CN-680000-FP083-A1.pdf

AHCA CONTRACT NO. FP083

AMENDMENT NO. 1

AHCA Contract No. FP083, Amendment No. 1, Page 1 of 6 April 2020

THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency” and CAREPLUS HEALTH PLANS, INC., hereinafter referred to as the “Vendor”, is hereby amended as follows:

1. Standard Contract, is hereby amended to now include Attachment V, Agency Approved Modifications to the Standard Contract, attached hereto and made part of this Contract.

2. Attachment I, Scope of Services, Section III., Method of Payment, Sub-Section B., Financial Consequences as Liquidated Damages, Item 1., Performance Standards and Liquidated Damages, Table 1, Performance Standards and Liquidated Damages, is hereby deleted in its entirety and replaced with Table 1-A, Revised Performance Standards and Liquidated Damages, as follows. All references in this Contract to Table 1, shall hereinafter refer to Table 1-A.

TABLE 1-A

REVISED PERFORMANCE STANDARDS AND LIQUIDATED DAMAGES

Performance Standard Requirement Liquidated Damages to be Imposed

HIPAA

The Vendor shall comply with provisions of Health Insurance Portability and Accountability Act (HIPAA) / Health Information Technology for Economic and Clinical Health (HITECH).

$500.00 to $5,000.00, per incident, per occurrence, depending upon the severity. In addition, Federal penalties may apply in accordance with the HIPAA Act of 1996.

The Vendor shall not inappropriately release

PHI.

$500.00 to $5,000.00, per incident, per occurrence, depending upon the severity.

Records The Vendor shall comply with public records laws, in accordance with Section 119.0701, F.S.

$5,000.00 for each incident in which the Vendor does not comply with a public records request.

Background Screening Complete initial and renewal background screenings within required timeframes.

$250.00 per occurrence.

Submit policies and procedures within thirty

(30) calendar days of Contract execution.

$250.00 per calendar day beyond the due date.

Security Rating Score Annually maintain a top tier security risk score from the Agency’s selected information security rating service.

$5,000.00 per occurrence and $250.00 per day, if the Vendor does not improve to a top tier security risk score within three (3) months after its initial failure notification by the Agency, to annually obtain a top tier security risk score.

Services

Implement the approved Corrective Action Plan (CAP) by the Agency specified date.

$500.00 per calendar day for each calendar day that the approved CAP

DocuSign Envelope ID: 2A359A3F-698F-42E1-BF8A-660E269FE90A

AHCA Contract No. FP083, Amendment No. 1, Page 2 of 6

TABLE 1-A

REVISED PERFORMANCE STANDARDS AND LIQUIDATED DAMAGES

Performance Standard Requirement Liquidated Damages to be Imposed is not implemented to the satisfaction of the Agency.

Failure to respond to an Agency communication within the time prescribed by the Agency as described in this Contract.

$500.00 for each day beyond the due date until provided to the Agency.

Failure to provide covered services with reasonable promptness.

$2,500.00 per occurrence.

Failure by the Vendor 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 as described in this Contract. See also ancillary BAA between the parties.

$500.00 per enrollee per occurrence, not to exceed $10,000,000.00.

Failure to comply with marketing requirements as described in this Contract.

$2,500.00 per occurrence.

Failure to obtain approval of enrollee materials, as required by this Contract.

$1,000.00 per occurrence.

Failure to comply with the grievance and appeal notice requirements described in this Contract.

$1,000.00 per day

Failure to comply with timeframes for the grievance and appeal system.

$500.00 per occurrence

Failure to comply with all orders/official decisions relating to claim disputes, grievances, appeals and/or fair hearings, as they are issued.

$10,000.00 per occurrence.

Failure to provide continuation of services during the pendency of a Medicaid fair hearing and/or the Vendor’s appeal process where the enrollee has challenged a reduction or elimination of services as required by this 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 $500.00 per day for each day the Vendor fails to provide continuation or restoration as required by the Agency.

Failure to submit a fair hearing evidence packet with the required materials described in this Contract.

$1,000.00 per occurrence.

Failure to submit a fair hearing evidence packet within the time-frame described in this Contract and prehearing instructions.

$1,000.00 per occurrence.

Failure to provide necessary witnesses and evidentiary materials for fair hearings in accordance with this Contract.

$1,000.00 per occurrence.

AHCA Contract No. FP083, Amendment No. 1, Page 3 of 6

TABLE 1-A

REVISED PERFORMANCE STANDARDS AND LIQUIDATED DAMAGES

Performance Standard Requirement Liquidated Damages to be Imposed Failure to attend fair hearings as scheduled in accordance with this Contract.

$2,500.00 per occurrence.

Failure to provide restoration of services after the Vendor receives an adverse determination as a result of a Medicaid fair hearing or the Vendor’s appeal process as required by this 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 $500.00 per day for each day the Vendor fails to provide continuation or restoration as required by the Agency.

Failure to comply with provider network requirements specified in this Contract.

$1,000.00 per occurrence.

Failure to provide covered services within the timely access standards in this Contract.

$500.00 per day, per occurrence.

Failure to provide covered services within the geographic access standards in this Contract.

$500.00 per day, per occurrence.

Failure to comply with licensure or background screening requirements for Vendor principals in this Contract.

$5,000.00 per occurrence 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.

Failure to timely report notice of terminated providers due to imminent danger/impairment as described in this Contract.

$5,000.00 per occurrence.

Failure to receive prior written Agency approval of delegation to a subcontractor.

$25,000.00 per occurrence

Failure to maintain and/or provide proof of required insurance as described in this Contract.

$500.00 per day.

Failure to provide notice of noncompliance to the Agency within five (5) days or other Contract-specified period of time in accordance with this Contract.

$500.00 per day beginning on the next day after default by the Vendor.

Failure to cooperate fully with the Agency and/or State during an investigation of fraud or abuse, complaint, or grievances.

$500.00 per incident for failure to fully cooperate during an investigation.

Failure to timely submit complete and accurate quarterly internal audits.

$500.00 per day for each day that reporting requirements are not met.

Failure to timely report changes in ownership and control.

$5,000.00 per occurrence.

Failure to timely initiate a background screening via the Clearinghouse for newly hired principals.

$500.00 per occurrence.

AHCA Contract No. FP083, Amendment No. 1, Page 4 of 6

TABLE 1-A

REVISED PERFORMANCE STANDARDS AND LIQUIDATED DAMAGES

Performance Standard Requirement Liquidated Damages to be Imposed Failure to comply with public records laws, in accordance with s. 119.0701, F.S.

$5,000.00 per occurrence.

3. Attachment I, Scope of Services, Section VIII., Grievance and Appeals, Sub-Section A., Grievance and Appeal System for Services Provided Under this Contract for Applicable Integrated Plans, as defined in 42 CFR §422.561, Item 1., is hereby amended to now read as follows:

1. Consistent with state policy, the Vendor shall implement a grievance and appeal system and process grievances and appeals in compliance with the terms of 42 CFR §§ 422.629 – 422.634, 438.210, 438.400 and 438.402. This includes:

a. Grievances and appeals systems that meet the standards described in

§422.629;

b. An integrated grievance process that complies with §422.630;

c. A process for making integrated organization determinations consistent with §422.631;

d. Continuation of benefits while an integrated reconsideration is pending consistent with §422.632;

e. A process for making integrated reconsiderations consistent with

§422.633; and,

f. A process for effectuation of decisions consistent with §422.634.

4. Attachment I, Scope of Services, Section VIII., Grievance and Appeals, Sub-Section B., Grievance and Appeal System for Medicaid Services Provided Under this Contract for Non-Integrated Plans, Item 5., Process for Plan Appeals, Sub-Item m., Content of Notice, Sub-Item 5), is hereby deleted in its entirety.

5. Attachment I, Scope of Services, Section IX., System Functionality, Sub-Section D., is hereby deleted in its entirety.

6. Effective July 1, 2021, Attachment I, Scope of Services, Exhibit A, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services Effective January 1, 2021, is hereby deleted in its entirety and replaced with Exhibit A-1, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services Effective July 1, 2021, attached hereto and made part of this Contract. All references in this Contract to Exhibit A, shall hereinafter refer to Exhibit A-1.

7. Attachment I, Scope of Services, Exhibit B, Required Documentation And Reporting, is hereby deleted in its entirety and replaced with Exhibit B-1, Required

AHCA Contract No. FP083, Amendment No. 1, Page 5 of 6

Documentation/Reporting, attached hereto and made part of this Contract. All references in this Contract to Exhibit B, shall hereinafter refer to Exhibit B-1.

8. Attachment I, Scope of Services, Exhibit C, D-SNP Capitation Rates, is hereby deleted in its entirety and replaced with Exhibit C-1, MA D-SNP Capitation Rates, attached hereto and made part of this Contract. All references in this Contract to Exhibit C, shall hereinafter refer to Exhibit C-1.

All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.

This Amendment and all its attachments are hereby made a part of this Contract.

This Amendment cannot be executed unless all previous Amendments to this Contract have been fully executed.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP083, Amendment No. 1, Page 6 of 6

IN WITNESS WHEREOF, the Parties hereto have caused this fifteen (15) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

CAREPLUS HEALTH PLANS, INC. STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

SIGNED

BY:

SIGNED

BY:

NAME: NAME:

TITLE: TITLE:

DATE: DATE:

List of Attachments included as part of this Amendment:

Specify Type Number Description Attachment I Exhibit A-1 Medicare Advantage Dual Eligible Special Needs

Plan (D-SNP) Medicaid Covered Services Effective July 1, 2021 (3 Pages)

Attachment I Exhibit B-1 Required Documentation/Reporting (3 Pages) Attachment I Exhibit C-1 MA D-SNP Capitation Rates (2 Pages) Attachment V Agency Approved Modifications to the Standard

Contract (1 Page)

Timothy A. Wheatley

6/25/2021

Segment President, Retail

Simone Marstiller

Secretary

6/25/2021

ATTACHMENT I

EXHIBIT A-1

AHCA Contract No. FP083, Attachment I, Exhibit A-1, Page 1 of 3

Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services Effective July 1, 2021

Medicaid Services to be provided when not covered by Medicare

The Plan shall provide the covered services contained within the following Medicaid rules and associated fee schedules:

Rule No. Policy Name 59G-4.013 Allergy Services Coverage Policy

59G-4.020 Ambulatory Surgical Center Services Coverage Policy

59G-4.022 Anesthesia Services Coverage Policy

59G-4.025 Assistive Care Services Coverage and Limitations Handbook

59G-4.027 Behavioral Health Overlay Services Coverage and Limitations Handbook

59G-4.028 Behavioral Health Assessment Services 59G-4.031 Behavioral Health Community Support Services 59G-4.370 Behavioral Health Intervention Services 59G-4.029 Behavioral Health Medication Management Services 59G-4.052 Behavioral Health Therapy Services 59G-4.033 Cardiovascular Services Coverage Policy

59G-8.700 Child Health Services Targeted Case Management 59G-4.040 Chiropractic Services Coverage Policy

59G-4.050 Community Behavioral Health Services 59G-4.055 County Health Department Services 59G-4.060 Dental Services Coverage Policy 59G-4.105 Dialysis Services Coverage Policy

59G-4.070 Durable Medical Equipment and Medical Supplies Coverage and Limitations Handbook

59G-4.085 Early Intervention Services Coverage Policy 59G-4.015 Emergency Transportation Services Coverage Policy 59G-4.087 Evaluation and Management Services Coverage Policy

59G-4.100 Federally Qualified Health Center Services 59G-4.026 Gastrointestinal Services Coverage Policy

59G-4.108 Genitourinary Services Coverage Policy

59G-4.110 Hearing Services Coverage Policy

59G-4.130 Home Health Services Coverage Policy

59G-4.150 Inpatient Hospital Services Coverage Policy

59G-4.032 Integumentary Services Coverage Policy

59G-4.190 Laboratory Services Coverage Policy

59G-1.045 Medicaid Forms 59G-4.197 Medical Foster Care Services 59G-4.199 Mental Health Targeted Case Management Handbook

59G-4.201 Neurology Services Coverage Policy

59G-4.330 Non-Emergency Transportation Services Coverage Policy

59G-4.200 Nursing Facility Services Coverage Policy 59G-4.318 Occupational Therapy Services Coverage Policy 59G-4.207 Oral and Maxillofacial Surgery Services Coverage Policy

DocuSign Envelope ID: 2A359A3F-698F-42E1-BF8A-660E269FE90A http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/forms.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml

AHCA Contract No. FP083, Attachment I, Exhibit A-1, Page 2 of 3

59G-4.211 Orthopedic Services Coverage Policy

59G-4.160 Outpatient Hospital Services Coverage Policy

59G-4.222 Pain Management Services Coverage Policy

59G-4.215 Personal Care Services Coverage Policy 59G-4.320 Physical Therapy Services Coverage Policy 59G-4.220 Podiatry Services Coverage Policy

59G-4.250 Prescribed Drug Services Coverage, Limitations and Reimbursement Handbook

59G-4.261 Private Duty Nursing Services Coverage Policy 59G-4.002 Provider Reimbursement Schedules and Billing Codes 59G-4.240 Radiology and Nuclear Medicine Services Coverage Policy

59G-4.264 Regional Perinatal Intensive Care Center Services

59G-4.030 Reproductive Services Coverage Policy

59G-4.235 Respiratory System Services Coverage Policy

59G-4.322 Respiratory Therapy Services Coverage Policy 59G-4.280 Rural Health Clinic Services 59G-4.295 Specialized Therapeutic Services Coverage and Limitations Handbook

59G-4.324 Speech-Language Pathology Services Coverage Policy 59G-4.120 Statewide Inpatient Psychiatric Program Coverage Policy

59G-4.360 Transplant Services Coverage Policy

59G-4.340 Visual Aid Services Coverage Policy

59G-4.210 Visual Care Services Coverage Policy

Please note: There may be instances when the Medicaid limit is greater than the Medicare limit. In those instances where the Medicare limit has been exhausted, the Plan shall cover the difference for those eligible recipients.

Additional Medicaid Required Covered Services:

Durable Medical Equipment and Medical Supplies

Notwithstanding the limitations prescribed by the Durable Medical Equipment Services Coverage and Limitations Handbook, the Plan shall provide specialized medical equipment and supplies (e.g., incontinence supplies) to enrollees with a diagnosis of AIDS, and who have had a history of an AIDS-related opportunistic infection. The Plan may place appropriate limits on such services on the basis of medical necessity.

Therapy Services

The Plan shall provide medical massage therapy services to enrollees diagnosed with AIDS, and who have had a history of an AIDS-related opportunistic infection for the treatment of peripheral neuropathy or severe neuromuscular pain and lymphedema. The Plan may place appropriate limits on such services on the basis of medical necessity.

http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/reimbursement.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml

AHCA Contract No. FP083, Attachment I, Exhibit A-1, Page 3 of 3

Nursing Facility Services

(a) The DSNP shall provide nursing facility services for enrollees under the age of eighteen (18) years.

(b) The DSNP shall provide nursing facility services for enrollees ages eighteen (18) years of age and older in the following circumstances:

(1) For up to one-hundred twenty (120) days from the date of the most recent nursing facility admission, regardless of payer, when:

i. The enrollee is in need of long-term nursing facility services;

ii. The enrollee has completed all PASRR requirements;

iii. The DCF has determined the enrollee is eligible for Institutional Care Program (ICP) Medicaid; and

iv. The enrollee is not yet enrolled in the Long-Term Care program.

(2) The DSNP shall reimburse in accordance with Rule 59G-1.052, F.A.C. for nursing facility services provided during the Medicare coinsurance days (day twenty-one (21) up to day one hundred (100)) for Medicare co-payments and co-insurance if the requirements of PASRR are met and the enrollee: has QMB benefits and is also eligible for full Florida Medicaid benefits; is receiving SSI; or has Medicare benefits other than QMB and is also eligible for the Institutional Care Program.

(c) The D-SNP is not obligated to provide any services not specified in this Contract, except as federally required under EPSDT provisions.

(b) Services not recognized in this Exhibit are not included in the capitated rate paid to the Vendor by the Agency. The Contractor is not required to provide these services, but is responsible for ensuring coordination of these services, per the federal regulations described at 42 CFR §422.107(c)(1).

EXHIBIT B-1

AHCA Contract No. FP083, Attachment I, Exhibit B-1, Page 1 of 3

REQUIRED DOCUMENTATION/REPORTING

DOCUMENT REQUIRED PRIOR TO

CONTRACT

EXECUTION

UPON

REQUEST

OTHER

Unaudited DSNP Financial Report

(formerly named Special Needs Plan Revenue and Expense Schedule Statement Template Tool)

Submitted annually by July 1st

Independently Audited DSNP Financial Report

Submitted annually by September 15th

Valid certificate of authority issued by the State of Florida Department of Financial Services Office of Insurance Regulation as a risk bearing entity (either a health maintenance organization or a health insurer)

X X

Certificate of Liability Insurance X X Plans must submit updated Certificate of Liability Insurance upon renewal

Approval from the Centers for Medicare and Medicaid Services qualifying as a MA SNP

X

Service Areas Covered including Medicare Contract number and Plan Benefit Package (PBP) number

X X Upon initial submission to CMS for review. Plans must notify the Agency; their proposed plan to amend their existing Services Areas and/or PBP

Summary of Benefits X X

AHCA Contract No. FP083, Attachment I, Exhibit B-1, Page 2 of 3

Quality reports, measures, and findings generated from the Plan’s quality management programs

X

Agreement that network providers will not file additional claims for Medicaid deductibles or co-payment reimbursement to the Agency and that the network providers will not balance bill

X X

Written policies and procedures in place to ensure an adequate provider network for its members

X

Agreements between the Vendor and providers

X

HIPAA Policies and Procedures X

The Plan shall report to the Agency contract manager the discovery of any use or disclosure of PHI that is not in compliance with this Agreement or state or federal law, in accordance with said Business Associate Agreement in a manner and format prescribed by the Agency.

Report within ten

(10) business days of discovery, any use or disclosure of protected health information when Vendor is aware.

Report within twenty-four (24) hours of discovery, any security incident of which the Vendor is aware.

Submit copies of all HHS breach notifications to the Agency no later than sixty (60) days after the end of each calendar year and shall concurrently submit an attestation in accordance with 42 CFR 438.606(c).

Annually, no later than sixty (60) days after the end of the calendar year.

Subcontractor Policies and Procedures

X

AHCA Contract No. FP083, Attachment I, Exhibit B-1, Page 3 of 3

Provider Training Materials X

Internal Audits Forty-five (45) calendar days after the end of each calendar quarter

Before providing transportation services, the Plan shall provide the Agency a copy of its policies and procedures for approval relating to the following:

(i) How the Plan will determine eligibility for each enrollee and what type of transportation to provide that enrollee;

(ii) The Plan's procedure for providing prior authorization to enrollees requesting transportation services;

(iii) How the 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 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 Plan will provide transportation services outside its region.

X

EXHIBIT C-1

AHCA Contract No. FP083, Attachment I, Exhibit C-1, Page 1 of 2

MA D-SNP CAPITATION RATES

DATE SPAN REGION CATEGORIES OF

MEDICAID

ELIGIBILITY

RATE

01/01/2021- 06/30/2021

One (1) Two (2) Three (3) Four (4) Five (5) Six (6) Seven (7) Eight (8)

QMB $35.58

01/01/2021- 06/30/2021

Nine (9) Ten (10) Eleven (11)

QMB $7.40

07/01/2021- 12/31/2021

One (1) Two (2) Three (3) Four (4) Five (5) Six (6) Seven (7) Eight (8)

QMB $37.54

12/31/2021

Nine (9)

QMB $8.14

01/01/2021- 06/30/2021

One (1) Two (2) Three (3) Four (4) Five (5) Six (6)

QMB Plus, SLMB Plus, and FBDE dual eligibles, excluding ICP eligible recipients

$80.33

01/01/2021- 06/30/2021

Nine (9) dual eligibles, $32.63

12/31/2021

One (1) Two (2) Three (3) Four (4)

QMB Plus, SLMB Plus, and FBDE dual eligibles, $94.31

EXHIBIT C-1

AHCA Contract No. FP083, Attachment I, Exhibit C-1, Page 2 of 2

Five (5) Six (6)

12/31/2021

Nine (9) dual eligibles, $57.62

ATTACHMENT V

AGENCY APPROVED MODIFICATIONS

TO THE STANDARD CONTRACT

AHCA Contract No. FP083, Attachment V, Page 1 of 1

A. Modifications to the Standard Contract

1. Section I., THE VENDOR HEREBY AGREES, Sub-Section F., Audits/Monitoring, Item 8., is hereby deleted in its entirety.