CN-680000-FP083-A4.pdf

AHCA CONTRACT NO. FP083

AMENDMENT NO. 04

AHCA Contract No. FP083, Amendment No. 04, 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. Effective January 1, 2024, 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, 2024, 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, 2024.

2. Effective January 1, 2025, 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, 2025, 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, 2025.

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 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:

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

DocuSign Envelope ID: 9029D655-1812-4F1D-BED0-F829A9B36382

George Renaudin

President, Medicare and Medicaid

6/27/2024

Stefan Grow

Chief of Staff

6/30/2024

AHCA CONTRACT NO. FP083

AMENDMENT NO. 04

AHCA Contract No. FP083, Amendment No. 04, Page 2 of 2

List of Attachments included as part of this Amendment:

Specify Type Number Description Attachment I Exhibit C – Effective January 1, 2024, D-SNP

Capitation Rates (1 Page) Attachment I

Exhibit D – Effective January 1, 2025, D-SNP Type and Applicable Service Areas (1 Page)

ATTACHMENT I

EXHIBIT C – EFFECTIVE JANUARY 1, 2024

AHCA Contract No. FP083, Attachment I, Exhibit C – Effective 01/01/24, Page 1 of 1

D-SNP CAPITATION RATES

DATE SPAN REGION CATEGORIES OF

MEDICAID

ELIGIBILITY

RATE

01/01/2024- 12/31/2024

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

QMB $44.16

01/01/2024- 12/31/2024

Nine (9)

QMB $24.14

01/01/2024-

Ten (10)

QMB $14.79

01/01/2024- 12/31/2024

Eleven (11) QMB $11.20

01/01/2024- 12/31/2024

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

QMB Plus, SLMB Plus, and FBDE

$84.25

01/01/2024-

Nine (9)

QMB Plus, SLMB Plus, and FBDE

$75.70

01/01/2024-

Ten (10)

QMB Plus, SLMB

$47.26

01/01/2024- 12/31/2024

Eleven (11) QMB Plus, SLMB

$103.92

ATTACHMENT I

EXHIBIT D – EFFECTIVE JANUARY 1, 2025

D-SNP TYPE AND APPLICABLE SERVICE AREAS

AHCA Contract No. FP083, Attachment I, Exhibit D – Effective 01/01/25, Page 1 of 1

D-SNP PLAN

NAME

D-SNP

TYPE

CATEGORIES

OF MEDICAID

ELIGIBILITY

CMS

CONTRACT

NUMBER

(H#)

PLAN

BENEFIT

PACKAGE

(PBP#)

SERVICE

AREA

CareNeeds Platinum (HMO

D-SNP)

HIDE QMB, QMB+,

SLMB, SLMB+, QI,

QDWI, FBDE

H1019 023 Broward, Miami-Dade, Palm Beach

CareNeeds Plus (HMO D-

SNP)

HIDE QMB, QMB+,

H1019 073

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

Johns, Sumter, Volusia

CareNeeds Platinum

(HMO D-

SNP)

HIDE QMB, QMB+,

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

Johns, Sumter, Volusia