florida Patient’s Bill of Rights and Responsibilities, available upon request by an enrollee, at each of the provider's offices.

(5) Attestation to the correctness/completeness of the provider's application.

(6) Statement regarding any history of loss or limitation of privileges or disciplinary activity as described in s. 456.039, F.S.

(7) A statement from each provider applicant regarding the following:

(a) Any physical or mental health problems that may affect the provider's ability to provide health care;

(b) Any history of chemical dependency/substance abuse;

(c) Any history of loss of license and/or felony convictions; and

(d) The provider is eligible to become a Medicaid provider.

(8) Current curriculum vitae, which includes at least five (5) years of work history.

(9) Proof of the provider's medical school graduation, completion of residency and other postgraduate training. Evidence of board certification shall suffice in lieu of proof of medical school graduation, residency and other postgraduate training, if applicable.

(10) Evidence of specialty board certification, if applicable.

b. The Managed Care Plan shall recredential its providers at least every three (3) years using information from ongoing provider monitoring.

c. Hospital ancillary providers are not required to be independently credentialed if those providers serve Managed Care Plan enrollees only through the hospital.

2. Provider Contract Requirements

a. The Managed Care Plan shall include the following additional provisions in its MMA provider contracts:

(1) If there is a Managed Care Plan physician incentive plan, include a statement that the Managed Care Plan shall make no specific payment directly or indirectly under a physician incentive plan to a provider as an inducement to reduce or limit, medically necessary services to an enrollee, and that incentive plans shall not contain provisions that provide incentives, monetary or otherwise, for withholding medically necessary care;

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 87 of 102

(2) Require providers to meet timely access standards pursuant to this Contract;

(3) Require that all providers agreeing to participate in the network as PCPs fully accept and agree to responsibilities and duties associated with the PCP designation;

(4) Contain no provision that prohibits the provider from providing inpatient services in a participating hospital to an enrollee if such services are determined to be medically necessary and covered services under this Contract;

(5) For hospital contracts, include rates that are in accordance with s. 409.975(6), F.S.;

(6) For hospital contracts, include a clause that states whether the Managed Care Plan or the hospital will complete the DCF Excel spreadsheet for unborn activation and include Provider-Preventable Conditions (PPC) reporting requirements as specified in Section V, Covered Services;

(7) If copayments are waived as an expanded benefit, the provider must not charge enrollees copayments for covered services; and if copayments are not waived as an expanded benefit, that the amount paid to providers shall be the contracted amount, less any applicable copayments; and

(8) If the provider has been approved by the Managed Care Plan to provide services through telemedicine, specify that the provider is required to have protocols to prevent fraud and abuse. The provider must implement telemedicine fraud and abuse protocols that address:

(a) Authentication and authorization of users;

(b) Authentication of the origin of the information;

(c) The prevention of unauthorized access to the system or information;

(d) System security, including the integrity of information that is collected, program integrity and system integrity; and

(e) Maintenance of documentation about system and information usage.

D. Provider Services

1. Additional Provider Handbook Requirements

The Managed Care Plan shall include the following information in provider handbooks:

a. Child Health Check-Up program services and standards;

b. PCP responsibilities;

c. Information on the Managed Care Plan’s Healthy Behaviors programs;

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d. If Managed Care Plan allows the use of telemedicine, telemedicine requirements for providers; and

e. If copayments are waived as an expanded benefit, the provider must not charge enrollees copayments for covered services; and if copayments are not waived as an expanded benefit, that the amount paid to providers shall be the contracted amount, less any applicable copayments.

E. Medical/Case Record Requirements

1. Standards for Medical/Case Records

a. All records shall contain documentation to include the following items for services provided through telemedicine:

(1) A brief explanation of the use of telemedicine in each progress note;

(2) Documentation of telemedicine equipment used for the particular covered services provided;

(3) A signed statement from the enrollee or the enrollee’s representative indicating their choice to receive services through telemedicine. This statement may be for a set period of treatment or one-time visit, as applicable to the service(s) provided; and

(4) For telepsychiatry, the results of the assessment, findings and practitioner(s) plan for next steps.

Section VII. Quality and Utilization Management

A. Quality Improvement

There are no additional quality improvements provisions unique to the MMA managed care program.

B. Performance Measures (PMs)

The Managed Care Plan shall collect and report the following performance measures, certified via qualified auditor.

HEDIS
1	Adolescent Well Care Visits - (AWC)
2	Adults' Access to Preventive/Ambulatory Health Services - (AAP)
3	Annual Dental Visits - (ADV)

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HEDIS
4	Antidepressant Medication Management - (AMM)
5	BMI Assessment – (ABA)
6	Breast Cancer Screening – (BCS)
7	Cervical Cancer Screening – (CCS)
8	Childhood Immunization Status – (CIS) – Combo 2 and 3
9	Comprehensive Diabetes Care – (CDC) · Hemoglobin A1c (HbA1c) testing · HbA1c poor control · HbA1c control (<8%) · Eye exam (retinal) performed · LDL-C screening · LDL-C control (<100 mg/dL) · Medical attention for nephropathy
10	Controlling High Blood Pressure – (CBP)
11	Follow-up Care for Children Prescribed ADHD Medication – (ADD)
12	Immunizations for Adolescents – (IMA)
13	Chlamydia Screening for Women – (CHL)
14	Pharyngitis – Appropriate Testing related to Antibiotic Dispensing – (CWP)
15	Prenatal and Postpartum Care – (PPC)
16	Use of Appropriate Medications for People With Asthma – (ASM)
17	Well-Child Visits in the First 15 Months of Life – (W15)
18	Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – (W34)
19	Children and Adolescents’ Access to Primary Care - (CAP)
20	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
21	Ambulatory Care - (AMB)
22	Lead Screening in Children – (LSC)

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 90 of 102

HEDIS
23	Annual Monitoring for Patients on Persistent Medications
24	Plan All-Cause Readmissions
Agency-Defined
1	Mental Health Readmission Rate – (RER)
2	Frequency of HIV Disease Monitoring Lab Tests – (CD4 and VL)
3	Highly Active Anti-Retroviral Treatment – (HAART)
4	HIV-Related Medical Visits – (HIVV)
5	Complete Oral Evaluation
6	Sealants
7	Transportation Timeliness (TRT)
8	Transportation Availability (TRA)
HEDIS & Agency-Defined
1	Follow-Up after Hospitalization for Mental Illness – (FHM)
2	Prenatal Care Frequency (PCF)
Joint Commission
1	Antenatal Steroids

C. Performance Improvement Projects

The Managed Care Plan shall perform four (4) Agency-approved statewide performance improvement projects as specified below:

1. One (1) of the PIPs shall combine a focus on improving prenatal care and well-child visits in the first fifteen (15) months;

2. One (1) of the PIPs shall focus on preventive dental care for childrenl

3. One (1) of the PIPs shall be an administrative PIP focusing on a topic prior approved by the Agency; and

4. One (1) PIP shall be a choice of PIP in one of the following topic areas: population health issues (such as diabetes, hypertension and asthma) within a specific geographic area that have been identified as in need of improvement; integrating primary care and behavioral health; and reducing preventable readmissions.

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D. Satisfaction and Experience Surveys

1. Enrollee Satisfaction Survey

a. The Managed Care Plan shall conduct an annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for a time period specified by the Agency.

b. The Managed Care Plans shall report CAHPS survey results to the Agency with an action plan to address the results of the CAHPS survey by July 1 of each Contract year. (See Section XIV, Reporting Requirements.)

c. The Managed Care Plan shall submit a corrective action plan, as required by the Agency, within sixty (60) days of the request from the Agency to address any deficiencies identified in the annual CAHPS survey.

d. The Managed Care Plan shall use the results of the annual CAHPS survey to develop and implement plan-wide activities designed to improve member satisfaction. Activities conducted by the Managed Care Plan pertaining to improving member satisfaction resulting from the annual member satisfaction survey must be reported to the Agency on a quarterly basis.

E. Provider- Specific Performance Monitoring

1. Medical/Case Record Review

a. The Managed Care Plan shall conduct medical/case record reviews of all PCP sites that serve ten (10) or more enrollees. Practice sites include individual offices, clinics, multi-provider practices and facilities at least once every three (3) years.

(1) The Managed Care Plan shall review a reasonable number of records at each site to determine compliance. Five (5) to ten (10) records per site is a generally-accepted target, though additional reviews must be completed for large group practices or when additional data is necessary in specific instances.

F. Other Quality Management Requirements

MMA Managed Care Plans and Comprehensive LTC Managed Care Plans shall develop a reporting and management system for critical and adverse incidents that occur in all service delivery settings applicable to enrollees with MMA benefits only.

G. Utilization Management

There are no additional utilization management contract provisions unique to the MMA managed care program.

H. Continuity of Care in Enrollment

There are no additional continuity of care in enrollment contract provisions unique to the MMA managed care program.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 92 of 102

Section VIII. Administration and Management

A. Organizational Governance and Staffing

There are no additional subcontract provisions unique to the MMA managed care program.

B. Subcontracts

There are no additional subcontract provisions unique to the MMA managed care program.

C. Information Management and Systems

There are no additional information management and systems provisions unique to the MMA managed care program.

D. Claims and Provider Payment

There are no additional claims and provider payment provisions unique to the MMA managed care program.

E. Encounter Data Requirements

There are no additional encounter data provisions unique to the MMA managed care program.

F. Fraud and Abuse Prevention

There are no additional fraud and abuse prevention provisions unique to the MMA managed care program.

Section IX. Method of Payment

A. Fixed Price Unit Contract

There are no additional provisions unique to the MMA managed care program.

B. Payment Provisions

1. The Agency shall pay the Managed Care Plan one kick payment for each heart, liver and lung transplant covered for enrollees who are not also eligible for Medicare.

2. The Agency shall make kick payments for heart, liver and lung transplants in the amounts specified in the resulting Contract.

3. To receive a kick payment for a heart, liver and/or lung transplant, the Managed Care Plan must adhere to the specific requirements listed in subsection 4. below and adhere to the following requirements:

a. The Managed Care Plan must have provided the covered transplant while the recipient was enrolled in the Managed Care Plan; and

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 93 of 102

b. The Managed Care Plan shall submit any required documentation to the Agency upon its request in order to receive the transplant kick payment.

4. In addition to subsection 3. above, to receive a kick payment for covered transplants provided to an enrollee without Medicare, the Managed Care Plan shall comply with the following requirements:

a. For each transplant provided, the Managed Care Plan shall submit an accurate and complete CMS-1500 claim form (CMS-1500) and operative report to the fiscal agent within the required Medicaid FFS claims submittal timeframes;

b. The Managed Care Plan shall list itself as both the pay-to and the treating provider on the CMS-1500; and

c. The Managed Care Plan shall use the following list of transplant procedure codes relative to the type of transplant performed when completing Field 24 D on the CMS-1500.

CPT Code	Transplant CPT Code Description
32851	lung single, without bypass
32852	lung single, with bypass
32853	lung double, without bypass
32854	lung double, with bypass
33945	heart transplant with or without recipient cardiectomy
47135	liver, allotransplantation, orthotopic, partial or whole from cadaver or living donor
7136	liver, heterotopic, partial or whole from cadaver or living donor any age

5. Upon receipt of acceptable quarterly reports of utilization and encounter data for physicians eligible for the ACA primary care physician payment increase, the Agency shall pay the Managed Care Plan a supplemental payment for eligible services provided between January 1, 2013 and December 31, 2014. This payment will be based on the Agency’s approved Managed Care Plan payment methodology from CMS.

a. The Agency shall notify the Managed Care Plan of the supplemental payment being made.

b. Such payment shall be made through the Medicaid fiscal agent. The Managed Care Plan shall address errors found regarding such reports in accordance with Section XIII.F.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 94 of 102

Section X. Financial Requirements

A. Insolvency Protection

There are no additional insolvency provisions unique to the MMA managed care program.

B. Surplus

There are no surplus provisions unique to the MMA managed care program.

C. Interest

There are no additional interest provisions unique to the MMA managed care program.

D. Third Party Resources

There are no additional third party resources provisions unique to the MMA managed care program.

E. Assignment

There are no additional assignment provisions unique to the MMA managed care program.

F. Financial Reporting

1. Medical Loss Ratio

a. The Managed Care Plan must maintain an annual (July 1 – June 30) medical loss ratio (MLR) of a minimum of eighty-five percent (85%) for the first full year of MMA program operation, beginning July 1, 2015.

b. The Agency will calculate the MLR in a manner consistent with 45 CFR Part 158 and s. 409.9122(21)(b) and (c), F.S. To demonstrate ongoing compliance, the Managed Care Plan shall complete and submit appropriate financial reports, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. The Agency will provide additional guidance to Comprehensive LTC managed care plans within the Managed Care Plan Report Guide, as appropriate, to ensure that all relevant Federal requirements are met.

c. The federal Centers for Medicare & Medicaid Services, will determine the corrective action for non-compliance with this requirement.

G. Inspection and Audit of Financial Records

There are no additional inspection provisions unique to the MMA managed care program.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 95 of 102

Section XI. Sanctions

A. Contract Violations and Non-Compliance

There are no additional provisions unique to the MMA managed care program.

B. Performance Measure Action Plans (PMAP) and Corrective Action Plans (CAP)

There are no PMAP and/or CAP contract provisions unique to the MMA managed care program.

C. Performance Measure Sanctions

1. The Agency may sanction the Managed Care 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 plan’s performance is not consistent with the Agency’s expected minimum standards, as specified in this subsection.

2. The Agency shall assign performance measures a point value that correlates to the National Committee for Quality Assurance HEDIS National Means and Percentiles for Medicaid plans. 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

3. The Agency may require the Managed Care Plan to complete a Performance Measure Action Plan (PMAP) after the first year of poor performance.

4. The Managed Care Plan may receive a monetary sanction of up to $10,000 for each performance measure group where the group score is below three (3). Performance measure groups are as follows:

a. Mental Health and Substance Abuse

(1) Antidepressant Medication Management

(2) Follow-up Care for Children Prescribed ADHD Medication

(3) Follow-up after Hospitalization for Mental Illness (7 day)

(4) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 96 of 102

b. Well-Child

(1) Adolescent Well Care Visits

(2) Childhood Immunization Status – Combo 3

(3) Immunizations for Adolescents

(4) Well-Child Visits in the First 15 Months of Life (6 or more)

(5) Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life

(6) Lead Screening in Children

c. Other Preventive Care

(1) Adults’ Access to Preventive/Ambulatory Health Services

(2) Annual Dental Visits

(3) BMI Assessment

(4) Breast Cancer Screening

(5) Cervical Cancer Screening

(6) Children and Adolescents’ Access to Primary Care

(7) Chlamydia Screening for Women

d. Prenatal/Perinatal

(1) Prenatal and Postpartum Care (includes two (2) measures)

(2) Prenatal Care Frequency

e. Diabetes – Comprehensive Diabetes Care measure components

(1) HbA1c Testing

(2) HbA1c Control (< 8%)

(3) Eye Exam

(4) LDL-C Screening

(5) LDL-C Control

(6) Medical Attention for Nephropathy

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 97 of 102

f. Other Chronic and Acute Care

(1) Controlling High Blood Pressure

(2) Pharyngitis – Appropriate Testing related to Antibiotic Dispensing

(3) Use of Appropriate Medications for People with Asthma

(4) Annual Monitoring for Patients on Persistent Medications

The Agency may amend the performance measure groups with sixty (60) days’ advance notice.

D. Other Sanctions

There are no additional provisions unique to the MMA managed care program.

E. Notice of Sanctions

There are no additional notice provisions unique to the MMA managed care program.

F. Dispute of Sanctions

There are no additional disputes provisions unique to the MMA managed care program.

Section XII. Special Terms and Conditions

The Special Terms and Conditions in Section XII, Special Terms and Conditions apply to all MMA Managed Care Plans and Comprehensive LTC Managed Care Plans unless specifically noted otherwise in this Exhibit.

Section XIII. Liquidated Damages

A. Damages

Additional damages issues and amounts unique to the MMA managed care program are specified below.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 98 of 102

B. Issues and Amounts

If the Managed Care Plan fails to perform any of the services set forth in the Contract, the Agency may assess liquidated damages for each occurrence listed in the MMA Issues and Amounts Table below.

Liquidated Damages Issues and Amounts
#	MMA PROGRAM ISSUES	DAMAGES
1.	Failure to obtain and/or maintain managed behavioral health organization (MBHO) national accreditation as described in the Contract.	$500 per day for every calendar day beyond the day accreditation status must be in place.
2.	Failure to comply with the medical/case records documentation requirements pursuant to the Contract	$500 per enrollee file (medical/case) that does not include all of the required elements.
3.	Failure to have a face-to-face contact between the case manager and/or behavioral health provider, if applicable, and each enrollee as described in the Contract.	$5,000 for each occurrence.
4.	Failure to comply with the federal and/or state CHCUP sixty percent (60%) screening rate and/or federal eighty percent (80%) CHCUP participation rate requirements the Contract.	$50,000 per occurrence in addition to $10,000 for each percentage point less than the target.
5.	Failure to comply with the preventive dental services rate requirement of at least twenty-eight percent (28%), described in the Contract.	$50,000 per occurrence in addition to $10,000 for each percentage point less than the target.
6.	Failure to accurately report utilization and encounter data for physicians that are eligible for the ACA primary care physician fee increase as described in the Contract.	$5,000 per occurrence.
7.	Failure to timely report utilization and encounter data for physicians that are eligible for the ACA primary care physician fee increase as described in the Contract.	$1,000 per day.
8.	The Managed Care Plan receives a score of lower than three (3) on the mental health and substance abuse performance measure group, as described in the Contract.	$10,000 for the performance measure group.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 99 of 102

Liquidated Damages Issues and Amounts
9.	The Managed Care Plan receives a score of lower than three (3) on the well-child performance measure group, as described in the Contract.	$10,000 for the performance measure group.
10.	The Managed Care Plan receives a score of lower than three (3) on the other preventive care performance measure group, as described in the Contract.	$10,000 for the performance measure group.
11.	The Managed Care Plan receives a score of lower than three (3) on the prenatal-postpartum performance measure group, as described in the Contract.	$10,000 for the performance measure group.
12.	The Managed Care Plan receives a score lower than three (3) on the diabetes performance measure group, as described the Contract.	$10,000 for the performance measure group.
13.	The Managed Care Plan receives a score of lower than three (3) on the chronic care performance measure group, as described in the Contract.	$10,000 for the performance measure group.
14.	The Managed Care Plan receives a score of zero (0) on one or more of the following individual measures: (1) Follow-Up after Hospitalization for Mental Illness (7 day) (2) Antidepressant Medication Management (3) Follow-Up Care for Children Prescribed ADHD Medication (4) Use of Appropriate Medications for People with Asthma (5) Controlling High Blood Pressure (6) Comprehensive Diabetes Care (excluding the blood pressure submeasures)	$500 for each enrollee of the denominator not present in the numerator. If no improvement in subsequent years, $1,000 for each enrollee of the denominator not present in the numerator.

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 100 of 102

B. Performance Measure Liquidated Damages

1. The Agency may impose liquidated damages for performance measures as described below in the event that the Managed Care Plan fails to perform at the level of the Agency’s expected minimum standards, as specified in sub-item 2 of this item.

2. The Agency shall compare the Managed Care Plan’s performance measure rates to the National Committee for Quality Assurance (NCQA) HEDIS National Means and Percentiles for Medicaid plans. For each measure where the Managed Care Plan’s rate falls below the 50th percentile, the Managed Care Plan may receive liquidated damages. Liquidated damages will be calculated based on the number of members enrolled in the Managed Care Plan.

3. Liquidated damages will be assessed at the following rates by percentile under which the Managed Care Plan’s rate falls for each measure. The 40^th percentile rate will be calculated as a midpoint between the 25^th and 50^th percentile rates that are published by NCQA.

PM Ranking	Amount per member
40th – 49th percentile	$1.25
25th – 39th percentile	$2.00
10th – 24th percentile	$2.75
< 10th percentile	$3.50

4. The Agency may assess liquidated damages for each of the following measures:

a. Antidepressant Medication Management (acute);

b. Follow-up Care for Children Prescribed ADHD Medication (initiation);

c. Follow-up after Hospitalization for Mental Illness (7 day);

d. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (initiation – total);

e. Adolescent Well Care Visits;

f. Childhood Immunization Status – Combo 3;

g. Immunizations for Adolescents;

h. Well-Child Visits in the First 15 Months of Life (6 or more);

i. Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life;

j. Lead Screening in Children;

k. Adults’ Access to Preventive/Ambulatory Health Services (total);

l. Annual Dental Visits (total);

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 101 of 102

m. BMI Assessment;

n. Breast Cancer Screening;

o. Cervical Cancer Screening;

p. Children and Adolescents’ Access to Primary Care (includes 4 age group rates);

q. Chlamydia Screening for Women (total);

r. Prenatal and Postpartum Care (includes two (2) measures);

s. Prenatal Care Frequency;

t. Comprehensive Diabetes Care - HbA1c Testing;

u. Comprehensive Diabetes Care - HbA1c Control (< 8%);

v. Comprehensive Diabetes Care - Eye Exam;

w. Comprehensive Diabetes Care - LDL-C Screening;

x. Comprehensive Diabetes Care - LDL-C Control;

y. Comprehensive Diabetes Care - Medical Attention for Nephropathy;

z. Controlling High Blood Pressure;

aa. Pharyngitis – Appropriate Testing related to Antibiotic Dispensing;

bb. Use of Appropriate Medications for People with Asthma (total); and

cc. Annual Monitoring for Patients on Persistent Medications (total)

5. The Agency may amend the performance measure listing with sixty (60) days’ advance notice.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 102 of 102

Section XIV. Reporting Requirements

A. Required Reports

The Managed Care Plan shall comply with all reporting requirements set forth in this Contract, including reports specific to MMA managed care plans as specified in the Summary of Reporting Requirements Table below and the Managed Care Plan Report Guide.

Summary of Reporting Requirements
Report Name	Plan Type	Frequency
CHCUP (CMS-416) and FL 80% Screening	All MMA Plans	Annually
Affordable Care Act (ACA) Physician Fee Increase Quarterly Report quarter of 2014)	All MMA Plans	Quarterly
Hernandez Settlement Ombudsman Log	All MMA Plans	Quarterly
Hernandez Settlement Agreement Survey	All MMA Plans	Annually
PCP Appointment Report	All MMA Plans	Annually
ER Visits for Enrollees without PCP appointment	All MMA Plans	Monthly
Customized Benefit Notification	All MMA Plans	Monthly
Patient Centered Medical Home (PCMH) Providers	All MMA Plans	Quarterly
Healthy Behaviors	All MMA Plans	Quarterly
Timely Access/PCP Wait Times Report	All MMA Plans	Annually
Quarterly and Annual Medical Loss Ratio (MLR) Reports	All MMA Plans	Quarterly Annually
Additional Network Adequacy Standards	All MMA Plans	Monthly
Electronic Health Records Standards	All MMA Plans	Quarterly

AHCA Contract No. FP020, Attachment II, Exhibit II-A, Page 103 of 102

ATTACHMENT II

EXHIBIT II-B

LONG-TERM CARE (LTC) MANAGED CARE PROGRAM

Section I. Definitions and Acronyms

The definitions and acronyms in Core Provisions Section I, Definitions and Acronyms apply to all LTC Managed Care Plans and Comprehensive LTC Managed Care Plans unless specifically noted otherwise in this Exhibit.

Section II. General Overview

The provisions in this Exhibit apply to all LTC Managed Care Plans and Comprehensive LTC Managed Care Plans.

In accord with the order of precedence listed in Attachment I, any additional items or enhancements listed in the Managed Care Plan’s response to the Invitation to Negotiate are included in this Exhibit by this reference.

Section III. Eligibility and Enrollment

A. Eligibility

1. Mandatory Populations

a. Eligible recipients age eighteen (18) or older in any of the following programs or eligibility categories are required to enroll in a Managed Care Plan if they have been determined by CARES to meet the nursing facility level of care:

(1) Temporary Assistance to Needy Families (TANF);

(2) SSI (Aged, Blind and Disabled);

(3) Institutional Care;

(4) Hospice;

(5) Aged/Disabled Adult waiver;

(6) Individuals who age out of Children’s Medical Services and meet the following criteria for the Aged/Disabled Adult waiver:

(a) Received care from Children’s Medical Services prior to turning age 21;

(b) Age 21 and older;

(c) Cognitively intact;

(d) Medically complex; and

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 1 of 76

(e) Technologically dependent.

(7) Assisted Living waiver;

(8) Nursing Home Diversion waiver;

(9) Channeling waiver;

(10) Low Income Families and Children;

(11) MEDS (SOBRA) for children born after 9/30/83 (age 18 — 20);

(12) MEDS AD (SOBRA) for aged and disabled;

(13) Protected Medicaid (aged and disabled);

(14) Full Benefit Dual Eligibles (Medicare and Medicaid);

(15) Individuals enrolled in the Frail/Elderly Program component of United Healthcare HMO; and

(16) Medicaid Pending for Long-term Care Managed Care HCBS waiver services.

2. Voluntary Populations

Eligible recipients eighteen (18) years or older in any of the following eligibility categories may, but are not required to, enroll in a Managed Care Plan if they have been determined by CARES to meet the nursing facility level of care:

a. Traumatic Brain and Spinal Cord Injury waiver;

b. Project AIDS Care (PAC) waiver;

c. Adult Cystic Fibrosis waiver;

d. Program of All-Inclusive Care for the Elderly (PACE) plan members;

e. Familial Dysautonomia waiver;

f. Model waiver (age 18 — 20);

g. Developmental Disabilities waiver (iBudget and Tiers 1-4);

h. Medicaid for the Aged and Disabled (MEDS AD) — Sixth Omnibus Budget Reconciliation Act (SOBRA) for aged and disabled — enrolled in Developmental Disabilities (DD) waiver; and

i. Recipients with other creditable coverage excluding Medicare.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 2 of 76

3. Excluded Populations

a. Recipients in any eligibility category not listed in items A., Eligibility, sub-items 1., Mandatory Populations and 2., Voluntary Populations, above are excluded from enrollment in a LTC Managed Care Plan.

b. In addition, regardless of eligibility category, the following recipients are excluded from enrollment in a LTC Managed Care Plan:

(1) Recipients residing in residential commitment facilities operated through DJJ or mental health facilities;

(2) Recipients residing in DD centers including Sunland and Tacachale;

(3) Children receiving services in a prescribed pediatric extended care center (PPEC);

(4) Children with chronic conditions enrolled in the Children’s Medical Services Network; and

(5) Recipients in the Health Insurance Premium Payment (HIPP) program.

4. Medicaid Pending for Home and Community-Based Services

a. The Managed Care Plan shall authorize and provide services to Medicaid Pending enrollees as specified in Section V, Covered Services.

b. Medicaid Pending recipients may choose to disenroll from the Managed Care Plan at any time, but the Managed Care Plan shall not encourage the enrollee to do so. However, Medicaid Pending recipients may not change managed care plans until full financial Medicaid eligibility is complete.

c. The Managed Care Plan shall be responsible for reimbursing subcontracted providers for the provision of home and community-based services (HCBS) during the Medicaid Pending period, whether or not the enrollee is determined financially eligible for Medicaid by DCF. The Managed Care Plan shall assist Medicaid Pending enrollees with completing the DCF financial eligibility process.

d. The Agency will notify the Managed Care Plan in a format to be determined by the Agency of Medicaid Pending recipients that have chosen to enroll in the Managed Care Plan on a schedule consistent with the X-12 834 monthly enrollment files. On the first of the month after the notification, the Managed Care Plan shall provide services as indicated in Section V, Covered Services. The Managed Care Plan shall not deny or delay services covered under this Contract to Medicaid Pending enrollees based on their Medicaid eligibility status.

e. The Agency will notify the Managed Care Plan if and when Medicaid Pending enrollees are determined financially eligible by DCF via the X-12 834 enrollment files. If full Medicaid eligibility is granted by DCF, the Managed Care Plan shall be reimbursed a capitated rate, by whole months, retroactive to the first of the month in which the recipient was enrolled into the Managed Care Plan as a Medicaid Pending enrollee. At the request of the Agency,

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 3 of 76

the Managed Care Plan shall provide documentation to prove all medically necessary services were provided for the Medicaid Pending recipient during their pending status.

f. If DCF determines the recipient is not financially eligible for Medicaid, the Managed Care Plan may terminate services and seek reimbursement from the enrollee. In this instance only, the Managed Care Plan may seek reimbursement only from the individual for documented services, claims, copayments and deductibles paid on behalf of the Medicaid Pending enrollee for services covered under this Contract during the period in which the Managed Care Plan should have received a capitation payment for the enrollee in a Medicaid Pending status. The Managed Care Plan shall send the affected enrollee an itemized bill for services. The itemized bill and related documentation shall be included in the enrollee’s case notes. The Managed Care Plan shall not allow subcontractors to seek payment from the Medicaid Pending enrollee on behalf of the Managed Care Plan.

B. Enrollment

There are no additional enrollment provisions unique to the LTC managed care program.

C. Disenrollment

There are no additional disenrollment provisions unique to the LTC managed care program.

D. Marketing

There are no additional marketing provisions unique to the LTC managed care program.

Section IV. Enrollee Services and Grievance Procedures

A. Enrollee Materials

1. New Enrollee Procedures and Materials

For each new HCBS enrollee, the Managed Care Plan shall complete and submit to DCF a 2515 form (Certification of Enrollment Status HCBS) within five (5) business days after receipt of the applicable enrollment file from the Agency or its agent. The Managed Care Plan shall retain proof of submission of the completed 2515 form to DCF.

2. Enrollee Handbook Requirements

The Managed Care Plan shall include additional information in its handbooks applicable to the LTC program, as follows:

a. An explanation of the role of the case manager and how to access a case manager;

b. Instructions on how to access services included in an enrollee’s plan of care;

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 4 of 76

c. Information regarding how to develop the enrollee disaster/emergency plan including information on personal and family plans and shelters, dealing with special medical needs, local shelter listings, special needs registry, evacuation information, emergency preparedness publications for people with disabilities, and information for caregivers, all of which is available at the web site www.floridadisaster.org;

d. Information regarding how to develop a contingency plan to cover gaps in services;

e. A signature page for signature of the enrollee/authorized representative;

f. Instructions on how to access appropriate state or local educational and consumer resources providing additional information regarding residential facilities and other Long-term Care providers in the Managed Care Plan’s network. At a minimum, the Managed Care Plan shall include the current website addresses for the Agency’s Health Finder website (www.FloridaHealthFinder.gov) and the Department of Elder Affairs’ Florida Affordable Assisted Living consumer website (http://elderaffairs.state.fl.us/faal/).

g. Information regarding participant direction for the following services:

(1) Attendant care services;

(2) Homemaker services;

(3) Personal care services;

(4) Adult companion care services; and

(5) Intermittent and skilled nursing.

h. Patient responsibility obligations for enrollees residing in a residential facility.

B. Enrollee Services

1. Medicaid Redetermination Assistance

a. The Managed Care Plan shall send enrollees Medicaid redetermination notices and assist enrollees with maintaining eligibility.

b. The Managed Care Plan shall develop a process for tracking eligibility redetermination and documenting the assistance provided by the Managed Care Plan to ensure continuous Medicaid eligibility, including both financial and medical/functional eligibility.

c. The Managed Care Plan’s assistance shall include:

(1) Within the requirements provided below, using Medicaid recipient redetermination date information provided by the Agency to remind enrollees that their Medicaid eligibility may end soon and to reapply for Medicaid if needed;

(2) Assisting enrollees to understand applicable Medicaid income and asset limits and, as appropriate and needed, supporting enrollees to meet verification requirements;

(3) Assisting enrollees to understand any patient responsibility obligation they may need to meet to maintain Medicaid eligibility;

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 5 of 76

(4) Assisting enrollees to understand the implications of their functional level of care as it relates to the eligibility criteria for the program;

(5) Having staff that has received Agency-specified training complete the Agency-defined reassessment form and submit it to CARES staff to review and determine whether the enrollee continues to meet nursing facility level of care; and

(6) If appropriate and needed, assisting enrollees to obtain an authorized representative.

d. The Agency will provide Medicaid recipient redetermination date information to the Managed Care Plan.

e. The Managed Care Plan shall train all affected staff, prior to implementation, on its policies and procedures and the Agency’s requirements regarding the use of redetermination date information. The Managed Care Plan shall document such training has occurred, including a record of those trained, for the Agency’s review within five (5) business days after the Agency’s request.

f. The Managed Care Plan shall use redetermination date information in written notices to be sent to their enrollees reminding them that their Medicaid eligibility may end soon and to reapply for Medicaid if needed. The Managed Care Plan shall adhere to the following requirements:

(1) The Managed Care Plan shall mail the redetermination date notice to each enrollee for whom it has received a redetermination date. The Managed Care Plan may send one (1) notice to the enrollee’s household when there are multiple enrollees within a family who have the same Medicaid redetermination date, provided that these enrollees share the same mailing address.

(2) The Managed Care Plan shall use the Agency-provided LTC template for its redetermination date notices. The Managed Care Plan may put this template on its letterhead for mailing; however, the Managed Care Plan shall make no other changes, additions or deletions to the letter text.

(3) The Managed Care Plan shall mail the redetermination date notice to each enrollee no more than sixty (60) days and no less than thirty (30) days before the redetermination date occurs.

g. The Managed Care Plan shall keep the following information about each mailing made available for the Agency’s review within five (5) business days after the Agency’s request. For each month of mailings, a dated hard copy or pdf. of the monthly template used for that specific mailing shall include:

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 6 of 76

(1) A list of enrollees to whom a mailing was sent. This list shall include each enrollee’s name and Medicaid identification number, the address to which the notice was mailed, and the date of the Agency’s enrollment file used to create the mailing list; and

(2) A log of returned, undeliverable mail received for these notices, by month, for each enrollee for whom a returned notice was received.

h. The Managed Care Plan shall keep up-to-date and approved policies and procedures regarding the use, storage and securing of this information as well as address all requirements of this subsection.

i. Should any complaint or investigation by the Agency result in a finding that the Managed Care Plan has violated this subsection, the Managed Care Plan may be sanctioned in accordance with Section XI, Sanctions. In addition to any other sanctions available in Section XI, Sanctions, the first such violation may result in a thirty- (30) day suspension of use of Medicaid redetermination dates; any subsequent violations will result in thirty (30) day incremental increases in the suspension of use of Medicaid redetermination dates. In the event of any subsequent violations, additional penalties may be imposed in accordance with Section XI, Sanctions. Additional or subsequent violations may result in the Agency’s rescinding provision of redetermination date information to the Managed Care Plan.

C. Grievance System

There are no additional grievance system provisions unique to the LTC managed care program.

Section V. Covered Services

A. Required Benefits

1. Specific LTC Services to be Provided

a. The Managed Care Plan shall provide the services listed below in accordance with the Florida Medicaid State Plan, the Florida Medicaid Coverage and Limitations Handbooks, the Florida Medicaid fee schedules, and the provisions herein, unless otherwise specified elsewhere in this Contract. The Managed Care Plan shall comply with all state and federal laws pertaining to the provision of such services. The following provisions highlight key requirements for certain covered services, including requirements specific to the LTC program.

(1) Adult Companion Care — Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions assist or supervise the enrollee with tasks such as meal preparation or laundry and shopping, but do not perform these activities as discreet services. The provision of companion services does not entail hands-on nursing care. This service includes light housekeeping tasks incidental to the care and supervision of the enrollee.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 7 of 76

(2) Adult Day Health Care — Services provided pursuant to Chapter 429, Part III, F.S. Services furnished in an outpatient setting which encompass both the health and social services needed to ensure optimal functioning of an enrollee, including social services to help with personal and family problems and planned group therapeutic activities. Adult day health care includes nutritional meals. Meals are included as a part of this service when the patient is at the center during meal times. Adult day health care provides medical screening emphasizing prevention and continuity of care, including routine blood pressure checks and diabetic maintenance checks. Physical, occupational and speech therapies indicated in the enrollee's plan of care are furnished as components of this service. Nursing services, which include periodic evaluation, medical supervision and supervision of self-care services directed toward activities of daily living and personal hygiene, are also a component of this service. The inclusion of physical, occupational and speech therapy services, and nursing services as components of adult day health services does not require the Managed Care Plan to contract with the adult day health provider to deliver these services when they are included in an enrollee’s plan of care. The Managed Care Plan may contract with the adult day health care provider for the delivery of these services or the Managed Care Plan may contract with other providers qualified to deliver these services pursuant to the terms of this Contract.

(3) Assistive Care Services -- An integrated set of twenty-four (24) hour services only for Medicaid-eligible residents in adult family care homes.

(4) Assisted Living — A service comprising personal care, homemaker, chore, attendant care, companion care, medication oversight, and therapeutic social and recreational programming provided in a home-like environment in an assisted living facility, licensed pursuant to Chapter 429 Part I, F.S., in conjunction with living in the facility. Service providers shall ensure enrollees reside in a facility offering care with HCB characteristics in accordance with item 3., Home-Like Environment and Community Inclusion – (HCB Characteristics), below. This service includes twenty-four- (24) hour onsite response staff to meet scheduled or unpredictable needs in a way that promotes maximum dignity independence, and to provide supervision, safety and security. Individualized care is furnished to persons who reside in their own living units (which may include dual occupied units when both occupants consent to the arrangement) which may or may not include kitchenette and/or living rooms and which contain bedrooms and toilet facilities. The resident has a right to privacy. Living units may be locked at the discretion of the resident, except when a physician or mental health professional has certified in writing that the resident is sufficiently cognitively impaired as to be a danger to self or others if given the opportunity to lock the door and all protections have been met to ensure individuals’ rights have not been violated. The facility shall have a central dining room, living room or parlor, and common activity areas, which may also serve as living rooms or dining rooms. The resident retains the right to assume risk, tempered only by a person’s ability to assume responsibility for that risk. Care shall be furnished in a way that fosters the independence of each consumer to facilitate aging in place. Routines of care provision and service delivery shall be consumer-driven to the maximum extent possible, and treat each person with dignity and respect. The Managed Care Plan may arrange for other authorized service providers to deliver care to residents of assisted living facilities in the same manner as those services would be delivered

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to a person in their own home. ALF administrators, direct service personnel and other outside service personnel such as physical therapists have a responsibility to encourage enrollees to take part in social, educational and recreational activities they are capable of enjoying. All services provided by the assisted living facility shall be included in a care plan maintained at the facility with a copy provided to the enrollee’s case manager. The Managed Care Plan shall be responsible for placing enrollees in the appropriate assisted living facility setting based on each enrollee’s choice and service needs.

(5) Attendant Care — Hands-on care, of both a supportive and health-related nature, specific to the needs of a medically stable, physically handicapped individual. Supportive services are those which substitute for the absence, loss, diminution or impairment of a physical or cognitive function. This service may include skilled or nursing care to the extent permitted by state law. Housekeeping activities which are incidental to the performance of care may also be furnished as part of this activity.

(6) Behavioral Management — This service provides behavioral health care services to address mental health or substance abuse needs of members. These services are in excess of those listed in the Community Behavioral Health Services Coverage and Limitations Handbook and the Mental Health Targeted Case Management Coverage and Limitations Handbook. The services are used to maximize reduction of the enrollee’s disability and restoration to the best possible functional level and may include, but are not limited to: an evaluation of the origin and trigger of the presenting behavior; development of strategies to address the behavior; implementation of an intervention by the provider; and assistance for the caregiver in being able to intervene and maintain the improved behavior.

(7) Caregiver Training — Training and counseling services for individuals who provide unpaid support, training, companionship or supervision to enrollees. For purposes of this service, individual is defined as any person, family member, neighbor, friend, companion or co-worker who provides uncompensated care, training, guidance, companionship or support to an enrollee. This service may not be provided to train paid caregivers. Training includes instruction about treatment regimens and other services included in the plan of care, use of equipment specified in the plan of care, and includes updates as necessary to safely maintain the enrollee at home. Counseling shall be aimed at assisting the unpaid caregiver in meeting the needs of the enrollee. All training for individuals who provide unpaid support to the enrollee shall be included in the enrollee’s plan of care.

(8) Care Coordination/Case Management -- Services that assist enrollees in gaining access to needed waiver and other State plan services, as well as other needed medical, social, and educational services, regardless of the funding source for the services to which access is gained. Case management services contribute to the coordination and integration of care delivery through the ongoing monitoring of service provision as prescribed in each enrollee's plan of care.

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(9) Home Accessibility Adaptation Services — Physical adaptations to the home required by the enrollee's plan of care which are necessary to ensure the health, welfare and safety of the enrollee or which enable the enrollee to function with greater independence in the home and without which the enrollee would require institutionalization. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems to accommodate the medical equipment and supplies, which are necessary for the welfare of the enrollee. Excluded are those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the enrollee, such as carpeting, roof repair or central air conditioning. Adaptations which add to the total square footage of the home are not included in this service. All services shall be provided in accordance with applicable state and local building codes.

(10) Home Delivered Meals — Nutritionally sound meals to be delivered to the residence of an enrollee who has difficulty shopping for or preparing food without assistance. Each meal is designed to provide a minimum thirty-three and three tenths percent (33.3%) of the current Dietary Reference Intake (DRI). The meals shall meet the current Dietary Guidelines for Americans, the USDA My Pyramid Food Intake Pattern and reflect the predominant statewide demographic.

(11) Homemaker Services — General household activities such as meal preparation and routine household care provided by a trained homemaker when the individual regularly responsible for these activities is temporarily absent or unable to manage these activities. Chore services, including heavy chore services, and pest control may be included in this service.

(12) Hospice — Services are forms of palliative medical care and services designed to meet the physical, social, psychological, emotional and spiritual needs of terminally ill recipients and their families. Hospice care focuses on palliative care rather than curative care. An individual is considered to be terminally ill if he has a medical diagnosis with a life expectancy of six (6) months or less if the disease runs its normal course.

(13) Intermittent and Skilled Nursing — The scope and nature of these services do not differ from skilled nursing furnished under the State Plan. This service includes the home health benefit available under the Medicaid state plan as well as expanded nursing services coverage under this waiver. Services listed in the plan of care that are within the scope of Florida’s Nurse Practice Act and are provided by a registered professional nurse, or licensed practical or vocational nurse under the supervision of a registered nurse, licensed to practice in the state. Skilled nursing services shall be listed in the enrollee’s plan of care and are provided on an intermittent basis to enrollees who either do not require continuous nursing supervision or whose need is predictable.

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(14) Medical Equipment and Supplies — Medical equipment and supplies, specified in the plan of care, include: (a) devices, controls or appliances that enable the enrollee to increase the ability to perform activities of daily living; (b) devices, controls or appliances that enable the enrollee to perceive, control or communicate the environment in which he or she lives; (c) items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items; (d) such other durable and non-durable medical equipment that is necessary to address enrollee functional limitations; (e) necessary medical supplies not available under the State Plan including consumable medical supplies such as adult disposable diapers. This service includes the durable medical equipment benefits available under the state plan service as well as expanded medical equipment and supplies coverage under this waiver. All items shall meet applicable standards of manufacture, design and installation. This service also includes repair of such items as well as replacement parts.

(15) Medication Administration — Pursuant to s. 429.256, F.S., assistance with self-administration of medications, whether in the home or a facility, includes taking the medication from where it is stored and delivering it to the enrollee; removing a prescribed amount of medication from the container and placing it in the enrollee’s hand or another container; helping the enrollee by lifting the container to their mouth; applying topical medications; and keeping a record of when an enrollee receives assistance with self-administration of their medications.

(16) Medication Management — Review by the licensed nurse of all prescriptions and over-the-counter medications taken by the enrollee, in conjunction with the enrollee’s physician. The purpose of the review is to assess whether the enrollee’s medication is accurate, valid, non-duplicative and correct for the diagnosis; that therapeutic doses and administration are at an optimum level; that there is appropriate laboratory monitoring and follow-up taking place; and that drug interactions, allergies and contraindications and being assessed and prevented.

(17) Nutritional Assessment/Risk Reduction Services — An assessment, hands-on care, and guidance to caregivers and enrollees with respect to nutrition. This service teaches caregivers and enrollees to follow dietary specifications that are essential to the enrollee’s health and physical functioning, to prepare and eat nutritionally appropriate meals and promote better health through improved nutrition. This service may include instructions on shopping for quality food and food preparation.

(18) Nursing Facility Services — Services furnished in a health care facility licensed under Chapter 395 or Chapter 400, F.S. per the Nursing Facility Coverage and Limitation Handbook.

(19) Personal Care — A service that provides assistance with eating, bathing, dressing, personal hygiene, and other activities of daily living. This service includes assistance with preparation of meals, but does not include the cost of the meals. This service may also include housekeeping chores such as bed making, dusting and vacuuming, which are incidental to the care furnished or are essential to the health and welfare of the enrollee, rather than the enrollee's family.

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(20) Personal Emergency Response Systems (PERS) — The installation and service of an electronic device that enables enrollees at high risk of institutionalization to secure help in an emergency. The PERS is connected to the person's phone and programmed to signal a response center once a "help" button is activated. The enrollee may also wear a portable "help" button to allow for mobility. PERS services are generally limited to those enrollees who live alone or who are alone for significant parts of the day and who would otherwise require extensive supervision.

(21) Respite Care — Services provided to enrollees unable to care for themselves furnished on a short-term basis due to the absence or need for relief of persons normally providing the care. Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist. Respite care is provided in the home/place of residence, Medicaid licensed hospital, nursing facility or assisted living facility.

(22) Occupational Therapy — Treatment to restore, improve or maintain impaired functions aimed at increasing or maintaining the enrollee’s ability to perform tasks required for independent functioning when determined through a multi-disciplinary assessment to improve an enrollee’s capability to live safely in the home setting.

(23) Physical Therapy — Treatment to restore, improve or maintain impaired functions by use of physical, chemical and other properties of heat, light, electricity or sound, and by massage and active, resistive or passive exercise. There shall be an explanation that the patient’s condition will be improved significantly (the outcome of the therapies shall be measureable by the attending medical professional) in a reasonable (and generally predictable) period of time based on an assessment of restoration potential, or a determination that services are necessary to a safe and effective maintenance program for the enrollee, using activities and chemicals with heat, light, electricity or sound, and by massage and active, resistive or passive exercise when determined through a multi-disciplinary assessment to improve an enrollee’s capability to live safely in the home setting.

(24) Respiratory Therapy — Treatment of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system. Services include evaluation and treatment related to pulmonary dysfunction.

(25) Speech Therapy — The identification and treatment of neurological deficiencies related to feeding problems, congenital or trauma-related maxillofacial anomalies, autism, or neurological conditions that effect oral motor functions. Therapy services include the evaluation and treatment of problems related to an oral motor dysfunction when determined through a multi-disciplinary assessment to improve an enrollee’s capability to live safely in the home setting.

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(26) Transportation – Non-emergent transportation services shall be offered in accordance with the enrollee’s plan of care and coordinated with other service delivery systems. This non-emergency transportation service includes trips to and from services offered by the LTC Managed Care Plan and includes trips to and from the Managed Care Plan’s expanded benefits.

b. The Managed Care Plan shall provide covered services to enrollees who lose eligibility for up to sixty (60) days. Likewise, care coordination/case management services shall continue for such enrollees for up to sixty (60) days.

2. Participant Direction Option (PDO)

a. General Provisions

(1) The Managed Care Plan is responsible for implementing and managing the Participant Direction Option (PDO) as defined in Section I, Definitions and Acronyms. The Managed Care Plan shall ensure the PDO is available to all Long-term Care enrollees who have any PDO-qualifying service on their authorized care plan and who live in their own home or family home.

(2) An enrollee’s care plan shall include one or more of the following services in order for the enrollee to be eligible to participate in the PDO: adult companion care, attendant care, homemaker services, intermittent and skilled nursing, or personal care. The enrollee may choose to participate in the PDO for one or more of the eligible PDO services, as outlined in their authorized care plan.

(3) Enrollees who receive PDO services shall be called “participants” in any PDO specific published materials. The enrollee shall have employer authority. An enrollee may delegate their employer authority to a representative. The representative can neither be paid for services as a representative, nor be a direct service worker. For the purposes of this section, “enrollee” means the enrollee or their representative.

(4) The Managed Care Plan shall develop PDO-specific policies and procedures that shall be updated at least annually and shall obtain Agency approval prior to distributing PDO materials to enrollees, representatives, direct service workers, and case managers.

(5) The Managed Care Plan shall operate the PDO service delivery option in a manner consistent with the PDO Manual and the PDO Participant Guidelines provided by the Agency.

(6) The Agency will provide templates for the following to the Managed Care Plan: PDO Consent Form, PDO Representative Agreement, PDO Participant Guidelines, PDO Training Evaluations, and PDO Pre-Screening Tool.

(7) The Managed Care Plan shall maintain books, records, documents, and other evidence of PDO-related expenditures using generally accepted accounting principles (GAAP).

(8) The Managed Care Plan shall submit a PDO report monthly as specified in Section XIV, Reporting Requirements and the Managed Care Plan Report Guide. The

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Managed Care Plan shall provide ad-hoc PDO related information, records, and statistics, at the request of the Agency within the specified timeframe.

(9) The Agency will conduct PDO satisfaction surveys on at least an annual basis and shall provide results to the Managed Care Plan for use in quality improvement plans.

(10) The Managed Care Plan shall cooperate with, and participate in, ongoing evaluations and focus groups conducted by the Agency to evaluate the quality of the PDO.

b. Training Requirements

(1) The Managed Care Plan shall ensure all applicable staff receives basic training on the PDO service delivery option

(2) The Managed Care Plan shall designate staff to participate in PDO training conducted by the Agency.

(3) The Managed Care Plan shall ensure an adequate number of case managers are trained extensively in the PDO. This extensive PDO training, beyond the general PDO informational training, is provided to case managers who serve enrollees and consists of training specific to PDO employer responsibilities, such as: completing federal and state tax documents, interviewing potential direct service workers, developing Emergency Back-up Plans, training direct service workers, completing the PDO Pre-Screening tool, evaluating direct service worker job performance, and completing and submitting timesheets.

(4) The Managed Care Plan shall submit completed PDO Training Evaluations from all Managed Care Plan staff and case manager trainings, to the Agency, on at least an annual basis. The Agency will supply a PDO Training Evaluation template to be distributed during all Managed Care Plan staff and case manager trainings.

(5) The Managed Care Plan shall provide PDO-trained staff as part of the enrollee and provider call centers to be available during the business hours specified in this Contract.

c. PDO Case Management

(1) The case manager is responsible for informing enrollees of the option to participate in the PDO when any of the PDO services are listed on the enrollee’s authorized care plan.

(2) The Managed Care Plan shall assign a case manager trained extensively in the PDO within two business days of an enrollee electing to participate in the PDO delivery option.

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(3) In addition to the other case manager requirements in this Contract, all case managers are responsible for:

(a) Documenting the PDO was offered to the enrollee, initially and annually, upon reassessment. This documentation shall be signed by the enrollee and included in the case file;

(b) Referring Managed Care Plan enrollees, who have expressed an interest in choosing the PDO, to available case managers who have received specialized PDO training.

(4) In addition to the other case manager requirements in this Contract, case managers who have received extensive PDO training are responsible for:

(a) Completing the PDO Pre-Screening Tool with each enrollee and prospective representative;

(b) Ensuring enrollees choosing the PDO understand their roles and responsibilities;

(c) Ensuring the Participant Agreement is signed by enrollees and included in the case file;

(d) Facilitating the transition of enrollees to, and from, the PDO service delivery system;

(e) Ensuring PDO and non-PDO services do not duplicate;

(f) Training enrollees, initially, and as needed, on employer responsibilities such as: creating job descriptions, interviewing, hiring, training, supervising, evaluating job performance, and terminating employment of the direct service worker(s);

(g) Assisting enrollees as needed with finding and hiring direct service workers;

(h) Assisting enrollee’s with resolving disputes with direct service workers and/or taking employment action against direct service workers;

(i) Assisting enrollees with developing emergency back-up plans including identifying Plan network providers and explaining the process for accessing network providers in the event of a foreseeable or unplanned lapse in PDO services;

(j) Assisting and training enrollees as requested in PDO related subjects.

d. Enrollee Employer Authority/Direct Service Workers

(1) Enrollees may hire any individual who satisfies the minimum qualifications set forth in Section VII, Provider Network including, but not limited to, neighbors, family members, or friends. The Managed Care Plan shall not restrict an enrollees’ choice

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of direct service worker(s) or require them to choose providers in the Managed Care Plan’s provider network.

(2) The Managed Care Plan shall inform enrollees, upon choosing the PDO, of the rate of payment for the PDO services. If the rate of payment changes for any PDO service, the Managed Care Plan shall provide a written notice to the applicable enrollees and direct service workers, at least thirty (30) days prior to the change.

(3) The Managed Care Plan shall ensure the enrollees update their Participant/Direct Service Worker Agreement indicating any changes in rate of payment.

(4) The Managed Care Plan shall provide instructions to the enrollee regarding the submission of timesheets.

(5) The Managed Care Plan shall ensure the Participant/Direct Service Worker Agreement includes, at a minimum, include the following:

(a) Service(s) to be provided;

(b) Hourly rate;

(c) Direct service worker work schedule;

(d) Relationship of the direct service worker to the enrollee;

(e) Job description and duties;

(f) Agreement statement; and

(g) Dated signatures of the case manager, enrollee, and direct service worker.

(6) The Managed Care Plan shall pay for Level 2 background screening for at least one representative (if applicable) per enrollee and at least one direct service worker for each service per enrollee, per Contract year. The Managed Care Plan shall receive the results of the background screening and make a determination of clearance, adhering to all requirements in Chapters 435 and 408.809 F.S.

(7) The Managed Care Plan shall monitor over and under use of services based on payroll and an enrollee’s approved care plan and provide reports to the Agency, or its designee.

e. Fiscal/Employer Agent

(1) The Managed Care Plan shall be the Fiscal/Employer Agent (F/EA) for PDO enrollee’s or may sub-contract this function. Should any of the F/EA duties be sub-contracted, the Managed Care Plan shall provide enrollees with at least thirty (30) days’ notice informing them that the Managed Care Plan shall utilize a subcontractor to perform certain F/EA duties.

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(2) The Managed Care Plan shall meet all applicable PDO-related Federal and State requirements and shall be operated in accordance with Section 3504 of the Internal Revenue Code, per Revenue Procedure 70-6 and Section 3504 Agent Employment Tax Liability proposed regulations (REG-137036-08) issued by the IRS on January 13, 2010.

(3) The Managed Care Plan remain abreast of all federal and state F/EA requirements and tax forms, and shall ensure all materials distributed to enrollees, representatives, direct service workers, and case managers are current, and in accordance with the appropriate federal and state regulations.

(4) The Managed Care Plan shall have a separate Federal Employer Identification Number (FEIN) that is used only for purposes of representing enrollees as employers. This FEIN should not be used to file or pay taxes for the Managed Care Plan’s staff.

(5) The Managed Care Plan shall complete the following payroll and F/EA tasks:

(a) Develop a pay schedule and distribute it to all enrollees at least annually;

(b) Collect and process timesheets submitted by the enrollee. Resolve any timesheet issues with the enrollee and/or direct service worker;

(c) Disburse payroll (no less than twice per month) by direct deposit or pre-paid card to each direct service worker who has a complete and current Hiring Packet on file and has provided services to an enrollee as authorized in the enrollee’s care plan and the Participant/ Direct Service Worker Agreement by the published pay date;

(d) Maintain payroll documentation for all direct service workers;

(e) Compute, maintain, and appropriately withhold all employer and direct service worker taxes pursuant to federal and state law. All payments that are not in compliance with federal and state tax withholding, reporting, and payment requirements shall be corrected within two (2) business days of identifying an error;

(f) Process applicable direct service worker garnishments, liens, and levies in accordance with state and federal garnishment rules. Submit payments and reports to applicable agencies per garnishment instructions;

(g) Deposit direct service worker aggregate payroll deductions per federal and state tax deposit requirements. Federal Income Tax, Social Security and Medicare and enrollee Federal Social Security and Medicare (FICA) taxes in the aggregate per deposit frequency required by an F/EA.(see http://www.irs.gov/businesses/small/article/0,,id=98818,00.html);

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(h) Deposit employer aggregate tax deductions per federal and state tax deposit requirements. Federal Unemployment Tax (FUTA) shall be deposited in the aggregate per F/EA deposit frequency. (see http://www.irs.gov/businesses/small/article/0,,id=98818,00.html);

(i) Refund over-collected FICA for direct service workers who earn less than the Federal FICA threshold for the calendar year (see IRS Publication 15, Circular E for threshold information);

(j) File a single IRS Form 941, Employer’s Quarterly Tax Return in the aggregate on behalf of all enrollees represented by the Managed Care Plan. Form 941 is completed using the Managed Care Plan’s separate F/EA, FEIN. Wages and taxes reported represent total, aggregate wages and taxes for all enrollees represented by the Managed Care Plan. Schedule B should be completed per rules. The Managed Care Plan shall also complete and submit Schedule R with the Form 941. Schedule R disaggregates each enrollee’s employer wages and federal tax liability;

(k) Adjust Forms 941 as applicable by completing and filing IRS Form 941-X.

(l) File a single IRS Form 940, Employer’s Annual Federal Unemployment Tax Return in the aggregate on behalf of all enrollees represented by the Managed Care Plan. Form 940 is completed using the Managed Care Plan’s separate FEIN. Wages and FUTA tax reported represent total, aggregate wages and taxes for all enrollees represented by the Managed Care Plan. Note: Even Managed Care Plans incorporated with a nonprofit 501c3 status SHALL file and pay FUTA on behalf of enrollees;

(m) Process and distribute IRS Forms W-2 to the direct service workers and submit them electronically according to IRS Form W-2 instructions, per IRS rules and regulations;

(n) Track payroll disbursed to all direct service workers and provide reports as may be required by the Agency or its designee in accordance with this Contract;

(o) Provide written notification to the case manager and enrollee if utilization is less than 10% of the monthly hours as approved on the authorized care plan for more than one month;

(p) Obtain workers’ compensation coverage for the enrollee’s direct service workers, if required by Florida statute or rule (see, e.g., Chapter 440, F.S., and Rule 69L, F.A.C.), which shall be funded by the Managed Care Plan;

(q) Comply with, and support enrollee compliance with, state workers’ compensation audits as applicable;

(r) Prepare for and support enrollee preparation for unemployment claim proceedings, as applicable;

(s) Maintain records in compliance with Fair Labor Standards Act requirements for employers;

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(t) Ensure a payroll system with maximum data integrity in which direct service workers are not paid above authorized hours as prescribed in the enrollee’s care plan and the Participant/Direct Service Worker Agreement;

(u) Respond to requests for direct service worker employment verification;

(v) Perform all duties regarding disenrollment of an enrollee from the PDO, including final federal and state tax filings and payments and revocation of accounts, numbers, and authorizations previously obtained by the Managed Care Plan. This includes retiring the FEIN and State Unemployment Tax Account (SUTA) Number;

(w) Provide a transitioning enrollee’s new plan with the enrollee’s FEIN and SUTA numbers.

f. PDO Monitoring

The Managed Care Plan shall monitor for compliance with PDO requirements, and shall report to the Agency or its designee upon request for an annual F/EA Quality Assessment and Performance Review including:

(1) Whether timesheets are signed by the enrollee (or representative, if applicable) and the direct service worker;

(2) Utilization of services based on payroll and an enrollee’s approved care plan;

(3) Whether services, duties, and hours listed on the Participant/Direct Service Worker Agreement are in compliance with the authorized care plan;

(4) Whether direct service workers are qualified pursuant to the PDO Participant Guidelines and the PDO Manual, prior to providing services to an enrollee;

(5) Duplication of PDO and non-PDO services.

3. Home-Like Environment and Community Inclusion - (HCB Characteristics)

a. Each enrollee is guaranteed the right to receive home and community-based services in a home-like environment and participate in his or her community regardless of his or her living arrangement.

b. The Managed Care Plan shall ensure enrollees who reside in assisted living facilities and adult family care homes reside in a home-like environment, and are integrated into their community as much as possible, unless medical, physical, or cognitive impairments restrict or limit exercise of these options which, at a minimum, includes the following characteristics:

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(1) Choice of: private or semi-private rooms; roommate for semi-private rooms; locking door to living unit; access to telephone and length of use; eating schedule; and participation in facility and community activities;

(2) Ability to have unlimited visitation; and snacks as desired; and

(3) Ability to prepare snacks as desired; and maintain personal sleeping schedule.

c. The Managed Care Plan shall include language in the enrollee handbook explaining the enrollee’s right to receive home and community-based services in a HCB characteristic compliant setting regardless of their living arrangement. It shall provide enrollees with information regarding the community integration goal planning process and their participation in that process.

d. The case manager shall work with the enrollee and their providers as appropriate to facilitate the enrollee’s personal goals and community activities. The case manager is responsible for continuously educating the enrollee of their rights and documenting their efforts in the case file for Agency review.

e. The case manager shall discuss these rights with enrollees residing in assisted living facilities and adult family care homes at least annually and document this in the case file for Agency review.

f. The Managed Care Plan shall include language provided by the Agency pursuant to HCB characteristics in its provider contract agreements with assisted living facility and adult family care home providers, and shall require these providers to be in compliance with the Assisted Care Communities Resident Bill of Rights per s. 429.28, Florida Statutes.

g. The Managed Care Plan shall verify during the credentialing and recredentialing process that assisted living facilities and adult family care homes conform to the HCB characteristics as described herein. Verification shall include on-site review of the facilities by the managed care plan staff prior to the Managed Care Plan offering the provider as a provider choice to enrollees.

h. The Managed Care Plan shall include documentation of all network assisted living facility and adult family care homes’ compliance with the requirements of this contract in each provider’s credentialing and recredentialing file for Agency review.

i. The Managed Care Plan shall take corrective action as necessary if the Managed Care Plan or the Agency concludes an assisted living facility or adult family care home does not meet the HCB characteristics.

j. Upon receipt of finding an assisted living facility or adult family care home is not in compliance with and part of the HCB characteristics, the Managed Care Plan shall have fifteen (15) business days to both ensure the deficiencies are rectified and submit accompanying documentation to the Agency, or if required, to submit a corrective action plan.

k. The Managed Care Plan shall not place, shall not continue to place, and shall not receive reimbursement for, enrollees in an assisted living facility or adult family care home that

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does not meet the HCB characteristics and/or does not have an effective provider agreement including the HCB characteristic language provided by the Agency.

l. The Managed Care Plan shall transition enrollees out of assisted living facilities and adult family care homes that do not meet HCB characteristics and do not take corrective action if the enrollee wishes to remain enrolled in the Managed Care Plan.

m. The Managed Care Plan may involuntarily disenroll an enrollee who wishes to remain in an assisted living facility or adult family care home that does not comply with HCB characteristics pursuant to this Contract.

B. Expanded Benefits

There are no additional expanded benefits provisions unique to the LTC managed care program.

C. Excluded Services

There are no additional excluded services provisions unique to the LTC managed care program.

D. Coverage Provisions

1. Case Closure Standard

a. Case managers are required to provide community referral information on available services and resources to meet the needs of enrollees who are no longer eligible for the Long-term Care component of the SMMC program.

b. If a service is closed because the Managed Care Plan has determined that it is no longer medically necessary, the enrollee shall be given a written Notice of Action regarding the intent to discontinue the service that contains information about his/her rights with regards to that decision.

c. When the enrollee’s enrollment will be changed to another Managed Care Plan, the case manager shall coordinate a transfer between the managed care plans. This includes transferring case management records from the prior twelve (12) months to the new managed care plan.

d. The case manager is responsible for notification of and coordination with service providers to assure a thorough discharge planning process and transition case management.

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e. Case notes shall be updated to reflect closure activity, including, but not limited to:

(1) Reason for the closure;

(2) Enrollee’s status at the time of the closure; and

(3) Referrals to community resources if the enrollee is no longer Medicaid eligible.

2. Abuse/Neglect and Adverse Incident Reporting Standard

The Managed Care Plan shall ensure the adherence to the following provisions:

After receiving a referral, Florida Adult Protective Services Unit assigns a risk-level designation of “low,” “intermediate” or “high” for each referral. If the enrollee needs immediate protection from further harm, which can be accomplished completely or in part with the provision of home and community-based services, the referral is designated "high” risk. The Managed Care Plan shall serve enrollees who have been designated “high” risk within seventy-two (72) hours after being referred to the Managed Care Plan from the Florida Adult Protective Services Unit or designee, as mandated by Florida Statute. To ensure the Florida Adult Protective Services Unit can easily contact the Managed Care Plan, the Managed Care Plan shall provide the Florida Adult Protective Services Unit a primary and back-up contact person, including a telephone number, for “high” risk referrals. The Managed Care Plan’s contacts shall return calls from the Florida Adult Protective Services Unit within twenty-four (24) hours of initial contact by the Florida Adult Protective Services Unit.

3. Monitoring of Care Coordination and Services

a. The Managed Care Plan shall describe inter-departmental interface with UM, Care Coordination, Quality Management and inter-agency coordination (e.g., DOEA, AHCA) in the Case Management Program Description. Interface shall include electronic and written reports and verbal communication required for coordination of care planning activities.

b. Service Gap Identification and Contingency Plan

(1) The Managed Care Plan shall ensure the case manager review, with the enrollee and/or representative, the Managed Care Plan’s process for immediately reporting any unplanned gaps in service delivery at the time of each plan of care review for each HCBS enrollee receiving in-home HCBS.

(2) The Managed Care Plan shall develop a standardized system for verifying and documenting the delivery of services with the enrollee or representative after authorization. The case manager shall verify the Managed Care Plan’s documentation of assisted living services components and their delivery as detailed in the plan of care during each face-to-face review.

(3) The Managed Care Plan shall develop a form for use as a Service Gap Contingency and Back-Up Plan for enrollees receiving HCBS in the home. A gap in in-home HCBS is defined as the difference between the number of hours of home care worker critical service scheduled in each enrollee’s HCBS plan of care and the hours of the scheduled type of in-home HCBS that are actually delivered to the enrollee. This

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 22 of 76

form shall be reviewed and approved by the Agency prior to implementation. The Service Gap Contingency and Back-Up Plan shall also be completed for those enrollees who will receive any of the following HCBS services that allow the enrollee to remain in their own home:

(a) Personal Care/Attendant Care Services, including participant directed services;

(b) Homemaker;

(c) In-Home Respite; and/or

(d) Skilled and intermittent Nursing.

(4) The following situations are not considered gaps:

(a) The enrollee is not available to receive the service when the service provider arrives at the enrollee’s home at the scheduled time;

(b) The enrollee refuses the caregiver when s/he arrives at the enrollee’s home, unless the service provider’s ability to accomplish the assigned duties is significantly impaired by the caregiver’s condition or state (e.g., drug and/or alcohol intoxication);

(c) The enrollee refuses services;

(d) The provider agency or case manager is able to find an alternative service provider for the scheduled service when the regular service provider becomes unavailable;

(e) The enrollee and regular service provider agree in advance to reschedule all or part of a scheduled service; and/or

(f) The service provider refuses to go or return to an unsafe or threatening environment at the enrollee’s residence.

(5) The contingency plan must include information about actions that the enrollee and/or representative should take to report any gaps and what resources are available to the enrollee, including on-call back-up service providers and the enrollee’s informal support system, to resolve unforeseeable gaps (e.g., regular service provider illness, resignation without notice, transportation failure, etc.) within three (3) hours unless otherwise indicated by the enrollee. The informal support system shall not be considered the primary source of assistance in the event of a gap, unless this is the enrollee’s/family’s choice.

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(6) The Managed Care Plan’s contingency plan shall include the telephone numbers for provider and/or Managed Care Plan that will be responded to promptly twenty-four hours per day, seven days per week (24/7).

(7) In those instances where an unforeseeable gap in in-home HCBS occurs, it is the responsibility of the Managed Care Plan to ensure that in-home HCBS are provided within three hours of the report of the gap. If the provider agency or case manager is able to contact the enrollee or representative before the scheduled service to advise him/her that the regular service provider will be unavailable, the enrollee or representative may choose to receive the service from a back-up substitute service provider, at an alternative time from the regular service provider or from an alternate service provider from the enrollee’s informal support system. The enrollee or representative has the final say in how (informal versus paid service provider) and when care to replace a scheduled service provider who is unavailable will be delivered.

(8) When the Managed Care Plan is notified of a gap in services, the enrollee or enrollee representative shall receive a response acknowledging the gap.

(9) The contingency plan shall be discussed with the enrollee/representative at least quarterly. A copy of the contingency plan shall be given to the enrollee when developed and at the time of each review visit and updated as necessary.

4. Monitoring Activities

a. The Managed Care Plan shall implement a systematic method of monitoring its case management program to include, but not be limited to conducting quarterly case file audits and quarterly reviews of the consistency of enrollee assessments/service authorizations (inter-rater reliability). The Managed Care Plan shall compile reports of these monitoring activities to include an analysis of the data and a description of the continuous improvement strategies the Managed Care Plan has taken to resolve identified issues. This information shall be submitted to the Agency on a quarterly basis, thirty (30) days after the close of each quarter.

b. The case management case file audit tool to be used by the Managed Care Plan shall be approved by the Agency prior to implementation and revision.

c. At a minimum the case file and plan of care audit tool shall include:

(1) Verification of participant eligibility;

(2) Proper completion of assessment;

(3) Evidence of special screening for and monitoring of high risk persons and conditions;

(4) Comprehensive plan of care consistent with assessment and properly completed and signed by the individual;

(5) Management of diagnosis;

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(6) All assessment forms and plans of care are complete and comprehensive including all required signatures whenever appropriate;

(7) Appropriateness and timeliness of care;

(8) Use of services;

(9) Ongoing case narrative documenting case management visits and other contacts;

(10) Documentation of individual provider choice and Medicaid Fair-Hearing information;

(11) Evidence of quality monitoring and improvement;

(12) Satisfaction survey; and

(13) Review of complaint and the quality remediation to resolve and prevent problems.

d. The Managed Care Plan shall have data collection and analysis capabilities that enable the tracking of enrollee service utilization, cost and demographic information and maintain documentation of the need for all services provided to enrollees.

e. Utilization reporting shall include but not be limited to:

(1) Reporting by level of service;

(2) Identification of HCBS enrollees not using services;

(3) Participant direction enrollment and activity report;

(4) Care coordination/case management activity report; and

(5) Case management file audit report.

f. The Managed Care Plan shall provide reports demonstrating case management monitoring and evaluation as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. These reports shall include results for the following performance measures but not limited to:

(1) Level of care related reassessments within three-hundred thirty-five (335) days of previous level of care determination;

(2) Complete and accurate level of care forms for annual re-evaluations sent to CARES within thirty (30) days of LOC due date;

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(3) Number and percent of staff meeting mandated abuse, neglect and exploitation training requirements;

(4) Plan of care audit results;

(5) Number and percentage of enrollee plans of care being distributed within ten (10) business days of development to the enrollee’s PCP;

(6) Number and percentage of plans of care/summaries where enrollee participation is verified by signatures;

(7) Number and percentage of enrollee plans of care reviewed for changing needs on a face-to-face basis at least every three (3) months and updated as appropriate;

(8) Number and percentage of plan of care services delivered according to the plan of care as to service type, scope, amount and frequency;

(9) Number and percentage of enrollees with plans of care addressing all identified care needs;

(10) Number and frequency of enrollees having executed freedom of choice forms in their files;

(11) Number/percent of adverse/critical incidents reported within twenty-four (24) hours to the appropriate agency;

(12) Number and percent of case files that include evidence that advance directives were discussed with the enrollee; and

(13) Number and percent of enrollees requesting a Fair Hearing and outcomes.

g. The Managed Care Plan shall develop an organized quality assurance and quality improvement program to enhance delivery of services through systemic identification and resolution of enrollee issues as specified in Section VII, Quality and Utilization Management.

h. The Managed Care Plan shall develop a recording and tracking system log for enrollee complaints and resolutions and identify and resolve enrollee satisfaction issues, as specified in Core Provision, Section IV, Enrollee Services and Grievance Procedures.

5. Missed Services

The Managed Care Plan shall submit a monthly summary report of all missed facility and non-facility services in accordance with Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. For months without missed services, the Managed Care Plan shall submit a report explaining that no authorized covered services were missed during the reported month.

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6. Continuity of Care During Temporary Loss of Eligibility

The Managed Care Plan shall provide covered services to enrollees who lose eligibility for up to sixty (60) days. Likewise, care coordination/case management services shall continue for such enrollees for up to sixty (60) days.

7. Behavioral Health

The Managed Care Plan is responsible for coordinating with other entities available to provide behavioral health services including:

a. Developing and implementing a plan to ensure compliance with s. 394.4574, F.S., related to services provided to residents of licensed assisted living facilities that hold a limited mental health license. A cooperative agreement, as defined in s. 429.02, F.S., shall be developed with the ALF if an enrollee is a resident of the ALF.

b. Ensuring that appropriate behavioral health screening and assessment services are provided to plan enrollees and that medically necessary mental health targeted case management and behavioral health care services are available to all enrollees who reside in this type of setting.

c. Educating Managed Care Plan staff on screening; privacy and consent regulations and procedures; referral processes; and follow-up and provider coordination requirements.

d. Developing a systematic process for coordinating referrals to services for enrollees who request or who are identified by screening as being in need of behavior health care, by facilitating contact with the Medical Assistance managed care plan or other relevant entity or referring them to treatment providers for assessment and treatment.

e. Ensuring coordination of care of any specialized services identified in the PASRR:

(1) Federal regulations (42CFR 483.100-483.138) require Preadmission Screening and Resident Review (PASRR) for all residents of Medicaid-certified nursing facilities, regardless of payer, based on s. 1919(e)(7) of the Social Security Act. The purpose is to ensure that nursing facility applicants and residents with serious mental illness (MI), mental retardation (MR), or a related condition receive a thorough evaluation, found to be appropriate for nursing facility placement, and will receive all specialized services necessary to meet their unique needs in the least restricting setting.

(2) The PASRR process includes:

(a) PASRR Level I screening to identify possible MI/MR or related condition; and

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(b) PASRR Level II evaluation and determination when a Level I screening indicates possible MI/MR or related condition, or a Resident Review is required.

(3) Detailed information and forms related to PASRR are available at the following website: http://elderaffairs.state.fl.us/doea/cares-pasrr.php

(4) Medicaid reimbursement for nursing facility services requires providers to keep the following hard-copy documentation on file to support that:

(a) PASRR determined the recipient appropriate for the nursing facility setting;

(b) DCF determined the individual eligible for ICP; and

(c) DCF determined the monthly amount of the ICP-eligible recipient’s patient responsibility.

(5) Medicaid reimbursements are subject to recoupment, and providers are subject to sanctions and fines for any date of service:

(a) PASRR was not performed in a complete, timely and accurate manner;

(b) PASRR had not determined the individual appropriate for the nursing facility setting; or

(c) DCF had not determined the individual eligible for ICP.

f. Documenting all efforts to coordinate services, including the following:

(1) Authorizations for release of information;

(2) Intake and referral;

(3) Diagnosis and evaluation;

(4) Needs assessment;

(5) Plan of care development;

(6) Resource assessment;

(7) Plan of care implementation;

(8) Medication management;

(9) Progress reports;

(10) Reassessment and revision of plans of care; and

(11) Routine monitoring of services by appropriate clinical staff.

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g. Ensuring that a community living support plan, as defined in Core Provision, Section I, Definitions and Acronyms, is developed and implemented for each enrollee who is a resident of an ALF or an AFCH, and that it is updated annually.

h. Coordinating care (including communication of medication management, treatment plans and progress among behavioral health providers, medical specialists and Long-term Care providers).

i. Ensure that a quarterly review of the enrollee’s plan of care is conducted to determine the appropriateness and adequacy of services, and to ensure that the services furnished are consistent with the nature and severity of needs. Documentation of this quarterly review shall be maintained on file and provided at the Agency’s request.

j. Maintaining information about the enrollee’s behavioral health condition, the types of services to be furnished, the amount, frequency and duration of each service, and the provider who will furnish each service.

k. Provide training to the ALF staff and administrators of the procedures to follow should an urgent or emergent behavior health condition arise and ensuring that the procedures are followed; Assist the facility to develop and implement procedures for responding to urgent and emergent behavior health conditions, if none exist.

l. Ensuring that facilities are fully compliant with the voluntary, involuntary and transport provisions of the Baker Act (see chapters 394, 400 and 429, F.S.) for Long-term Care residents who are sent to a hospital or Baker Act receiving facility for psychiatric issues.

m. Ensuring through monitoring and reporting that facilities are fully compliant with Baker Act requirements (see s. 394.451, F.S.).

n. Provide training to ALF staff which includes:

(1) Signs and symptoms of mental illness;

(2) Behavior management strategies;

(3) Identification of suicide risk and management;

(4) Verbal de-escalation strategies for aggressive behavior;

(5) Trauma informed care;

(6) Documentation and reporting of behavior health concerns; and

(7) Abuse, neglect, exploitation and adverse incident reporting standards (as found in Core Provision, Section V, Covered Services.)

E. Care Coordination / Case Management

1. Case Management Program Description

The Managed Care Plan shall submit a Case Management Program Description annually to the Agency by June 1. The Case Management Program Description shall address:

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a. How the Managed Care Plan shall implement and monitor the case management program and standards outlined in this Exhibit.

b. A description of the methodology for assigning and monitoring case management caseloads and emergency preparedness plans.

c. An evaluation of the Managed Care Plan’s case management program from the previous year, highlighting lessons learned and strategies for improvement.

2. Case Management Staff Qualifications and Experience

a. Case managers shall meet one of the following qualifications:

(1) Case Managers with the following qualifications shall also have a minimum of two (2) years of relevant experience:

(a) Bachelor’s degree in social work, sociology, psychology, gerontology or a related social services field;

(b) Registered nurse, licensed to practice in the state;

(c) Bachelor’s degree in a field other than social science; or

(2) Case Managers with the following qualifications shall also have a minimum of four (4) years of relevant experience: Licensed Practical Nurse, licensed to practice in the state.

(3) Case Managers without the aforementioned qualifications may substitute professional human service experience on a year-for-year basis for the educational requirement. Case Managers without a bachelor’s degree shall have a minimum of six (6) years of relevant experience.

b. All case managers are required to obtain a successful Level 2 criminal history and/or background investigation.

c. All Case Managers shall have at least four (4) hours of in-service training in the identification of abuse, neglect and exploitation and shall complete this training requirement annually.

d. The Managed Care Plan shall ensure that a staff person(s) is designated as the expert(s) on housing, education and employment issues and resources within the Managed Care Plan’s Contract region(s). This individual shall be available to assist case managers with up-to-date information designed to aid enrollees in making informed decisions about their independent living options.

3. Case Management Supervision

a. Supervision of case managers:

A supervisor-to-case-manager ratio shall be established that is conducive to a sound support structure for case managers. Supervisors shall have adequate time to train and review the work of newly hired case managers as well as provide support and guidance

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 30 of 76

to established case managers. A system of internal monitoring of the case management program, to include case file audits and reviews of the consistency of enrollee assessments and service authorizations, shall be established and applied, at a minimum, on a quarterly basis. The results of this monitoring, including the development and implementation of continuous improvement strategies to address identified deficiencies, shall be documented and made available to the Agency upon request.

b. Case management supervisor qualifications:

(1) Successful completion of a Level 2 criminal history and/or background investigation; and

(2) Master’s degree in a human service, social science or health field and has a minimum of two (2) years’ experience in case management, at least one (1) year of which shall be related to the elderly and disabled populations; or

(3) Bachelor’s degree in a human service, social science or health field with a minimum of five (5) years’ experience in case management, at least one (1) year of which shall be related to the elderly and disabled populations; or

(4) Professional human service, social science or health related experience may be substituted on a year-for-year basis for the educational requirement, (i.e., a high school diploma or equivalent and nine (9) years of experience in a human service, social science or health field, five (5) years of which shall be related to case management, at least one (1) year of which shall be related to elders and individuals with disabilities).

4. Training

a. The Managed Care Plan shall provide case managers with adequate orientation and ongoing training on subjects relevant to the population served. Documentation of training dates and staff attendance as well as copies of materials used shall be maintained. The respondent shall ensure that there is a training plan in place to provide uniform training to all case managers. This plan should include formal training classes as well as practicum observation and instruction for newly hired case managers.

b. Newly hired case managers shall be provided orientation and training in a minimum of the following areas:

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(1) The role of the case manager in utilizing a person-centered approach to Long-term Care case management, including involving the enrollee and their family in decision making and care planning;

(2) Enrollee rights and responsibilities;

(3) Enrollee safety and infection control;

(4) Participant Direction Option (overview);

(5) Case management responsibilities as outlined in this Exhibit;

(6) Case management procedures specific to the Managed Care Plan;

(7) The Long-term Care component of SMMC and the continuum of Long-term Care services including available service settings and service restrictions/limitations;

(8) The Managed Care Plan’s provider network by location, service type and capacity;

(9) Information on local resources for housing, education and employment services/program that could help enrollees gain greater self-sufficiency in these areas;

(10) Responsibilities related to monitoring for and reporting of regulatory issues and quality of care concerns, including, but not limited to, suspected abuse/neglect and/or exploitation and adverse incidents (see Chapters 39 and 415, F.S.);

(11) General medical information, such as symptoms, medications and treatments for diagnostic categories common to the Long-term Care population serviced by the Managed Care Plan;

(12) Behavioral health information, including identification of enrollee’s behavioral health needs and how to refer to behavioral health services;

(13) Reassessment processes using the Agency’s required forms.

c. In addition to review of areas covered in orientation, all case managers shall also be provided with regular ongoing training on topics relevant to the population(s) served. The following are examples of topics that could be covered:

(1) In-service training on issues affecting the aged and disabled population;

(2) Abuse, neglect and exploitation training;

(3) Alzheimer’s disease and related disorders continuing education training from a qualified individual or entity, focusing on newly developed topics in the field;

(4) Policy updates and new procedures;

(5) Refresher training for areas found deficient through the Managed Care Plan;

(6) Interviewing skills;

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(7) Assessment/observation skills;

(8) Cultural competency;

(9) Enrollee rights;

(10) Participant Direction Option (extensive);

(11) Critical incident and adverse event reporting;

(12) Medical/behavioral health issues;

(13) Medication awareness (including identifying barriers to compliance and side effects); and/or

(14) The Managed Care Plan shall ensure all case management staff hold current CPR certification.

5. Caseload and Contact Management

a. The Managed Care Plan shall have an adequate number of qualified and trained case managers to meet the needs of enrollees.

b. Caseload:

(1) The Managed Care Plan shall ensure that case manager caseloads do not exceed a ratio of sixty (60) enrollees to one case manager for enrollees that reside in the community and no more than a ratio of one-hundred (100) enrollees to one (1) case manager for enrollees that reside in a nursing facility. Where the case manager's caseload consists of enrollees who reside in the community and enrollees who reside in nursing facilities (mixed caseload), the Managed Care Plan shall ensure the ratio of enrollees to one (1) case manager does not exceed sixty (60).

(2) The Managed Care Plan shall have written protocols to ensure newly enrolled enrollees are assigned to a case manager immediately upon enrollment. The case manager assigned to special subpopulations (e.g., individuals with AIDS, dementia, behavioral health issues or traumatic brain injury) shall have experience or training in case management techniques for such populations.

(3) The Managed Care Plan shall ensure that case managers are not assigned duties unrelated to enrollee-specific case management for more than fifteen percent (15%) of their time if they carry a full caseload.

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(4) Caseload Exceptions: The Managed Care Plan shall receive authorization from the Agency prior to implementing caseloads whose values exceed those outlined above. Lower caseload sizes may be established by the Managed Care Plan and do not require authorization.

(5) The Managed Care Plan shall report to the Agency monthly on its case manager caseloads as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

c. Initial Contact:

(1) An onsite visit to develop an individualized plan of care shall be completed by the Managed Care Plan within five (5) business days of the enrollee’s effective date of enrollment for enrollees in the community (including ALFs and AFCHs) and within seven (7) business days of the effective date of enrollment for those enrolled in a nursing facility. If information obtained during the initial contact or during the eligibility determination indicates the enrollee has more immediate needs for services, the onsite visit should be completed as soon as possible. Services covered under this Contract may not be denied based on an incomplete plan of care.

(2) The Managed Care Plan shall follow up with the enrollee or the enrollee’s authorized representative by telephone within seven (7) business days after initial contact and care plan development to ensure that services were started on the first of the month, if applicable.

(3) The enrollee shall be present for, and be included in, the onsite visit. The enrollee representative shall be contacted for care planning, including establishing service needs and setting goals, if the enrollee is unable to participate due to cognitive impairment, or the enrollee has a designated representative or a legal guardian.

(4) If the case manager is unable to locate/contact an enrollee via telephone, visit or letter, or through information from the enrollee’s relatives, neighbors or others, another letter requesting that the enrollee contact the case manager should be left at, or sent to, the enrollee’s residence. If there is no contact within thirty (30) days from the enrollee’s date of enrollment, the case shall be referred to the Agency Contract manager via e-mail or phone call.

(5) All contacts attempted and made with, or regarding, an enrollee shall be documented in the enrollee’s case file.

(6) The case manager is responsible for explaining the enrollee’s rights and responsibilities including the procedures for filing a grievance, appeal or fair hearing, including continuation of benefits during the fair hearing process.

d. Frequency and type of ongoing minimum contact requirements include:

(1) Maintain, at a minimum, monthly telephone contact with the enrollee to verify satisfaction and receipt of services;

(2) The case manager shall evaluate and document the HCB characteristics as part of the care planning process and update of the plan of care for enrollees residing in

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 34 of 76

ALFs and AFCHs during face-to-face visits every ninety (90) days. The responses to the HCB characteristics queries shall become part of the case record documentation of the update;

(3) Review the plan of care in a face-to-face visit every ninety (90) days and, if necessary, update the enrollee’s plan of care;

(4) Review the plan of care in a face-to-face visit more frequently than once every ninety (90) days if the enrollee’s condition changes or requires it; and

(5) Have an annual face-to-face visit with the enrollee to complete the annual reassessment using Agency-required forms and to determine the enrollee’s functional status, satisfaction with services, changes in service needs and develop a new plan of care.

e. If the enrollee is not capable of making his/her own decisions, but does not have a legal representative or enrollee representative available, the case manager shall refer the case to the Public Guardianship Program or other available resource. If a guardian/fiduciary is not available, the reason shall be documented in the file.

f. If the case manager is unable to contact an enrolled enrollee to schedule an ongoing visit, a letter shall be sent to the enrollee or authorized representative requesting contact within ten (10) business days from the date of the letter. If no response is received by the designated date, the Managed Care Plan shall send the Agency a notice in a format specified by the Agency indicating loss of contact for possible disenrollment from the LTC component of SMMC.

g. Access to case managers and back-up case managers:

(1) Enrollee shall be able to contact the case manager during business hours with emergency or back-up through an after-hours telephone line.

(2) A system of back-up case managers shall be in place and enrollees who contact an office when their case manager is unavailable shall be given the opportunity to be referred to a back-up for assistance.

(3) There shall be a mechanism to ensure enrollees, representatives and providers receive timely communication when messages are left for case managers.

6. Case Management of Enrollees

The Managed Care Plan shall ensure the adherence to the following provisions.

a. Person-centered approach: Case managers are expected to use a person-centered approach regarding the enrollee assessment and needs, taking into account not only covered services, but also other needed services and community resources, regardless of payor source, as applicable. Elements of the case management process include:

(1) Identification;

(2) Outreach;

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(3) Contact and visits;

(4) Initial (immediate care needs) and ongoing (care needs necessary after immediate care needs stabilized);

(5) Enrollee packet/informing enrollee;

(6) Comprehensive assessment;

(7) Core assessment criteria (applicable to all plans);

(8) Assessment of risks and barriers;

(9) CARES assessment;

(10) Plan of care and coordination of services; and

(11) Assistance to enrollees living in the community in developing a personal emergency plan and determining whether they need to register with a Special Needs Shelter.

b. Needs Assessment Standard

(1) The case manager shall review and utilize Agency-required forms when completing the initial assessment of the enrollee and developing the initial plan of care.

(2) Assessment will include an individual risk assessment to identify safety, health and behavioral risks that should be addressed in developing the plan of care.

c. Care Planning Standard

(1) The case manager shall develop a single, comprehensive, person centered plan of care specific to the enrollee’s needs and goals that are identified using, at a minimum, the assessment form(s) provided to the Managed Care Plan by the Agency and the Managed Care Plan’s assessment tool, if applicable. The enrollee or legal guardian and the guardian advocate, caregiver, PCP or other enrollee-authorized representative shall be consulted in the development of the plan of care.

(2) Care planning includes, but is not limited to face-to-face discussion with the enrollee, the enrollee’s representative and any other enrollee-approved person, that includes a systematic approach to the assessment of the enrollee’s strengths and needs in at least the following areas:

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(a) Functional abilities;

(b) Medical conditions;

(c) Physical and cognitive functioning;

(d) Behavioral health;

(e) Personal goals;

(f) Social/environmental/cultural factors;

(g) Existing support system;

(h) End-of life decisions;

(i) Recommendations of the enrollee’s primary care provider (PCP); and

(j) Input from service providers, as applicable.

(3) The plan of care template shall at a minimum include:

(a) Enrollee’s Name and Medicaid ID number and SSN;

(b) Plan of care effective date (the first date a recipient is enrolled in the Managed Care Plan);

(c) Plan of care review date (at a minimum, every ninety (90) days);

(d) Services needed, including routine medical and waiver services;

(e) Each service authorization begin and end date;

(f) All the services and supports to be provided regardless of the funding source;

(g) All service providers;

(h) The enrollee’s assisted living service components provided by the ALF as well as the amount and frequency of those services if the enrollee resides in an ALF;

(i) The number of units of each service to be provided;

(j) The date on which the Managed Care Plan shall submit the completed Agency-required reassessment tool and required medical documentation to CARES;

(k) Case Manager's’ signature; and

(l) Enrollee or authorized representative’s signature and date.

(4) The plan of care (reviewed face-to-face with the enrollee at a minimum every three (3) months) shall also include:

(a) Goals and objectives;

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(b) Service schedules;

(c) Medication management strategies;

(d) Barriers to progress; and

(e) Detail of interventions.

(5) The Managed Care Plan shall submit the plan of care template that includes these minimum components to the Agency for approval forty-five (45) days prior to implementation.

(6) Together, the case manager and enrollee shall develop goals that address the issues that are identified in the care planning process including goals that ensure the enrollee is integrated into the community. Goals should be built on the enrollee’s strengths and include steps that the enrollee will take to achieve the goal. Goals shall be written to outline clear expectations about what is to be achieved through the service delivery and care coordination processes. Enrollee goals shall:

(a) Be enrollee specific;

(b) Be measurable;

(c) Specify a plan of action/interventions to be used to meet the goals;

(d) Include a timeframe for the attainment of the desired outcome; and

(e) Be reviewed at each assessment visit and progress shall be documented. Progress means information regarding potential barriers, changes that need to be made to the goal and/or plan of action, and, if the goal has been met but will be continued, the reason(s) for this.

(7) The case manager is responsible for identifying the enrollee’s primary care provider (PCP) and specialists involved in the enrollee’s treatment and obtaining the required authorizations for release of information in order to coordinate and communication with the primary care provider and other treatment providers.

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(8) The case manager is responsible for informing enrollees’ primary care and other treatment providers that recipients should be encouraged to adopt healthy habits and maintain their personal independence.

(9) Upon the enrollee’s or enrollee representative’s agreement to the plan of care, the case manager is responsible for coordinating the services with appropriate providers.

(10) Copies of the plan of care shall be forwarded to the enrollee’s primary care provider and, if applicable, to the facility where the enrollee resides within ten (10) business days of development.

(11) The plan of care shall document that the process for enrollee grievance and appeals was clearly explained. It shall be noted for each service whether the frequency/quantity of the service has changed since the previous plan of care. The enrollee or representative shall indicate whether they agree or disagree with each service authorization and sign the plan of care at initial development and when there are changes in services. The case manager shall provide a copy of the plan of care to the enrollee or representative and maintain a copy in the case file.

(12) Enrollees who reside in “own home” settings should be encouraged, and assisted as indicated, by the case manager to have a disaster/emergency plan for their household that considers the special needs of the enrollee. If applicable, this plan shall be placed in the enrollee’s case file. Informational materials are available at the Federal Emergency Management Agency’s (FEMA) website at www.fema.gov or www.ready.gov. Enrollees should also be encouraged to register with the state’s Emergency Preparedness Special Needs Shelter Registry. For more information go to. http://www.doh.state.fl.us/phnursing/SpNS/SpecialNeedsShelter.html

(13) At initial plan of care development and when there are changes in services, the case manager shall create a plan of care summary. The case manager shall provide the enrollee or enrollee’s representative with a plan of care summary containing the following minimum components:

(a) The enrollee’s name;

(b) The enrollee’s date of birth and Medicaid ID Number;

(c) Covered services provided including routine medical and HCBS services;

(d) Begin date of services;

(e) Providers;

(f) Amount and frequency;

(g) Case manager’s signature; and

(h) Enrollee or the enrollee’s authorized representative’s signature and date.

d. Placement/Service Planning Standard

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(1) Service authorizations shall reflect services as specified in the plan of care. When developing service authorizations, case managers shall authorize ongoing services within timeframes specified in the plan of care.

(2) The authorization time period shall be consistent with the end date of the services as specified in the plan of care.

(3) When service needs are identified, the enrollee shall be given information about the available providers so that an informed choice of providers can be made. The entire care planning process shall be documented in the case record.

(4) The case manager shall ensure that the enrollee or representative understands that some Long-term Care services (such as home health nurse, home health aide or durable medical equipment (DME) shall be prescribed by the PCP.

(5) The case manager is responsible for coordinating physician’s orders for those services requiring a physician’s order.

(6) If the enrollee does not have a PCP or wishes to change PCP, it is the case manager’s responsibility to coordinate the effort to obtain a PCP or to change the PCP.

(7) The case manager shall also verify that medically necessary services are available in the enrollee’s community. If a service is not currently available, the case manager shall substitute a combination of other services in order to meet the enrollee’s needs until such time as the desired service becomes available. A temporary alternative placement may be needed if services cannot be provided to safely meet the enrollee’s needs.

(8) Enrollees cannot be required to enter an alternative residential placement/setting because it is more cost-effective than living in his/her home.

(9) If the enrollee disagrees with the assessment and/or authorization of placement/services (including the amount and/or frequency of a service), the case manager shall provide the enrollee with a written notice of action that explains the enrollee’s right to file an appeal regarding the placement or plan of care determination.

(10) If the case manager and PCP or attending physician do not agree regarding the need for a change in level of care, placement or physician’s orders for medical services, the case manager shall refer the case to the Managed Care Plan’s Medical Director for review. The Medical Director is responsible for reviewing the case, discussing it with the PCP and/or attending physician if necessary, and making a determination in order to resolve the issue.

(11) The enrollee or enrollee representative shall be notified in writing of any denial, reduction, termination or suspension of services, that varies from the type, amount, or frequency of services detailed on the plan of care that the enrollee or his/her representative has signed. Refer to Section IV, Enrollee Services and Grievance Procedures.

(12) The Managed Care Plan shall submit a monthly summary report of all enrollees whose services have been denied, reduced, or terminated for any reason as

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specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

(13) The Managed Care Plan shall submit a summary report of the physical location/residence of all enrollees, including Medicaid Pending enrollees, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

e. Reassessment Standard

(1) The Managed Care Plan shall submit quarterly reports to the Agency on those enrollees receiving annual level of care redeterminations, within 365 days of the previous determination, enrollees having current level of care based on the Agency-required assessment tool and required medical documentation and on enrollees requesting a fair hearing related to their level of care, as specified in Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide.

(2) Case managers are responsible for ongoing monitoring of the services and placement of each enrollee assigned to their caseload in order to assess the continued suitability of the services and placement in meeting the enrollee’s needs as well as the quality of the care delivered by the enrollee’s service providers.

(3) Case managers are responsible for ensuring that an enrollee’s care is coordinated, including, but not limited to:

(a) Ensuring each enrollee has an ongoing source of primary care appropriate to his/her needs;

(b) Coordinating the services furnished to the enrollee with services the enrollee receives from any other managed care entity or any other health care payor source;

(c) Conducting Long-term Care planning and face-to-face reassessments for level-of-care determination as required by this Contract;

(d) Tracking level-of-care redeterminations to ensure enrollees are reassessed face-to-face with the Agency-required assessment tool and required medical documentation and a new level of care determination authorized annually. Enrollees residing and remaining in the nursing home setting are exempt from the annual level of care redetermination requirement. If the Agency-required assessment tool is not submitted to the state in a timely manner and the level of care expires, the case manager is responsible for ensuring that a new Agency-required certification form is completed, signed and dated by a physician;

(e) For enrollees residing and remaining in the community, the Managed Care Plan shall conduct the annual reassessment and required medical documentation and submit to CARES no earlier than sixty (60), and no later than thirty (30) days prior to the one (1) year anniversary date of the previous Notification of Level of Care form;

(f) For enrollees transitioned from the nursing facility into the community within twelve (12) months of their initial level of care determination, the Managed Care

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Plan shall submit the reassessment thirty (30) days prior to the date on the initial Notification of Level of Care form;

(g) For enrollees that reside in a nursing facility more than twelve (12) months before being transitioned into the community, the reassessment shall be due thirty (30) days prior to the anniversary date of discharge from the nursing facility;

(h) Tracking an enrollee’s Medicaid financial eligibility on annual basis, and are responsible for helping the enrollee continuously maintain Medicaid financial eligibility. If the enrollee loses Medicaid financial eligibility due to inaction or lack of follow-through with the DCF redetermination process, the case manager shall help the enrollee regain Medicaid financial eligibility; and

(i) Referring pregnant enrollees to appropriate maternity and family services and notifying medical service payers of enrollee status for further eligibility determination for the enrollee and unborn infant.

(4) Case managers shall conduct a face-to-face review within five (5) business days following an enrollee’s change of placement type (e.g., from HCBS to an institutional setting, own home to assisted living facility or institutional setting to HCBS). This review shall be conducted to ensure that appropriate services are in place and that the enrollee agrees with the plan of care as authorized.

(5) The case manager shall meet face-to-face at least every three (3) months with the enrollee and/or representative, in order to:

(a) Discuss the type, amount and providers of authorized services. If any issues are reported or discovered, the case manager shall take and document action taken to resolve these as quickly as possible;

(b) Assess needs, including any changes to the enrollee’s informal support system;

(c) Discuss the enrollee’s perception of his/her progress toward established goals;

(d) Identify any barriers to the achievement of the enrollee’s goals;

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(e) Develop new goals as needed;

(f) Review, at least annually, the enrollee handbook to ensure enrollees/representatives are familiar with the contents, especially as related to the grievance and reporting abuse, neglect, and exploitation, appeals process, covered services and their rights/responsibilities;

(g) Document the enrollee’s current functional, medical, behavioral and social strengths; and

(h) Complete the Agency-required assessment form and medical documentation annually.

(6) The enrollee representative shall be involved for the above if the enrollee is unable to participate due to a cognitive impairment or if the enrollee has a legal guardian.

(7) The case manager shall document contacts and face-to-face visits at the time of each visit or contact and when there are any changes in services. The enrollee or representative shall indicate whether they agree or disagree with each service authorization and sign the plan of care each time changes occur. The enrollee shall be given a copy of each signed plan of care.

(8) The enrollee’s HCBS providers shall be contacted at least annually to discuss their assessment of the enrollee’s needs and status. Contact should be made as soon as possible to address problems or issues identified by the enrollee/representative or case manager. This should include providers of such services as personal or attendant care, home delivered meals, therapy, etc.

7. Disease Management Program

a. In addition to the disease management program specified in Attachment I, the Managed Care Plan shall include disease management programs for:

(1) Dementia and Alzheimer’s issues;

(2) Cancer;

(3) Diabetes;

(4) Chronic Obstructive Pulmonary Disease (COPD); and

(5) End of life issues including information on advance directives.

b. The Managed Care Plan shall develop and implement a disease management programs to combine elements of caregiver support and disease management. The integrated program shall be aimed at providing enrollee caregivers, circles of support for enrollees and the enrollee with support and education to help care for and improve the health and quality of life for the enrollee living with chronic conditions in the home.

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F. Quality Enhancements

The Managed Care Plan shall offer quality enhancements (QE) to enrollees as specified below:

1. Safety concerns in the home and fall prevention;

2. End of life issues, including information on advanced directives; and

3. Ensuring that case managers and providers screen enrollees for signs of domestic violence and offer referral services to applicable domestic violence prevention community agencies.

Section VI. Provider Network

A. Network Adequacy Standards

1. Network Capacity and Geographic Access Standards

a. In accordance with s. 409.982(4), F.S., and s. 409.98(1) - (19), F.S., the Managed Care Plan’s network shall include the following types of providers: (See LTC Provider Qualifications and Minimum Network Adequacy Requirements Table, for minimum waiver network standards)

(1) Adult companion providers;

(2) Adult day health care centers;

(3) Adult family care homes;

(4) Assistive care service providers;

(5) Assisted living facilities;

(6) Attendant care providers;

(7) Behavior management providers;

(8) Caregiver training providers;

(9) Case managers or case management agency;

(10) Community care for the elderly lead agencies (CCEs);

(11) Health care services pools;

(12) Home adaptation accessibility providers;

(13) Home health agencies;

(14) Homemaker and companion service providers;

(15) Hospices;

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(16) Medication administration providers;

(17) Medication management providers;

(18) Medical supplies providers;

(19) Nurse registries;

(20) Nursing facilities;

(21) Nutritional assessment and risk reduction providers;

(22) Personal care providers;

(23) Personal emergency response system providers;

(24) Transportation providers; and

(25) Therapy (occupational, speech, respiratory, and physical) providers.

b. In accordance with s. 409.982(1), F.S., the Managed Care Plan may limit the providers in its network based on credentials, quality and price; however, during the period between October 1, 2013 and September 30, 2014, the Managed Care Plan shall, in good faith, offer a provider contract to all of the following providers in the region:

(1) Nursing facilities;

(2) Hospices; and

(3) Aging network services providers that previously participated in home and community-based waivers serving elders or community-service programs administered by DOEA, as identified by the state.

c. In accordance with s. 409.982(1), F.S., after twelve (12) months of active participation in the Managed Care Plan’s network, the Managed Care Plan may exclude any of the providers named in b. above for failure to meet quality or performance criteria.

d. Therapy, facility-based hospice, and adult day health care services shall be available within an average of thirty (30) minutes from an enrollee’s residence or other preferred location within the region. The Agency may waive this requirement, in writing, for rural areas and for areas where there is no applicable provider within a thirty (30) minute average travel time. Travel time requirements for adult day health care and therapy services are increased to sixty (60) minutes for rural areas.

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e. Unless otherwise provided in this Contract or authorized by the Agency, the Managed Care Plan shall ensure that each county in a region has at least two (2) providers available to deliver each covered HCBS. For HCBS provided in an enrollee’s place of residence, the provider does not need to be located in the county of the enrollee’s residence but shall be willing and able to serve residents of that county. For adult day health care, the service provider does not have to be located in the enrollee’s county of residence, but shall meet the access standards for adult day health care.

f. Facility-based services are those services the enrollee receives from the residential facility in which they live. For purposes of this Contract assisted living facility, adult family care homes, assistive care, and nursing facility care services are facility-based.

g. The Managed Care Plan shall contract with at least two (2) facility-based service providers per county in the region(s) it serves and meet the licensed bed ratio requirement of one (1) licensed bed for each enrollee included in the applicable maximum enrollment level. If the Managed Care Plan demonstrates to the Agency’s satisfaction that it is not feasible to meet either or both requirements within a specific county within a contracted region, the Agency may provide written authorization to use network facilities from one or more neighboring counties within the region to meet network requirements.

h. If the Managed Care Plan is able to demonstrate to the Agency’s satisfaction that a region as a whole is unable to meet either or both network requirements for facility-based services, the Agency may waive the requirement at its discretion in writing. As soon as additional service providers become available, however, the Managed Care Plan shall augment its network to include such providers in order to meet the network adequacy requirements. Such a written waiver shall require attestation by the Managed Care Plan that it agrees to modify its network to include such providers as they become available.

i. Facilities from neighboring counties within the region are allowed as additional network providers above and beyond the required number. No state approval is required to include these additional providers in the Managed Care Plan network as long as minimum requirements specified in Section VII.A.7. have been met.

j. The Managed Care Plan may not include facility-based service providers from outside the region as network providers unless the Managed Care Plan’s provider agreement or subcontract specifies that it will serve the respective region(s); however, such providers may not be used to meet the region’s minimum network requirements. A waiver from the Agency will be necessary if the Managed Care Plan cannot meet network requirements for facility-based services for a region using only providers located within that region.

k. The Managed Care Plan shall provide authorized HCBS within the timeframe prescribed in Section V, Covered Services. This includes initiating HCBS in the enrollee’s plan of care within the timeframes specified in this Contract and continuing services in accordance with the enrollee’s plan of care, including the amount, frequency, duration and scope of each service in accordance with the enrollee’s service schedule.

l. The Managed Care Plan shall permit enrollees in the community to choose care through participant direction for allowable services as specified in Section V, Covered Services. Such providers shall agree to all applicable terms of the Managed Care Plan’s policies and procedures. Such qualification requirements shall include the minimum provider

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qualifications in Table 2 and all training and background screening requirements. The Managed Care Plan shall develop any necessary policies, procedures, or agreements to allow providers to provide care to enrollees where appropriate.

m. The Managed Care Plan shall not continue to contract with providers designated as chronic poor performers, pursuant to the Managed Care Plan’s policies and procedures.

n. The Managed Care Plan shall permit enrollees to choose from among all Managed Care Plan network residential facilities with a Medicaid-designated bed available. The Managed Care Plan shall inform the enrollee of any residential facilities that have specific cultural or religious affiliations. If the enrollee makes a choice, the Managed Care Plan shall make a reasonable effort to place the enrollee in the facility of the enrollee’s choice. In the event the enrollee does not make a choice, the Managed Care Plan shall place the enrollee in a participating residential facility with a Medicaid-designated bed available within the closest geographical proximity to the enrollee’s current residence. All Managed Care Plan enrollee placements into participating or non-participating residential facilities shall be appropriate to the enrollees’ needs.

B. Network Development and Management Plan

1. Regional Network Changes

The Managed Care Plan shall notify the Agency within seven (7) business days of any significant changes to its regional provider network. A significant change is defined as follows:

a. Managed Care Plans shall report to the Agency a loss of a nursing facility, adult day health care center, adult family care home or assisted living facility in a region where another participating nursing facility, adult day health care center, adult family care home or assisted living facility of equal service ability is not available to ensure compliance with the geographic access standards specified in this Exhibit.

b. If the Managed Care Plan excludes an Aging Network Provider, as defined by the state, the Managed Care Plan shall provide written notice to all enrollees who have chosen that provider for care, and the notice shall be provided at least thirty (30) days before the effective date of the exclusion.

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C. Provider Credentialing and Contracting

1. Credentialing and Recredentialing

a. The Managed Care Plan shall establish and verify provider credentialing and recredentialing criteria that includes a determination of whether the provider, or employee or volunteer of the provider, meets the definition of “direct service provider” and completion of a Level 2 criminal history background screening on each direct service provider to determine whether any have disqualifying offenses as provided for in s. 430.0402, F.S., and s. 435.04, F.S. Any provider or employee or volunteer of the provider meeting the definition of “direct service provider” who has a disqualifying offense is prohibited from providing services to enrollees. No additional Level 2 screening is required if the individual is qualified for licensure or employment by the Agency pursuant to its background screening standards under s. 408.809, F.S., and the individual is providing a service that is within the scope of his or her licensed practice or employment. (See s. 430.0402(3), F.S.)

(1) The Managed Care Plan shall maintain a signed affidavit from each provider attesting to its compliance with this requirement, or with the requirements of its licensing agency if the licensing agency requires Level 2 screening of direct services providers.

(2) The Managed Care Plan shall include compliance with this requirement in its provider contracts and subcontracts and verify compliance as part of its subcontractor and provider monitoring activity.

b. The Managed Care Plan shall establish and verify provider credentialing and recredentialing criteria to ensure that assisted living facilities and adult family care homes meet the minimum HCB characteristics as defined in this Contract.

c. The Managed Care Plan’s credentialing and recredentialing process shall include ensuring that all Long-term Care providers are appropriately qualified, as specified in Table 1 - LTC Provider Qualifications & Minimum Network Adequacy Requirements, and Table 2 – PDO Provider Qualifications below.

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Table 1

LTC Provider Qualifications & Minimum Network Adequacy Requirements Table

Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Adult Companion	Community Care for the Elderly (CCE) Provider	As defined in Ch. 410 or 430, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Center for Independent Living	As defined under 413.371, F. S.
	Homemaker/Companion Agency	Registration in accordance with 400.509, F.S.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	Nurse Registries	Licensed per Chapter 400.506, F. S.
	Health Care Service Pools	Licensed per Chapter 400, Part IX, F. S.
Adult Day Care (Adult Day Health Care)	Assisted Living Facility (ALF)	Licensed per Ch. 429, Part I, F.S. with a written approval from 768 AHCA’s HQA office to provide services under 429.905(2) F.S.	At least two (2) providers serving each county of the region AND at least (1) provider within thirty (30) minutes travel time.	At least two (2) providers serving each county of the region AND at least (1) provider within 60 minutes travel time.
	Adult Day Care Center	Licensed per Ch. 429, Part III, F.S.
Assisted Living Facility Services	Assisted Living Facility	Licensed per Ch. 429, Part I, F.S.**	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the.
Assistive Care Services	Adult Family Care Home (AFCH)	Licensed per Ch. 429, Part II, F.S.**	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Attendant Care	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484. Services must be provided by a licensed RN or LPN.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Registered Nurse (RN), Licensed Practical Nurse (LPN)	Licensed per Ch. 464, F.S.
	Nurse Registry	Licensed per 400.506, F.S. Services must be provided by a licensed RN or LPN.
Behavior Management	Clinical Social Worker, Mental Health Counselor	Licensed per Ch. 491, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Community Mental Health Center	Licensed per Ch. 394, F.S.
	Home Health Agencies	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484. Direct service provider must have a minimum of two (2) years direct experience working with adult populations diagnosed with Alzheimer's disease, other dementias or persistent behavioral problems.
	Nurse Registries	Licensed per 400.506, F.S. Direct service provider must have a minimum of two (2) years direct experience working with adult populations diagnosed with Alzheimer's disease, other dementias or persistent behavioral problems.
	Psychologist	Licensed per Ch. 490, F.S.
	Registered Nurse	Licensed per Ch. 464, Part I "Nurse Practice Act", F.S. and Ch. 64B9 "Board of Nursing", F.A.C; Minimum of two (2) years direct experience working with adult populations diagnosed with Alzheimer's disease, other dementias or persistent behavioral problems.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Caregiver Training	CCE Provider	As defined in Ch. 410 or 430, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region
	Clinical Social Worker, Mental Health Counselor	Licensed per Ch. 491, F.S.
	RN, LPN	Licensed per Ch. 400, Part III, F.S.
	Home Health Agency	Optional to meet Federal Conditions of Participation under 42 CFR 484.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Case Management	Case Managers employed or contracted by Managed Care Plans	Either: 2+ yrs. of relevant experience and; (1) BA or BS in Social Work, Sociology, Psychology, Gerontology or related social services field; (2) RN licensed in FL; (3) BA or BS in unrelated field, OR: 4+ yrs. relevant experience and LPN licensed in FL, OR: 6+ years of professional human service experience. All must have four (4) hrs. of in-service training in identifying and reporting abuse, neglect and exploitation	Each case manager's caseload may not exceed sixty (60) for enrollees in HCBS settings, one-hundred (100) for enrollees in nursing facilities or sixty (60) when the case manager has a mixed caseload	Each case manager's caseload may not exceed sixty (60) for enrollees in HCBS settings, one-hundred (100) for enrollees in nursing facilities or sixty (60) when the case manager has a mixed caseload.
	Center for Independent Living	Either: 2+ yrs. of relevant experience and; (1) BA or BS in Social Work, Sociology, Psychology, Gerontology or related social services field; (2) RN licensed in FL; (3) BA or BS in unrelated field, OR: 4+ yrs. relevant experience and LPN licensed in FL, OR: 6+ years of professional human service experience. All must have four (4) hrs. of in-service training in identifying and reporting abuse, neglect and exploitation
	Case Management Agency	Either: 2+ yrs. of relevant experience and; (1) BA or BS in Social Work, Sociology, Psychology, Gerontology or related social services field; (2) RN licensed in FL; (3) BA or BS in unrelated field, OR: 4+ yrs. relevant experience and LPN licensed in FL, OR: 6+ years of professional human service experience. All must have four (4) hrs. of in-service training in identifying and reporting abuse, neglect and exploitation Designated a CCE Lead Agency by DOEA (per Ch. 430 F.S.) or other agency meeting comparable standards as determined by DOEA.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Home Accessibility Adaptation	Independent Provider	Licensed per state and local building codes or other licensure appropriate to tasks performed. Ch. 205, F.S.; Licensed by local city and/or county occupational license boards for the type of work being performed. Required to furnish proof of current insurance.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Center for Independent Living	As defined under 413.371, F. S. and licensed under Ch. 205, F. S.
	General Contractor	Licensed per 459.131, F.S.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Home Delivered Meals	Food Establishment Older American’s Act	Permit under 500.12, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	(OAA) Provider	As defined in Rule 58A-1, F.A.C.
	CCE Provider	As defined in Ch. 410 or 430, F.S.
	Food Service Establishment	Licensed per S.509.241, F.S.
Homemaker	Nurse Registry	Licensed per 400.506, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	CCE Provider	As defined in Ch. 410 or 430, F.S.
	Center for Independent Living	As defined under 413.371, F. S.
	Homemaker/Companion Agency	Registration in accordance with Ch. 400.509, F.S.
	Health Care Service Pools	Licensed per Chapter 400, Part IX, F. S.
Hospice	Hospice Organizations	Hospice providers must be licensed under Chapter 400, Part IV, F. S. and meet Medicaid and Medicare conditions of participation annually.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
Intermittent and Skilled Nursing	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
Medication Administration	RN, LPN	Licensed per Ch. 464, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	Nurse Registry	Licensed per 400.506, F.S.
	Unlicensed Staff Member Trained per 58A-5.0191(5), F.A.C.	Trained per 58A-5.0191(5), F.A.C.; demonstrate ability to accurately read and interpret a prescription label.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 54 of 76

Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Medication Management	Home Health Agencies	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484. Individuals providing services must be an RN or LPN.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Nurse Registries	Licensed per 400.506, F.S. Individuals providing services must be an RN or LPN.
	Licensed Nurse, LPN	Licensed per Ch. 464, F.S.
Medical Equipment & Supplies	Pharmacy	Licensed per Ch. 465, F.S.; Permitted per Ch. 465, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	Home Medical Equipment Company	Licensed per Ch. 400, Part VII, F.S. if providing, or intends to provide, medical equipment and services. No license required if providing, or intends to provide, medical supplies only.

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Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Nutritional Assessment and Risk Reduction	CCE Provider	As defined in Ch. 410 or 430, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	Nurse Registry	Licensed per 400.506, F.S.
	Other Health Care Professional	Shall practice within the legal scope of their practice.
	Dietician/Nutritionist or Nutrition Counselor	Licensed per Ch. 468, Part X, F.S.
Nursing Facility Care	See State Plan Requirements.	See State Plan Requirements.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
Personal Care	Nurse Registry	Licensed per 400.506, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	CCE Provider	As defined in Ch. 410 or 430, F.S.
Personal Emergency Response System	Alarm System Contractor	Certified per Ch. 489, Part II, F.S.	At least two (2) providers. serving each county of the region.	At least two (2) providers serving each county of the region.
	Low-Voltage Contractors and Electrical Contractors	Exempt from licensure in accordance with 489.503(15)(a-d), F.S. and 489.503(16), F.S.
Respite Care	CCE Provider	As defined in Ch. 410 or 430, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Nurse Registry	Licensed per 400.506, F.S.
	Adult Day Care Center	Licensed per Ch. 429, Part III, F.S.
	Assisted Living Facility**	Licensed per Ch. 429, Part I, F.S.
	Nursing Facility	Licensed per Ch. 400, Part II, F.S.
	Center for Independent Living	As defined under 413.371, F. S.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
	Homemaker/ Companion Agency	Registration in accordance with 400.509, F.S.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 56 of 76

Long-term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications	Minimum Network Adequacy Requirements*
			Urban Counties	Rural Counties
Transportation	Independent (private auto, wheelchair van, bus, taxi)	Licensed per Ch. 322, F.S. or residential facility providers that comply with requirements of Ch. 427, F.S.	At least two (2) providers serving each county of the region.	At least two (2) providers serving each county of the region.
	Community Transportation Coordinator	Licensed per Chapter 316 and 322, F. S., in accordance with Chapter 41-2, F. A.C.
Occupational Therapy	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.	At least two (2) providers serving each county of the region AND at least (1) provider within thirty (30) minutes travel time.	At least two (2) providers serving each county of the region AND at least (1) provider within sixty (60) minutes travel time.
	Occupational Therapist Assistant	Licensed per Ch. 468, Part III, F.S.
	Occupational Therapist Assistant	Licensed per Ch. 468, Part III, F.S.
Physical Therapy	Physical Therapist	Licensed per Ch. 486, F.S.	At least two (2) providers serving each county of the region AND at least (1) provider within thirty (30) minutes travel time.	At least two (2) providers serving each county of the region AND at least (1) provider within sixty (60) minutes travel time.
	Physical Therapist Assistant	Licensed per Ch. 486, F.S.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.
Respiratory Therapy	Home Health Agency	Home Health Agencies licensed per Chapter 400, Part III,F. S, employing certified respiratory therapists licensed under Chapter 468, F. S and may meet Federal Conditions of Participation under 42 CFR 484 or individuals licensed per Chapter 468, F. S. as certified respiratory therapists.	At least two (2) providers serving each county of the region AND at least (1) provider within thirty (30) minutes travel time.	At least two (2) providers serving each county of the region AND at least (1) provider within sixty (60) minutes travel time.
	Respiratory Therapist	Licensed per Ch. 468, F.S.
	Health Care Service Pools	Licensed per Chapter 400, Part IX, F. S.
Speech Therapy	Speech-Language Pathologist	Licensed per Ch. 468, Part I, F.S.	At least two (2) providers serving each county of the region AND at least (1) provider within thirty (30) minutes travel time.	At least two (2) providers serving each county of the region AND at least (1) provider within sixty (60) minutes travel time.
	Home Health Agency	Licensed per Ch. 400, Part III, F.S.; Optional to meet Federal Conditions of Participation under 42 CFR 484.

*The Agency reserves the right to change Minimum Provider Qualifications and Minimum Network Adequacy Requirements.

**Additional qualifications: See Section V.A.2.g for HCB characteristics requirements.

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AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 57 of 76

Table 2

PDO Provider Qualifications

Long-Term Care Plan Benefit	Qualified Service Provider Types	Minimum Provider Qualifications
Adult Companion	Individual	None *
Attendant Care	Registered Nurse (RN), Licensed Practical Nurse (LPN)	Licensed per Chapter 464, F. S.*
Homemaker	Individual	None *
Intermittent/ Skilled Nursing	Registered Nurse (RN), Licensed Practical Nurse (LPN)	Licensed per Chapter 464, F. S.*
Personal Care	Individual	None*

*Individuals of the enrollee’s choosing may provide PDO services so long as they meet the minimum provider qualifications as above and are eighteen (18) years of age or older. PDO providers are also required to sign a Participant/Direct Service Worker Agreement and obtain a satisfactory Level 2 background screening.

2. Provider Contract Requirements

a. The Managed Care Plan shall include the following provisions in its provider contracts:

(1) Require that each provider develop and maintain policies and procedures for back-up plans in the event of absent employees, and that each provider maintain sufficient staffing levels to ensure that service delivery is not interrupted due to absent employees;

(2) Include requirements for residential facilities regarding collection of patient responsibility, including prohibiting the assessment of late fees; and

(3) For assisted living facilities and adult family care homes, that they shall conform to the HCB characteristics pursuant this Contract. The Managed Care Plan shall include the following statement verbatim in its provider contracts with assisted living facility and adult family care home providers:

(Insert ALF/AFCH identifier) will support the enrollee’s community inclusion and integration by working with the case manager and enrollee to facilitate the enrollee’s personal goals and community activities.

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Enrollees residing in (insert ALF/AFCH identifier) shall be offered services with the following options unless medical, physical, or cognitive impairments restrict or limit exercise of these options.

Choice of:

• Private or semi-private rooms;

• Roommate for semi-private rooms;

• Locking door to living unit;

• Access to telephone and length of use;

• Eating schedule; and

• Participation in facility and community activities.

Ability to have:

• Unlimited visitation; and

• Snacks as desired.

Ability to:

• Prepare snacks as desired; and

• Maintain personal sleeping schedule.

(4) The Managed Care Plan shall include the following statement in its provider contract with assisted living facility providers:

(Insert ALF identifier) hereby agrees to accept monthly payments from (insert plan identifier) for enrollee services as full and final payment for all Long-term Care services detailed in the enrollee’s plan of care which are to be provided by (insert ALF identifier). Enrollees remain responsible for the separate ALF room and board costs as detailed in their resident contract. As enrollees age in place and require more intense or additional Long-term Care services, (insert ALF identifier) may not request payment for new or additional services from an enrollee, their family members or personal representative. (Insert ALF identifier) may only negotiate payment terms for services pursuant to this provider contract with (insert plan identifier).

(5) The Managed Care Plan shall include the following provision it its provider contract with nursing facilities and hospices: The provider shall maintain active Medicaid enrollment and submit required cost reports to the Agency for the duration of this agreement.

D. Provider Services

1. Provider Handbook and Bulletin Requirements

a. The Managed Care Plan shall include the following information in its provider handbooks:

(1) The role of case managers;

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(2) Requirements for HCBS providers regarding critical incident reporting and management; and

(3) Requirements for residential facilities regarding patient responsibility.

E. Medical/ Case Records Requirements

1. Standards for Medical/Case Records

a. The Managed Care Plan shall ensure the adherence to the following provisions.

(1) The enrollee’s case record documents all activities and interactions with the enrollee and any other provider(s) involved in the support and care of the enrollee. The record shall include, at a minimum, the following information:

(a) Enrollee demographic data including emergency contact information, guardian contact data, if applicable, permission forms and copies of assessments, evaluations, and medical and medication information;

(b) Legal data such as guardianship papers, court orders and release forms;

(c) Copies of eligibility documentations, including level of care determinations by CARES;

(d) Identification of the enrollee’s PCP;

(e) Information from quarterly onsite assessments that addresses at least the following:

i. Enrollee’s current medical/functional/behavioral health status, including strengths and needs;

ii. Identification of family/informal support system or community resources and their availability to assist the enrollee, including barriers to assistance;

iii. Enrollee’s ability to participate in the review and/or who case manager discusses service needs and goals with if the enrollee was unable to participate, and

iv. Environmental and/or other special needs.

(f) Needs assessments, including all physician referrals;

(g) Documentation of HCB characteristics for enrollees in ALFs and AFCHs. The responses to the HCB characteristics queries and enrollee limitations shall be documented;

(h) Documentation of interaction and contacts (including telephone contacts) with enrollee, family of enrollees, service providers or others related to services;

(i) Documentation of issues relevant to the enrollee remaining in the community with supports and services consistent with his or her capacities and abilities.

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This includes monitoring achievement of goals and objectives as set forth in the plan of care;

(j) Residential agreements between facilities and the enrollee;

(k) Problems with service providers shall be addressed in the narrative with a planned course of action noted;

(l) Copies of eligibility documents, including LOC determinations;

(m) Record of Service authorizations;

(n) CARES assessment documents;

(o) Documentation that the enrollee has received and signed, if applicable, all required plan and program information (including copies of the enrollee handbook, provider directory, etc.);

(p) Documentation of the discussion of Advanced Directives and Do Not Resuscitate orders;

(q) Documentation of the discussion with the enrollee on the procedures for filing complaints and grievances;

(r) Documentation of the choice of a participant-directed care option;

(s) Notices of Action sent to the enrollee regarding denial or changes to services (discontinuance, termination, reduction or suspension);

(t) Enrollee-specific correspondence;

(u) Physician’s orders for Long-term Care services and equipment;

(v) Provider evaluations/assessments and/or progress reports (e.g., home health, therapy, behavioral health);

(w) Case notes including documentation of the type of contact made with the enrollee and/or all other persons who may be involved with the enrollee’s care (e.g., providers);

(x) Other documentation as required by the Managed Care Plan; and

(y) Copy of the contingency plan and other documentation that indicates the enrollee/representative has been advised regarding how to report unplanned gaps in authorized service delivery.

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(2) Case management enrollee file information shall be maintained by the Managed Care Plan in compliance with state regulations for record retention. Per 42 CFR 441.303(c)(3), written and electronically retrievable documentation of all evaluations and re-evaluations shall be maintained as required in 45 CFR 92.42. The Managed Care Plan shall specify in policy where records of evaluation and re-evaluations of level of care are maintained and exchanged with the CARES unit.

(3) The Managed Care Plan shall adhere to the confidentiality standards under the Health Insurance Portability and Accountability Act (HIPAA).

(4) Case files shall be kept secured.

(5) All narratives in case records shall be electronically signed and dated by the case manager. Electronic signatures with date stamps are allowable for electronic case records.

Section VII. Quality and Utilization Management

A. Quality Improvement

There are no additional quality improvements provisions unique to the LTC managed care program.

B. Performance Measures (PMs)

1. Required Performance Measures (PMs)

a. The Managed Care Plan shall collect and report the following performance measures, certified via qualified auditor.

HEDIS
1	Care for Older Adults (COA): Add age bands: 18 to 60 years as of December 31 of the measurement year* 61 to 65 years as of December 31 of the measurement year* 66 years and older as of December 31 of the measurement year
Agency — Defined
2	Required Record Documentation (RRD)
3	Face-To-Face Encounters (F2F)
4	Case Manager Training (CMT)
5	Timeliness of Services (TOS)
6	Prevalence of antipsychotic drug use in long-stay dementia residents
Survey-Based Measures
7	CAHPS Nursing Home Survey — Long-Stay Resident: Staffing Composite (Items 10, 12-17)
8	CAHPS Nursing Home Survey — Long-Stay Resident: Recommend nursing home to others (Item 35)

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9	Satisfaction with Long-Term Care Plan: CAHPS Supplemental Question and Enrollee Satisfaction Survey Item 11
10	Satisfaction with Care Manager: CAHPS Supplemental Question and Enrollee Satisfaction Survey Item 5
11	Rating of Quality of Services: CAHPS Supplemental Question and Enrollee Satisfaction Survey: Item 8

*Agency addition to HEDIS

b. The Agency, at its sole discretion, may add and/or change required performance measures based on state and federal quality initiatives. These measures may include, but are not limited to, Medicare measures related to nursing home care and home-based care. Examples of measures that may be included are avoidable hospitalizations; hospital readmissions; prevalence of pressure ulcers; prevalence of use of restraints; rates of antipsychotic drug use; prevalence of dehydration among enrollees; and prevalence of Baker Act-related hospitalizations.

C. Performance Improvement Projects (PIPs)

The Managed Care Plan shall perform two (2) Agency-approved statewide performance improvement projects as specified below:

1. The clinical PIP shall relate to care in a nursing facility.

2. The non-clinical PIP shall relate to care in a home and community-based setting.

D. Satisfaction and Experience Surveys

1. Enrollee Satisfaction Survey

a. The Managed Care Plan shall conduct an annual enrollee satisfaction survey for a time period specified by the Agency.

b. The Managed Care Plans shall report results of the enrollee satisfaction survey to the Agency with an action plan to address the results of the survey (See Section XIV, Reporting Requirements.) according to the following schedule:

(1) The first enrollee survey results report will be due to the Agency by December 31, 2014.

(2) The second enrollee survey results report will be due to the Agency by October 1, 2015.

(3) In 2016 and thereafter, enrollee survey results reports will be due to the Agency by July 1 of each Contract year.

c. The Managed Care Plan submit a corrective action plan, as required by the Agency, within sixty 60 days of the request from the Agency to address any deficiencies the annual enrollee satisfaction survey.

d. The Managed Care Plan shall use the results of the annual member satisfaction survey to develop and implement plan-wide activities designed to improve member satisfaction.

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Activities conducted by the Managed Care Plan pertaining to improving member satisfaction resulting from the annual enrollee satisfaction survey must be reported to the Agency on a quarterly basis.

E. Provider- Specific Performance Monitoring

1. Medical/Case Record Review

a. The Managed Care Plan shall conduct medical/case record reviews at the following provider sites:

(1) Adult Family Care Homes at least once every two (2) years; and

(2) Assisted Living Facilities at least once every two (2) years.

F. Other Quality Management Requirements

1. Critical Incidents

a. The Managed Care Plan shall develop and implement a critical and adverse incident reporting and management system for incidents that occur in a home and community-based Long-term Care service delivery setting, including: community-based residential alternatives other than assisted living facilities; other HCBS provider sites; and an enrollee’s home, if the incident is related to the provision of covered HCBS.

b. The Managed Care Plan shall require HCBS providers to report adverse incidents to the Managed Care Plans within twenty-four (24) hours of the incident. The Managed Care Plan shall not require nursing facilities or assisted living facilities to report adverse incidents or provide incident reports to the Managed Care Plan. Adverse incidents occurring in nursing facilities and assisted living facilities will be addressed in accordance with Florida law, including but not limited to ss. 400.147, 429.23, Chapter 39 and Chapter 415, F.S.

c. If the event involves a health and safety issue for an enrollee with LTC benefits, the LTC Managed Care Plan or Comprehensive LTC Managed Care Plan and case manager shall arrange for the enrollee to move from his/her current location or change providers to accommodate a safe environment and participating or direct service provider of the enrollee’s choice.

d. If an investigation of suspected abuse, neglect or exploitation requires the enrollee to move from his/her current locations, the LTC Managed Care Plan or Comprehensive LTC Managed Care Plan shall coordinate with the investigator to find a safe living environment or another participating provider of the enrollee’s choice.

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AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 64 of 76

G. Utilization Management

There are no additional utilization management provisions unique to the LTC managed care program.

H. Continuity of Care in Enrollment

There are no additional continuity of care in enrollment provisions unique to the LTC managed care program.

Section VIII. Administration and Management

A. Organizational Governance and Staffing

Addition requirements related to case management staffing are specified in Section V.E. 2, Case Management Staff Qualifications and Experience

B. Subcontracts

There are no additional subcontract provisions unique to the LTC managed care program.

C. Information Management and Systems

There are no additional information management and systems provisions unique to the LTC managed care program.

D. Claims and Provider Payment

There are no additional claims and provider payment provisions unique to the LTC managed care program.

E. Encounter Data Requirements

There are no additional encounter data provisions unique to the LTC managed care program.

F. Fraud and Abuse Prevention

There are no additional fraud and abuse prevention provisions unique to the LTC managed care program.

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Section IX. Method of Payment

A. Fixed Price Unit Contract

There are no additional provisions unique to the LTC managed care program.

B. Payment Provisions

1. Capitation Rates

a. The Agency will prospectively adjust the base capitation rates included in Attachment I, Scope of Services to reflect the Managed Care Plan’s enrolled risk.

b. The Agency will develop a pre-enrollment benchmark case mix for each region based on analysis of the most recent twelve (12) months of historical data that allows for three (3) months of claims run out. The enrollment distribution will be calculated using population segmentation logic consistent with that used in rate development. Recipients whose last care setting prior to the start of the capitation rate period was nursing facility will be classified as Non-HCBS. Recipients who become program-eligible after the start of the capitation rate period will be classified as Non-HCBS based on program codes that indicate Institutional Care Program eligibility. Enrollees not meeting the Non-HCBS classification criteria will be classified as HCBS. For rate purposes, for both the transitioned and new enrollees, the recipient’s initial classification will remain valid through the duration of the capitation rate period.

c. Month 1: In each region, the Agency will pay the Managed Care Plan a blended capitation rate that reflects the regional pre-enrollment benchmark case mix, adjusted for the Agency-required transition percentage, which is included as Attachment I, Scope of Services, Exhibit I-C. AHCA will later perform a reconciliation based on month one (1) actual enrollment and case mix for each plan.

d. Subsequent months: For the second month and each subsequent month of the contract payment period, AHCA will develop a blended capitation rate for the Managed Care Plan, adjusted for the new enrollments and disenrollments that occurred in the previous month, and adjusted for the Agency-required transition percentage.

e. Once ninety-five percent (95%) of regional eligible recipients are enrolled in managed care plans, the Agency will ensure that the recalibrated rates are budget neutral to the State on a PMPM basis. The benchmark against which budget neutrality will be measured is the region-wide rate based on the pre-enrollment case mix with the Agency-required transition percentage.

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2. Rate Adjustments and Reconciliations

a. Pursuant to ss. 409.983(6) and 409.983(7), F.S., the Agency will reconcile the Managed Care Plan’s payments to nursing facilities, including patient responsibility and hospices as follows:

(1) Actual nursing facility payments shall be reconciled by the Agency to ensure actual claim payments are, at a minimum, the same as Medicaid fee-for-service (FFS) claim payments. Any Managed Care Plan provider payments to nursing homes in excess of FFS claim payment will not be reimbursed by the Agency or in any way increase per member per month payment to the Managed Care Plan in any current or future capitation rate setting period. The Managed Care Plan accepts and assumes all risks of excess payments as a cost of doing business and cannot seek additional Medicaid payments for such business decisions. Any inadvertent payments made by the Agency to a Managed Care Plan in excess of the FFS amount shall be overpayments and shall be recouped.

(a) The nursing facility rate reconciliation process required by 409.983(6), Florida Statutes, is as follows:

i. The Agency will set facility–specific payment rates based on the rate methodology outlined in the most recent version of the Florida Title XIX Long-term Care Reimbursement Plan. The Managed Care Plan shall pay nursing facilities an amount no less than the nursing facility specific payment rates set by the Agency and published on the Agency website. The Managed Care Plan shall use the published facility-specific rates as a minimum payment level for all future payments.

ii. Participating nursing facilities shall maintain their active Medicaid enrollment and submit required cost reports to the Agency.

iii. For changes in nursing facility payment rates that apply prospectively, the following process shall be used:

• The Agency will annually reconcile between the nursing facility payment rates used in the capitation rates and the actual published payment rates. This Managed Care Plan-specific reconciliation will be performed using the Managed Care Plan’s own utilization, as reflected through encounter data that covers the capitation rate period dates of services with at least four (4) months of claims run out.

• The Managed Care Plan shall review and provide written comments or a letter of concurrence to the Agency within forty-five (45) days after receipt of the reconciliation results. This reconciliation is considered final if the Managed Care Plan concurs with the result.

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• Comments and errors identified are limited to the published rates reviewed and related Managed Care Plan nursing facility and hospice payments, methodology and/or calculations.

• If the Managed Care Plan or the Agency comments that such an error has occurred, a new forty-five (45) calendar review period shall start on the date the Managed Care Plan receives the Agency’s final determination of the reconciliation results. The Agency’s final determination of the reconciliation results shall be final and conclusive. The Managed Care Plan may dispute the Agency’s decision as per Section XVI.I., Disputes, if it does not concur with the results.

• If the Managed Care Plan does not provide comments within the forty-five (45) calendar day period, no further opportunity for review consideration will be provided.

iv. For changes in nursing facility payment rates that apply retroactively, the following process shall be used:

• The Agency will settle directly with nursing facilities that were overpaid for the prior period. The Managed Care Plan shall not collect such payments from the nursing facilities.

• The Agency may settle directly with nursing facilities that were underpaid for the prior period, or may send the payment to the Managed Care Plan for distribution to the affected nursing facility. If the Managed Care Plan is asked to distribute an underpayment to a nursing facility under this process, payment to the facility shall be made within fifteen (15) days of receiving the payment from the Agency.

(2) Hospices: The Agency will set hospice level of care and room and board rates based upon the rate development methodology detailed in 42 CFR Part 418 for per diem rates and Chapter 409.906 (14), Florida Statutes and 59G-4.140, Florida Administrative Code, for room and board rates. The Managed Care Plan shall pay hospices an amount no less than the hospice payment rates set by the Agency and published on the Agency website no later than October 1 of each year for per diem rates and January 1 and July 1 of each year for room and board rates for nursing home residents. The Managed Care Plan shall use the published hospice rates as a minimum payment level for all future payments.

(a) Participating hospices shall maintain their active Medicaid enrollment and submit room and board cost logs to the Agency.

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(b) For changes in hospice per diem and room and board payment rates that apply prospectively, the following process shall be used:

i. The Agency will annually reconcile between the hospice per diem and room and board payment rates used in the capitation rates paid and the actual published payment rates. This hospice-specific reconciliation will be performed using the Managed Care Plan’s own utilization, as reflected through encounter data that covers the capitation rate period dates of services with at least four (4) months of claims run out.

ii. The Managed Care Plan shall review and provide written comments or a letter of concurrence to the Agency within forty-five (45) days after receipt of the reconciliation results. This reconciliation is considered final if the Managed Care Plan concurs with the result.

iii. Comments and errors identified are limited to the published rates reviewed and related Managed Care Plan hospice payments, and methodology, and/or calculations.

iv. If the Managed Care Plan or the Agency comments that such an error has occurred, a new forty-five (45) calendar review period shall start on the date the Managed Care Plan receives the Agency’s final determination of the reconciliation results. The Agency’s final determination of the reconciliation results shall be final and conclusive. The Managed Care Plan may dispute the Agency’s decision as per Section XVI.I., Disputes, if it does not concur with the results.

v. If the Managed Care Plan does not provide comments within the forty-five (45) calendar day period, no further opportunity for review consideration will be provided.

(3) Patient Responsibility Reconciliation. The Managed Care Plan shall have its annual patient responsibility collections and HCBS waiver service costs report reviewed annually to verify the patient responsibility collections on a per capita basis did not exceed the cost of HCBS services. If the per capita patient responsibility collections exceed the HCBS waiver costs, the Agency will adjust the capitation to correct the Managed Care Plan overpayment.

(4) Nursing Facility, Hospice and Patient Responsibility Collection Reconciliation Schedule. The Agency will announce the reconciliation schedule after the close of each capitation rate period. The Managed Care Plan shall respond to any Agency requests for additional information concerning the reconciliation within fifteen (15) days of notification.

(5) Actual hospice payments shall be reconciled by the Agency to ensure actual claim payments are, at a minimum, the same as Medicaid fee-for-service (FFS) claim payments. Any Managed Care Plan provider payments to hospices in excess of FFS claim payment will not be reimbursed by the agency or in any way increase per member per month payment to the Managed Care Plan in any current or future capitation rate setting period. The Managed Care Plan accepts and assumes all

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 69 of 76

risks of excess payments as a cost of doing business and cannot seek additional Medicaid payments for such business decisions. Any inadvertent payments made by the Agency to a Managed Care Plan in excess of the FFS amount shall be overpayments and shall be recouped.

Section X. Financial Requirements

A. Insolvency Protection

There are no additional insolvency provisions unique to the LTC managed care program.

B. Surplus

There are no surplus provisions unique to the LTC managed care program.

C. Interest

There are no additional interest provisions unique to the LTC managed care program.

D. Third Party Resources

1. Patient Responsibility

a. The Managed Care Plan is responsible for collecting patient responsibility as determined by DCF and shall have policies and procedures to ensure that, where applicable, enrollees are assessed for and pay their patient responsibility. Some enrollees have no patient responsibility either because of their limited income or the methodology used to determine patient responsibility.

b. The Managed Care Plan may transfer the responsibility for collecting its enrollees’ patient responsibility to residential providers and compensate these providers net of the patient responsibility amount. If the Managed Care Plan transfers collection of patient responsibility to the provider, the provider contract shall specify complete details of both parties’ obligations in the collection of patient responsibility. The Managed Care Plan shall either collect patient responsibility from all of its residential providers or transfer collection to all of its residential providers.

c. The Managed Care Plan shall have a system in place to track the receipt of patient responsibility at the enrollee level irrespective of which entity collects the patient responsibility. This data shall be available upon request by the Agency. The Managed Care Plan or its providers shall not assess late fees for the collection of patient responsibility from enrollees.

d. The Managed Care Plan shall submit a Patient Responsibility Report annually, in accordance with Section XIV, Reporting Requirements, and the Managed Care Plan Report Guide. If an enrollee’s patient responsibility exceeds the reported Medicaid Home and Community Based service expenditure, the Agency will employ the reconciliation process detailed in Section IX.B., Payment Provisions, to determine if a payment adjustment is required.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 70 of 76

E. Assignment

There are no additional assignment provisions unique to the LTC managed care program.

F. Financial Reporting

There are no additional financial reporting provisions unique to the LTC managed care program.

G. Inspection and Audit of Financial Records

There are no additional inspection provisions unique to the LTC managed care program.

Section XI. Sanctions

A. Contract Violations and Non-Compliance

There are no additional provisions unique to the LTC managed care program.

B. Performance Measure Action Plans (PMAP) and Corrective Action Plans (CAP)

There are no additional PMAP and/or CAP provisions unique to the LTC managed care program.

C. Performance Measure Sanctions

1. The Agency may sanction the Managed Care Plan for failure to achieve minimum performance scores on performance measures specified by the Agency after the first year of poor performance. The HEDIS measure will be compared to the National Committee for Quality Assurance HEDIS National Means and Percentiles. The Agency-defined measures have threshold rates (percentages) that may trigger a sanction. The Survey-based measures have threshold average ratings (from 0-10) that may trigger a sanction.

Performance Measure Sanction Table – Effective 8/01/2013 – 8/31/2018
HEDIS Measures	Rate and applicable sanction
Care for Older Adults	Rate < 25th percentile - immediate monetary sanction and PMAP may be imposed Rate < 50th percentile - PMAP may be required
Agency-defined Measures	Rate and applicable sanction
Required Record Documentation – numerators 1-4	Rate < 85% - immediate monetary sanction and PMAP may be imposed Rate < 90% - PMAP may be required
Face-to-Face Encounters
Care Manager Training
Timeliness of Service
Survey-based Measures	Average rating and applicable sanction
Satisfaction with Long-term Care Plan	Rate 4.0 or lower – immediate monetary sanction and PMAP may be imposed Rate 5.0 or lower – PMAP may be required
Satisfaction with Care Manager
Rating of Quality of Services

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 71 of 76

2. Monetary sanctions: The Managed Care Plan may receive a monetary sanction for measures for which their scores meet the thresholds given in the above table for the first offense. Managed Care Plans shall receive a monetary sanction for measures for which their scores meet the thresholds given in the above table for the second offense and subsequent offenses. For the HEDIS and Agency-defined measures, if the Health Plan has a score/rate that triggers an immediate monetary sanction, the Health Plan may be sanctioned $500 for each case in the denominator not present in the numerator. If the Health Plan fails to improve these performance measures in subsequent years, the Agency will impose a sanction of $1,000 per case. For each Survey-based measure in the table above for which the Health Plan has an average rate that triggers an immediate monetary sanction, the Health Plan may be sanctioned $10,000.

3. The Agency may amend the performance measure thresholds and sanctions and will notice the Managed Care Plans prior to the start of the applicable measurement year or with an amount of notice mutually agreed upon by the Agency and the Managed Care Plans. Amendments to the performance measure thresholds and sanctions may include, but are not limited to, adding and removing performance measures from the sanction strategy, changing thresholds for sanctions, and changing the monetary amounts of sanctions.

D. Other Sanctions

There are no additional provisions unique to the LTC managed care program.

E. Notice of Sanctions

There are no additional notice provisions unique to the LTC managed care program.

F. Dispute of Sanctions

There are no additional disputes provisions unique to the LTC managed care program.

Section XII. Special Terms and Conditions

The Special Terms and Conditions in Section XII, Special Terms and Conditions apply to all LTC Managed Care Plans and Comprehensive LTC Managed Care Plans unless specifically noted otherwise in this Exhibit.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 72 of 76

Section XIII. Liquidated Damages

A. Damages

Additional damages issues and amounts unique to the LTC managed care program are specified below.

B. Issues and Amounts

If the Managed Care Plan fails to perform any of the services set forth in the Contract, the Agency may assess liquidated damages for each occurrence listed in the LTC Issues and Amounts Table below.

Liquidated Damages Issues and Amounts
#	LTC PROGRAM ISSUE	DAMAGES
1	Failure to comply with the medical/case records documentation requirements pursuant to the Contract.	$500 per plan of care for HCBS enrollees that does not include all of the required elements. $500 per member file that does not include all of the required elements. $500 per face-to-face visit where the care coordinator fails to document the specified observations. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the caseload and staffing requirements
2	Failure to comply with the timeframes for developing and approving a plan of care for transitioning or initiating home and community-based services as described in the Contract.	$500 per day, per occurrence.
3	Failure to have a face-to-face contact between the Managed Care Plan case manager and each enrollee at least every ninety (90) days or following a significant change as described in the Contract.	$5,000 for each occurrence.
4	Failure to complete in a timely manner minimum care coordination contacts required for persons transitioned from a nursing facility to a community placement as described in the Contract.	$500 per day, per occurrence.
5	Failure to meet the performance standards established by the Agency regarding missed visits for personal care, attendant care, homemaker, or home- delivered meals for enrollees (referred to herein as “specified HCBS”) pursuant to the Contract.	$500 per day, per occurrence.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 73 of 76

Liquidated Damages Issues and Amounts
#	LTC PROGRAM ISSUE	DAMAGES
6	Failure to develop a person-centered plan of care for an enrollee that includes all of the required elements, and which has been reviewed with and signed and dated by the member or authorized representative, unless the member/representative refuses to sign, which shall be documented in writing as described in the Contract.	$500 per deficient plan of care. These amounts shall be multiplied by two (2) when the Managed Care Plan has not complied with the caseload and staffing requirements specified in the Contract.
7	Failure to meet any timeframe regarding care coordination for members as described in the Contract.	$250 per calendar day, per occurrence.
8	Failure to follow-up within seven (7) days of service authorization for the initial care plan to ensure that services are in place as described in the Contract	$5,000 for each occurrence.
9	Failure to provide a copy of the care plan to each enrollee's PCP and residential facility in the timeframes as described in the Contract.	$500 per calendar day.
10	Failure to report enrollees that do not receive any Long-term Care services listed in the approved care plan for a month, as described in the Contract.	For each enrollee, an amount equal to the capitation rate for the month in which the enrollee did not receive long- term care services.
11	Failure to comply with obligations and time frames in the delivery of annual face-to-face reassessments for level of care as described in the Contract.	$1,000 per occurrence.
12	Failure to ensure that for each enrollee all necessary paperwork is submitted to DCF within the timeframes included in the Contract.	$100 assessed for each enrollee who temporarily loses eligibility (for less than 60 days) pursuant to a redetermination.
13	Failure to follow-up within twenty-four (24) hours of initial contact by the Florida Adult Protective Services Unit pursuant to the Contract	$5,000 for each occurrence
14	Performance Measure: Care for Older Adults	Failure to achieve a rate at the 25th percentile (per the NCQA National Means and Percentiles, Medicare) or higher will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below the 25th percentile in subsequent years, damages will be $1,000 per case.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 74 of 76

Liquidated Damages Issues and Amounts
#	LTC PROGRAM ISSUE	DAMAGES
15	Performance Measure: Required Record Documentation – numerators 1-4	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.
16	Performance Measure: Face-to-Face Encounters	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.
17	Performance Measure: Care Manager Training	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.
18	Performance Measure: Timeliness of Service	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.
19	Performance Measure: Satisfaction with Care Manager and LTC Managed Care Plan	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 75 of 76

Liquidated Damages Issues and Amounts
#	LTC PROGRAM ISSUE	DAMAGES
20	Performance Measure: Rating of Quality of Services	Failure to achieve a rate of 90% or higher for each of these measures will result in liquidated damages of $500 per each case in the denominator not present in the numerator for the measure. If the Managed Care Plan’s rate remains below 90% in subsequent years, damages will be $1,000 per case.

Section XIV. Reporting Requirements

A. Managed Care Plan Reporting Requirements

1. Required Reports

The Managed Care Plan shall comply with all reporting requirements set forth in this Contract, including reports specific to LTC Managed Care Plans as specified in the Summary of Reporting Requirements Table below and the Managed Care Plan Report Guide.

Summary of Reporting Requirements
Report Name	Plan Type	Frequency
Participant Direction (PDO) Roster Report	All LTC Plans	Monthly
Utilization Report	All LTC Plans	Quarterly
Case Management File Audit Report	All LTC Plans	Quarterly
Case Management Monitoring and Evaluation Report	All LTC Plans	Quarterly and Annually
Missed Services Report	All LTC Plans	Monthly
Case Manager Caseload Report	All LTC Plans	Monthly
Denial, Reduction or Termination of Services Report	All LTC Plans	Monthly
Enrollee Roster and Facility Residence Report	All LTC Plans	Monthly
Level of Care Report	All LTC Plans	Quarterly
Patient Responsibility Report	All LTC Plans	Annually

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment II, Exhibit II-B, Page 76 of 76

ATTACHMENT III

BUSINESS ASSOCIATE AGREEMENT

The parties to this Attachment agree that the following provisions constitute a business associate agreement for purposes of complying with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This Attachment is applicable if the Vendor is a business associate within the meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.

The Vendor certifies and agrees as to abide by the following:

1. Definitions. Unless specifically stated in this Attachment, the definition of the terms contained herein shall have the same meaning and effect as defined in 45 C.F.R. 160 and 164.

1a. Protected Health Information. For purposes of this Attachment, protected health information shall have the same meaning and effect as defined in 45 C.F.R. 160 and 164, limited to the information created, received, maintained or transmitted by the Vendor from, or on behalf of, the Agency.

1b. Security Incident. For purposes of this Attachment, security incident means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system and includes any event resulting in computer systems, networks, or data being viewed, manipulated, damaged, destroyed or made inaccessible by an unauthorized activity.

2. Applicability of HITECH and HIPAA Privacy Rule and Security Rule Provisions. As provided by federal law, Title XIII of the American Recovery and Reinvestment Act of 2009 (ARRA), also known as the Health Information Technology Economic and Clinical Health (HITECH) Act, requires a Business Associate (Vendor) that contracts with the Agency, a HIPAA covered entity, to comply with the provisions of the HIPAA Privacy and Security Rules (45 C.F.R. 160 and 164).

3. Use and Disclosure of Protected Health Information. The Vendor shall comply with the provisions of 45 CFR 164.504(e)(2)(ii). The Vendor shall not use or disclose protected health information other than as permitted by this Contract or by federal and state law. The sale of protected health information or any components thereof is prohibited except as provided in 45 CFR 164.502(a)(5). The Vendor will use appropriate safeguards to prevent the use or disclosure of protected health information for any purpose not in conformity with this Contract and federal and state law. The Vendor will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic protected health information the Vendor creates, receives, maintains, or transmits on behalf of the Agency.

4. Use and Disclosure of Information for Management. Administration, and Legal Responsibilities. The Vendor is permitted to use and disclose protected health information received from the Agency for the proper management and administration of the Vendor or to carry out the legal responsibilities of the Vendor, in accordance with 45 C.F.R. 164.504(e)(4). Such disclosure is only permissible where required by law, or where the Vendor obtains reasonable assurances from the person to whom the protected health information is disclosed that: (1) the protected health information will be held confidentially, (2) the protected health information will be used

AHCA Contract No. FP020, Attachment III, Page 1 of 4

AHCA Form 2100-0017 (Rev. AUG 2013)

or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and (3) the person notifies the Vendor of any instance of which it is aware in which the confidentiality of the protected health information has been breached.

5. Disclosure to Third Parties. The Vendor will not divulge, disclose, or communicate protected health information to any third party for any purpose not in conformity with this Contract without prior written approval from the Agency. The Vendor shall ensure that any agent, including a subcontractor, to whom it provides protected health information received from, or created or received by the Vendor on behalf of, the Agency agrees to the same terms, conditions, and restrictions that apply to the Vendor with respect to protected health information. The Vendor’s subcontracts shall fully comply with the requirements of 45 CFR 164.314(a)(2)(iii).

6. Access to Information. The Vendor shall make protected health information available in accordance with federal and state law, including providing a right of access to persons who are the subjects of the protected health information in accordance with 45 C.F.R. 164.524.

7. Amendment and Incorporation of Amendments. The Vendor shall make protected health information available for amendment and to incorporate any amendments to the protected health information in accordance with 45 C.F.R. 164.526.

8. Accounting for Disclosures. The Vendor shall make protected health information available as required to provide an accounting of disclosures in accordance with 45 C.F.R. 164.528. The Vendor shall document all disclosures of protected health information as needed for the Agency to respond to a request for an accounting of disclosures in accordance with 45 C.F.R. 164.528.

9. Access to Books and Records. The Vendor shall make its internal practices, books, and records relating to the use and disclosure of protected health information received from, or created or received by the Vendor on behalf of the Agency, available to the Secretary of the Department of Health and Human Services (“HHS”) or the Secretary’s designee for purposes of determining compliance with the HHS Privacy Regulations.

10. Reporting. The Vendor shall make a good faith effort to identify any use or disclosure of protected health information not provided for in this Contract.

10a. To Agency. The Vendor will report to the Agency, within ten (10) business days of discovery, any use or disclosure of protected health information not provided for in this Contract of which the Vendor is aware. The Vendor will report to the Agency, within twenty-four (24) hours of discovery, any security incident of which the Vendor is aware. A violation of this paragraph shall be a material violation of this Contract. Such notice shall include the identification of each individual whose unsecured protected health information has been, or is reasonably believed by the Vendor to have been, accessed, acquired, used, or disclosed during such breach.

10b. To Individuals. In the case of a breach of protected health information discovered by the Vendor, the Vendor shall first notify the Agency of the pertinent details of the breach and upon prior approval of the Agency shall notify each individual whose unsecured protected health information has been, or is reasonably believed by the Vendor to have been, accessed, acquired, used or disclosed as a result of such breach. Such notification shall be in writing by first-class mail to the individual (or the next of kin if the individual is deceased) at the last known address of the individual or next of kin, respectively, or, if

AHCA Contract No. FP020, Attachment III, Page 2 of 4

AHCA Form 2100-0017 (Rev. AUG 2013)

specified as a preference by the individual, by electronic mail. Where there is insufficient, or out-of-date contract information (including a phone number, email address, or any other form of appropriate communication) that precludes written (or, if specifically requested, electronic) notification to the individual, a substitute form of notice shall be provided, including, in the case that there are 10 or more individuals for which there is insufficient or out-of-date contact information, a conspicuous posting on the Web site of the covered entity involved or notice in major print of broadcast media, including major media in the geographic areas where the individuals affected by the breach likely reside. In any case deemed by the Vendor to require urgency because of possible imminent misuse of unsecured protected health information, the Vendor may also provide information to individuals by telephone or other means, as appropriate.

10c. To Media. In the case of a breach of protected health information discovered by the Vendor where the unsecured protected health information of more than 500 persons is reasonably believed to have been, accessed, acquired, used or disclosed, after prior approval by the Agency, the Vendor shall provide notice to prominent media outlets serving the State or relevant portion of the State involved.

10d. To Secretary of Health and Human Services (HHS). The Vendor shall cooperate with the Agency to provide notice to the Secretary of HHS of unsecured protected health information that has been acquired or disclosed in a breach.

(i) Vendors Who Are Covered Entities. In the event of a breach by a contractor or subcontractor of the Vendor, and the Vendor is a HIPAA covered entity, the Vendor shall be considered the covered entity for purposes of notification to the Secretary of HHS pursuant to 45 CFR 164.408. The Vendor shall be responsible for filing the notification to the Secretary of HHS and will identify itself as the covered entity in the notice. If the breach was with respect to 500 or more individuals, the Vendor shall provide a copy of the notice to the Agency, along with the Vendor’s breach risk assessment for review at least 15 business days prior to the date required by 45 C.F.R. 164.408 (b) for the Vendor to file the notice with the Secretary of HHS. If the breach was with respect to less than 500 individuals, the Vendor shall notify the Secretary of HHS within the notification timeframe imposed by 45 C.F.R. 164.408(c) and shall contemporaneously submit copies of said notifications to the Agency.

10e. Content of Notices. All notices required under this Attachment shall include the content set forth Section 13402(f), Title XIII of the American Recovery and Reinvestment Act of 2009 and 45 C.F.R. 164.404(c), except that references therein to a “covered entity” shall be read as references to the Vendor.

10f. Financial Responsibility. The Vendor shall be responsible for all costs related to the notices required under this Attachment.

11. Mitigation. Vendor shall mitigate, to the extent practicable, any harmful effect that is known to the Vendor of a use or disclosure of protected health information in violation of this Attachment.

12. Termination. Upon the Agency's discovery of a material breach of this Attachment, the Agency shall have the right to assess liquidated damages as specified elsewhere in the contact to which this Contract is an attachment, and/or to terminate this Contract.

AHCA Contract No. FP020, Attachment III, Page 3 of 4

AHCA Form 2100-0017 (Rev. AUG 2013)

12a. Effect of Termination. At the termination of this Contract, the Vendor shall return all protected health information that the Vendor still maintains in any form, including any copies or hybrid or merged databases made by the Vendor; or with prior written approval of the Agency, the protected health information may be destroyed by the Vendor after its use. If the protected health information is destroyed pursuant to the Agency's prior written approval, the Vendor must provide a written confirmation of such destruction to the Agency. If return or destruction of the protected health information is determined not feasible by the Agency, the Vendor agrees to protect the protected health information and treat it as strictly confidential.

The Vendor has caused this Attachment to be signed and delivered by its duly authorized representative, as of the date set forth below.

Vendor Name: WELLCARE OF FLORIDA, INC.

D/B/A STAYWELL HEALTH PLAN OF FLORIDA, INC.

/s/ David McNichols	February 3, 2014
Signature	Date
David McNichols
Name and Title of Authorized Signer

AHCA Contract No. FP020, Attachment III, Page 4 of 4

AHCA Form 2100-0017 (Rev. AUG 2013)

ATTACHMENT IV

CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

/s/ David McNichols	February 3, 2014
Signature	Date
David McNichols	Contract No. FP020
Name of Authorized Individual	Application or Contract Number
WellCare of Florida, Inc. d/b/a Staywell	3031 N. Rocky Point Dr. West, Tampa, FL 33607
Name and Address of Organization

AHCA Contract No. FP020, Attachment IV, Page 1 of 1

AHCA Form 2100-0010 (Rev. OCT02)

ATTACHMENT V

CERTIFICATION REGARDING

DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CONTRACTS/SUBCONTRACTS

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987, Federal Register (52 Fed. Reg., pages 20360-20369).

INSTRUCTIONS

1. Each Vendor whose contract/subcontract equals or exceeds $25,000 in federal monies must sign this certification prior to execution of each contract/subcontract. Additionally, Vendors who audit federal programs must also sign, regardless of the contract amount. The Agency for Health Care Administration cannot contract with these types of Vendors if they are debarred or suspended by the federal government.

2. This certification is a material representation of fact upon which reliance is placed when this contract/subcontract is entered into. If it is later determined that the signer knowingly rendered an erroneous certification, the Federal Government may pursue available remedies, including suspension and/or debarment.

3. The Vendor shall provide immediate written notice to the contract manager at any time the Vendor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "debarred," "suspended," "ineligible," "person," "principal," and "voluntarily excluded," as used in this certification, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the contract manager for assistance in obtaining a copy of those regulations.

5. The Vendor agrees by submitting this certification that, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this contract/subcontract unless authorized by the Federal Government.

6. The Vendor further agrees by submitting this certification that it will require each subcontractor of this contract/subcontract, whose payment will equal or exceed $25,000 in federal monies, to submit a signed copy of this certification.

7. The Agency for Health Care Administration may rely upon a certification of a Vendor that it is not debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it knows that the certification is erroneous.

8. This signed certification must be kept in the contract manager's contract file. Subcontractor's certifications must be kept at the contractor's business location.

CERTIFICATION

(1) The prospective Vendor certifies, by signing this certification, that neither he nor his principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this contract/subcontract by any federal department or agency.

(2) Where the prospective Vendor is unable to certify to any of the statements in this certification, such prospective Vendor shall attach an explanation to this certification.

/s/ David McNichols	February 3, 2014
Signature	Date
David McNichols
Name and Title of Authorized Signer

AHCA Contract No. FP020, Attachment V, Page 1 of 1

AHCA Form 2100-0009 (JAN 03)

ATTACHMENT VI

VENDOR CERTIFICATION REGARDING

SCRUTINIZED COMPANIES LISTS

Vendor Name: WellCare of Florida, Inc. d/b/a Staywell

Vendor FEIN: 59-2583622

Vendor’s Authorized Representative Name and Title: David McNichols, State President

Address: 3031 N. Rocky Point Drive West

City: Tampa  State:Florida  Zip: 33607

Telephone Number: 813-206-3213

Email Address: David.McNichols@wellcare.com

Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. Both lists are created pursuant to section 215.473, Florida Statutes.

As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified above in the section entitled “Vendor Name” is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney’s fees, and/or costs.

Certified By: /s/ David McNichols,

who is authorized to sign on behalf of the above referenced company.

Authorized Signature Print Name and Title: David McNichols, State President

AHCA Contract No. FP020, Attachment VI, Page 1 of 1

EX-31.1

EXHIBIT 31.1

CERTIFICATION

I, David Gallitano, certify that:

1. I have reviewed this Quarterly Report on Form 10-Q of WellCare Health Plans, Inc.;

2. Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

3. Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

4. The registrant's other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:

a. Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b. Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c. Evaluated the effectiveness of the registrant's disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d. Disclosed in this report any change in the registrant's internal control over financial reporting that occurred during the registrant's most recent fiscal quarter (the registrant's fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant's internal control over financial reporting; and

5. The registrant's other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant's auditors and the audit committee of the registrant's board of directors (or persons performing the equivalent functions):

a. All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant's ability to record, process, summarize and report financial information; and

b. Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant's internal control over financial reporting.

Date:	May 8, 2014	/s/ David Gallitano
		David Gallitano, Chairman of the Board and Chief Executive Officer
		(Principal Executive Officer)

EX-31.2

EXHIBIT 31.2

CERTIFICATION

I, Thomas L. Tran, certify that:

1. I have reviewed this Quarterly Report on Form 10-Q of WellCare Health Plans, Inc.;

2. Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

3. Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

4. The registrant's other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:

a. Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b. Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c. Evaluated the effectiveness of the registrant's disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d. Disclosed in this report any change in the registrant's internal control over financial reporting that occurred during the registrant's most recent fiscal quarter (the registrant's fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant's internal control over financial reporting; and

5. The registrant's other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant's auditors and the audit committee of the registrant's board of directors (or persons performing the equivalent functions):

a. All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant's ability to record, process, summarize and report financial information; and

b. Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant's internal control over financial reporting.

Date:	May 8, 2014	/s/ Thomas L. Tran
		Thomas L. Tran
		Senior Vice President and Chief Financial Officer
		(Principal Financial Officer)

EX-32.1

EXHIBIT 32.1

CERTIFICATION PURSUANT TO

18 U.S.C. SECTION 1350,

AS ADOPTED PURSUANT TO SECTION 906

OF THE SARBANES-OXLEY ACT OF 2002

In connection with the Quarterly Report on Form 10-Q of WellCare Health Plans, Inc. (the "Company") for the quarter ended March 31, 2014 as filed with the Securities and Exchange Commission on the date hereof (the "Form 10-Q"), I, David Gallitano, Chairman of the Board and Chief Executive Officer of the Company, hereby certify, pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002, that:

(1) The Form 10-Q fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934; and

(2) The information contained in the Form 10-Q fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date:	May 8, 2014	/s/ David Gallitano
		David Gallitano, Chairman of the Board and Chief Executive Officer
		(Principal Executive Officer)

EX-32.2

EXHIBIT 32.2

CERTIFICATION PURSUANT TO

18 U.S.C. SECTION 1350,

AS ADOPTED PURSUANT TO SECTION 906

OF THE SARBANES-OXLEY ACT OF 2002

In connection with the Quarterly Report on Form 10-Q of WellCare Health Plans, Inc. (the "Company") for the quarter ended March 31, 2014 as filed with the Securities and Exchange Commission on the date hereof (the "Form 10-Q"), I, Thomas L. Tran, Senior Vice President and Chief Financial Officer of the Company, hereby certify, pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002, that:

(1) The Form 10-Q fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934; and

(2) The information contained in the Form 10-K fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date:	May 8, 2014	/s/ Thomas L. Tran
		Thomas L. Tran
		Senior Vice President and Chief Financial Officer
		(Principal Financial Officer)

XML

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Organizational Details (Details)	1 Months Ended
	Jul. 31, 2002 Transaction	Mar. 31, 2014 Members State
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Number of states		49
Business Acquisitions, Number of Transactions	2
Number of members		3,500,000

XML

FAIR VALUE MEASUREMENTS (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Dec. 31, 2013
Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments	$ 1,800.0
Fair Value, Measurements, Recurring [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments		395.1
Total restricted investments	94.9	82.5
Fair Value, Measurements, Recurring [Member] | Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments		1.4
Fair Value, Measurements, Recurring [Member] | Variable Rate Bond Fund [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	110.3
Fair Value, Measurements, Recurring [Member] | U.S. Government Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments		1,800.0
Fair Value, Measurements, Recurring [Member] | Cash [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments		40.2
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	181.3	148.3
Total restricted investments	93.5	81.1
Amounts payable related to investigation resolution	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Asset-backed Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Auction Rate Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Corporate Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Foreign Government Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Money Market Funds [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	43.4	43.4
Total restricted investments	18.9	19.0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Municipal Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Variable Rate Bond Fund [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	110.3	85.3
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | U.S. Government Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	27.6	19.6
Total restricted investments	25.3	21.9
Fair Value, Measurements, Recurring [Member] | Quoted Prices in Active Markets for Identical Assets (Level 1) [Member] | Cash [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments	49.3	40.2
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	211.9	215.0
Total restricted investments	1.4	1.4
Amounts payable related to investigation resolution	34.4	70.3
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Asset-backed Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0.6	1.6
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Auction Rate Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	1.1	1.6
Total restricted investments	1.4	1.4
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Corporate Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	75.3	102.9
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Foreign Government Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	3.8
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Money Market Funds [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Municipal Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	119.8	108.9
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Variable Rate Bond Fund [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | U.S. Government Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	11.3	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 2 [Member] | Cash [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	31.9	31.8
Total restricted investments	0	0
Amounts payable related to investigation resolution	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Asset-backed Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Auction Rate Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	31.9	31.8
Auction rate securities measured at fair value on a recurring basis using significant unobservable inputs [Rollforward]
Beginning balance	31.8
Realized gains (losses) in earnings	0
Unrealized gains (losses) in other comprehensive income	0.1
Purchases, sales and redemptions	0
Net transfers in or (out) of Level 3	0
Ending balance	31.9
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Corporate Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Foreign Government Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Money Market Funds [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Municipal Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Variable Rate Bond Fund [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | U.S. Government Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Significant Unobservable Inputs (Level 3) [Member] | Cash [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments	0	0
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	425.1
Amounts payable related to investigation resolution	34.4	70.3
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Asset-backed Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	0.6	1.6
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Auction Rate Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	31.9	31.8
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Certificates of Deposit [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	1.1	1.6
Total restricted investments	1.4
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Corporate Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	75.3	102.9
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Foreign Government Debt Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	3.8
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Money Market Funds [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	43.4	43.4
Total restricted investments	18.9	19.0
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Municipal Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	119.8	108.9
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Variable Rate Bond Fund [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments		85.3
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | U.S. Government Securities [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total investments	38.9	19.6
Total restricted investments	25.3	21.9
Fair Value, Measurements, Recurring [Member] | Estimate of Fair Value Measurement [Member] | Cash [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total restricted investments	$ 49.3

XML

EQUITY-BASED COMPENSATION (Details) (USD $) In Millions, except Share data, unless otherwise specified	3 Months Ended
	Mar. 31, 2014		Mar. 31, 2013
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Compensation expense	$ 1.2		$ 3.7
Unrecognized compensation cost	22.3
Weighted-average period over which compensation costs are expected to be recognized (in years)	2 years 2 months 10 days
Share Price	$ 63.52
Restricted Stock Units (RSUs) [Member]
Equity Instruments Other than Options [Roll Forward]
Outstanding as of beginning of period (in shares)	259,836
Granted (in shares)	137,356
Vested (in shares)	(54,869)
Forfeited and expired (in shares)	(12,472)
Outstanding at end of period (in shares)	329,851
Weighted Average Grant-Date Fair Value [Rollforward]
Outstanding as of beginning of period (in dollars per share)	$ 56.51
Granted (in dollars per share)	$ 61.71
Vested (in dollars per share)	$ 58.80
Forfeited and expired (in dollars per share)	$ 57.23
Outstanding as of end of period (in dollars per share)	$ 58.27
Performance Share Awards [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Unrecognized compensation cost	7.0
Stock Options [Member]
Stock Options [Rollforward]
Outstanding as of beginning of period (in shares)	31,381
Granted (in shares)	0
Exercised (in shares)	(13,000)
Forfeited and expired (in shares)	0
Outstanding at end of period (in shares)	18,381	[1]
Vested and exercisable (shares)	98,484
Weighted Average Exercise Price [Rollforward]
Outstanding as of beginning of period (in dollars per share)	$ 29.47
Granted (in dollars per share)	$ 0.00
Exercised (in dollars per share)	$ 19.96
Forfeited and expired (in dollars per share)	$ 0.00
Outstanding at end of period (in dollars per share)	$ 36.20
Aggregate Intrinsic Value [Abstract]
Outstanding at end of period	$ 0.5
Weighted Average Remaining Contractual Term [Abstract]
Outstanding at end of period (in years)	1 year 6 months 0 days
Performance Share Awards [Member]
Equity Instruments Other than Options [Roll Forward]
Outstanding as of beginning of period (in shares)	288,487
Granted (in shares)	153,070
Vested (in shares)	(62,640)
Forfeited and expired (in shares)	(21,949)
Outstanding at end of period (in shares)	356,968
Weighted Average Grant-Date Fair Value [Rollforward]
Outstanding as of beginning of period (in dollars per share)	$ 55.30
Granted (in dollars per share)	$ 59.93
Vested (in dollars per share)	$ 40.57
Forfeited and expired (in dollars per share)	$ 59.86
Outstanding as of end of period (in dollars per share)	$ 59.59
Market Stock Units [Member]
Equity Instruments Other than Options [Roll Forward]
Outstanding as of beginning of period (in shares)	83,889
Granted (in shares)	62,238
Vested (in shares)	0
Forfeited and expired (in shares)	(8,236)
Outstanding at end of period (in shares)	137,891
Weighted Average Grant-Date Fair Value [Rollforward]
Outstanding as of beginning of period (in dollars per share)	$ 79.38
Granted (in dollars per share)	$ 70.36
Vested (in dollars per share)	$ 0.00
Forfeited and expired (in dollars per share)	$ 75.72
Outstanding as of end of period (in dollars per share)	$ 75.53

[1] All of the Company's outstanding stock options were vested and exercisable as of March 31, 2014.

XML

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Medicare Part D Settlements (Details)	3 Months Ended
	Mar. 31, 2014
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Drug costs reimbursed	80.00%
Number of Months Discounts are Reported	37 months

XML

EQUITY-BASED COMPENSATION (Tables)

3 Months Ended

Mar. 31, 2014

Disclosure of Compensation Related Costs, Share-based Payments [Abstract]

Summary of stock option activity

A summary of stock option activity for the quarter ended March 31, 2014, and the aggregate intrinsic value and weighted average remaining contractual term for stock options as of March 31, 2014, is presented in the table below.

	Shares		Weighted Average Exercise Price		Aggregate Intrinsic Value		Weighted Average Remaining Contractual Term (Years)
Outstanding as of January 1, 2014	31,381		$	29.47
Granted	—		—
Exercised	(13,000	)	19.96
Forfeited and expired	—		—
Outstanding as of March 31, 2014 (1)	18,381		$	36.20	$	0.5	1.5

(1)    All of the Company's outstanding stock options were vested and exercisable as of March 31, 2014.

Summary of restricted stock and restricted stock unit activity

A summary of RSU activity for the quarter ended March 31, 2014 is presented in the table below.

	RSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	259,836		$	56.51
Granted	137,356		61.71
Vested	(54,869	)	58.80
Forfeited and expired	(12,472	)	57.23
Outstanding as of March 31, 2014	329,851		58.27

A summary of our MSU activity for the quarter ended March 31, 2014 is presented in the table below.

	MSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	83,889		$	79.38
Granted	62,238		70.36
Vested	—		—
Forfeited and expired	(8,236	)	75.72
Outstanding as of March 31, 2014	137,891		75.53

Summary of performance stock unit activity

EQUITY-BASED COMPENSATION

Compensation expense related to our equity-based compensation awards was $1.2 million and $3.7 million for the quarters ended March 31, 2014 and March 31, 2013, respectively. As of March 31, 2014, there was $22.3 million of unrecognized compensation cost related to non-vested equity-based compensation arrangements that is expected to be recognized over a weighted-average period of 2.2 years. The unrecognized compensation cost for our PSUs, which are subject to variable accounting, was determined based on the closing common stock price of $63.52 as of March 31, 2014 and amounted to approximately $7.0 million of the total unrecognized compensation. Due to the nature of the accounting for these awards, future compensation cost will fluctuate based on changes in our common stock price.

A summary of stock option activity for the quarter ended March 31, 2014, and the aggregate intrinsic value and weighted average remaining contractual term for stock options as of March 31, 2014, is presented in the table below.

	Shares		Weighted Average Exercise Price		Aggregate Intrinsic Value		Weighted Average Remaining Contractual Term (Years)
Outstanding as of January 1, 2014	31,381		$	29.47
Granted	—		—
Exercised	(13,000	)	19.96
Forfeited and expired	—		—
Outstanding as of March 31, 2014 (1)	18,381		$	36.20	$	0.5	1.5

(1)    All of the Company's outstanding stock options were vested and exercisable as of March 31, 2014.

A summary of RSU activity for the quarter ended March 31, 2014 is presented in the table below.

	RSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	259,836		$	56.51
Granted	137,356		61.71
Vested	(54,869	)	58.80
Forfeited and expired	(12,472	)	57.23
Outstanding as of March 31, 2014	329,851		58.27

A summary of our MSU activity for the quarter ended March 31, 2014 is presented in the table below.

	MSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	83,889		$	79.38
Granted	62,238		70.36
Vested	—		—
Forfeited and expired	(8,236	)	75.72
Outstanding as of March 31, 2014	137,891		75.53

A summary of the activity for our PSU awards, which are subject to variable accounting, for the quarter ended March 31, 2014 is presented in the table below.

	PSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	288,487		$	55.30
Granted	153,070		59.93
Vested	(62,640	)	40.57
Forfeited and expired	(21,949	)	59.86
Outstanding as of March 31, 2014	356,968		59.59

XML

INCOME TAXES (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013
Income Tax Disclosure [Abstract]
Effective income tax rate (in hundredths)	32.80%	5.90%
Increase in tax benefit from agreement with IRS		$ 7.6

XML

SEGMENT REPORTING (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended			3 Months Ended													3 Months Ended
	Mar. 31, 2014 Segment OperatingSegment	Mar. 31, 2013	Dec. 31, 2013 OperatingSegment	Mar. 31, 2014 Medicaid [Member]	Mar. 31, 2013 Medicaid [Member]	Mar. 31, 2014 Medicare Health Plans [Member]	Mar. 31, 2013 Medicare Health Plans [Member]	Mar. 31, 2014 Prescription Drug Plans [Member]	Mar. 31, 2013 Prescription Drug Plans [Member]	Mar. 31, 2014 Florida [Member] Regions	Mar. 31, 2013 Florida [Member]	Mar. 31, 2014 Georgia [Member] Option	Mar. 31, 2013 Georgia [Member]	Mar. 31, 2014 Kentucky [Member]	Mar. 31, 2013 Kentucky [Member]	Nov. 02, 2011 Kentucky [Member] Option	Mar. 31, 2014 Weighted Average [Member] Windsor Health Plans, Inc. [Member]	Mar. 31, 2014 Weighted Average [Member] Broker Network [Member] Windsor Health Plans, Inc. [Member]
Segment Reporting Information [Line Items]
Finite-Lived Intangible Asset, Useful Life																	11 years 6 months 0 days	10 years
Number of reportable segments	3
Premium revenue net of premium tax										10.00%	12.00%	12.00%	16.00%	17.00%	13.00%
Number of renewal options												2				4
Term of optional renewals												1 year
Initial term of long-term contracts										3 years				3 years
Number of Regions executed contracts										8
Total number of regions										11
Initial term of short-term contracts														1 year
Premium revenue	$ 2,975.1	$ 2,252.3		$ 1,638.8	$ 1,310.4	$ 963.3	$ 718.9	$ 373.0	$ 223.0
Medical benefits expense	2,629.9	1,987.3		1,389.3	1,130.7	851.5	625.6	389.1	231.0
ACA Industry Fee	32.3	0		18.9	0	10.7	0	2.7	0
Gross margin	312.9	265.0		230.6	179.7	101.1	93.3	(18.8)	(8.0)
Investment and other income	10.6	4.3
Other expenses	(286.2)	(246.4)
Income from operations	$ 37.3	$ 22.9
Number of operating segments prior to 1/1/2014			3

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Proforma Financial Information (Details) (USD $) In Millions, except Per Share data, unless otherwise specified	3 Months Ended
	Mar. 31, 2013
Business Acquisition, Pro Forma Information, Nonrecurring Adjustment [Line Items]
Business Acquisitions, Pro Forma Premium Revenues	$ 2,564.9
Business Acquisition, Pro Forma Net Income (Loss)	$ 8.4
Business Acquisition, Pro Forma Earnings Per Share, Basic	$ 0.19
Business Acquisition, Pro Forma Earnings Per Share, Diluted	$ 0.19

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DEBT (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended				0 Months Ended	12 Months Ended		12 Months Ended
	Mar. 31, 2014	Mar. 31, 2013	Mar. 31, 2014 Senior Notes [Member]	Dec. 31, 2013 Senior Notes [Member]	Feb. 12, 2013 Revolving Credit Facility [Member]	Dec. 31, 2013 Revolving Credit Facility [Member]	Dec. 31, 2013 Letter of Credit [Member]	Dec. 31, 2013 Debt Instrument, Redemption, Period Two [Member]	Dec. 31, 2013 Debt Instrument, Redemption, Period One [Member]	Dec. 31, 2013 Debt Instrument, Redemption, Period Three [Member]	Dec. 31, 2013 Debt Instrument, Redemption, Period Four [Member]
Debt Instrument [Line Items]
Debt Instrument, Redemption Price, Percentage of Principal Amount Redeemed									40.00%
Debt Instrument, Redemption Price, Percentage								102.875%	105.75%	101.438%	100.00%
Debt Instrument, Face Amount			$ 600.0	$ 600.0
Debt Instrument, Interest Rate, Stated Percentage				5.75%
Revolving credit facility, maximum borrowing capacity						300.0	75.0
Additional Debt Permitted						75.0
Unutilized commitments fee, minimum (in hundredths)					0.25%
Unutilized commitments fee maximum (in hundredths)					0.375%
Interest expense	$ 9.2	$ 1.6

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SEGMENT REPORTING

3 Months Ended

Mar. 31, 2014

Segment Reporting [Abstract]

SEGMENT REPORTING

SEGMENT REPORTING

On a regular basis, we evaluate discrete financial information and assess the performance of our three reportable segments, Medicaid Health Plans, Medicare Health Plans and Medicare PDPs, to determine the most appropriate use and allocation of Company resources. Prior to the Windsor acquisition, we identified three operating segments for our company: Medicaid, MA and PDP. In conjunction with the Windsor acquisition, we began offering Medicare Supplement products and we reassessed our segment reporting practices and made revisions to reflect our current method of managing performance and determining resource allocation, which includes reviewing the results of Medicare Supplement and MA operations acquired as part of the Windsor acquisition together with our legacy MA plans. Accordingly, we are including results for Medicare Supplement operations together with MA and have renamed the segment as Medicare Health Plans. Similarly, we are including the PDP operations acquired as part of the Windsor acquisition together with WellCare’s PDPs and have renamed the segment as Medicare PDPs. In addition, we have renamed the Medicaid segment Medicaid Health Plans; however, there were no changes to the composition of this segment.

Medicaid Health Plans

Our Medicaid Health Plans segment includes plans for beneficiaries of Temporary Assistance for Needy Families ("TANF"), Supplemental Security Income ("SSI"), Aged Blind and Disabled ("ABD") and other state-based programs that are not part of the Medicaid program, such as Children's Health Insurance Program ("CHIP"), Family Health Plus ("FHP"), and Managed Long-Term Care ("MLTC") programs. TANF generally provides assistance to low-income families with children. ABD and SSI generally provide assistance to low-income aged, blind or disabled individuals. CHIP and FHP programs provide assistance to qualifying families who are not eligible for Medicaid because their income exceeds the applicable income thresholds. The MLTC program is designed to help people with chronic illnesses or who have disabilities and need health and long-term care services, such as home care or adult day care, to enable them to stay in their homes and communities as long as possible.

Our Medicaid operations in certain states individually account for 10% or more of our consolidated premium revenue. Those states, and the respective Medicaid premium revenue as a percentage of total consolidated premium revenue, are as follows: 

	For the Three Months Ended March 31,
	2014	2013
Georgia	12%	16%
Florida	10%	12%
Kentucky	17%	13%

The state of Florida renewed our Florida Medicaid contracts for a three-year period beginning September 1, 2012 through August 31, 2015. We expect these contracts to be terminated early in connection with the implementation of the new program. In February 2014, we executed a contract with the Florida Agency for Health Care Administration ("AHCA") to provide Medicaid services in eight out of the state's 11 regions. We expect that starting in the second quarter of 2014, two to three regions will be launched per month, and all regions should be launched by late summer or early fall of 2014.

The Georgia Department of Community Health (the "Georgia DCH") exercised its option in June 2013 to extend the term of our Georgia Medicaid contract until June 30, 2014. In April 2014, the Georgia DCH amended our Georgia Medicaid contract to include two additional one-year renewal options, exercisable by the Georgia DCH, which could potentially extend the contract term to June 30, 2016.

Our primary Kentucky contract commenced in July 2011 and has an initial three-year term and provides for four additional one-year option terms, exercisable upon mutual agreement of the parties, which potentially extends the total term until July 2018. The first option term, through June 30, 2015, has been exercised.

Medicare Health Plans

Our Medicare Health Plans reportable segment includes the combined operations of both the MA and Medicare Supplement operating segments. Medicare is a federal program that provides eligible persons age 65 and over and some disabled persons with a variety of hospital, medical and prescription drug benefits. MA is Medicare's managed care alternative to the original Medicare program, which provides individuals standard Medicare benefits directly through CMS. Our MA CCPs generally require members to seek health care services and select a primary care physician from a network of health care providers. In addition, we offer coverage of prescription drug benefits under the Medicare Part D program as a component of most of our MA plans. Medicare Supplement policies are offered in 39 states as of March 31, 2014.

Medicare PDPs

We offer stand-alone Medicare Part D coverage to Medicare-eligible beneficiaries in our Medicare PDPs segment. The Medicare Part D prescription drug benefit is supported by risk sharing with the federal government through risk corridors designed to limit the losses and gains of the participating drug plans and by reinsurance for catastrophic drug costs. The government subsidy is based on the national weighted average monthly bid for this coverage, adjusted for risk factor payments. Additional subsidies are provided for dually-eligible beneficiaries and specified low-income beneficiaries. The Part D program offers national in-network prescription drug coverage that is subject to limitations in certain circumstances.

Summary of Financial Information

We allocate goodwill and other intangible assets to our reportable operating segments. We do not allocate any other assets and liabilities, investment and other income, or selling, general and administrative, depreciation and amortization, or interest expense to our reportable operating segments, with the exception of the ACA industry fee. The Company's decision-makers primarily use premium revenue, medical benefits expense and gross margin to evaluate the performance of our reportable operating segments. A summary of financial information for our reportable operating segments through the gross margin level and a reconciliation to income before income taxes is presented in the tables below.

	For the Three Months Ended March 31,
	2014			2013
Premium revenue:	(in millions)
Medicaid Health Plans	$	1,638.8		$	1,310.4
Medicare Health Plans	963.3			718.9
Medicare PDPs	373.0			223.0
Total premium revenue	2,975.1			2,252.3
Medical benefits expense:
Medicaid Health Plans	1,389.3			1,130.7
Medicare Health Plans	851.5			625.6
Medicare PDPs	389.1			231.0
Total medical benefits expense	2,629.9			1,987.3
ACA industry fee expense:
Medicaid Health Plans	18.9			—
Medicare Health Plans	10.7			—
Medicare PDPs	2.7			—
Total ACA industry fee expense	32.3			—
Gross margin
Medicaid Health Plans	230.6			179.7
Medicare Health Plans	101.1			93.3
Medicare PDPs	(18.8		)	(8.0		)
Total gross margin	312.9			265.0
Investment and other income	10.6			4.3
Other expenses	(286.2		)	(246.4		)
Income from operations	$	37.3		$	22.9

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NET INCOME PER COMMON SHARE (Details)	3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013
Earnings Per Share [Abstract]
Weighted-average common shares outstanding - basic	43,802,047	43,325,381
Dilutive effect of:
Unvested restricted stock, restricted stock units, market stock units and performance stock units	308,133	426,593
Stock options	13,611	200,485
Weighted-average common shares outstanding - diluted	44,123,791	43,952,459
Anti-dilutive stock options and restricted stock awards excluded from computation	72,457	184,536

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Completed and Pending Acquisitions (Details) (USD $) In Millions, unless otherwise specified	Mar. 31, 2014 Members County	Dec. 31, 2013
Business Acquisition [Line Items]
Goodwill	$ 244.9	$ 236.8
Number of members	3,500,000
Total Number of CMS PDP Counties	34
Healthfirst Health Plan of New Jersey [Member]
Business Acquisition [Line Items]
Number of Counties of Operation	12
Number of members	49,000
Medicare Advantage [Member] | Windsor Health Plans, Inc. [Member]
Business Acquisition [Line Items]
Number of Counties of Operation	192
Number of members	38,000
Medicare Supplement [Domain] | Windsor Health Plans, Inc. [Member]
Business Acquisition [Line Items]
Number of members	48,000
Number of States in which Entity Operates	39
Prescription Drug Plans [Member]
Business Acquisition [Line Items]
Number of CMS Counties of Operation	11
Prescription Drug Plans [Member] | Windsor Health Plans, Inc. [Member]
Business Acquisition [Line Items]
Number of members	109,000
Medicaid [Member]
Business Acquisition [Line Items]
Goodwill	134.5	126.8
Medicare Health Plans [Member]
Business Acquisition [Line Items]
Goodwill	$ 110.4	$ 110.0

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES (Details) (USD $) In Millions, unless otherwise specified	1 Months Ended	3 Months Ended
	Jul. 31, 2002 Transaction	Mar. 31, 2014 State Members	Mar. 31, 2013
Revenue, Expired Contracts [Line Items]
Business Acquisitions, Number of Transactions	2
Number of members		3,500,000
Number of states		49
ACA Industry Fee		$ 32.3	$ 0
ACA Industry Fee recognized as revenue		23.6
Ohio [Member]
Revenue, Expired Contracts [Line Items]
Consolidated premium revenue, net of taxes			$ 65.0
Percentage of consolidated premium revenue			2.90%

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INVESTMENTS (Details) (USD $)	3 Months Ended
	Mar. 31, 2014	Dec. 31, 2013
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	$ 426,800,000	$ 397,000,000
Gross Unrealized Gains	800,000	600,000
Gross Unrealized Losses	(2,500,000)	(2,500,000)
Estimated Fair Value	425,100,000	395,100,000
Within 1 Year	288,700,000
1 Through 5 Years	94,800,000
5 Through 10 Years	5,900,000
Thereafter	35,700,000
Auction Rate Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	34,200,000	34,200,000
Gross Unrealized Gains	0	0
Gross Unrealized Losses	(2,300,000)	(2,400,000)
Estimated Fair Value	31,900,000
Within 1 Year	0
1 Through 5 Years	0
5 Through 10 Years	0
Thereafter	31,900,000
Estimated fair falue of municipal note security	31,900,000	31,800,000
Redemptions or sales	0
Realized losses	0
Certificates of Deposit [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	1,100,000	1,600,000
Gross Unrealized Gains	0	0
Gross Unrealized Losses	0	0
Estimated Fair Value	1,100,000	1,600,000
Within 1 Year	1,100,000
1 Through 5 Years	0
5 Through 10 Years	0
Thereafter	0
Corporate Debt and Other Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	79,600,000	104,500,000
Gross Unrealized Gains	200,000	100,000
Gross Unrealized Losses	(100,000)	(100,000)
Estimated Fair Value	79,700,000	104,500,000
Within 1 Year	47,000,000
1 Through 5 Years	29,600,000
5 Through 10 Years	900,000
Thereafter	2,200,000
Money Market Funds [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	43,400,000	43,400,000
Gross Unrealized Gains	0	0
Gross Unrealized Losses	0	0
Estimated Fair Value	43,400,000	43,400,000
Within 1 Year	43,400,000
1 Through 5 Years	0
5 Through 10 Years	0
Thereafter	0
Municipal Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	119,700,000	108,900,000
Gross Unrealized Gains	100,000	0
Gross Unrealized Losses	0	0
Estimated Fair Value	119,800,000	108,900,000
Within 1 Year	84,700,000
1 Through 5 Years	31,100,000
5 Through 10 Years	2,500,000
Thereafter	1,500,000
Bonds [Member]
Schedule of Available-for-sale Securities [Line Items]
Estimated Fair Value	110,300,000
Within 1 Year	110,300,000
1 Through 5 Years	0
5 Through 10 Years	0
Thereafter	0
Variable Rate Bond Fund [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	109,900,000	84,900,000
Gross Unrealized Gains	400,000	400,000
Gross Unrealized Losses	0	0
Estimated Fair Value	110,300,000	85,300,000
US Government Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	38,900,000	19,500,000
Gross Unrealized Gains	100,000	100,000
Gross Unrealized Losses	(100,000)	0
Estimated Fair Value	38,900,000	19,600,000
Within 1 Year	2,200,000
1 Through 5 Years	34,100,000
5 Through 10 Years	2,500,000
Thereafter	100,000
External Credit Rating, Investment Grade [Member] | Auction Rate Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	22,600,000
Number of Securities	2
External Credit Rating, Non Investment Grade [Member] | Auction Rate Securities [Member]
Schedule of Available-for-sale Securities [Line Items]
Amortized Cost	$ 11,600,000
Number of Securities	1

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Revenue Recognition (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Dec. 31, 2013
Organization, Consolidation and Presentation of Financial Statements [Abstract]
General term of MA contracts with CMS	1 year
General term of PDP contracts with CMS	1 year
Premiums Receivable, Allowance for Doubtful Accounts	$ 8.6	$ 15.8

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Risk Adjusted Premiums (Details) (USD $) In Millions, unless otherwise specified	Mar. 31, 2014	Dec. 31, 2013
Segment Reporting Information [Line Items]
Risk Adjusted Premiums	$ 178.6	$ 107.2

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ACQUISITIONS (Notes)

3 Months Ended

Mar. 31, 2014

Business Combinations [Abstract]

ACQUISITIONS

ACQUISITIONS

Windsor

On January 1, 2014, we acquired all of the outstanding stock of Windsor from Munich Health North America, Inc., a part of Munich Re Group. Through its subsidiaries, Windsor serves Medicare beneficiaries with MA, PDP and Medicare Supplement products. As of March 31, 2014, Windsor offered MA plans in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee through which it served 38,000 members. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it served 48,000 members in 39 states as of March 31, 2014. Windsor also offers PDPs in 11 of the 34 CMS regions, through which it served approximately 109,000 beneficiaries as of March 31, 2014. We included the results of Windsor's operations from the date of acquisition in our condensed consolidated financial statements. Windsor’s operations contributed premium revenue of $167.6 million and a net pre-tax loss of $17.4 million, including certain one-time costs for severance and integration, which are included in our condensed consolidated statement of comprehensive income for the quarter ended March 31, 2014.

The following table summarizes the preliminary estimated fair values of tangible and intangible assets acquired and liabilities assumed at the acquisition date.

Cash and cash equivalents	$	169.0
Investments	47.1
Premiums receivable, net	87.4
Other intangible assets	54.3
Pharmacy rebates receivable, net	35.4
Other assets	27.9
Deferred tax asset	29.6
Total assets acquired	450.7
Medical benefits payable	(118.1		)
Accrued expenses and other payables	(74.1		)
Deferred tax liability	(20.6		)
Total liabilities assumed	(212.8		)
Fair value of net assets acquired	$	237.9

As a result of the Windsor acquisition, the estimated fair value of the net tangible and intangible assets that we acquired exceeded the total consideration payable to the seller by approximately $28.3 million. When assessing this result from an accounting perspective, we considered:

▪ the seller’s decision to divest Windsor following a review of its business strategy in the U.S. and focus on other types of health businesses;

▪ the value of net assets we acquired included the benefit of net operating losses and other tax benefits that the seller was not able to utilize given its tax position, and

▪ a credit reflected in the purchase price for certain transition costs we expected to incur after the transaction closed.

After consideration of all relevant factors, including those cited above, and verifying that all assets acquired and liabilities assumed were identified, we concluded that the excess fair value of $28.3 million constituted a bargain purchase gain in accordance with accounting rules related to business combinations. The amount of the gain could change depending on the resolution of certain matters related to the purchase price.

As reflected in the table above, we recorded $54.3 million for the preliminary valuation of identified other intangible assets, including MA and Medicare Supplement membership bases of $20.1 million (15-year useful life), PDP membership bases of $17.5 million (8-year useful life), provider networks of $5.2 million (15-year useful life), broker networks of $3.3 million (10-year useful life) and aggregated other identified intangible assets of $8.2 million (9-year useful life). We valued the other intangible assets using a combination of income and cost approaches, where appropriate. Membership bases were valued based on the income approach using a discounted future cash flow analysis based on our consideration of historical financial results and expected industry and market trends. We discounted the future cash flows by a weighted-average cost of capital based on an analysis of the cost of capital for guideline companies within our industry. We amortize the intangible assets on a straight-line basis over the period we expect these assets to contribute directly or indirectly to the future cash flows. The weighted average amortization period for these intangibles was 11.5 years. The allocation of the purchase price is based on certain preliminary data and could change when final information is obtained.

WellCare of South Carolina

On January 31, 2013, we acquired all outstanding stock of WellCare of South Carolina, Inc. ("WCSC"), formerly UnitedHealthcare of South Carolina, Inc., a South Carolina Medicaid subsidiary of UnitedHealth Group Incorporated. We included the results of WCSC's operations from the date of acquisition in our condensed consolidated financial statements.

We completed certain aspects of the accounting for the WCSC acquisition during the first quarter of 2014, and based on the final purchase price allocation, we allocated $24.7 million of the purchase price to identified tangible net assets and $9.5 million of the purchase price to identified intangible assets. We recorded the excess of purchase price over the aggregate fair values of $12.7 million as goodwill. The recorded goodwill and other intangible assets related to the WCSC acquisition are deductible for tax purposes.

Missouri Care

On March 31, 2013, we acquired all outstanding stock of Missouri Care, Incorporated, a subsidiary of Aetna Inc. ("Missouri Care"), which participates in the Missouri HealthNet Medicaid program. We began serving Missouri Care members effective April 1, 2013 and we included the results of Missouri Care's operations from the date of acquisition in our condensed consolidated financial statements. As of March 31, 2014, Missouri Care membership approximated 99,000.

We completed certain aspects of the accounting for the Missouri Care acquisition during the first quarter of 2014, and based on the final purchase price allocation, we allocated $10.2 million of the purchase price to identified tangible net assets and $7.1 million of the purchase price to identified intangible assets. We recorded the excess of purchase price over the aggregate fair values of $10.7 million as goodwill, which reflects a $7.7 million increase recognized during the first quarter of 2014. The recorded goodwill and other intangible assets related to the Missouri Care acquisition are deductible for tax purposes.

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Minimum Medical Expense and Risk Corridor Provisions (Details)	3 Months Ended
	Mar. 31, 2014
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Minimum variance above target amount before CMS makes additional payments to plan sponsors	5.00%
Variance threshold below which the company must refund to CMS a portion of premiums received	5.00%

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ACQUISITIONS (Details) (USD $) In Millions, unless otherwise specified			3 Months Ended
	Mar. 31, 2014 County Members	Dec. 31, 2013	Mar. 31, 2014 Windsor Health Plans, Inc. [Member]	Jan. 02, 2014 Windsor Health Plans, Inc. [Member]	Jan. 31, 2013 WellCare of South Carolina [Member]	Mar. 31, 2014 Missouri Care, Inc. [Member] Members	Mar. 31, 2013 Missouri Care, Inc. [Member]	Jan. 31, 2013 Tangible Assets and Liabilities [Member] WellCare of South Carolina [Member]	Mar. 31, 2013 Tangible Assets and Liabilities [Member] Missouri Care, Inc. [Member]	Mar. 31, 2014 Medicare Advantage [Member] Windsor Health Plans, Inc. [Member] Members County	Mar. 31, 2014 Medicare Advantage [Member] Medicare Supplement [Domain] Members State	Mar. 31, 2014 Medicare Advantage [Member] Prescription Drug Plans [Member] Members	Mar. 31, 2014 Prescription Drug Plans [Member] County
Business Acquisition [Line Items]
Number of members	3,500,000
Assets acquired:
Cash and cash equivalents				$ 169.0
Investments				47.1
Premiums receivable, net				87.4
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Current Assets, Receivables, Pharmacy Rebates, Net				35.4
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Current Assets, Other				27.9
Other assets				29.6
Total assets acquired				450.7
Liabilities assumed:
Medical benefits payable				(118.1)
Accrued expenses and other payables				(74.1)
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Deferred Tax Liabilities Noncurrent				(20.6)
Total liabilities assumed				(212.8)
Fair value of net tangible assets acquired				237.9				24.7	10.2
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Finite-Lived Intangibles				54.3	9.5		7.1
Goodwill	244.9	236.8			12.7		10.7
Membership						99,000				38,000	48,000	109,000
Number of Counties of Operation										192
Business Acquisitions, Purchase Price Allocation, Subsequent Years, Remaining Adjustments						7.7
Number of States in which Entity Operates											39
Number of CMS Counties of Operation													11
Total Number of CMS PDP Counties	34
Business Combination, Pro Forma Information, Revenue of Acquiree since Acquisition Date, Actual			167.6
Business Combination, Pro Forma Information, Earnings or Loss of Acquiree since Acquisition Date, Actual			$ 17.4

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CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME (USD $) In Millions, except Share data, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013
Revenues:
Premium	$ 2,975.1	$ 2,252.3
Investment and other income	10.6	4.3
Total revenues	2,985.7	2,256.6
Expenses:
Medical benefits	2,629.9	1,987.3
Selling, general and administrative	245.3	213.4
ACA Industry Fee	32.3	0
Medicaid premium taxes	17.1	21.3
Depreciation and amortization	14.6	10.1
Interest	9.2	1.6
Total expenses	2,948.4	2,233.7
Income from operations	37.3	22.9
Business Combination, Bargain Purchase, Gain Recognized, Amount	28.3	0
Income (Loss) from Continuing Operations before Income Taxes, Extraordinary Items, Noncontrolling Interest	65.6	22.9
Income tax expense	21.5	1.4
Net income	44.1	21.5
Other comprehensive (loss) income, before tax:
Change in net unrealized gains and losses on available-for-sale securities	0.2	(0.8)
Income tax expense (benefit) related to other comprehensive income (loss)	(0.1)	(0.3)
Other comprehensive income (loss), net of tax	0.3	(0.5)
Comprehensive income	$ 44.4	$ 21.0
Net income per common share:
Basic net income per share (in dollars per share)	$ 1.01	$ 0.50
Diluted net income per share (in dollars per share)	$ 1.00	$ 0.49
Weighted average common shares outstanding:
Basic (in shares)	43,802,047	43,325,381
Diluted (in shares)	44,123,791	43,952,459

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RESTRICTED INVESTMENTS (Details) (USD $)	3 Months Ended
	Mar. 31, 2014	Sep. 30, 2013	Mar. 31, 2013	Dec. 31, 2013
Restricted Cash and Cash Equivalents Items [Line Items]
Amortized cost	$ 95,000,000			$ 82,600,000
Gross unrealized gains	0			0
Gross unrealized losses	(100,000)			(100,000)
Estimated fair value	94,900,000			82,500,000
Realized gains or losses	0	0	0
Money Market Funds [Member]
Restricted Cash and Cash Equivalents Items [Line Items]
Amortized cost	18,900,000			19,000,000
Gross unrealized gains	0			0
Gross unrealized losses	0			0
Estimated fair value	18,900,000			19,000,000
Cash [Member]
Restricted Cash and Cash Equivalents Items [Line Items]
Amortized cost	49,300,000			40,200,000
Gross unrealized gains	0			0
Gross unrealized losses	0			0
Estimated fair value	49,300,000			40,200,000
Certificates of Deposit [Member]
Restricted Cash and Cash Equivalents Items [Line Items]
Amortized cost	1,400,000			1,400,000
Gross unrealized gains	0			0
Gross unrealized losses	0			0
Estimated fair value	1,400,000			1,400,000
US Government Securities [Member]
Restricted Cash and Cash Equivalents Items [Line Items]
Amortized cost	25,400,000			22,000,000
Gross unrealized gains	0			0
Gross unrealized losses	(100,000)			(100,000)
Estimated fair value	$ 25,300,000			$ 21,900,000

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CONSOLIDATED STATEMENTS OF CASH FLOWS (Unaudited) (USD $) In Millions, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013
Cash (used in) provided by operating activities:
Net income	$ 44.1	$ 21.5
Adjustments to reconcile net income to net cash (used in) provided by operating activities:
Depreciation and amortization	14.6	10.1
Equity-based compensation expense	1.2	3.7
Business Combination, Bargain Purchase, Gain Recognized, Amount	(28.3)	0
ACA Industry Fee	32.3	0
Deferred taxes, net	5.9	9.6
Provision for doubtful receivables	3.7	3.0
Incremental tax benefit from equity-based compensation	(0.2)	(2.1)
Changes in operating accounts, net of effects from acquisitions:
Premiums receivable, net	(33.1)	(13.6)
Pharmacy rebates receivable, net	(34.6)	6.7
Prepaid expenses and other current assets, net	17.2	3.5
Medical benefits payable	51.1	77.0
Unearned premiums	(0.5)	0
Accounts payable and other accrued expenses	35.3	(45.8)
Other payables to government partners	(99.7)	(22.2)
Amount payable related to investigation resolution	(35.9)	(13.8)
Income taxes receivable/payable, net	12.3	(6.5)
Other, net	0.7	0
Net cash (used in) provided by operating activities	(13.9)	31.1
Cash provided by (used in) investing activities:
Acquisitions, net of cash acquired	164.2	(39.2)
Purchases of investments	(90.6)	(144.5)
Proceeds from sale and maturities of investments	107.9	138.2
Purchases of restricted investments	(12.3)	(4.9)
Proceeds from maturities of restricted investments	6.3	4.9
Additions to property, equipment and capitalized software, net	(13.2)	(15.9)
Net cash provided by (used in) investing activities	162.3	(61.4)
Cash provided by financing activities:
Proceeds from debt, net of financing costs paid	0	228.5
Proceeds from exercises of stock options	0.2	4.0
Incremental tax benefit from equity-based compensation	0.2	2.1
Repurchase and retirement of shares to satisfy tax withholding requirements	(2.2)	(2.7)
Payments on debt	0	(9.5)
Payments on capital leases	(0.4)	(0.3)
Funds received for the benefit of members, net	29.6	85.9
Net cash provided by financing activities	27.4	308.0
Increase in cash and cash equivalents	175.8	277.7
Balance at beginning of period	1,482.5	1,100.5
Balance at end of period	1,658.3	1,378.2
SUPPLEMENTAL DISCLOSURES OF CASH FLOW INFORMATION:
Cash paid for taxes	3.3	1.1
Cash paid for interest	0.2	0.7
SUPPLEMENTAL DISCLOSURES OF NON-CASH TRANSACTIONS:
Non-cash additions to property, equipment, and capitalized software	$ 2.1	$ 3.9

XML

Equity Based Compensation Programs (Details)	3 Months Ended
	Mar. 31, 2014	Jun. 30, 2013
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares authorized (in shares)		2,500,000
Number of calendar days preceding the end of the fiscal year prior to the vesting date with the maximum quotient	30 days
Minimum percentage multiplier of MSUs	50.00%
Cliff vesting target range percentage minimum	0.00%
Minimum [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Cliff vesting target range percentage maximum	150.00%
Maximum [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Cliff vesting target range percentage maximum	200.00%
Market Stock Units [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Vesting period of certain equity-based compensation	3 years
Performance Share Awards [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Vesting period of certain equity-based compensation	3 years

XML

NET INCOME PER COMMON SHARE (Tables)

3 Months Ended

Mar. 31, 2014

Earnings Per Share [Abstract]

Schedule of net income per share

The calculation of the weighted-average common shares outstanding — diluted is as follows:

	For the Three Months Ended March 31,
	2014	2013
Weighted-average common shares outstanding — basic	43,802,047	43,325,381
Dilutive effect of:
Unvested restricted stock, restricted stock units, market stock and performance stock units	308,133	426,593
Stock options	13,611	200,485
Weighted-average common shares outstanding — diluted	44,123,791	43,952,459
Anti-dilutive stock options, restricted stock and performance based awards excluded from computation	72,457	184,536

XML

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES - Goodwill and Intangible Assets (Details) (USD $) In Thousands, unless otherwise specified	3 Months Ended
	Mar. 31, 2014
Finite-Lived Intangible Assets [Line Items]
Goodwill impairment loss	$ 0
Minimum [Member]
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life	1 year
Maximum [Member]
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life	15 years

XML

RESTRICTED INVESTMENTS (Tables)

3 Months Ended

Mar. 31, 2014

Restricted Investments Note [Abstract]

Schedule of Restricted Investments

The amortized cost, gross unrealized gains, gross unrealized losses and fair value of our restricted investment securities are as follows: 

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Cash	$	49.3	$	—	$	—		$	49.3
Certificates of deposit	1.4		—		—			1.4
Money market funds	18.9		—		—			18.9
U.S. government securities	25.4		—		(0.1		)	25.3
	$	95.0	$	—	$	(0.1	)	$	94.9
December 31, 2013
Cash	$	40.2	$	—	$	—		$	40.2
Certificates of deposit	1.4		—		—			1.4
Money market funds	19.0		—		—			19.0
U.S. government securities	22.0		—		(0.1		)	21.9
	$	82.6	$	—	$	(0.1	)	$	82.5

XML

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES

3 Months Ended

Mar. 31, 2014

Organization, Consolidation and Presentation of Financial Statements [Abstract]

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES

GANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES

WellCare Health Plans, Inc. (the "Company," "we," "us," or "our"), provides managed care services for government-sponsored health care coverage with a focus on Medicaid and Medicare programs. The Company was formed as a Delaware limited liability company in May 2002 to acquire our Florida, New York and Connecticut health plans. We completed the acquisition of the health plans through two concurrent transactions in July 2002. In July 2004, immediately prior to the closing of our initial public offering, we merged the limited liability company into a Delaware corporation and changed our name to WellCare Health Plans, Inc.

As of March 31, 2014, we served approximately 3.5 million members. During the quarter ended March 31, 2014, we operated Medicaid health plans in Florida, Georgia, Hawaii, Illinois, Kentucky, Missouri, New Jersey, New York and South Carolina. In connection with our acquisitions of Medicaid plans in South Carolina and Missouri (see Note 2), our Medicaid operations in those states began in February 2013 and April 2013, respectively.

Our Medicaid contract in Ohio expired on June 30, 2012. We were not awarded a Medicaid contract in Ohio for the 2013 fiscal year; however, the state contracted with us to provide services to Ohio Medicaid beneficiaries through the transition period, which ended June 30, 2013. As of July 1, 2013, we no longer provided Medicaid services in Ohio. The Ohio Medicaid contract accounted for approximately $65.0 million, or 2.9%, of our consolidated premium revenue for the quarter ended March 31, 2013.

As of March 31, 2014, we also operated Medicare Advantage ("MA") coordinated care plans ("CCPs") in Arizona, Arkansas, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Mississippi, Missouri, New Jersey, New York, Ohio, South Carolina, Tennessee and Texas, as well as stand-alone Medicare prescription drug plans ("PDP") in 49 states and the District of Columbia. Our MA plans in Arkansas, Mississippi, South Carolina and Tennessee are attributable to our acquisition of Windsor Health Group, Inc. ("Windsor") and our MA operations in those states began on January 1, 2014.

Completed and Pending Acquisitions

On January 1, 2014, we acquired all of the outstanding stock of Windsor from Munich Health North America, Inc., a part of Munich Re Group. Through its subsidiaries, Windsor serves Medicare beneficiaries with MA, PDP and Medicare Supplement products. As of March 31, 2014, Windsor offered MA plans in 192 counties in the states of Arkansas, Mississippi, South Carolina and Tennessee through which it served 38,000 members. In addition, one of Windsor’s subsidiaries offers Medicare Supplement insurance policies through which it served 48,000 members in 39 states as of March 31, 2014. Windsor also offers PDPs in 11 of the 34 CMS regions, through which it served approximately 109,000 beneficiaries as of March 31, 2014. We included the results of Windsor's operations from the date of acquisition in our condensed consolidated financial statements.

In September 2013, we also entered into an agreement to acquire certain assets of Healthfirst Health Plan of New Jersey, Inc. ("Healthfirst NJ"). As of March 2014, Healthfirst NJ serves approximately 49,000 Medicaid members in 12 counties in the state. The acquisition is expected to close at the end of the second quarter of 2014, subject to customary regulatory approvals. Upon closure of the transaction, we will acquire Healthfirst NJ’s membership and substantially all of its provider network. We expect to start serving Healthfirst NJ members effective July 1, 2014.

Basis of Presentation and Use of Estimates

The accompanying unaudited condensed consolidated balance sheets and statements of comprehensive income, changes in stockholders' equity, and cash flows include the accounts of the Company and all of its majority-owned subsidiaries. We eliminated all intercompany accounts and transactions.

The accompanying unaudited condensed consolidated interim financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America ("GAAP") and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, certain information and footnote disclosures normally included in financial statements prepared in accordance with GAAP have been condensed or omitted. The accompanying unaudited condensed consolidated interim financial statements should be read in conjunction with the condensed consolidated financial statements and notes thereto for the fiscal year ended December 31, 2013 included in our Annual Report on Form 10-K, filed with the U.S. Securities and Exchange Commission in February 2014. Results for the interim periods presented are not necessarily indicative of results that may be expected for the entire year or any other interim period.

In the opinion of management, the interim financial statements reflect all normal recurring adjustments that we consider necessary for the fair presentation of our financial position, results of operations and cash flows for the interim periods presented. In accordance with GAAP, we make certain estimates and assumptions that affect the amounts reported in the condensed consolidated interim financial statements and accompanying notes. We base these estimates on our knowledge of current events and anticipated future events and evaluate and update our assumptions and estimates on an ongoing basis; however, actual results may differ from our estimates. We evaluated all material events subsequent to the date of these condensed consolidated interim financial statements.

Significant Accounting Policies

Revenue Recognition

We earn premium revenue through our participation in Medicaid, Medicaid-related and Medicare programs.

State governments individually operate and implement and, together with the federal government's Centers for Medicare & Medicaid Services ("CMS"), fund and regulate the Medicaid program. We provide benefits to low-income and disabled persons under the Medicaid program and are paid premiums based on contracts with government agencies in the states in which we operate health plans. Our Medicaid contracts are generally multi-year contracts subject to annual renewal provisions. Rate changes are typically made at the commencement of each new contract renewal period. In some instances, our fixed Medicaid premiums are subject to risk score adjustments based on the acuity of our membership. State agencies analyze encounter submissions of processed claims data to determine the acuity of our membership relative to the entire state's Medicaid membership.

We operate our MA plans under the Medicare Part C program and provide our eligible members with benefits comparable to those available under Medicare Parts A and B. Most of our MA plans and all of our PDPs offer prescription drug benefits to eligible members under the Medicare Part D program. Premiums for each MA member are based on our annual bids, although the rates vary according to a combination of factors, including upper payment limits established by CMS, the member's geographic location, age, gender, medical history or condition, or the services rendered to the member. Our MA contracts with CMS generally have terms of one year and expire at the end of each calendar year. PDP premiums are also based upon contracts with CMS that have a term of one year and expire at the end of each calendar year. We provide annual written bids to CMS for our PDPs, which reflect the estimated costs of providing prescription drug benefits over the plan year. Changes in MA and PDP members' health status also impact monthly premiums as described under "Risk-Adjusted Medicare Premiums" below. CMS pays all of the premium for Medicare Part C and substantially all of the premium for Medicare Part D coverage. We bill the remaining Medicare Part D premium to PDP and MA members with Part D benefits based on the plan year bid submitted to CMS. For qualifying low-income subsidy ("LIS") members, CMS pays for some or all of the LIS members' monthly premium. The CMS payment is dependent upon the member's income level as determined by the Social Security Administration.

We receive premiums from CMS and state agencies on a per member per month ("PMPM") basis for the members that are assigned to, or have selected, us to provide health care services under our Medicare and Medicaid contracts. We recognize premium revenue in the period in which we are obligated to provide services to our members. CMS and state agencies generally pay us in the month in which we provide services. We record premiums earned, but not received as premiums receivable and record premiums received in advance of the period of service as unearned premiums in the condensed consolidated balance sheets. Unearned premiums are recognized as revenue when we provide the related services. On a monthly basis, we bill members for any premiums for which they are responsible according to their respective plan. Member premiums are recognized as revenue in the period of service. We reduce recorded premium revenue and member premiums receivable by the amount we estimate may not be collectible, based on our evaluation of historical trends. We also routinely monitor the collectability of premiums receivable from CMS and state agencies, including Medicaid receivables for obstetric deliveries and newborns and net receivables for member retroactivity. We reduce revenue and premiums receivable by the amounts we estimate may not be collectible. We report premiums receivable, net of an allowance for uncollectible premiums receivable, which was $8.6 million and $15.8 million, at March 31, 2014 and December 31, 2013, respectively. Historically, the allowance for member premiums receivable has not been material relative to consolidated premium revenue.

We record retroactive adjustments to revenues based on changes in the number and eligibility status of our members subsequent to when we recorded revenue related to those members and months of service. We receive premium payments based upon eligibility lists produced by CMS and state agencies. We verify these lists to determine whether we have been paid for the correct premium category and program. From time to time, CMS and state agencies require us to reimburse them for premiums that we received for individuals who were subsequently determined by us, or by CMS or state agencies, to be ineligible for any government-sponsored program or to belong to a plan other than ours. We receive additional premiums from CMS and state agencies for individuals who were subsequently determined to belong to our plan for periods in which we received no premium for those members. We estimate the amount of outstanding retroactivity adjustments and adjust premium revenue based on historical trends, premiums billed, the volume of member and contract renewal activity and other information. We record amounts receivable or payable in premiums receivable, net and other accrued expenses and liabilities in the condensed consolidated balance sheets.

Supplemental Medicaid Premiums

We earn, or earned, supplemental premium payments for eligible obstetric deliveries and newborns of our Medicaid members in Georgia, Illinois, Kentucky, Missouri, New York, South Carolina and, until June 30, 2013, in Ohio. Each state Medicaid contract specifies how and when these supplemental payments are earned and paid. Upon delivery of a newborn, we notify the state agency according to the contract terms. We also earn supplemental Medicaid premium payments in some states for high cost drugs and certain services such as early childhood prevention screenings. We recognize supplemental premium revenue in the period we provide related services to our members.

Risk-Adjusted Medicare Premiums 

CMS employs a risk-adjustment model to determine the premium amount it pays for each MA and PDP member. This model apportions premiums paid to all plans according to the health status of each beneficiary enrolled, resulting in higher scores for members with predictably higher costs. The model uses diagnosis data from inpatient and ambulatory treatment settings to calculate each risk score. We collect claims and encounter data for our MA members and submit the necessary diagnosis data to CMS within prescribed deadlines. After reviewing the respective submissions, CMS establishes the premium payments to MA plans at the beginning of the plan year, and then adjusts premium levels on a retroactive basis. The first retroactive adjustment for a given plan year generally occurs during the third quarter of that year and represents the update of risk scores for the current plan year based on the severity of claims incurred in the prior plan year. CMS then issues a final retroactive risk-adjusted premium settlement for that plan year in the following year.

We develop our estimates for risk-adjusted premiums utilizing historical experience and predictive models as sufficient member risk score data becomes available over the course of each CMS plan year. We populate our models with available risk score data on our members and base risk premium adjustments on risk score data from the previous year. We are not privy to risk score data for members new to our plans in the current plan year; therefore we include assumptions regarding these members' risk scores. We periodically revise our estimates of risk-adjusted premiums as additional diagnosis code information is reported to CMS and adjust our estimates to actual amounts when the ultimate adjustment settlements are either received from CMS or we receive notification from CMS of such settlement amounts. As a result of the variability of factors that determine our estimates for risk-adjusted premiums, the actual amount of the CMS retroactive payment could be materially more or less than our estimates and could have a material effect on our results of operations, financial position and cash flows. We record any changes in estimates in current operations as adjustments to premium revenue. Historically, we have not experienced significant differences between our estimates and amounts ultimately received. However, in the third quarter of 2013, we recognized risk adjusted premium received as part of the 2012 final settlement that was higher than our original estimates, mainly related to members in our California MA plan that were new to Medicare in 2012. Additionally, the data provided to CMS to determine members' risk scores is subject to audit by CMS even after the annual settlements occur. An audit may result in the refund of premiums to CMS. While our experience to date has not resulted in a material refund, future refunds could materially reduce premium revenue in the year in which CMS determines a refund is required and could be material to our results of operations, financial position and cash flows. Premiums receivable in the accompanying condensed consolidated balance sheets include risk-adjusted premiums receivable of $178.6 million and $107.2 million as of March 31, 2014 and December 31, 2013, respectively.

Minimum Medical Expense and Risk Corridor Provisions

We may be required to refund certain premium revenue to CMS and state government agencies under various contractual and plan arrangements. We estimate the impact of the following arrangements on a monthly basis and reflect any adjustments to premium revenues in current operations. We report the estimated net amounts due to CMS and state agencies in other payables to government partners in the condensed consolidated balance sheets.

Certain of our Medicaid contracts require us to expend a minimum percentage of premiums on eligible medical benefits expense. To the extent that we expend less than the minimum percentage of the premiums on eligible medical benefits expense, we are required to refund to the state all or some portion of the difference between the minimum and our actual allowable medical benefits expense. We estimate the amounts due to the state agencies as a return of premium based on the terms of our contracts with the applicable state agency.

Our MA and PDP prescription drug plan premiums are subject to risk sharing through the CMS Medicare Part D risk corridor provisions. The risk corridor calculation compares our actual experience to the target amount of prescription drug costs, limited to costs under the standard coverage as defined by CMS, less rebates included in our submitted plan year bid. We receive additional premium from CMS if our actual experience is more than 5% above the target amount. We refund premiums to CMS if our actual experience is more than 5% below the target amount. After the close of the annual plan year, CMS performs the risk corridor calculation and any differences are settled between CMS and our plans. We have not historically experienced material differences between the subsequent CMS settlement amount and our estimates.

Medicare Part D Settlements

We receive certain Part D prospective subsidy payments from CMS for our MA and PDP members based on the estimated costs of providing prescription drug benefits over the plan year. After the close of the annual plan year, CMS reconciles our actual experience to the prospective payments we received and any differences are settled between CMS and our plans. As such, these subsidies represent funding from CMS for which we assume no risk. We do not recognize the receipt of these subsidies as premium revenue and we do not recognize the payments of related prescription drug benefits as medical benefits expense. We report the subsidies received and benefits paid on a net basis as funds receivable (held) for the benefit of members in the condensed consolidated balance sheets. We also report the net receipts and payments as a financing activity in our condensed consolidated statements of cash flows. CMS pays the following subsidies prospectively as a fixed PMPM amount based upon the plan year bid submitted by us:

Low-Income Cost Sharing Subsidy—CMS reimburses us for all or a portion of qualifying LIS members' deductible, coinsurance and co-payment amounts above the out-of-pocket threshold.

Catastrophic Reinsurance Subsidy—CMS reimburses us for 80% of the drug costs after a member reaches his or her out-of-pocket catastrophic threshold through a catastrophic reinsurance subsidy.

Coverage Gap Discount Subsidy—We advance the pharmaceutical manufacturers gap coverage discounts at the point of sale. On a periodic basis, CMS bills pharmaceutical manufacturers for discounts advanced by us. Pharmaceutical manufacturers remit payments for invoiced amounts directly to us. CMS reduces subsequent prospective payments made to us by the discount amounts billed to manufacturers.

CMS generally performs the Part D payment reconciliation in the fourth quarter of the following plan year based on prescription drug event data we submit to CMS within prescribed deadlines. After the Part D payment reconciliation for coverage gap discount subsidies, we may continue to report discounts to CMS for 37 months following the end of the plan year. CMS will invoice manufacturers for these discounts and we will be paid through the quarterly manufacturer payments. Historically, we have not experienced material adjustments related to the CMS annual reconciliation of prior plan year low-income cost sharing, catastrophic reinsurance, and coverage gap discount subsidies.

Medical Benefits and Medical Benefits Payable

We recognize the cost of medical benefits in the period in which services are provided, including an estimate of the cost of medical benefits incurred but not reported ("IBNR"). Medical benefits expense includes direct medical expenses and certain medically-related administrative costs.

Direct medical expenses include amounts paid or payable to hospitals, physicians and providers of ancillary services, such as laboratories and pharmacies. We also record direct medical expenses for estimated referral claims related to health care providers under contract with us who are financially troubled or insolvent and who may not be able to honor their obligations for the costs of medical services provided by others. In these instances, we may be required to honor these obligations for legal or business reasons. Based on our current assessment of providers under contract with us, such losses have not been and are not expected to be significant. We record direct medical expense for our estimates of provider settlement due to clarification of contract terms, out-of-network reimbursement, claims payment differences and amounts due to contracted providers under risk-sharing arrangements. We estimate pharmacy rebates earned based on historical utilization of specific pharmaceuticals, current utilization and contract terms and record amounts as a reduction of recorded direct medical expenses.

Consistent with the criteria specified and defined in guidance issued by the Department of Health and Human Services ("HHS") for costs that qualify to be reported as medical benefits under the minimum medical loss ratio provision of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the "ACA"), we record certain medically-related administrative costs such as preventive health and wellness, care management, and other quality improvement costs, as medical benefits expense. All other medically-related administrative costs, such as utilization review services, network and provider credentialing and claims handling costs, are recorded in selling, general, and administrative expense.

Medical benefits payable represents amounts for claims fully adjudicated but not yet paid and estimates for IBNR. Our estimate of IBNR is the most significant estimate included in our condensed consolidated financial statements. We determine our best estimate of the base liability for IBNR utilizing consistent standard actuarial methodologies based upon key assumptions which vary by business segment. Our assumptions include current payment experience, trend factors and completion factors. Trend factors in our standard actuarial methodologies include contractual requirements, historic utilization trends, the interval between the date services are rendered and the date claims are paid, denied claims activity, disputed claims activity, benefit changes, expected health care cost inflation, seasonality patterns, maturity of lines of business, changes in membership and other factors.

After determining an estimate of the base liability for IBNR, we make an additional estimate, also using standard actuarial techniques, to account for adverse conditions that may cause actual claims to be higher than the estimated base reserve. We refer to this additional liability as the provision for moderately adverse conditions. Our estimate of the provision for moderately adverse conditions captures the potential adverse development from factors such as:

• our entry into new geographical markets;

• our provision of services to new populations such as the aged, blind and disabled;

• variations in utilization of benefits and increasing medical costs;

• changes in provider reimbursement arrangements;

• variations in claims processing speed and patterns, claims payment and the severity of claims; and

• health epidemics or outbreaks of disease such as the flu.

We consider the base actuarial model liability and the provision for moderately adverse conditions as part of our overall assessment of our IBNR estimate to properly reflect the complexity of our business, the number of states in which we operate, and the need to account for different health care benefit packages among those states. We evaluate our estimates of medical benefits payable as we obtain more complete claims information and medical expense trend data over time. Volatility in members' needs for medical services, provider claims submissions and our payment processes result in identifiable patterns emerging several months after the causes of deviations from our assumed trends occur. Changes in our estimates of medical benefits payable cannot typically be explained by any single factor, but are the result of a number of interrelated variables, all of which influence the resulting medical cost trend. We record differences between actual experience and estimates used to establish the liability, which we refer to as favorable and unfavorable prior period reserve developments, as increases or decreases to medical benefits expense in the period we identify the differences.

For the quarter ended March 31, 2014, we recognized approximately $32.5 million of net unfavorable development related to prior fiscal years. For the quarter ended March 31, 2013 we recognized approximately $15.9 million of net favorable development related to prior years. The unfavorable development recognized in 2014 was primarily due to higher than expected medical services in our Medicare Health Plan segment, that was not discernible until the impact became clearer over time as claim payments were processed. In addition, we incurred expense associated with adjustments to prior year enhanced payments to Medicaid primary care providers, as mandated by the ACA. The net favorable prior year development recognized in 2013 was due mainly to lower than projected utilization in our Medicaid segment, and to a lesser extent, in our Medicare segment.

Reinsurance

We cede certain premiums and medical benefits to other insurance companies under various reinsurance agreements in order to increase our capacity to write larger risks and maintain our exposure to loss within our capital resources. We are contingently liable in the event the reinsurance companies do not meet their contractual obligations. We evaluate the financial condition of the reinsurance companies on a regular basis and only contract with well-known, well-established reinsurance companies that are supported by strong financial ratings. We account for reinsurance premiums and medical expense recoveries according to the terms of the underlying reinsurance contracts.

ACA Industry Fee

The ACA imposes an annual premium-based health insurance industry assessment (the "ACA industry fee") on health insurers beginning in 2014. The total ACA industry fee levied on the health insurance industry will be $8 billion in 2014, with increasing annual amounts thereafter and growing to $14.3 billion by 2018. After 2018, the ACA industry fee increases according to an index based on net premium growth. The assessment will be levied on certain health insurers that provide insurance in the assessment year, and will be allocated to health insurers based on each health insurer's share of net premiums for all U.S. health insurers in the year preceding the assessment. The ACA industry fee will not be deductible for income tax purposes, which will significantly increase our effective income tax rate. We currently estimate that we will incur approximately $129.0 million in such fees in 2014, based on our estimated share of total 2013 industry premiums. However, the final fee amount will not be determined until August 2014. The estimated liability for the fee was accrued in full as of January 1, 2014, with a corresponding deferred expense asset that is being amortized to expense on a straight line basis. We have recognized approximately $32.3 million of such amortization as ACA industry fee expense in the first quarter of 2014.

We have received amendments, written agreements or other documentation from our state Medicaid customers in Florida, Georgia, Kentucky, Missouri and South Carolina which provides for them to reimburse us for the portion of the ACA industry fee attributable to the Medicaid programs in those states, including the related state and federal income tax gross-ups. Consequently, we recognized $23.6 million of reimbursement for the ACA industry fee as premium revenue in the quarter ended March 31, 2014. We currently expect to be reimbursed by our state Medicaid customers in Hawaii, Illinois, New York and Ohio for the impact of the fee on our Medicaid plans, including its non-deductibility for income tax purposes. However, the revenue recognition for such reimbursement is delayed until we are able to reach contractual agreement with these customers, and the timing of revenue recognition for these other markets will not match the expense recognition of the fee. MA and PDP premiums will not be adjusted to offset the impact of the ACA industry fee.

Equity-Based Employee Compensation

During the second quarter of 2013, our stockholders approved the WellCare Health Plans, Inc. 2013 Incentive Compensation Plan (the "2013 Plan"). Upon approval of the 2013 Plan, a total of 2,500,000 shares of our common stock were available for issuance pursuant to the 2013 Plan, minus any shares subject to outstanding awards granted on or after January 1, 2013 under our 2004 Equity Incentive Plan ("the Prior Plan"). In addition, shares subject to awards forfeited under the Prior Plan will become available for issuance under the 2013 Plan. No further awards are permitted to be granted under our Prior Plan. The Compensation Committee of our Board of Directors (the "Compensation Committee") awards certain equity-based compensation under our stock plans, including stock options, restricted stock, restricted stock units ("RSUs"), performance stock units ("PSUs") and market stock units ("MSUs"). We estimate equity-based compensation expense based on awards ultimately expected to vest. We make assumptions of forfeiture rates at the time of grant and continuously reassess our assumptions based on actual forfeiture experience.

We estimate compensation cost for stock options, restricted stock, RSUs and MSUs based on the fair value at the time of grant and recognize expense over the vesting period of the award. For stock options, the grant date fair value is measured using the Black-Scholes options-pricing model. For restricted stock and RSUs, the grant date fair value is based on the closing price of our common stock on the grant date. For MSUs, the fair value at the grant date is measured using a Monte Carlo simulation approach which estimates the fair value of awards based on randomly generated simulated stock-price paths through a lattice-type structure. MSUs expected to vest are recognized as expense on a straight-line basis over the vesting period, which is generally three years. The number of shares of common stock earned upon vesting is determined based on the ratio of the Company's common stock price during the last 30 market trading days of the calendar year immediately preceding the vesting date to the comparable common stock price as of the grant date, applied to the base units granted. The performance ratio is capped at 150% or 200%, depending on the grant date. If our common stock price declines by more than 50% over the performance period, no shares are earned by the recipient.

At its sole discretion, the Compensation Committee sets certain financial and quality-based performance goals and a target award amount for each award of PSUs. PSUs generally cliff-vest three years from the grant date based on the achievement of the performance goals and are conditioned on the employee's continued service through the vesting date. The actual number of common stock shares earned upon vesting will range from zero shares up to 150% or 200% of the target award, depending on the award date. PSUs do not have a grant date or grant fair value for accounting purposes as the subjective nature of the terms of the PSUs precludes a mutual understanding of the key terms and conditions. We recognize expense for PSUs ultimately expected to vest over the requisite service period based on our estimates of progress made towards the achievement of the predetermined performance measures and changes in the market price of our common stock.

Medicaid Premium Taxes

Premium rates established in the Medicaid contracts with Georgia, Hawaii and New York, and, until June 30, 2013, Ohio, include, or included, an assessment or tax on Medicaid premiums. We recognize the premium tax assessment as expense in the period during which we earn the related premium revenue and remit the taxes back to the state agencies on a periodic basis.

Property, Equipment and Capitalized Software, net

Property, equipment and capitalized software are stated at historical cost, net of accumulated depreciation. We capitalize certain costs incurred in the development of internal-use software, including external direct costs of materials and services and payroll costs of employees devoted to specific software development. We expense other software development costs, such as training and data conversion costs, as incurred. We capitalize the costs of improvements that extend the useful lives of the related assets.

We record depreciation expense using the straight-line method over the estimated useful lives of the related assets, which ranges from three to ten years for leasehold improvements, five for furniture and equipment, and three to five years for computer equipment and software. We include amortization of equipment under capital leases in depreciation expense. We record maintenance and repair costs as selling, general and administrative expense when incurred.

On an ongoing basis, we review events or changes in circumstances that may indicate that the carrying value of an asset may not be recoverable. If the carrying value of an asset exceeds the sum of estimated undiscounted future cash flows, we recognize an impairment loss in the current period for the difference between estimated fair value and carrying value. If assets are determined to be recoverable but the useful lives are shorter than we originally estimated, we depreciate the remaining net book value of the asset over the newly determined remaining useful lives.

Goodwill and Intangible Assets

Goodwill represents the excess of the cost over the fair market value of net assets acquired and is attributable to our Medicaid and Medicare Health Plans reporting segments. Goodwill recorded at March 31, 2014 was $244.9 million, which consisted of $134.5 million and $110.4 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Goodwill recorded at December 31, 2013 was $236.8 million, which consisted of $126.8 million and $110.0 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Other intangible assets include provider networks, broker networks, trademarks, state contracts, non-compete agreements, licenses and permits. We amortize other intangible assets over their estimated useful lives ranging from approximately one to 15 years. These assets are allocated to reporting segments for impairment testing purposes.

We review goodwill and intangible assets for impairment at least annually, or more frequently if events or changes in our business climate occur that may potentially affect the estimated useful life or the recoverability of the remaining balance of goodwill or intangible assets. Such events or changes in circumstances would include significant changes in membership, state funding, federal and state government contracts and provider networks. To determine whether goodwill is impaired, we perform a multi-step impairment test. First, we can elect to perform a qualitative assessment of each reporting unit to determine whether facts and circumstances support a determination that their fair values are greater than their carrying values. If the qualitative analysis is not conclusive, or if we elect to proceed directly with quantitative testing, we will then measure the fair values of the reporting units using a two-step approach. In the first step, we determine the fair value of the reporting unit using both income and market approaches. We calculate fair value based on our assumptions of key factors such as projected revenues and the discount factor. While we believe these assumptions and estimates are appropriate, other assumptions and estimates could be applied and may produce significantly different results. If the fair value of the reporting unit is less than its carrying value, we measure and record the amount of the goodwill impairment, if any, by comparing the implied fair value of the reporting unit's goodwill to the carrying value. We perform our annual goodwill impairment test based on our financial position and results of operations through the second quarter of each year, which generally coincides with the finalization of federal and state contract negotiations and our initial budgeting process.

In 2013, we elected to bypass the optional qualitative fair value assessment and conducted our annual quantitative test for goodwill impairment during the third quarter of 2013. Based on the results of our quantitative test, we determined that the fair values of our reporting units exceeded their carrying values and therefore no further testing was required, and we believe that such assets are not impaired as of March 31, 2014.

Income Taxes

We record income tax expense as incurred based on enacted tax rates, estimates of book-to-tax differences in income, and projections of income that will be earned in each taxing jurisdiction. We recognize deferred tax assets and liabilities for the estimated future tax consequences of differences between the carrying amounts of existing assets and liabilities and their respective tax basis. We measure deferred tax assets and liabilities using tax rates applicable to taxable income in the years in which we expect to recover or settle those temporary differences. We record a valuation allowance on deferred taxes if we determine it is more likely than not that we will not fully realize the future benefit of deferred tax assets. We file tax returns after the close of our fiscal year end and adjust our estimated tax receivable or liability to the actual tax receivable or due per the filed state and federal tax returns. Historically, we have not experienced significant differences between our estimates of income tax expense and actual amounts incurred.

State and federal taxing authorities may challenge the positions we take on our filed tax returns. We evaluate our tax positions and only recognize a tax benefit if it is more likely than not that a tax audit will sustain our conclusion. Based on our evaluation of tax positions, we believe that potential tax exposures have been recorded appropriately. State and federal taxing authorities may propose additional tax assessments based on periodic audits of our tax returns. We believe our tax positions comply with applicable tax law in all material aspects and we will vigorously defend our positions on audit. The ultimate resolution of these audits may materially impact our financial position, results of operations or cash flows. We have not experienced material adjustments to our condensed consolidated financial statements as a result of these audits.

We participate in the Internal Revenue Service ("IRS") Compliance Assurance Process ("CAP"). The objective of CAP is to reduce taxpayer burden and uncertainty by working with the IRS to ensure tax return accuracy prior to filing, thereby reducing or eliminating the need for post-filing examinations.

Pro Forma Financial Information

The results of operations and financial condition for our 2014 and 2013 acquisitions have been included in our condensed consolidated financial statements since the respective acquisition dates. The unaudited pro forma financial information presented below assumes that the acquisitions occurred as of January 1, 2013. The pro forma adjustments include the pro forma effect of the amortization of finite-lived intangible assets arising from the purchase price allocations, adjustments necessary to align the acquired companies' accounting policies to our accounting policies and the associated income tax effects of the pro forma adjustments. The following unaudited pro forma results have been prepared for comparative purposes only and do not purport to be indicative of the results of operations that would have occurred had the acquisitions been consummated at the beginning of the periods presented. Only pro forma results for the first quarter of 2013 have been presented, as Windsor was acquired on January 1, 2014 and their results of operations have been included in our condensed consolidated financial statements from this date.

	Pro forma - unaudited
	For Quarter ended March 31, 2013
(in millions, except per share data)
Premium revenues	$	2,564.9
Net earnings	$	8.4
Earnings per share:
Basic	$	0.19
Diluted	$	0.19

Recently Adopted Accounting Standards

In July 2013, the Financial Accounting Standards Board ("FASB") issued ASU 2013-11, "Incomes Taxes (Topic 740): Presentation of an Unrecognized Tax Benefit When a Net Operating Loss Carryforward, a Similar Tax Loss, or a Tax Credit Carryforward Exists." This update addresses the diversity in practice regarding financial statement presentation of an unrecognized tax benefit when a net operating loss carryforward, a similar tax loss, or a tax credit carryforward exists. The guidance requires an unrecognized tax benefit, or a portion thereof, to be presented in the financial statements as a reduction to a deferred tax asset for a net operating loss carryforward, a similar tax loss, or a tax credit carryforward. To the extent the deferred tax asset is not available at the reporting date to settle any additional income taxes that would result from the disallowance of a tax position, the unrecognized tax benefit should be presented in the financial statements as a liability and should not be combined with the deferred tax asset. The amendments in this standard are effective for reporting periods beginning after December 15, 2013, with early adoption permitted. We adopted this standard effective January 1, 2014, without any material impact on our consolidated financial position, results of operations or cash flows.

In February 2013, the FASB issued ASU 2013-04, "Liabilities (Topic 405): Obligations Resulting from Joint and Several Liability Arrangements for Which the Total Amount of the Obligation Is Fixed at the Reporting Date." This update provides guidance for the recognition, measurement and disclosure of obligations resulting from joint and several liability arrangements for which the total amount of the obligation within the scope of the guidance is fixed at the reporting date. The guidance in this update also requires the entity to disclose the nature and amount of the obligation, as well as other information about such obligations. The guidance is effective for fiscal years beginning after December 15, 2013, with early adoption permitted. We adopted this standard effective January 1, 2014, without any material impact on our consolidated financial position, results of operations or cash flows.

In July 2011, the FASB issued ASU 2011-06, "Other Expenses – Fees Paid to the Federal Government by Health Insurers." This update addresses accounting for the annual fees mandated by the ACA. The ACA imposes an annual fee on health insurers, payable to the U.S. government, calculated on net premiums and third-party administrative agreement fees. The updated standard requires that the liability for the fee be estimated and accrued in full once the entity provides qualifying health insurance in the applicable calendar year in which the fee is payable with a corresponding deferred cost that is amortized to expense. The fees are initiated for calendar years beginning January 1, 2014, and the amendments provided by this update become effective for calendar years beginning after December 31, 2013. We adopted this standard effective January 1, 2014, and at March 31, 2014, our estimated liability for the ACA industry fee is approximately $129.0 million.

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CONSOLIDATED BALANCE SHEETS (Unaudited) (USD $)	Mar. 31, 2014	Dec. 31, 2013
Current Assets:
Cash and cash equivalents	$ 1,658,300,000	$ 1,482,500,000
Investments	288,700,000	314,700,000
Premiums receivable, net	607,400,000	490,700,000
Pharmacy rebates receivable, net	235,500,000	165,500,000
Receivables from government partners	79,100,000	0
Funds receivable for the benefit of members	67,000,000	93,500,000
Deferred ACA Industry Fee Asset	96,800,000	0
Income taxes receivable	0	7,100,000
Prepaid expenses and other current assets, net	112,900,000	115,000,000
Deferred income tax asset	29,500,000	23,700,000
Total current assets	3,175,200,000	2,692,700,000
Property, equipment and capitalized software, net	152,500,000	147,400,000
Goodwill	244,900,000	236,800,000
Other intangible assets, net	121,800,000	66,500,000
Long-term investments	136,400,000	80,400,000
Restricted investments	94,900,000	82,500,000
Other assets	10,600,000	144,400,000
Total Assets	3,936,300,000	3,450,700,000
Current Liabilities:
Medical benefits payable	1,132,700,000	953,400,000
Unearned premiums	4,000,000	200,000
ACA Industry Fee	129,000,000	0
Accounts payable	19,000,000	22,300,000
Income taxes payable	5,000,000	0
Other accrued expenses and liabilities	370,200,000	187,700,000
Current portion of amount payable related to investigation resolution	34,400,000	36,200,000
Other payables to government partners	16,700,000	37,300,000
Total current liabilities	1,711,000,000	1,237,100,000
Deferred income tax liability	58,000,000	55,400,000
Amount payable related to investigation resolution	0	34,100,000
Long-term debt	600,000,000	600,000,000
Other liabilities	5,600,000	6,200,000
Total liabilities	2,374,600,000	1,932,800,000
Commitments and contingencies (see Note 11)	0	0
Stockholders' Equity:
Preferred stock, $0.01 par value (20,000,000 authorized, no shares issued or outstanding)	0	0
Common stock, $0.01 par value (100,000,000 authorized, 43,858,148 and 43,766,645 shares issued and outstanding at March 31, 2014 and December 31, 2013, respectively)	400,000	400,000
Paid-in capital	488,800,000	489,400,000
Retained earnings	1,073,500,000	1,029,400,000
Accumulated other comprehensive loss	(1,000,000)	(1,300,000)
Total stockholders' equity	1,561,700,000	1,517,900,000
Total Liabilities and Stockholders' Equity	$ 3,936,300,000	$ 3,450,700,000

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COMMITMENTS AND CONTINGENCIES

3 Months Ended

Mar. 31, 2014

Commitments and Contingencies Disclosure [Abstract]

COMMITMENTS AND CONTINGENCIES

COMMITMENTS AND CONTINGENCIES

Government Investigations

Under the terms of settlement agreements entered into on April 26, 2011, and finalized on March 23, 2012, to resolve matters under investigation by the Civil Division of the U.S. Department of Justice ("Civil Division") and certain other federal and state enforcement agencies (the "Settlement"), we agreed to pay the Civil Division a total of $137.5 million in four annual installments of $34.4 million over 36 months, plus interest accrued at 3.125%. The estimated fair value of the discounted remaining liability, and related interest, was $34.4 million at March 31, 2014, all of which has been included in the current amounts payable related to the investigation resolution in the accompanying condensed consolidated balance sheet as of March 31, 2014.

The Settlement also provides for a contingent payment of an additional $35.0 million in the event that we are acquired or otherwise experience a change in control on or before April 30, 2015, provided that the change in control transaction exceeds certain minimum transaction value thresholds as specified in the Settlement.

Securities Class Action Complaint

In December 2010, we entered into a Stipulation and Agreement of Settlement (the "Stipulation Agreement") with the lead plaintiffs in the consolidated securities class action Eastwood Enterprises, L.L.C. v. Farha, et al., Case No. 8:07-cv-1940-VMC-EAJ. The Stipulation Agreement requires us to pay to the class 25% of any sums we recover from Todd Farha, Paul Behrens and/or Thaddeus Bereday related to the same facts and circumstances that gave rise to the consolidated securities class action. Messrs. Farha, Behrens and Bereday are three former executives that were implicated in the government investigations of the Company that commenced in 2007.

Corporate Integrity Agreement

We operate under a Corporate Integrity Agreement (the "Corporate Integrity Agreement") with the Office of Inspector General of the United States Department of Health and Human Services ("OIG-HHS"). The Corporate Integrity Agreement has a term of five years from its effective date of April 26, 2011 and mandates various ethics and compliance programs designed to help ensure our ongoing compliance with federal health care program requirements. The terms of the Corporate Integrity Agreement include certain organizational structure requirements, internal monitoring requirements, compliance training, screening processes for employees, reporting requirements to OIG-HHS, and the engagement of an independent review organization to review and prepare written reports regarding, among other things, WellCare's reporting practices and bid submissions to federal health care programs.

Indemnification Obligations

Under Delaware law, our charter and bylaws and certain indemnification agreements to which we are a party, we are obligated to indemnify, or we have otherwise agreed to indemnify, certain of our current and former directors, officers and associates with respect to current and future investigations and litigation, including the matters discussed in this footnote. The indemnification agreements for our directors and executive officers with respect to events occurring prior to May 2009 require us to indemnify an indemnitee to the fullest extent permitted by law if the indemnitee was or is or becomes a party to or witness or other participant in any proceeding by reason of any event or occurrence related to the indemnitee's status as a director, officer, employee, agent or fiduciary of the Company or any of our subsidiaries and all expenses, including attorney's fees, judgments, fines, settlement amounts and interest and other charges, and any taxes as a result of the receipt of payments under the indemnification agreement. We will not indemnify the indemnitee if not permitted under applicable law. We are required to advance all expenses incurred by the indemnitee. We are entitled to reimbursement by an indemnitee of expenses advanced if the indemnitee is not permitted to be reimbursed under applicable law after a final judicial determination is made and all rights of appeal have been exhausted or lapsed.

We amended and restated our indemnification agreements in May 2009. The revised agreements apply to our officers and directors with respect to events occurring after that time. Pursuant to the 2009 indemnification agreements, we will indemnify the indemnitee against all expenses, including attorney's fees, judgments, penalties, fines, settlement amounts and any taxes imposed as a result of payments made under the indemnification agreement incurred in connection with any proceedings that relate to the indemnitee's status as a director, officer or employee of the Company or any of our subsidiaries or any other enterprise that the indemnitee was serving at our request. We will also indemnify for expenses incurred by the indemnitee if an indemnitee, by reason of his or her corporate status, is a witness in any proceeding. Further, we are required to indemnify for expenses incurred by an indemnitee in defense of a proceeding to the extent the indemnitee has been successful on the merits or otherwise. Finally, if the indemnitee is involved in certain proceedings as a result of the indemnitee's corporate status, we are required to advance the indemnitee's reasonable expenses incurred in connection with such proceeding, subject to the requirement that the indemnitee repay the expenses if it is ultimately determined that the indemnitee is not entitled to be indemnified. We are not obligated to indemnify an indemnitee for losses incurred in connection with any proceeding if a determination has not been made by the Board of Directors, a committee of disinterested directors or independent legal counsel in the specific case that the indemnitee has satisfied any standards of conduct required as a condition to indemnification under Section 145 of the Delaware General Corporation Law.

Pursuant to our obligations, we have advanced, and will continue to advance, legal fees and related expenses to three former officers and two former associates who were criminally indicted in connection with the government investigations of the Company that commenced in 2007 related to federal criminal health care fraud charges including conspiracy to defraud the United States, false statements relating to health care matters, and health care fraud in connection with their defense of criminal charges. In June 2013, the jury in the criminal trial reached guilty verdicts on multiple charges for the four individuals that were tried in 2013. Sentencing is expected in the second quarter of 2014. At this time, we do not know whether any of these four individuals will appeal. The fifth individual is expected to be tried at a future date.

We have also previously advanced legal fees and related expenses to these five individuals regarding disputes in Delaware Chancery Court related to whether we were legally obligated to advance fees or indemnify certain of these executives; the class actions titled Eastwood Enterprises, L.L.C. v. Farha, et al. and Hutton v. WellCare Health Plans, Inc. et al. filed in federal court; six stockholder derivative actions filed in federal and state courts between October 2007 and January 2008; an investigation by the United States Securities & Exchange Commission (the "Commission"); and an action by the Commission filed in January 2012 against Messrs. Farha, Behrens and Bereday. The Delaware Chancery Court cases have concluded. We settled the class actions in May 2011. In 2010, we settled the stockholder derivative actions and we were realigned as the plaintiff to pursue our claims against Messrs. Farha, Behrens and Bereday. These actions, as well as the action by the Commission, have been stayed until at least 90 days after the conclusion of the criminal trial (including post-trial motions and proceedings).

In connection with these matters, we have advanced, to the five individuals, cumulative legal fees and related expenses of approximately $163.7 million from the inception of the investigations to March 31, 2014. We incurred $7.8 million and $18.9 million of these legal fees and related expenses during the three months ended March 31, 2014 and 2013, respectively. We expense these costs as incurred and classify the costs as selling, general and administrative expense incurred in connection with the investigations and related matters.

We expect the continuing cost of our obligations to the five individuals in connection with their defense and appeal of criminal charges and related litigation to be significant and to continue for a number of years. We have exhausted our insurance policies related to reimbursement of our advancement of fees related to these matters. We are unable to estimate the total amount of these costs or a range of possible loss. Accordingly, we continue to expense these costs as incurred. Though we have requested restitution damages in the criminal case and even if it is eventually determined that we are entitled to reimbursement of the advanced expenses, it is possible that we may not be able to recover all or any portion of our damages or advances. Our indemnification obligations and requirements to advance legal fees and expenses may have a material adverse effect on our financial condition, results of operations and cash flows.

Other Lawsuits and Claims

Based on the nature of our business, we are subject to regulatory reviews or other investigations by various state insurance and health care regulatory authorities and other state and federal regulatory authorities. These authorities regularly scrutinize the business practices of health insurance and benefits companies and their reviews focus on numerous facets of our business, including claims payment practices, provider contracting, competitive practices, commission payments, privacy issues and utilization management practices, among others. Some of these reviews have historically resulted in fines imposed on us and some have required changes to our business practices. We continue to be subject to such reviews, which may result in additional fines and/or sanctions being imposed, premium refunds or additional changes in our business practices.

Separate and apart from the legal matters described above, we are also involved in other legal actions in the normal course of our business, including, without limitation, wage and hour claims and provider disputes regarding payment of claims. Some of these actions seek monetary damages including claims for liquidated or punitive damages, which are not covered by insurance. We review relevant information with respect to litigation matters and we update our estimates of reasonably possible losses and related disclosures. We accrue an estimate for contingent liabilities, including attorney's fees related to these matters, if a loss is probable and estimable. Currently, we do not expect that the resolution of any currently pending actions, either individually or in the aggregate, will differ materially from our current estimates or have a material adverse effect on our results of operations, financial condition and cash flows. However, the outcome of any legal actions cannot be predicted, and therefore, actual results may differ from those estimates.

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Document and Entity Information	3 Months Ended
	Mar. 31, 2014	May 06, 2014
Document and Entity Information [Abstract]
Entity Registrant Name	WELLCARE HEALTH PLANS, INC.
Entity Central Index Key	0001279363
Current Fiscal Year End Date	--12-31
Entity Well-known Seasoned Issuer	Yes
Entity Voluntary Filers	No
Entity Current Reporting Status	Yes
Entity Filer Category	Large Accelerated Filer
Entity Common Stock, Shares Outstanding		43,870,733
Document Fiscal Year Focus	2014
Document Fiscal Period Focus	Q1
Document Type	10-Q
Amendment Flag	false
Document Period End Date	Mar. 31, 2014

XML

ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES (Policies)

3 Months Ended

Mar. 31, 2014

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Risk Adjusted Premiums [Policy Text Block]

Risk-Adjusted Medicare Premiums 

CMS employs a risk-adjustment model to determine the premium amount it pays for each MA and PDP member. This model apportions premiums paid to all plans according to the health status of each beneficiary enrolled, resulting in higher scores for members with predictably higher costs. The model uses diagnosis data from inpatient and ambulatory treatment settings to calculate each risk score. We collect claims and encounter data for our MA members and submit the necessary diagnosis data to CMS within prescribed deadlines. After reviewing the respective submissions, CMS establishes the premium payments to MA plans at the beginning of the plan year, and then adjusts premium levels on a retroactive basis. The first retroactive adjustment for a given plan year generally occurs during the third quarter of that year and represents the update of risk scores for the current plan year based on the severity of claims incurred in the prior plan year. CMS then issues a final retroactive risk-adjusted premium settlement for that plan year in the following year.

We develop our estimates for risk-adjusted premiums utilizing historical experience and predictive models as sufficient member risk score data becomes available over the course of each CMS plan year. We populate our models with available risk score data on our members and base risk premium adjustments on risk score data from the previous year. We are not privy to risk score data for members new to our plans in the current plan year; therefore we include assumptions regarding these members' risk scores. We periodically revise our estimates of risk-adjusted premiums as additional diagnosis code information is reported to CMS and adjust our estimates to actual amounts when the ultimate adjustment settlements are either received from CMS or we receive notification from CMS of such settlement amounts. As a result of the variability of factors that determine our estimates for risk-adjusted premiums, the actual amount of the CMS retroactive payment could be materially more or less than our estimates and could have a material effect on our results of operations, financial position and cash flows. We record any changes in estimates in current operations as adjustments to premium revenue. Historically, we have not experienced significant differences between our estimates and amounts ultimately received. However, in the third quarter of 2013, we recognized risk adjusted premium received as part of the 2012 final settlement that was higher than our original estimates, mainly related to members in our California MA plan that were new to Medicare in 2012. Additionally, the data provided to CMS to determine members' risk scores is subject to audit by CMS even after the annual settlements occur. An audit may result in the refund of premiums to CMS. While our experience to date has not resulted in a material refund, future refunds could materially reduce premium revenue in the year in which CMS determines a refund is required and could be material to our results of operations, financial position and cash flows. Premiums receivable in the accompanying condensed consolidated balance sheets include risk-adjusted premiums receivable of $178.6 million and $107.2 million as of March 31, 2014 and December 31, 2013, respectively.

Revenue Recognition

Revenue Recognition

We earn premium revenue through our participation in Medicaid, Medicaid-related and Medicare programs.

State governments individually operate and implement and, together with the federal government's Centers for Medicare & Medicaid Services ("CMS"), fund and regulate the Medicaid program. We provide benefits to low-income and disabled persons under the Medicaid program and are paid premiums based on contracts with government agencies in the states in which we operate health plans. Our Medicaid contracts are generally multi-year contracts subject to annual renewal provisions. Rate changes are typically made at the commencement of each new contract renewal period. In some instances, our fixed Medicaid premiums are subject to risk score adjustments based on the acuity of our membership. State agencies analyze encounter submissions of processed claims data to determine the acuity of our membership relative to the entire state's Medicaid membership.

We operate our MA plans under the Medicare Part C program and provide our eligible members with benefits comparable to those available under Medicare Parts A and B. Most of our MA plans and all of our PDPs offer prescription drug benefits to eligible members under the Medicare Part D program. Premiums for each MA member are based on our annual bids, although the rates vary according to a combination of factors, including upper payment limits established by CMS, the member's geographic location, age, gender, medical history or condition, or the services rendered to the member. Our MA contracts with CMS generally have terms of one year and expire at the end of each calendar year. PDP premiums are also based upon contracts with CMS that have a term of one year and expire at the end of each calendar year. We provide annual written bids to CMS for our PDPs, which reflect the estimated costs of providing prescription drug benefits over the plan year. Changes in MA and PDP members' health status also impact monthly premiums as described under "Risk-Adjusted Medicare Premiums" below. CMS pays all of the premium for Medicare Part C and substantially all of the premium for Medicare Part D coverage. We bill the remaining Medicare Part D premium to PDP and MA members with Part D benefits based on the plan year bid submitted to CMS. For qualifying low-income subsidy ("LIS") members, CMS pays for some or all of the LIS members' monthly premium. The CMS payment is dependent upon the member's income level as determined by the Social Security Administration.

We receive premiums from CMS and state agencies on a per member per month ("PMPM") basis for the members that are assigned to, or have selected, us to provide health care services under our Medicare and Medicaid contracts. We recognize premium revenue in the period in which we are obligated to provide services to our members. CMS and state agencies generally pay us in the month in which we provide services. We record premiums earned, but not received as premiums receivable and record premiums received in advance of the period of service as unearned premiums in the condensed consolidated balance sheets. Unearned premiums are recognized as revenue when we provide the related services. On a monthly basis, we bill members for any premiums for which they are responsible according to their respective plan. Member premiums are recognized as revenue in the period of service. We reduce recorded premium revenue and member premiums receivable by the amount we estimate may not be collectible, based on our evaluation of historical trends. We also routinely monitor the collectability of premiums receivable from CMS and state agencies, including Medicaid receivables for obstetric deliveries and newborns and net receivables for member retroactivity. We reduce revenue and premiums receivable by the amounts we estimate may not be collectible. We report premiums receivable, net of an allowance for uncollectible premiums receivable, which was $8.6 million and $15.8 million, at March 31, 2014 and December 31, 2013, respectively. Historically, the allowance for member premiums receivable has not been material relative to consolidated premium revenue.

We record retroactive adjustments to revenues based on changes in the number and eligibility status of our members subsequent to when we recorded revenue related to those members and months of service. We receive premium payments based upon eligibility lists produced by CMS and state agencies. We verify these lists to determine whether we have been paid for the correct premium category and program. From time to time, CMS and state agencies require us to reimburse them for premiums that we received for individuals who were subsequently determined by us, or by CMS or state agencies, to be ineligible for any government-sponsored program or to belong to a plan other than ours. We receive additional premiums from CMS and state agencies for individuals who were subsequently determined to belong to our plan for periods in which we received no premium for those members. We estimate the amount of outstanding retroactivity adjustments and adjust premium revenue based on historical trends, premiums billed, the volume of member and contract renewal activity and other information. We record amounts receivable or payable in premiums receivable, net and other accrued expenses and liabilities in the condensed consolidated balance sheets.

Supplemental Medicaid Premiums

We earn, or earned, supplemental premium payments for eligible obstetric deliveries and newborns of our Medicaid members in Georgia, Illinois, Kentucky, Missouri, New York, South Carolina and, until June 30, 2013, in Ohio. Each state Medicaid contract specifies how and when these supplemental payments are earned and paid. Upon delivery of a newborn, we notify the state agency according to the contract terms. We also earn supplemental Medicaid premium payments in some states for high cost drugs and certain services such as early childhood prevention screenings. We recognize supplemental premium revenue in the period we provide related services to our members.

Minimum Medical Expense and Risk Corridor Provisions

Minimum Medical Expense and Risk Corridor Provisions

We may be required to refund certain premium revenue to CMS and state government agencies under various contractual and plan arrangements. We estimate the impact of the following arrangements on a monthly basis and reflect any adjustments to premium revenues in current operations. We report the estimated net amounts due to CMS and state agencies in other payables to government partners in the condensed consolidated balance sheets.

Certain of our Medicaid contracts require us to expend a minimum percentage of premiums on eligible medical benefits expense. To the extent that we expend less than the minimum percentage of the premiums on eligible medical benefits expense, we are required to refund to the state all or some portion of the difference between the minimum and our actual allowable medical benefits expense. We estimate the amounts due to the state agencies as a return of premium based on the terms of our contracts with the applicable state agency.

Our MA and PDP prescription drug plan premiums are subject to risk sharing through the CMS Medicare Part D risk corridor provisions. The risk corridor calculation compares our actual experience to the target amount of prescription drug costs, limited to costs under the standard coverage as defined by CMS, less rebates included in our submitted plan year bid. We receive additional premium from CMS if our actual experience is more than 5% above the target amount. We refund premiums to CMS if our actual experience is more than 5% below the target amount. After the close of the annual plan year, CMS performs the risk corridor calculation and any differences are settled between CMS and our plans. We have not historically experienced material differences between the subsequent CMS settlement amount and our estimates.

Medicare Part D Settlements

Medicare Part D Settlements

We receive certain Part D prospective subsidy payments from CMS for our MA and PDP members based on the estimated costs of providing prescription drug benefits over the plan year. After the close of the annual plan year, CMS reconciles our actual experience to the prospective payments we received and any differences are settled between CMS and our plans. As such, these subsidies represent funding from CMS for which we assume no risk. We do not recognize the receipt of these subsidies as premium revenue and we do not recognize the payments of related prescription drug benefits as medical benefits expense. We report the subsidies received and benefits paid on a net basis as funds receivable (held) for the benefit of members in the condensed consolidated balance sheets. We also report the net receipts and payments as a financing activity in our condensed consolidated statements of cash flows. CMS pays the following subsidies prospectively as a fixed PMPM amount based upon the plan year bid submitted by us:

Low-Income Cost Sharing Subsidy—CMS reimburses us for all or a portion of qualifying LIS members' deductible, coinsurance and co-payment amounts above the out-of-pocket threshold.

Catastrophic Reinsurance Subsidy—CMS reimburses us for 80% of the drug costs after a member reaches his or her out-of-pocket catastrophic threshold through a catastrophic reinsurance subsidy.

Coverage Gap Discount Subsidy—We advance the pharmaceutical manufacturers gap coverage discounts at the point of sale. On a periodic basis, CMS bills pharmaceutical manufacturers for discounts advanced by us. Pharmaceutical manufacturers remit payments for invoiced amounts directly to us. CMS reduces subsequent prospective payments made to us by the discount amounts billed to manufacturers.

CMS generally performs the Part D payment reconciliation in the fourth quarter of the following plan year based on prescription drug event data we submit to CMS within prescribed deadlines. After the Part D payment reconciliation for coverage gap discount subsidies, we may continue to report discounts to CMS for 37 months following the end of the plan year. CMS will invoice manufacturers for these discounts and we will be paid through the quarterly manufacturer payments. Historically, we have not experienced material adjustments related to the CMS annual reconciliation of prior plan year low-income cost sharing, catastrophic reinsurance, and coverage gap discount subsidies.

Medical Benefits and Medical Benefits Payable

Medical Benefits and Medical Benefits Payable

We recognize the cost of medical benefits in the period in which services are provided, including an estimate of the cost of medical benefits incurred but not reported ("IBNR"). Medical benefits expense includes direct medical expenses and certain medically-related administrative costs.

Direct medical expenses include amounts paid or payable to hospitals, physicians and providers of ancillary services, such as laboratories and pharmacies. We also record direct medical expenses for estimated referral claims related to health care providers under contract with us who are financially troubled or insolvent and who may not be able to honor their obligations for the costs of medical services provided by others. In these instances, we may be required to honor these obligations for legal or business reasons. Based on our current assessment of providers under contract with us, such losses have not been and are not expected to be significant. We record direct medical expense for our estimates of provider settlement due to clarification of contract terms, out-of-network reimbursement, claims payment differences and amounts due to contracted providers under risk-sharing arrangements. We estimate pharmacy rebates earned based on historical utilization of specific pharmaceuticals, current utilization and contract terms and record amounts as a reduction of recorded direct medical expenses.

Consistent with the criteria specified and defined in guidance issued by the Department of Health and Human Services ("HHS") for costs that qualify to be reported as medical benefits under the minimum medical loss ratio provision of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the "ACA"), we record certain medically-related administrative costs such as preventive health and wellness, care management, and other quality improvement costs, as medical benefits expense. All other medically-related administrative costs, such as utilization review services, network and provider credentialing and claims handling costs, are recorded in selling, general, and administrative expense.

Medical benefits payable represents amounts for claims fully adjudicated but not yet paid and estimates for IBNR. Our estimate of IBNR is the most significant estimate included in our condensed consolidated financial statements. We determine our best estimate of the base liability for IBNR utilizing consistent standard actuarial methodologies based upon key assumptions which vary by business segment. Our assumptions include current payment experience, trend factors and completion factors. Trend factors in our standard actuarial methodologies include contractual requirements, historic utilization trends, the interval between the date services are rendered and the date claims are paid, denied claims activity, disputed claims activity, benefit changes, expected health care cost inflation, seasonality patterns, maturity of lines of business, changes in membership and other factors.

After determining an estimate of the base liability for IBNR, we make an additional estimate, also using standard actuarial techniques, to account for adverse conditions that may cause actual claims to be higher than the estimated base reserve. We refer to this additional liability as the provision for moderately adverse conditions. Our estimate of the provision for moderately adverse conditions captures the potential adverse development from factors such as:

• our entry into new geographical markets;

• our provision of services to new populations such as the aged, blind and disabled;

• variations in utilization of benefits and increasing medical costs;

• changes in provider reimbursement arrangements;

• variations in claims processing speed and patterns, claims payment and the severity of claims; and

• health epidemics or outbreaks of disease such as the flu.

We consider the base actuarial model liability and the provision for moderately adverse conditions as part of our overall assessment of our IBNR estimate to properly reflect the complexity of our business, the number of states in which we operate, and the need to account for different health care benefit packages among those states. We evaluate our estimates of medical benefits payable as we obtain more complete claims information and medical expense trend data over time. Volatility in members' needs for medical services, provider claims submissions and our payment processes result in identifiable patterns emerging several months after the causes of deviations from our assumed trends occur. Changes in our estimates of medical benefits payable cannot typically be explained by any single factor, but are the result of a number of interrelated variables, all of which influence the resulting medical cost trend. We record differences between actual experience and estimates used to establish the liability, which we refer to as favorable and unfavorable prior period reserve developments, as increases or decreases to medical benefits expense in the period we identify the differences.

For the quarter ended March 31, 2014, we recognized approximately $32.5 million of net unfavorable development related to prior fiscal years. For the quarter ended March 31, 2013 we recognized approximately $15.9 million of net favorable development related to prior years. The unfavorable development recognized in 2014 was primarily due to higher than expected medical services in our Medicare Health Plan segment, that was not discernible until the impact became clearer over time as claim payments were processed. In addition, we incurred expense associated with adjustments to prior year enhanced payments to Medicaid primary care providers, as mandated by the ACA. The net favorable prior year development recognized in 2013 was due mainly to lower than projected utilization in our Medicaid segment, and to a lesser extent, in our Medicare segment.

Reinsurance

Reinsurance

We cede certain premiums and medical benefits to other insurance companies under various reinsurance agreements in order to increase our capacity to write larger risks and maintain our exposure to loss within our capital resources. We are contingently liable in the event the reinsurance companies do not meet their contractual obligations. We evaluate the financial condition of the reinsurance companies on a regular basis and only contract with well-known, well-established reinsurance companies that are supported by strong financial ratings. We account for reinsurance premiums and medical expense recoveries according to the terms of the underlying reinsurance contracts.

ACA Industry Fee [Policy Text Block]

ACA Industry Fee

The ACA imposes an annual premium-based health insurance industry assessment (the "ACA industry fee") on health insurers beginning in 2014. The total ACA industry fee levied on the health insurance industry will be $8 billion in 2014, with increasing annual amounts thereafter and growing to $14.3 billion by 2018. After 2018, the ACA industry fee increases according to an index based on net premium growth. The assessment will be levied on certain health insurers that provide insurance in the assessment year, and will be allocated to health insurers based on each health insurer's share of net premiums for all U.S. health insurers in the year preceding the assessment. The ACA industry fee will not be deductible for income tax purposes, which will significantly increase our effective income tax rate. We currently estimate that we will incur approximately $129.0 million in such fees in 2014, based on our estimated share of total 2013 industry premiums. However, the final fee amount will not be determined until August 2014. The estimated liability for the fee was accrued in full as of January 1, 2014, with a corresponding deferred expense asset that is being amortized to expense on a straight line basis. We have recognized approximately $32.3 million of such amortization as ACA industry fee expense in the first quarter of 2014.

We have received amendments, written agreements or other documentation from our state Medicaid customers in Florida, Georgia, Kentucky, Missouri and South Carolina which provides for them to reimburse us for the portion of the ACA industry fee attributable to the Medicaid programs in those states, including the related state and federal income tax gross-ups. Consequently, we recognized $23.6 million of reimbursement for the ACA industry fee as premium revenue in the quarter ended March 31, 2014. We currently expect to be reimbursed by our state Medicaid customers in Hawaii, Illinois, New York and Ohio for the impact of the fee on our Medicaid plans, including its non-deductibility for income tax purposes. However, the revenue recognition for such reimbursement is delayed until we are able to reach contractual agreement with these customers, and the timing of revenue recognition for these other markets will not match the expense recognition of the fee. MA and PDP premiums will not be adjusted to offset the impact of the ACA industry fee.

Equity-Based Employee Compensation

Equity-Based Employee Compensation

During the second quarter of 2013, our stockholders approved the WellCare Health Plans, Inc. 2013 Incentive Compensation Plan (the "2013 Plan"). Upon approval of the 2013 Plan, a total of 2,500,000 shares of our common stock were available for issuance pursuant to the 2013 Plan, minus any shares subject to outstanding awards granted on or after January 1, 2013 under our 2004 Equity Incentive Plan ("the Prior Plan"). In addition, shares subject to awards forfeited under the Prior Plan will become available for issuance under the 2013 Plan. No further awards are permitted to be granted under our Prior Plan. The Compensation Committee of our Board of Directors (the "Compensation Committee") awards certain equity-based compensation under our stock plans, including stock options, restricted stock, restricted stock units ("RSUs"), performance stock units ("PSUs") and market stock units ("MSUs"). We estimate equity-based compensation expense based on awards ultimately expected to vest. We make assumptions of forfeiture rates at the time of grant and continuously reassess our assumptions based on actual forfeiture experience.

We estimate compensation cost for stock options, restricted stock, RSUs and MSUs based on the fair value at the time of grant and recognize expense over the vesting period of the award. For stock options, the grant date fair value is measured using the Black-Scholes options-pricing model. For restricted stock and RSUs, the grant date fair value is based on the closing price of our common stock on the grant date. For MSUs, the fair value at the grant date is measured using a Monte Carlo simulation approach which estimates the fair value of awards based on randomly generated simulated stock-price paths through a lattice-type structure. MSUs expected to vest are recognized as expense on a straight-line basis over the vesting period, which is generally three years. The number of shares of common stock earned upon vesting is determined based on the ratio of the Company's common stock price during the last 30 market trading days of the calendar year immediately preceding the vesting date to the comparable common stock price as of the grant date, applied to the base units granted. The performance ratio is capped at 150% or 200%, depending on the grant date. If our common stock price declines by more than 50% over the performance period, no shares are earned by the recipient.

At its sole discretion, the Compensation Committee sets certain financial and quality-based performance goals and a target award amount for each award of PSUs. PSUs generally cliff-vest three years from the grant date based on the achievement of the performance goals and are conditioned on the employee's continued service through the vesting date. The actual number of common stock shares earned upon vesting will range from zero shares up to 150% or 200% of the target award, depending on the award date. PSUs do not have a grant date or grant fair value for accounting purposes as the subjective nature of the terms of the PSUs precludes a mutual understanding of the key terms and conditions. We recognize expense for PSUs ultimately expected to vest over the requisite service period based on our estimates of progress made towards the achievement of the predetermined performance measures and changes in the market price of our common stock.

Medicaid Premium Taxes

Medicaid Premium Taxes

Premium rates established in the Medicaid contracts with Georgia, Hawaii and New York, and, until June 30, 2013, Ohio, include, or included, an assessment or tax on Medicaid premiums. We recognize the premium tax assessment as expense in the period during which we earn the related premium revenue and remit the taxes back to the state agencies on a periodic basis.

Property, Equipment and Capitalized Software, net

Property, Equipment and Capitalized Software, net

Property, equipment and capitalized software are stated at historical cost, net of accumulated depreciation. We capitalize certain costs incurred in the development of internal-use software, including external direct costs of materials and services and payroll costs of employees devoted to specific software development. We expense other software development costs, such as training and data conversion costs, as incurred. We capitalize the costs of improvements that extend the useful lives of the related assets.

We record depreciation expense using the straight-line method over the estimated useful lives of the related assets, which ranges from three to ten years for leasehold improvements, five for furniture and equipment, and three to five years for computer equipment and software. We include amortization of equipment under capital leases in depreciation expense. We record maintenance and repair costs as selling, general and administrative expense when incurred.

On an ongoing basis, we review events or changes in circumstances that may indicate that the carrying value of an asset may not be recoverable. If the carrying value of an asset exceeds the sum of estimated undiscounted future cash flows, we recognize an impairment loss in the current period for the difference between estimated fair value and carrying value. If assets are determined to be recoverable but the useful lives are shorter than we originally estimated, we depreciate the remaining net book value of the asset over the newly determined remaining useful lives.

Goodwill and Intangible Assets

Goodwill and Intangible Assets

Goodwill represents the excess of the cost over the fair market value of net assets acquired and is attributable to our Medicaid and Medicare Health Plans reporting segments. Goodwill recorded at March 31, 2014 was $244.9 million, which consisted of $134.5 million and $110.4 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Goodwill recorded at December 31, 2013 was $236.8 million, which consisted of $126.8 million and $110.0 million attributable to our Medicaid and Medicare Health Plans reporting segments, respectively. Other intangible assets include provider networks, broker networks, trademarks, state contracts, non-compete agreements, licenses and permits. We amortize other intangible assets over their estimated useful lives ranging from approximately one to 15 years. These assets are allocated to reporting segments for impairment testing purposes.

We review goodwill and intangible assets for impairment at least annually, or more frequently if events or changes in our business climate occur that may potentially affect the estimated useful life or the recoverability of the remaining balance of goodwill or intangible assets. Such events or changes in circumstances would include significant changes in membership, state funding, federal and state government contracts and provider networks. To determine whether goodwill is impaired, we perform a multi-step impairment test. First, we can elect to perform a qualitative assessment of each reporting unit to determine whether facts and circumstances support a determination that their fair values are greater than their carrying values. If the qualitative analysis is not conclusive, or if we elect to proceed directly with quantitative testing, we will then measure the fair values of the reporting units using a two-step approach. In the first step, we determine the fair value of the reporting unit using both income and market approaches. We calculate fair value based on our assumptions of key factors such as projected revenues and the discount factor. While we believe these assumptions and estimates are appropriate, other assumptions and estimates could be applied and may produce significantly different results. If the fair value of the reporting unit is less than its carrying value, we measure and record the amount of the goodwill impairment, if any, by comparing the implied fair value of the reporting unit's goodwill to the carrying value. We perform our annual goodwill impairment test based on our financial position and results of operations through the second quarter of each year, which generally coincides with the finalization of federal and state contract negotiations and our initial budgeting process.

In 2013, we elected to bypass the optional qualitative fair value assessment and conducted our annual quantitative test for goodwill impairment during the third quarter of 2013. Based on the results of our quantitative test, we determined that the fair values of our reporting units exceeded their carrying values and therefore no further testing was required, and we believe that such assets are not impaired as of March 31, 2014.

Income Taxes

Income Taxes

We record income tax expense as incurred based on enacted tax rates, estimates of book-to-tax differences in income, and projections of income that will be earned in each taxing jurisdiction. We recognize deferred tax assets and liabilities for the estimated future tax consequences of differences between the carrying amounts of existing assets and liabilities and their respective tax basis. We measure deferred tax assets and liabilities using tax rates applicable to taxable income in the years in which we expect to recover or settle those temporary differences. We record a valuation allowance on deferred taxes if we determine it is more likely than not that we will not fully realize the future benefit of deferred tax assets. We file tax returns after the close of our fiscal year end and adjust our estimated tax receivable or liability to the actual tax receivable or due per the filed state and federal tax returns. Historically, we have not experienced significant differences between our estimates of income tax expense and actual amounts incurred.

State and federal taxing authorities may challenge the positions we take on our filed tax returns. We evaluate our tax positions and only recognize a tax benefit if it is more likely than not that a tax audit will sustain our conclusion. Based on our evaluation of tax positions, we believe that potential tax exposures have been recorded appropriately. State and federal taxing authorities may propose additional tax assessments based on periodic audits of our tax returns. We believe our tax positions comply with applicable tax law in all material aspects and we will vigorously defend our positions on audit. The ultimate resolution of these audits may materially impact our financial position, results of operations or cash flows. We have not experienced material adjustments to our condensed consolidated financial statements as a result of these audits.

We participate in the Internal Revenue Service ("IRS") Compliance Assurance Process ("CAP"). The objective of CAP is to reduce taxpayer burden and uncertainty by working with the IRS to ensure tax return accuracy prior to filing, thereby reducing or eliminating the need for post-filing examinations.

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CONSOLIDATED BALANCE SHEETS (Unaudited) (Parenthetical) (USD $)	Mar. 31, 2014	Dec. 31, 2013
Stockholders' Equity:
Preferred stock, par value (in dollars per share)	$ 0.01	$ 0.01
Preferred stock, authorized (in shares)	20,000,000	20,000,000
Preferred stock, issued (in shares)	0	0
Preferred stock, outstanding (in shares)	0	0
Common stock, par value (in dollars per share)	$ 0.01	$ 0.01
Common stock, authorized (in shares)	100,000,000	100,000,000
Common stock, issued (in shares)	43,858,148	43,766,645
Common stock, outstanding (in shares)	43,858,148	43,766,645

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RESTRICTED INVESTMENTS

3 Months Ended

Mar. 31, 2014

Restricted Investments Note [Abstract]

RESTRICTED INVESTMENTS

RESTRICTED INVESTMENTS

The amortized cost, gross unrealized gains, gross unrealized losses and fair value of our restricted investment securities are as follows: 

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Cash	$	49.3	$	—	$	—		$	49.3
Certificates of deposit	1.4		—		—			1.4
Money market funds	18.9		—		—			18.9
U.S. government securities	25.4		—		(0.1		)	25.3
	$	95.0	$	—	$	(0.1	)	$	94.9
December 31, 2013
Cash	$	40.2	$	—	$	—		$	40.2
Certificates of deposit	1.4		—		—			1.4
Money market funds	19.0		—		—			19.0
U.S. government securities	22.0		—		(0.1		)	21.9
	$	82.6	$	—	$	(0.1	)	$	82.5

No realized gains or losses were recorded on restricted investments for the quarters ended March 31, 2014 and March 31, 2013.

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INVESTMENTS

3 Months Ended

Mar. 31, 2014

Investments, Debt and Equity Securities [Abstract]

INVESTMENTS

INVESTMENTS

The Company considers all of its investments as available-for-sale securities. The amortized cost, gross unrealized gains or losses and estimated fair value of short-term and long term investments by security type are summarized in the following tables.

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Auction rate securities	$	34.2	$	—	$	(2.3	)	$	31.9
Certificates of deposit	1.1		—		—			1.1
Corporate debt and other securities	79.6		0.2		(0.1		)	79.7
Money market funds	43.4		—		—			43.4
Municipal securities	119.7		0.1		—			119.8
Variable rate bond fund	109.9		0.4		—			110.3
U.S. government securities	38.9		0.1		(0.1		)	38.9
	$	426.8	$	0.8	$	(2.5	)	$	425.1
December 31, 2013
Auction rate securities	$	34.2	$	—	$	(2.4	)	$	31.8
Certificates of deposit	1.6		—		—			1.6
Corporate debt and other securities	104.5		0.1		(0.1		)	104.5
Money market funds	43.4		—		—			43.4
Municipal securities	108.9		—		—			108.9
Variable rate bond fund	84.9		0.4		—			85.3
U.S. government securities	19.5		0.1		—			19.6
	$	397.0	$	0.6	$	(2.5	)	$	395.1

Realized gains and losses on sales and redemptions of investments were not material for the three months ended March 31, 2014 and 2013.

Contractual maturities of available-for-sale investments at March 31, 2014 are as follows:

	Total		Within 1 Year		1 Through 5 Years		5 Through 10 Years		Thereafter
Auction rate securities	$	31.9	$	—	$	—	$	—	$	31.9
Certificates of deposit	1.1		1.1		—		—		—
Corporate debt and other securities	79.7		47.0		29.6		0.9		2.2
Money market funds	43.4		43.4		—		—		—
Municipal securities	119.8		84.7		31.1		2.5		1.5
Variable rate bond fund	110.3		110.3		—		—		—
U.S. government securities	38.9		2.2		34.1		2.5		0.1
	$	425.1	$	288.7	$	94.8	$	5.9	$	35.7

Actual maturities may differ from contractual maturities due to the exercise of pre-payment options.

Excluding investments in U.S. government securities, we are not exposed to any significant concentration of credit risk in our fixed maturities portfolio. Our long-term investments include $31.9 million estimated fair value of municipal note securities with an auction reset feature ("auction rate securities"), which were issued by various state and local municipal entities for the purpose of financing student loans, public projects and other activities. Liquidity for these auction rate securities is typically provided by an auction process which allows holders to sell their notes and resets the applicable interest rate at pre-determined intervals, usually every seven or 35 days. We consider our auction rate securities to be in an inactive market as auctions have continued to fail in 2014. Our auction rate securities have been in an unrealized loss position for more than twelve months. Two auction rate securities with an aggregate par value of $22.6 million have investment grade security credit ratings and one auction rate security with a par value of $11.6 million has a credit rating below investment grade. Our auction rate securities are covered by government guarantees or municipal bond insurance and we have the ability and intent to hold these securities until maturity or market stability is restored. Accordingly, we do not believe our auction rate securities are impaired and have not recorded any other-than-temporary impairment as of March 31, 2014.

There were no redemptions or sales of our auction rate securities during the quarters ended March 31, 2014 and March 31, 2013, and accordingly, we realized no losses associated with our auction rate securities during either of those periods.

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INVESTMENTS (Tables)

3 Months Ended

Mar. 31, 2014

Investments, Debt and Equity Securities [Abstract]

Available-for-sale investments

The amortized cost, gross unrealized gains or losses and estimated fair value of short-term and long term investments by security type are summarized in the following tables.

	Amortized Cost		Gross Unrealized Gains		Gross Unrealized Losses			Estimated Fair Value
March 31, 2014
Auction rate securities	$	34.2	$	—	$	(2.3	)	$	31.9
Certificates of deposit	1.1		—		—			1.1
Corporate debt and other securities	79.6		0.2		(0.1		)	79.7
Money market funds	43.4		—		—			43.4
Municipal securities	119.7		0.1		—			119.8
Variable rate bond fund	109.9		0.4		—			110.3
U.S. government securities	38.9		0.1		(0.1		)	38.9
	$	426.8	$	0.8	$	(2.5	)	$	425.1
December 31, 2013
Auction rate securities	$	34.2	$	—	$	(2.4	)	$	31.8
Certificates of deposit	1.6		—		—			1.6
Corporate debt and other securities	104.5		0.1		(0.1		)	104.5
Money market funds	43.4		—		—			43.4
Municipal securities	108.9		—		—			108.9
Variable rate bond fund	84.9		0.4		—			85.3
U.S. government securities	19.5		0.1		—			19.6
	$	397.0	$	0.6	$	(2.5	)	$	395.1

Contractual maturities of available-for-sale investments

Contractual maturities of available-for-sale investments at March 31, 2014 are as follows:

	Total		Within 1 Year		1 Through 5 Years		5 Through 10 Years		Thereafter
Auction rate securities	$	31.9	$	—	$	—	$	—	$	31.9
Certificates of deposit	1.1		1.1		—		—		—
Corporate debt and other securities	79.7		47.0		29.6		0.9		2.2
Money market funds	43.4		43.4		—		—		—
Municipal securities	119.8		84.7		31.1		2.5		1.5
Variable rate bond fund	110.3		110.3		—		—		—
U.S. government securities	38.9		2.2		34.1		2.5		0.1
	$	425.1	$	288.7	$	94.8	$	5.9	$	35.7

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Proforma Financial Information (Tables)

3 Months Ended

Mar. 31, 2014

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Business Acquisition, Pro Forma Information [Table Text Block]

Pro Forma Financial Information

The results of operations and financial condition for our 2014 and 2013 acquisitions have been included in our condensed consolidated financial statements since the respective acquisition dates. The unaudited pro forma financial information presented below assumes that the acquisitions occurred as of January 1, 2013. The pro forma adjustments include the pro forma effect of the amortization of finite-lived intangible assets arising from the purchase price allocations, adjustments necessary to align the acquired companies' accounting policies to our accounting policies and the associated income tax effects of the pro forma adjustments. The following unaudited pro forma results have been prepared for comparative purposes only and do not purport to be indicative of the results of operations that would have occurred had the acquisitions been consummated at the beginning of the periods presented. Only pro forma results for the first quarter of 2013 have been presented, as Windsor was acquired on January 1, 2014 and their results of operations have been included in our condensed consolidated financial statements from this date.

	Pro forma - unaudited
	For Quarter ended March 31, 2013
(in millions, except per share data)
Premium revenues	$	2,564.9
Net earnings	$	8.4
Earnings per share:
Basic	$	0.19
Diluted	$	0.19

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FAIR VALUE MEASUREMENTS

3 Months Ended

Mar. 31, 2014

Fair Value Disclosures [Abstract]

FAIR VALUE MEASUREMENTS

FAIR VALUE MEASUREMENTS

Our condensed consolidated balance sheets include the following financial instruments: cash and cash equivalents, investments, receivables, accounts payable, medical benefits payable, long-term debt and other liabilities. We consider the carrying amounts of cash and cash equivalents, receivables, other current assets and current liabilities to approximate their fair value due to the short period of time between the origination of these instruments and the expected realization or payment.

Recurring Fair Value Measurements

Assets and liabilities measured at fair value on a recurring basis at March 31, 2014 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	0.6	$	—		$	0.6	$	—
Auction rate securities	31.9		—			—		31.9
Certificates of deposit	1.1		—			1.1		—
Corporate debt securities	75.3		—			75.3		—
International government bonds	3.8		—			3.8		—
Money market funds	43.4		43.4			—		—
Municipal securities	119.8		—			119.8		—
U.S. government and agency obligations	38.9		27.6			11.3		—
Variable rate bond fund	110.3		110.3			—		—
Total investments	$	425.1	$	181.3		$	211.9	$	31.9
Restricted investments:
Cash	49.3		49.3			—		—
Certificates of deposit	1.4		—			1.4		—
Money market funds	18.9		18.9			—		—
U.S. government and agency obligations	25.3		25.3		1,800.0	—		—
Total restricted investments	$	94.9	$	93.5		$	1.4	$	—
Amounts accrued related to investigation resolution	$	34.4	$	—		$	34.4	$	—

Assets and liabilities measured at fair value on a recurring basis at December 31, 2013 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	1.6	$	—		$	1.6	$	—
Auction rate securities	31.8		—			—		31.8
Certificates of deposit	1.6		—			1.6		—
Corporate debt securities	102.9		—			102.9		—
Money market funds	43.4		43.4			—		—
Municipal securities	108.9		—			108.9		—
U.S. government securities	19.6		19.6			—		—
Variable rate bond fund	85.3		85.3			—		—
Total investments	$	395.1	$	148.3		$	215.0	$	31.8
Restricted investments:
Cash	$	40.2	$	40.2		$	—	$	—
Certificates of deposit	1.4		—			1.4		—
Money market funds	19.0		19.0			—		—
U.S. government securities	21.9		21.9		1,800.0	—		—
Total restricted investments	$	82.5	$	81.1		$	1.4	$	—
Amounts accrued related to investigation resolution	$	70.3	$	—		$	70.3	$	—

The following table presents the carrying value and fair value of our senior notes as of March 31, 2014 and December 31, 2013:

	March 31, 2014		December 31, 2013
Long term debt	$	600.0	$	600.0
Approximate fair value of our long-term debt	630.4		615.0

The fair value of our senior notes was determined based on quoted market prices at March 31, 2104 and December 31, 2013, respectively, and therefore would be classified within Level 1 of the fair value hierarchy.

The following table presents the changes in the fair value of our Level 3 auction rate securities for the quarter ended March 31, 2014.

Balance as of January 1, 2014	$	31.8
Realized gains (losses) in earnings	—
Unrealized gains (losses) in other comprehensive income	0.1
Purchases, sales and redemptions	—
Net transfers in or (out) of Level 3	—
Balance as of March 31, 2014	$	31.9

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EQUITY-BASED COMPENSATION

3 Months Ended

Mar. 31, 2014

Disclosure of Compensation Related Costs, Share-based Payments [Abstract]

EQUITY-BASED COMPENSATION

EQUITY-BASED COMPENSATION

Compensation expense related to our equity-based compensation awards was $1.2 million and $3.7 million for the quarters ended March 31, 2014 and March 31, 2013, respectively. As of March 31, 2014, there was $22.3 million of unrecognized compensation cost related to non-vested equity-based compensation arrangements that is expected to be recognized over a weighted-average period of 2.2 years. The unrecognized compensation cost for our PSUs, which are subject to variable accounting, was determined based on the closing common stock price of $63.52 as of March 31, 2014 and amounted to approximately $7.0 million of the total unrecognized compensation. Due to the nature of the accounting for these awards, future compensation cost will fluctuate based on changes in our common stock price.

A summary of stock option activity for the quarter ended March 31, 2014, and the aggregate intrinsic value and weighted average remaining contractual term for stock options as of March 31, 2014, is presented in the table below.

	Shares		Weighted Average Exercise Price		Aggregate Intrinsic Value		Weighted Average Remaining Contractual Term (Years)
Outstanding as of January 1, 2014	31,381		$	29.47
Granted	—		—
Exercised	(13,000	)	19.96
Forfeited and expired	—		—
Outstanding as of March 31, 2014 (1)	18,381		$	36.20	$	0.5	1.5

(1)    All of the Company's outstanding stock options were vested and exercisable as of March 31, 2014.

A summary of RSU activity for the quarter ended March 31, 2014 is presented in the table below.

	RSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	259,836		$	56.51
Granted	137,356		61.71
Vested	(54,869	)	58.80
Forfeited and expired	(12,472	)	57.23
Outstanding as of March 31, 2014	329,851		58.27

A summary of our MSU activity for the quarter ended March 31, 2014 is presented in the table below.

	MSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	83,889		$	79.38
Granted	62,238		70.36
Vested	—		—
Forfeited and expired	(8,236	)	75.72
Outstanding as of March 31, 2014	137,891		75.53

A summary of the activity for our PSU awards, which are subject to variable accounting, for the quarter ended March 31, 2014 is presented in the table below.

	PSUs		Weighted Average Grant-Date Fair Value
Outstanding as of January 1, 2014	288,487		$	55.30
Granted	153,070		59.93
Vested	(62,640	)	40.57
Forfeited and expired	(21,949	)	59.86
Outstanding as of March 31, 2014	356,968		59.59

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DEBT

3 Months Ended

Mar. 31, 2014

Debt Disclosure [Abstract]

DEBT

DEBT

Senior Notes due 2020

In November 2013, we completed the offering and sale of $600.0 million aggregate principal amount of 5.75% unsecured senior notes due 2020 (the “Senior Notes”). The aggregate net proceeds from the issuance of the Senior Notes were used to repay the full outstanding balance under our 2011 credit agreement, and the remaining net proceeds are being used for general corporate purposes, including organic growth opportunities and potential acquisitions. The Senior Notes will mature on November 15, 2020, and bear interest at a rate of 5.75% per annum. Interest is computed on the basis of a 360-day year comprised of twelve 30-day months. Interest on the Senior Notes is payable semi-annually on May 15 and November 15 of each year, commencing on May 15, 2014.

The Senior Notes were issued under an indenture, dated as of November 14, 2013 (the “Base Indenture”), as supplemented by the First Supplemental Indenture, dated as of November 14, 2013 (the “First Supplemental Indenture” and, together with the Base Indenture, the “Indenture”) each between us and The Bank of New York Mellon Trust Company, N.A., as trustee. The Indenture under which the notes were issued contains covenants that, among other things, limit our ability and the ability of our restricted subsidiaries to:

• incur additional indebtedness and issue preferred stock;

• pay dividends or make other distributions;

• make other restricted payments and investments;

• sell assets, including capital stock of restricted subsidiaries;

• create certain liens;

• incur restrictions on the ability of restricted subsidiaries to pay dividends or make other payments, and in the case of the our subsidiaries, guarantee indebtedness;

• engage in transactions with affiliates;

• create unrestricted subsidiaries; and

• merge or consolidate with other entities.

Ranking and Optional Redemption

The Senior Notes are senior obligations of our company and rank equally in right of payment with all of our other existing and future unsecured and unsubordinated indebtedness. In addition, the Senior Notes are structurally subordinated to all indebtedness and other liabilities of our subsidiaries (unless our subsidiaries become guarantors of the Senior Notes). We may redeem up to 40% of the aggregate principal amount of the Senior Notes at any time prior to November 15, 2016, at a redemption price equal to 105.75% of the principal amount of the Senior Notes redeemed, plus accrued and unpaid interest.

On or after November 15, 2016, we may on any one or more occasions redeem all or part of the Senior Notes, at the redemption prices (expressed as percentages of principal amount) set forth below, if redeemed during the twelve-month period beginning on November 15 of the years indicated below, subject to the rights of holders of Senior Notes on the relevant record date to receive interest due on the relevant interest payment date:

Period	Redemption Price
2016	102.875	%
2017	101.438	%
2018 and thereafter	100	%

The Senior Notes are classified as long-term debt in the Company’s condensed consolidated balance sheets at March 31, 2014 and December 31, 2013, respectively, based on their November 2020 maturity date.

Credit Arrangements

In November 2013, we entered into a credit agreement (the "Credit Agreement") which provides for a senior unsecured revolving loan facility (the “Revolving Credit Facility”) of up to $300.0 million, which may be used for general corporate purposes of the Company and its subsidiaries. The Revolving Credit Facility provides for up to $75.0 million for letters of credit. The Credit Agreement also provides that we may, at our option, increase the aggregate amount of the Revolving Credit Facility and/or obtain incremental term loans in an amount up to $75.0 million without the consent of any lenders not participating in such increase, subject to certain customary conditions and lenders committing to provide the increase in funding. The commitments under the Revolving Credit Facility expire on November 14, 2018 and any amounts outstanding under the facility will be payable in full at that time. Unutilized commitments under the Credit Agreement are subject to a fee of 0.25% to 0.375% depending upon our ratio of total debt to cash flow.

The Credit Agreement includes negative and financial covenants that limit certain activities of our company and its subsidiaries, including (i) restrictions on our ability to incur additional indebtedness; and (ii) financial covenants that require (a) the ratio of total debt to cash flow not to exceed a maximum; (b) a minimum interest expense and principal payment coverage ratio; and (c) a minimum level of statutory net worth for our health maintenance organization and insurance subsidiaries. The Credit Agreement also contains customary representations and warranties that must be accurate in order for us to borrow under the Revolving Credit Facility. In addition, the Credit Agreement contains customary events of default. If an event of default occurs and is continuing, we may be required immediately to repay all amounts outstanding under the Credit Agreement. Lenders holding at least 50% of the loans and commitments under the Credit Agreement may elect to accelerate the maturity of the loans and/or terminate the commitments under the Credit Agreement upon the occurrence and during the continuation of an event of default.

As of March 31, 2014 and as of the date of this filing, we have not drawn upon the Revolving Credit Facility and we remain in compliance with all covenants under both the Revolving Credit Facility and the Indenture.

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INCOME TAXES

3 Months Ended

Mar. 31, 2014

Income Tax Disclosure [Abstract]

INCOME TAXES

INCOME TAXES

Our effective income tax rate was 32.8% for the quarter ended March 31, 2014 compared to 5.9% for the same period in 2013. In 2014, the effective rate reflects the favorable impact of the Windsor bargain purchase gain, partially offset by the impact of the non-deductible ACA industry fee. The effective tax rate was lower in 2013 mainly due to an issue resolution agreement reached with the IRS in 2013 regarding the tax treatment of the investigation-related litigation and other resolution costs, resulting in approximately $7.6 million in additional tax benefit over what was recorded as of December 31, 2012.

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Medical Benefits and Medical Benefits Payable (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Unfavorable Development Related To Prior Fiscal Years	$ 32.5
Net favorable development related to prior fiscal years		$ 15.9

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COMMITMENTS AND CONTINGENCIES (Details) (USD $)	3 Months Ended		0 Months Ended	3 Months Ended		3 Months Ended			84 Months Ended
	Mar. 31, 2014 associate	Dec. 31, 2013	Mar. 23, 2012 Civil Inquiry [Member] Installment	Mar. 31, 2014 Civil Inquiry [Member]	Dec. 31, 2011 Class Action Complaints [Member]	Mar. 31, 2014 Corporate Integrity Agreement [Member]	Mar. 31, 2014 Derivative Lawsuits [Member] days person Employee Action	Mar. 31, 2013 Derivative Lawsuits [Member]	Dec. 31, 2013 Derivative Lawsuits [Member]
Loss Contingencies [Line Items]
Settlement agreement, amount			$ 137,500,000
Number of installments			4
Settlement Agreement Amount Of Installment Payments			34,400,000
Term of agreement				36 months		5 years
Settlement agreement, interest rate			3.125%
Amount of legal contingency accrual, current	34,400,000	36,200,000
Amount of legal contingency accrual, long-term	0	34,100,000
Settlement agreement, additional contingent amount			35,000,000
Portion of sums recovered from former officers to be paid to class members					25.00%
Number of former officers being pursued in action filed by entity							3
Number of former associates being pursued in action filed by entity							2
Number of former associates tried in 2013	4
Number of former employees being pursued in action filed by entity							5
Number of actions filed in the Federal Court							6
Number of days action against former associates is stayed	90 days
Legal fees							$ 7,800,000	$ 18,900,000	$ 163,700,000

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SEGMENT REPORTING (Tables)

3 Months Ended

Mar. 31, 2014

Segment Reporting [Abstract]

Revenue by geographic location

Our Medicaid operations in certain states individually account for 10% or more of our consolidated premium revenue. Those states, and the respective Medicaid premium revenue as a percentage of total consolidated premium revenue, are as follows: 

	For the Three Months Ended March 31,
	2014	2013
Georgia	12%	16%
Florida	10%	12%
Kentucky	17%	13%

Segment results

A summary of financial information for our reportable operating segments through the gross margin level and a reconciliation to income before income taxes is presented in the tables below.

	For the Three Months Ended March 31,
	2014			2013
Premium revenue:	(in millions)
Medicaid Health Plans	$	1,638.8		$	1,310.4
Medicare Health Plans	963.3			718.9
Medicare PDPs	373.0			223.0
Total premium revenue	2,975.1			2,252.3
Medical benefits expense:
Medicaid Health Plans	1,389.3			1,130.7
Medicare Health Plans	851.5			625.6
Medicare PDPs	389.1			231.0
Total medical benefits expense	2,629.9			1,987.3
ACA industry fee expense:
Medicaid Health Plans	18.9			—
Medicare Health Plans	10.7			—
Medicare PDPs	2.7			—
Total ACA industry fee expense	32.3			—
Gross margin
Medicaid Health Plans	230.6			179.7
Medicare Health Plans	101.1			93.3
Medicare PDPs	(18.8		)	(8.0		)
Total gross margin	312.9			265.0
Investment and other income	10.6			4.3
Other expenses	(286.2		)	(246.4		)
Income from operations	$	37.3		$	22.9

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DEBT Debt (Tables)

3 Months Ended

Mar. 31, 2013

Debt Instrument, Redemption [Line Items]

Schedule of Redemption Prices as Percentage of Principal Amount [Table Text Block]

On or after November 15, 2016, we may on any one or more occasions redeem all or part of the Senior Notes, at the redemption prices (expressed as percentages of principal amount) set forth below, if redeemed during the twelve-month period beginning on November 15 of the years indicated below, subject to the rights of holders of Senior Notes on the relevant record date to receive interest due on the relevant interest payment date:

Period	Redemption Price
2016	102.875	%
2017	101.438	%
2018 and thereafter	100	%

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FAIR VALUE MEASUREMENTS Fair Value of Debt (Details) (Senior Notes [Member], USD $) In Millions, unless otherwise specified	Mar. 31, 2014	Dec. 31, 2013
Senior Notes [Member]
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Debt Instrument, Face Amount	$ 600.0	$ 600.0
Long-term Debt, Fair Value	$ 630.4	$ 615.0

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ACQUISITIONS - Acquired Intangible Assets (Details) (USD $) In Millions, unless otherwise specified	3 Months Ended				3 Months Ended		3 Months Ended		3 Months Ended		3 Months Ended			3 Months Ended		3 Months Ended
	Mar. 31, 2014	Mar. 31, 2013	Jan. 31, 2013 WellCare of South Carolina [Member]	Jan. 02, 2014 Windsor Health Plans, Inc. [Member]	Mar. 31, 2014 Windsor Health Plans, Inc. [Member] Weighted Average [Member]	Jan. 02, 2014 Windsor Health Plans, Inc. [Member] Provider networks [Member]	Mar. 31, 2014 Windsor Health Plans, Inc. [Member] Provider networks [Member] Weighted Average [Member]	Jan. 02, 2014 Windsor Health Plans, Inc. [Member] Broker Network [Member]	Mar. 31, 2014 Windsor Health Plans, Inc. [Member] Broker Network [Member] Weighted Average [Member]	Jan. 02, 2014 Windsor Health Plans, Inc. [Member] Other Intangible Assets [Member]	Mar. 31, 2014 Windsor Health Plans, Inc. [Member] Other Intangible Assets [Member] Weighted Average [Member]	Mar. 31, 2013 Missouri Care, Inc. [Member]	Jan. 02, 2014 Medicare Health Plans [Member] Windsor Health Plans, Inc. [Member] Membership Base [Member]	Mar. 31, 2014 Medicare Health Plans [Member] Windsor Health Plans, Inc. [Member] Membership Base [Member] Weighted Average [Member]	Jan. 02, 2014 Prescription Drug Plans [Member] Windsor Health Plans, Inc. [Member] Membership Base [Member]	Mar. 31, 2014 Prescription Drug Plans [Member] Windsor Health Plans, Inc. [Member] Membership Base [Member] Weighted Average [Member]
Acquired Finite-Lived Intangible Assets [Line Items]
Business Combination, Bargain Purchase, Gain Recognized, Amount	$ 28.3	$ 0
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Finite-Lived Intangibles			$ 9.5	$ 54.3		$ 5.2		$ 3.3		$ 8.2		$ 7.1	$ 20.1		$ 17.5
Finite-Lived Intangible Asset, Useful Life					11 years 6 months 0 days		15 years		10 years		9 years			15 years		8 years

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CONSOLIDATED STATEMENT OF CHANGES IN STOCKHOLDERS' EQUITY (Unaudited) (USD $) In Millions, except Share data, unless otherwise specified	Total	Common Stock [Member]	Paid in Capital [Member]	Retained Earnings [Member]	Accumulated Other Comprehensive Loss [Member]
Balance at Dec. 31, 2013	$ 1,517.9	$ 0.4	$ 489.4	$ 1,029.4	$ (1.3)
Balance (in shares) at Dec. 31, 2013	43,766,645	43,766,645
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Common stock issued for exercised stock options	0.2	0	0.2	0	0
Common stock issued for exercised stock options (in shares)		11,671
Common stock issued for vested restricted stock, restricted stock units and performance stock units	(2.2)	0	(2.2)	0	0
Adjustments to Additional Paid in Capital, Share-based Compensation, Requisite Service Period Recognition	1.2	0	1.2	0	0
Repurchase and retirement of shares to satisfy tax withholding requirements (shares)		36,178
Repurchase and retirement of shares to satisfy tax withholding requirements	0	0	0	0	0
Common stock issued for vested restricted stock, restricted stock units, performance stock units and market stock units (in shares)		116,010
Incremental tax benefit from equity-based compensation	0.2	0	0.2	0	0
Comprehensive income	44.4	0	0	44.1	0.3
Balance at Mar. 31, 2014	$ 1,561.7	$ 0.4	$ 488.8	$ 1,073.5	$ (1.0)
Balance (in shares) at Mar. 31, 2014	43,858,148	43,858,148

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NET INCOME PER COMMON SHARE

3 Months Ended

Mar. 31, 2014

Earnings Per Share [Abstract]

NET INCOME PER COMMON SHARE

NET INCOME PER COMMON SHARE

We compute basic net income per common share on the basis of the weighted-average number of unrestricted common shares outstanding. We compute diluted net income per common share on the basis of the weighted-average number of unrestricted common shares outstanding plus the dilutive effect of outstanding stock options, restricted stock, RSUs, MSUs and PSUs using the treasury stock method.

The calculation of the weighted-average common shares outstanding — diluted is as follows:

	For the Three Months Ended March 31,
	2014	2013
Weighted-average common shares outstanding — basic	43,802,047	43,325,381
Dilutive effect of:
Unvested restricted stock, restricted stock units, market stock and performance stock units	308,133	426,593
Stock options	13,611	200,485
Weighted-average common shares outstanding — diluted	44,123,791	43,952,459
Anti-dilutive stock options, restricted stock and performance based awards excluded from computation	72,457	184,536

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FAIR VALUE MEASUREMENTS (Tables)

3 Months Ended

Mar. 31, 2014

Fair Value Disclosures [Abstract]

Assets and liabilities measured at fair value

Assets and liabilities measured at fair value on a recurring basis at March 31, 2014 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	0.6	$	—		$	0.6	$	—
Auction rate securities	31.9		—			—		31.9
Certificates of deposit	1.1		—			1.1		—
Corporate debt securities	75.3		—			75.3		—
International government bonds	3.8		—			3.8		—
Money market funds	43.4		43.4			—		—
Municipal securities	119.8		—			119.8		—
U.S. government and agency obligations	38.9		27.6			11.3		—
Variable rate bond fund	110.3		110.3			—		—
Total investments	$	425.1	$	181.3		$	211.9	$	31.9
Restricted investments:
Cash	49.3		49.3			—		—
Certificates of deposit	1.4		—			1.4		—
Money market funds	18.9		18.9			—		—
U.S. government and agency obligations	25.3		25.3		1,800.0	—		—
Total restricted investments	$	94.9	$	93.5		$	1.4	$	—
Amounts accrued related to investigation resolution	$	34.4	$	—		$	34.4	$	—

Assets and liabilities measured at fair value on a recurring basis at December 31, 2013 are as follows:

			Fair Value Measurements Using
	Carrying Value		Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments:
Asset backed securities	$	1.6	$	—		$	1.6	$	—
Auction rate securities	31.8		—			—		31.8
Certificates of deposit	1.6		—			1.6		—
Corporate debt securities	102.9		—			102.9		—
Money market funds	43.4		43.4			—		—
Municipal securities	108.9		—			108.9		—
U.S. government securities	19.6		19.6			—		—
Variable rate bond fund	85.3		85.3			—		—
Total investments	$	395.1	$	148.3		$	215.0	$	31.8
Restricted investments:
Cash	$	40.2	$	40.2		$	—	$	—
Certificates of deposit	1.4		—			1.4		—
Money market funds	19.0		19.0			—		—
U.S. government securities	21.9		21.9		1,800.0	—		—
Total restricted investments	$	82.5	$	81.1		$	1.4	$	—
Amounts accrued related to investigation resolution	$	70.3	$	—		$	70.3	$	—

Schedule of Carrying Values and Estimated Fair Values of Debt Instruments [Table Text Block]

The following table presents the carrying value and fair value of our senior notes as of March 31, 2014 and December 31, 2013:

	March 31, 2014		December 31, 2013
Long term debt	$	600.0	$	600.0
Approximate fair value of our long-term debt	630.4		615.0

The fair value of our senior notes was determined based on quoted market prices at March 31, 2104 and December 31, 2013, respectively, and therefore would be classified within Level 1 of the fair value hierarchy.

Auction rate securities measured at fair value on a recurring basis using significant unobservable inputs

The following table presents the changes in the fair value of our Level 3 auction rate securities for the quarter ended March 31, 2014.

Balance as of January 1, 2014	$	31.8
Realized gains (losses) in earnings	—
Unrealized gains (losses) in other comprehensive income	0.1
Purchases, sales and redemptions	—
Net transfers in or (out) of Level 3	—
Balance as of March 31, 2014	$	31.9

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ORGANIZATION, BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES Recently Adopted Accounting Standards (Details) (USD $) In Millions, unless otherwise specified	Mar. 31, 2014	Dec. 31, 2013
Organization, Consolidation and Presentation of Financial Statements [Abstract]
ACA Industry Fee	$ 129.0	$ 0

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ACQUISITIONS (Tables) (Windsor Health Plans, Inc. [Member])

3 Months Ended

Mar. 31, 2014

Windsor Health Plans, Inc. [Member]

Business Acquisition [Line Items]

Summary of fair values of assets acquired and liabilities assumed

The following table summarizes the preliminary estimated fair values of tangible and intangible assets acquired and liabilities assumed at the acquisition date.

Cash and cash equivalents	$	169.0
Investments	47.1
Premiums receivable, net	87.4
Other intangible assets	54.3
Pharmacy rebates receivable, net	35.4
Other assets	27.9
Deferred tax asset	29.6
Total assets acquired	450.7
Medical benefits payable	(118.1		)
Accrued expenses and other payables	(74.1		)
Deferred tax liability	(20.6		)
Total liabilities assumed	(212.8		)
Fair value of net assets acquired	$	237.9