CN-680000-FP083-A3.pdf

AHCA CONTRACT NO. FP83

AMENDMENT NO. 03

AHCA Contract No. FP83, Amendment No. 03, Page 1 of 2

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" or “Managed Care Plan,” is hereby amended as follows:

1. Standard Contract, Section III., THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE, Sub-Section B., Contract Managers, Item 1., is hereby amended to now read as follows:

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

Mary Bell Agency for Health Care Administration 2727 Mahan Drive MS #50 Tallahassee, FL 32308 850-412-4243 Mary.Bell@ahca.myflorida.com

2. Standard Contract, Section III., THE VENDOR AND AGENCY HEREBY MUTUALLY

AGREE, Sub-Section B., Contract Managers, Item 2., is hereby amended to now read as follows:

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

Marie Petroni Senior Insurance Product Compliance Professional Humana, Inc.

500 W. Main Street, Louisville, KY 40202 502-930-4638 mpetroni@humana.com

3. Effective January 1, 2023, Attachment I, Scope of Services, THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE, Exhibit C, MA D-SNP Capitation Rates, is hereby deleted in its entirety and replaced with Exhibit C – Effective January 1, 2023, D- SNP Capitation Rates, attached hereto and made a part of this Contract. All references in this Contract to Exhibit C, shall hereinafter refer to Exhibit C – Effective January 1, 2023.

4. Effective January 1, 2024, Attachment I, Scope of Services, THE VENDOR AND

AGENCY HEREBY MUTUALLY AGREE, Exhibit D, D-SNP Type and Applicable Service Areas, is hereby deleted in its entirety and replaced with Exhibit D – Effective January 1, 2024, D-SNP Type and Applicable Service Areas, attached hereto and made a part of this Contract. All references in this Contract to Exhibit D, shall hereinafter refer to Exhibit D – Effective January 1, 2024.

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

DocuSign Envelope ID: A9DC4BA5-BEC6-4615-B08E-83CF84562746 mailto:Mary.Bell@ahca.myflorida.com mailto:mpetroni@humana.com

AHCA CONTRACT NO. FP83

AMENDMENT NO. 03

AHCA Contract No. FP83, Amendment No. 03, Page 2 of 2

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

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

IN WITNESS WHEREOF, the Parties hereto have caused this four (4) 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 C – Effective January 1, 2023, D-SNP

Capitation Rates (1 Page) Attachment I Exhibit D – Effective January 1, 2024, D-SNP Type and Applicable Service Areas (1 Page)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

George Renaudin

6/23/2023

President, Medicare and Medicaid

6/30/2023

Stefan Grow

Chief of Staff

ATTACHMENT I

EXHIBIT C – EFFECTIVE JANUARY 1, 2023

AHCA Contract No. FP083, Attachment I, Exhibit C - Effective 01/01/23, Page 1 of 1

D-SNP CAPITATION RATES

DATE SPAN REGION CATEGORIES OF

MEDICAID

ELIGIBILITY

RATE

01/01/2023- 12/31/2023

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

QMB $44.68

01/01/2023- 12/31/2023

Nine (9)

QMB $14.04

01/01/2023-

Ten (10)

QMB $11.76

01/01/2023- 12/31/2023

Eleven (11) QMB $11.53

01/01/2023- 12/31/2023

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

QMB Plus, SLMB Plus, and FBDE

$82.40

01/01/2023-

Nine (9)

QMB Plus, SLMB Plus, and FBDE

$56.93

01/01/2023-

Ten (10)

QMB Plus, SLMB

$49.48

01/01/2023- 12/31/2023

Eleven (11) QMB Plus, SLMB

$94.43

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

ATTACHMENT I

EXHIBIT D – EFFECTIVE JANUARY 1, 2024

AHCA Contract No. FP083, Amendment 3, Attachment I, Exhibit D, Page 1 of 1

D-SNP TYPE AND APPLICABLE SERVICE AREAS

D-SNP PLAN

NAME

D-SNP

TYPE

CATEGORIES

OF MEDICAID

ELIGIBILITY

CMS

CONTRACT

NUMBER

(H#)

PLAN

BENEFIT

PACKAGE

(PBP#)

SERVICE

AREA

CareNeeds Plus (HMO D-

SNP)

HIDE QMB, QMB+,

SLMB, SLMB+, QI,

QDWI, FBDE

H1019 023 Broward, Miami- Dade, Palm Beach

CareNeeds

H1019 026 Hernando, Hillsborough, Lake, Marion, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, Sumter

CareNeeds

H1019 073 Brevard, Clay, Duval, Flagler, Indian River, St. Johns, Volusia

CareNeeds Platinum

(HMO D-

SNP)

HIDE QMB, QMB+,

SLMB, SLMB+, QI,

QDWI, FBDE

H1019 145 Broward, Miami-Dade, Palm Beach

CareNeeds Platinum

(HMO D-

SNP)

HIDE QMB, QMB+,

H1019 146 Brevard, Clay, Duval, Flagler, Hernando, Hillsborough, Indian River, Lake, Marion, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, St.

Johns, Sumter, Volusia