CN-680000-FP116-A1.pdf

AHCA CONTRACT NO. FP116

AMENDMENT NO. 1

AHCA Contract No. FP116, Amendment No. 1, Page 1 of 2 April 2020

THIS CONTRACT, entered into between the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and SUNSHINE STATE HEALTH PLAN, INC., hereinafter referred to as the "Vendor" or “Managed Care Plan,” is hereby amended as follows:

1. Standard Contract, the lead paragraph is hereby amended to now read as follows:

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 SUNSHINE STATE HEALTH PLAN, INC., hereinafter referred to as the "Vendor", whose address is 1299 NW 40th Avenue, Suite C, Lauderhill, Florida 33313, to provide a Comprehensive Long-Term Care Plus Plan and HIV/AIDS, Serious Mental Illness, and Child Welfare Specialty Plans.

2. 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:

Kelly Thiele Agency for Health Care Administration 2727 Mahan Drive, MS #50 Tallahassee, FL 32308

(850) 412-4011 Kelly.Thiele@ahca.myflorida.com

3. Attachment I, Scope of Services, Statewide Medicaid Managed Care Program, is hereby deleted in its entirety and replaced with Attachment I, Scope of Services - Update:

February 1, 2025, Statewide Medicaid Managed Care Program, attached hereto and made a part of this Contract. All references in this Contract to Attachment I, Scope of Services, Statewide Medicaid Managed Care Program, shall hereinafter refer to Attachment I, Scope of Services - Update: February 1, 2025, Statewide Medicaid Managed Care Program.

4. Attachment II, Scope of Service - Core Provisions, is hereby deleted in its entirety and replaced with Attachment II, Scope of Service - Core Provisions Update: February 1, 2025, attached hereto and made a part of this Contract. All references in this Contract to Attachment II, Scope of Service - Core Provisions, shall hereinafter refer to Attachment II, Scope of Service - Core Provisions Update: February 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 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.

Docusign Envelope ID: 6FADB03B-61B9-43E9-80DB-80F9B7AB59ED mailto:Kelly.Thiele@ahca.myflorida.com

AHCA CONTRACT NO. FP116

AMENDMENT NO. 1

AHCA Contract No. FP116, Amendment No. 1, Page 2 of 2 April 2020

IN WITNESS WHEREOF, the Parties hereto have caused this five hundred and eighty-seven

(587) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

SUNSHINE STATE HEALTH PLAN, 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 Scope of Services – Update: February 1, 2025, Statewide

Medicaid Managed Care Program (112 Pages) Attachment II Scope of Service - Core Provisions – Update: February 1, 2025 (473 Pages)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

2/6/2025

Charlene Zein

President & CEO

2/6/2025

Jason Weida

Secretary

SUNSHINE STATE HEALTH PLAN, INC.

ATTACHMENT I

SCOPE OF SERVICES -- UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 1 of 15

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 – Not for Use Unless

Approved by CMS;

(d) Exhibit I-D, Kick Payment Rates for Covered Obstetrical Delivery Services – Not for Use Unless Approved by CMS;

(e) Exhibit I-E, Value-Based Purchasing Performance Targets;

(f) Exhibit I-F, Birth Outcomes Targets;

(g) Exhibit I-G, After-hours and Telemedicine Targets;

(h) Exhibit I-H, Public Hospital Physician Uniform Payment Increase

– Not for Use Unless Approved by CMS;

(i) Exhibit I-I, Faculty Plans of Florida Medical School Faculty Physician Groups Rates – Not for Use Unless Approved by CMS;

(j) Exhibit I-J, Florida Cancer Hospital Minimum Fee Schedule Rates

– Not for Use Unless Approved by CMS;

(k) Exhibit I-K, MMA Physician Incentive Program (MPIP) Plan Summary;

(l) Exhibit I-L, Hospital Uniform Percentage Increase Payments –Not for Use Unless Approved by CMS;

(m) Exhibit I-M, Public Emergency Medical Transportation Provider Uniform Increase Payment -- Not for Use Unless Approved by CMS;

and

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 2 of 15

(n) Exhibit I-N, Plan-Specific Commitments.

(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)

B. Authorized Regions

The Managed Care Plan is authorized to provide services pursuant to this Contract in the region(s) for the applicable SMMC program as specified in the Authorized Regions Table, Table 1, below.

TABLE 1: AUTHORIZED REGIONS

Region Program Component MMA LTC Specialty

Region A X X X Region B X X X Region C X X X Region D X X X Region E X X X Region F X X X Region G X X X Region H X X X Region I X X X

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 the Required MMA Services Table, Table 2A and/or the Required LTC Services Table, Table 2B, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 3 of 15

TABLE 2A: REQUIRED MMA SERVICES

(1) Advanced Practice Registered Nurse

(2) Ambulatory Surgical Center Services

(3) Assistive Care Services

(4) Behavior Analysis Services

(5) Behavioral Health Services

(6) Birth Center and Licensed Midwife Services

(7) Clinic Services

(8) Chiropractic Services

(9) Child Health Check Up

(10) Immunizations

(11) Early Intervention Services

(12) Emergency 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 Foster Care Services

(21) Medical Supplies, Equipment, Prostheses and Orthoses

(22) Nursing Facility Services

(23) Optometric and Vision Services

(24) Physician Assistant Services

(25) Physician Services

(26) Podiatric Services

(27) Prescribed Drug Services

(28) Renal Dialysis Services

(29) Therapy Services

(30) Transportation Services

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 4 of 15

TABLE 2B: REQUIRED LTC SERVICES

(1) Adult Companion Care

(2) Adult Day Health Care

(3) Assistive Care Services

(4) Assisted Living

(5) Attendant Nursing 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 Supplies

(15) Medication 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 the Approved Expanded Benefits - Comprehensive Table, Table 3, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 5 of 15

TABLE 3: APPROVED EXPANDED BENEFITS

General Expanded Benefits - Available for children and/or adults X Asthma Home Care- May include benefits such as

Hypoallergenic Bedding, Carpet Cleaning, Pest Control, etc.

X Behavioral Health Integration Services/Collaborative Care X Cellular Phone Services X Child Enrichment Assistance- May include benefits such as After School Activity Stipend, Camp Scholarship etc.

X Disaster Relief Benefit- May include items such as a

Grocery and Cleaning Supplies Card, Shelf Stable Meals, etc.

X Doula Services X Durable Medical Equipment Services and Supplies- May include benefits such as Blood Pressure Monitors, Hospital Beds, etc.

Emergency Preparedness Kit- May include benefits such as Flashlight, First-Aid Kit, Emergency Survival Blanket, etc.

X Family Support Services- May include benefits such as Childcare Financial Assistance, Diaper Benefit, Therapy for Families of Nursing Facility Children, etc.

Financial Literacy X Fitness Benefit- May include benefits such as Gym

Memberships, Virtual Exercise Classes, etc.

X Food Assistance- May include benefits such as

Food/Grocery Stipends, Shelf Stable Meals, etc.

X Home Delivered Meals X Housing Assistance- May include benefits such as

Housing Stability, Utilities, incidentals, etc.

X Meals- Non-Emergency Transportation Day-Trips Medication Assisted Treatment Services Medication Safety Program- May include benefits such as a Medication Lockbox Member Support- May include benefits such as Personal

Support and/or Companionship X Mother and Baby Item Benefit- May include benefits such as Portable crib, Monitors, Car Seat, etc.

X Newborn Circumcision X Transportation- May include benefits such as Non-

Emergency Transportation, Non-Medical Transportation

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 6 of 15 and/or Caregiver Transportation; Library, Social, and other ancillary services.

Nursing Mothers Support Items X Nutritional Counseling Opioid Use Disorder/Substance Use Disorder Support

X Over-The-Counter Medications and Supplies X Prenatal Services- May include benefits such as Increased number of Prenatal and Postpartum Visits, Hospital Grade Breast Pumps, etc.

X Respite Care Services- May include benefits such as Caregiver Support due to Medical Conditions or Developmental Disabilities

School Supply Assistance Sensory/Comfort Item Benefit- May include items such as

Weighted Blankets, Sound Machine, Light Therapy Products, etc.

Sports Physical X Swimming Lessons (Drowning Prevention) X Tutoring, Vocational Training, and/or Job Readiness –

Hope Florida Support- May include benefits such as Life Skills Development, GED prep, Clothing, Tatoo removal, etc.

Virtual Pregnancy and Lactation Support Vision + Hearing Flex Card

X Waived Copayments Adult Expanded Benefits - These services are only available for adults because they are already covered for children on Medicaid when medically necessary

X Activity Therapy- May include benefits such as Art, Equine, and Pet Therapy

X Acupuncture X Adult Additional Primary Care Services- May include benefits such as Increased Office Visits X Adult Visual Aid and Hearing Services- May include benefits such as Contact Lenses, Hearing Aids, etc.

Behavioral- Assessment/Evaluation and Screening

Services Behavioral- Intensive Outpatient Treatment

X Behavioral Health- Individual Therapy Sessions to Caregivers

Behavioral Health Day Services/Day Treatment

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 7 of 15

Behavioral Health Medical Services- May include benefits such as Drug Screening, Medication Management, Verbal Interaction

Caregiver Support, Education, and Training X Chiropractic Services X Computerized Cognitive Behavioral Therapy Criminal Expungement Services Developmental Disabilities Stipend

X Financial Literacy X Home Health Nursing/Aide Services- May include benefits such as Extra Home Visits X Home Visit by a Clinical Social Worker X Massage Therapy X Medical Therapies- May include benefits such as additional Physical, Occupational, Speech and/or Respiratory Therapy

Substance Abuse Treatment or Detoxification Services (Outpatient)

Outpatient Hospital Services- May include benefits such as Waived Financial Limits, unlimited services such as Radiology Services, Sleep Studies, etc.

Psychosocial Rehabilitation Targeted Case Management Therapeutic Behavioral On-Site Services Therapy/Psychotherapy- Group Therapy and/or

Individual/Family Therapy Long-Term Care Services - these services are only available for LTC enrollees X ALF/AFCH- Bed Hold Days X ALF/Home Based Setting Move-In Items Aquatic Therapy

X Durable Medical Equipment and Misc. Items Benefit- May include benefits such as Mobility Items, Dental Kits, etc.

Hope Florida Program Support- Loneliness Support Mobile Personal Emergency Response System (PERS) Pet Support- May include benefits such as Pet Food, Vet

Visits, Kenneling, etc.

X Robotic Therapy Pet X Sensory/Comfort Item Benefit Support to Stay in Community Living

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 8 of 15

X Transition Assistance- Nursing Facility to Community

Setting- May include benefits such as Home Furniture, Safety Equipment, Assistance to secure Housing, etc.

Specialty Line of Business These services are only available for enrollees in a specialty line of business

Collaborative Care X Durable Medical Equipment and Misc. Items Benefit- May include benefits such as Mobility Items, Dental Kits, Condition Specific DME, etc.

X Legal Guardianship Assistance New Placement- Family Night Package Nutrition Shakes Peer Support Counseling- Individual and Group

Counseling X Robotic Therapy Pet X Sensory/Comfort Item Benefit Service/Therapy Animal Training and/or Maintenance

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 9 of 15

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(7), F.S., as denoted by “X” in the Plan Qualification Table, Table 4, below.

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 five plan types, denoted by authorized region(s) in the SMMC Plan Type Table, Table 5, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

(1) Managed Medical Assistance (MMA) Plan – A Managed Care Plan that is eligible to provide MMA services to recipients who are eligible only for MMA services. This plan type is not eligible to provide services to recipients who are eligible for LTC Services.

(2) Comprehensive Long-term Care Plus Plan (referred to as a

“Comprehensive Plus Plan”) – A Managed Care Plan that is eligible to provide MMA services to any MMA-eligible recipients and may concurrently provide LTC services to recipients eligible for LTC services. The Comprehensive Plus Plan also provides one or more MMA Specialty products to Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis.

(3) Comprehensive Long-term Care Plan (herein referred to as a

“Comprehensive Plan”) – A Managed Care Plan that is eligible to provide MMA services to any MMA-eligible recipients, may concurrently provide MMA and LTC services to recipients eligible for LTC services, and is eligible to provide LTC services to any recipient eligible only for LTC services.

(4) Select Comprehensive Plan – A Managed Care Plan that is eligible to provide concurrent MMA services and LTC services to eligible recipients enrolled in the LTC program. This plan type is not eligible to provide services to recipients who are eligible only for MMA services.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 10 of 15

(5) Managed Medical Assistance (MMA) Plus Plan– A Managed Care Plan that is eligible to provide MMA services to any MMA-eligible recipients and also provides one or more MMA Specialty products to Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis. This plan type is not eligible to provide services to recipients who are eligible for LTC Services.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 11 of 15

TABLE 5: SMMC PLAN TYPE

Region SMMC Program MMA/LTC Specialty 1 Specialty 2 Specialty 3

Region A Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region B Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region C Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region D Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region E Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region F Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region G Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region H Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

Region I Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS Child Welfare

C. Value-Based Purchasing Performance Targets

The Managed Care Plan shall achieve performance targets related to value-based purchasing (VBP) arrangements with primary care providers (PCPs). Value-based purchasing performance targets are contained in Exhibit I-E, Value-Based Purchasing Performance Targets, of this Attachment. Performance targets shall be in accordance with Attachment II and its Exhibits.

D. Birth Outcomes Targets

The Managed Care Plan shall meet the following performance targets contained in Exhibit I-F, Quality Benchmarks Statewide Targets, in accordance with Attachment II and its Exhibits; the ITN(s), including all addenda; the Vendor’s response to the ITN(s), and information provided through negotiations.

E. After Hours Access and Telemedicine Targets

The Managed Care Plan shall meet the following performance targets contained in Exhibit I-G, After Hours Access and Telemedicine Targets, in accordance with Attachment II and its Exhibits; the ITN(s), including all addenda; the Vendor’s response to the ITN(s), and information provided through negotiations.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 12 of 15

III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $51,181,005,711 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 Numbers specified in Exhibit I-B.

B. Managed Care Plan Rates-Not for Use Unless Approved by CMS

The capitation rate payment shall be in accordance with Attachment II and its Exhibits. The capitation rates are contained in Exhibit I-C, Managed Care Plan Rates - Not for Use Unless Approved by CMS of this Attachment.

Actuarial Notes:

The attached draft post-implementation rates will be updated prior to the implementation of the Program to reflect the following:

• Application of adjustments to apply specifically to February through September

2025;

• Addition of Behavior Analysis services;

• Refined adjustments to reflect final redetermination impacts;

• Updated legislative appropriation amounts;

• Updated trends due to consideration of more recent experience and additional drug treatments; and

• Other updates due to plan or Agency feedback.

C. Kick Payment Rates for Covered Obstetrical Delivery Services – Not for

Use Unless Approved by CMS

The kick payment rates shall be in accordance with Attachment II and its Exhibits. Kick Payment Rates for Covered Obstetrical Delivery Services are contained in Exhibit I-D, Kick Payment Rates for Covered Obstetrical Delivery Services – Not for Use Unless Approved by CMS of this Attachment.

D. Public Hospital Physician Uniform Payment Increase – Not for Use Unless

Approved by CMS

The per-member per-month (PMPM) rates for payment of qualified public hospital physicians shall be in accordance with Attachment II and its Exhibits. The Public Hospital Physician Uniform Payment Increase – Not for Use Unless Approved by CMS are contained in Exhibit I-H of this Attachment.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 13 of 15

E. Faculty Plans of Florida Medical School Faculty Physician Groups Rates – Not for Use Unless Approved by CMS

The per-member per-month (PMPM) rates for payment of Florida medical school faculty physician groups shall be in accordance with Attachment II and its Exhibits. The PMPM rates are contained in Exhibit I-I, Faculty Plans of Florida Medical School Faculty Physician Groups Rates – Not for Use Unless Approved by CMS, of this Attachment.

F. Florida Cancer Hospital Minimum Fee Schedule Rates – Not for Use Unless

The per-member per-month (PMPM) rates for payment of Florida cancer hospitals shall be in accordance with Attachment II and its Exhibits. The PMPM rates are contained in Exhibit I-J, Florida Cancer Hospital Minimum Fee Schedule Rates – Not for Use Unless Approved by CMS, of this Attachment.

G. MMA Physician Incentive Program (MPIP) Plan Summary

The Managed Care Plan shall reimburse qualified physicians in accordance with Attachment II and its Exhibits. The MMA Physician Incentive Program (MPIP) Plan Summary is described in Exhibit I-K of this Attachment.

H. Behavioral Health and Supportive Housing Assistance Pilot

The Managed Care Plan shall perform the Behavioral Health and Supportive Housing Assistance Pilot program enhancements in accordance with the Managed Care Plan’s Agency-approved pilot application, contained in the Agency’s contract management record. The per-member per-month (PMPM) rates for the enhanced housing and behavioral health payment shall be in accordance with Exhibit I-C, Managed Care Plan Rates - Not for Use Unless Approved by CMS of this Attachment.

I. Hospital Uniform Percentage Increase Payments-Not for Use Unless

The uniform percentage increase amounts for the hospital uniform percentage increase payments for qualified hospitals shall be in accordance with Attachment II and its Exhibits. The Hospital Uniform Percentage Increase Payments-Not for Use Unless Approved by CMS are contained in Exhibit I-L of this Attachment.

J. Public Emergency Medical Transportation Provider Uniform Increase

Payments – Not for Use Unless Approved by CMS

The per-member per-month (PMPM) rates for payment of qualified public emergency medical transportation providers shall be in accordance with Attachment II and its Exhibits. The Public Emergency Medical Transportation Provider Uniform Increase Payments – Not for Use Unless Approved by CMS are contained in Exhibit I-M of this Attachment.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 14 of 15

IV. Special Provisions

A. Order of Precedence

(1) For all applicable regions as specified in Table 1: Authorized Regions, 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:

a. This Contract, including all attachments;

b. The ITN(s), including all addenda; and

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

B. Plan-Specific Commitments

The Managed Care Plan shall perform the program enhancements in accordance with Attachment II and its Exhibits. The Managed Care Plan’s Plan-Specific Commitments are described in Exhibit I-N, Plan-Specific Commitments, of this Attachment. The Agency reserves the right to modify Exhibit I-N as needed. The Agency will provide the Managed Care Plan with at least thirty (30) calendar days written notice before changes become effective.

C. Special Terms and Conditions

The Managed Care Plan shall furnish to the Agency a performance bond in the amount of $72,000,000 in accordance with Attachment II, Section XV.W. of this Contract. The total performance bond amount is specified in the Total Performance Bond Amount Table, Table 6, below:

TABLE 6: TOTAL PERFORMANCE BOND AMOUNT

Awarded Region Plan Type Performance Bond Amount

A Comprehensive LTC Plus $5,000,000 B Comprehensive LTC Plus $5,000,000 C Comprehensive LTC Plus $5,000,000 D Comprehensive LTC Plus $5,000,000 E Comprehensive LTC Plus $5,000,000 F Comprehensive LTC Plus $5,000,000 G Comprehensive LTC Plus $5,000,000 H Comprehensive LTC Plus $5,000,000

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 15 of 15

TABLE 6: TOTAL PERFORMANCE BOND AMOUNT

Awarded Region Plan Type Performance Bond Amount

I Comprehensive LTC Plus $5,000,000 A Serious Mental Illness (SMI) $1,000,000 B Serious Mental Illness (SMI) $1,000,000 C Serious Mental Illness (SMI) $1,000,000 D Serious Mental Illness (SMI) $1,000,000 E Serious Mental Illness (SMI) $1,000,000 F Serious Mental Illness (SMI) $1,000,000 G Serious Mental Illness (SMI) $1,000,000 H Serious Mental Illness (SMI) $1,000,000 I Serious Mental Illness (SMI) $1,000,000

A HIV/AIDS $1,000,000

B HIV/AIDS $1,000,000

C HIV/AIDS $1,000,000

D HIV/AIDS $1,000,000

E HIV/AIDS $1,000,000

F HIV/AIDS $1,000,000

G HIV/AIDS $1,000,000

H HIV/AIDS $1,000,000

I HIV/AIDS $1,000,000

A Child Welfare $1,000,000 B Child Welfare $1,000,000 C Child Welfare $1,000,000 D Child Welfare $1,000,000 E Child Welfare $1,000,000 F Child Welfare $1,000,000 G Child Welfare $1,000,000 H Child Welfare $1,000,000 I Child Welfare $1,000,000

Total Performance Bond Amount: $72,000,000

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 1 of 6

EXHIBIT I-A

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

Approved Benefit Approved Limitations

General Expanded Benefits Behavioral Health Integration/Collaborative Care

Unlimited. No Prior Authorization required.

Biometric Equipment Blood pressure monitor, Weight scale. One (1) Digital blood pressure cuff every three (3) years;

One (1) weight scale every three (3) years. No Prior Authorization required

Camp Scholarship Community transition, waiver; per service. Prior Authorization required. One hundred fifty dollars ($150) voucher per year.

Care Grant Community transition, waiver; per service. Prior Authorization required. Up to one hundred fifty dollars ($150.00) per year per child This care grant would be used for services or supplies that the child could use for social or physical activities, such as gym membership, swimming lessons, sports equipment or supplies, art supplies and application fees for post high school education

Cellular Services (minutes and/or data) Prior Authorization required. Sunshine Health will connect enrollees to Safelink government cell phone service program. For enrollees who do not qualify for Safelink but are in case management, we offer our ConnectionsPlus program which provides a cell phone.

Comfort Kit for People Living with HIV Prior Authorization required. One per lifetime Dental Kits One (1) kit per pregnancy. Kit includes educational materials, toothbrush, toothpaste, and dental floss.

No Prior Authorization required.

Doula Services Unlimited per pregnancy. No Prior Authorization required.

Educational Vouchers and Career Planning Prior Authorization required. Educational Vouchers and Career Planning- one hundred fifty dollars ($150) voucher per lifetime for financial literacy, tutoring sessions, GED exam fees, classes, books, application fees.

Flu Prevention Kit

Prior Authorization required. One (1) Flu/Pandemic Prevention kit; 3 ply face masks – ten (10) pieces;

Oral digital thermometer; hand sanitizer; Eligible for the first one thousand (1,000) Sunshine State Health Plan enrollees who have received their flu vaccine (Must be requested by case manager).

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 2 of 6

Foster Care Comfort Kits Prior Authorization required. Transition of Care Comfort Kit includes a sturdy backpack or duffle bag filled with items such as a blanket, journal and pen, educational books and games, soft bear, stress ball, fidget spinner, and earbuds.

Grocery Benefit Medical nutrition group. Prior Authorization required. Grocery benefit, fifty dollars ($50) per year.

Home Delivered Meals (disaster preparedness/relief):

Prior Authorization required. For home delivered meals (disaster preparedness/relief): One (1) annually.

Home Delivered Meals (post-facility discharge hospital or nursing facility

Home delivered meals, including preparation, per meal. Prior Authorization required. For home delivered meals (post-facility discharge hospital or nursing facility): Unlimited

Home Delivered Meals for Enrollees who are Pregnant

Home Delivered Meals. Prior Authorization required. Up to two hundred sixty-six (266) Medically tailored meals for eligible enrollees.

Home Delivered Meals for People Living with HIV

Home delivered meals, including preparation, per meal. Prior Authorization required. Up to one hundred sixty-eight (168) meals per year for eligible enrollees.

Homemaker Services (e.g. hypoallergenic carpet cleanings) for Asthma and COPD

Prior Authorization required. Two (2) carpet cleanings per year for individuals diagnosed with Asthma or COPD.

Housing Assistance Supported housing. Prior Authorization required.

Maximum of two hundred fifty dollars ($250) per community-based enrollee per year to assist with housing related expenses (rent, utilities, etc.)

Hypoallergenic bedding and HEPA vacuum cleaner for Asthma and COPD

Prior Authorization required. 1) Unlimited Hypoallergenic Bedding. 2) One (1) HEPA Filter Vacuum Cleaner/ lifetime.

Joy for All™ battery-operated plush companion pet

Battery operated pet. Prior Authorization required.

One (1) per lifetime

Legal Guardianship Community transition, waiver, per service.

Maximum of five hundred dollars ($500.00) per eligible enrollee per lifetime. No Prior Authorization required.

Meal Stipend (available for long distance medical appointment day-trips)

Non-emergency transportation ancillary meals – recipient. Non-emergency transportation ancillary meals – escort. Prior Authorization required. Two hundred dollars ($200.00) per day up to one thousand dollars ($1,000.00) per year for trips greater than one hundred (100) miles with prior authorization.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 3 of 6

Newborn circumcision Circumcision neonate, One (1) per lifetime. No Prior Authorization required.

Over-the-Counter (OTC) medications and supplies

Various Products submitted through the annual OTC list submission. The Managed Care Plan shall provide a monthly OTC benefit limit of fifty dollars ($50) per household. No Prior Authorization required.

Prenatal Services Unlimited antepartum and postpartum visits, Breast Pump Rental – one (1) rental per two (2) years, Hospital Grade pump rental - Max of one (1) per year, Prior Authorization required for breast pump.

Respite Care Prior Authorization required. 10 days of out-of-home respite care per year.

Sensory Kits Prior Authorization required. Sensory support kit-one hundred dollars ($100) tailored to the developmental and diagnosis needs of enrollees.

They will choose from swinging/sensory swings, exercise balls for bouncing or rocking, weighted vests or blankets, warm compresses, manipulative toys, headphones, and/or ear plugs. One (1) per lifetime

Specialized childcare waiver, Specialized childcare waiver, per diem. Prior Authorization required. Childcare – one hundred fifty dollars ($150)/year.

Swimming Lessons (children only) Member must use their local YMCA for up to eight

(8) lessons, in group setting. In areas where a YMCA does not exist, members may use a local swim vendor for reimbursement. No Prior Authorization required.

Tutoring Prior Authorization required. Tutoring - Up to two

(2) hours of tutoring time per session; maximum of twelve (12) tutoring sessions annually

Tutoring, Vocational Training, and/or Job Readiness

Tattoo Removal-Up to five hundred dollars ($500) reimbursement per lifetime, with prior authorization.

Vital Records Support Prior Authorization required. Vital Records Support

- Up to fifty dollars ($50)/year.

Waived Copayments The Managed Care Plan shall waive copayments as a standard expanded benefit. No Prior Authorization required.

Welcome Baby! Bundle Prior Authorization required. Enrollee receives a Cribs for Kids® Safe Sleep Survival Kit with safe sleep educational material and one of the following:

Cribette, Car seat, Highchair, Baby Shower in a Box, Stroller. One (1) per pregnancy.

YMCA Membership Prior Authorization required. YMCA membership for individual enrollees or a family of four. The membership will include access to free-standing YMCA facilities as well as Y360, an on-demand

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 4 of 6 video platform for group exercise classes, youth sports training, wellbeing classes and more.

Maximum benefit of one hundred fifty dollars ($150) per year.

Adult Expanded Benefits

Acupuncture Services Prior Authorization required. Unlimited Adult additional primary care services Unlimited. No Prior Authorization required.

Adult visual aid services Contact lens - 6 months' supply with prescription, Frame - 1 per year. Eye Exam - 1 per year. No Prior Authorization required.

Art Therapy Prior Authorization required. Unlimited Assisted Living Bed Hold Days (HCBS) Reserving living space for up to thirty (30) days while the enrollee is inpatient in a hospital, rehabilitation center, nursing facility, or other setting. No Prior Authorization required.

Caregiver Swimming Lessons Prior Authorization required. Members caregiver must use their local YMCA for up to eight (8) lessons, in group setting. In areas where a YMCA does not exist, members may use a local swim vendor for reimbursement.

Chiropractic Services Prior Authorization required. Unlimited Computerized Cognitive Behavioral Therapy

Prior Authorization required. Unlimited visits for health and behavior assessment and reassessment; individual, group, and family (with or without the patient present) health and behavior intervention.

Durable medical Equipment (DME) services and supplies

Prior Authorization required. Unlimited for various medical supplies and equipment;

Equine Therapy Prior authorization required. Ten (10) sessions per year

Food Assistance Nutritional Counseling. No Prior Authorization required. Home Delivered Meals: Prior Authorization required-Ten (10) meals per approval.

Healthy Living Benefit Prior Authorization required. Devices to help enrollees maintain independence in their homes, such as reachers / grabbers, lumbar pillow, personal fan, clip on lamp, walker bag, or technology such as a smart home device to support healthy behaviors and disease management. One

(1) per lifetime.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 5 of 6

Hearing services for adults One hearing aid assessment, fitting, checking, and evaluation every two years; One in-ear monaural hearing aid per ear every two years; One hearing aid, all other types, per ear every two years. No Prior Authorization required.

Home Health Nursing/Aide Services Unlimited visits by a home health aide or certified nurse assistant (per hour and per visit); unlimited nursing care in the home provided by a registered nurse or licensed practical nurse (per hour and per diem); and unlimited personal care services (per fifteen (15) minute units and per diem) with prior authorization.

Home Visit by a Social Worker Services of clinical social worker in home health or hospice settings. Forty-eight (48) visits per year. No Prior Authorization required.

Housing Assistance Supported housing. Prior Authorization required.

Maximum of two thousand five hundred dollars ($2,500) per community-based enrollee per lifetime to assist with housing related expenses (rent, utilities, etc.)

Individual Therapy Sessions for Caregivers Prior Authorization required. Unlimited counseling visits including Initial Assessment

Long-Term Care Move-In Basket Prior Authorization required. Enrollees can select up to fifty dollars ($50.00) worth of items. One (1) per lifetime

Massage Therapy Prior Authorization required. Unlimited

Non-Medical Transportation Transportation ancillary: parking fees, tolls, other;

three (3) round trips per month

Non-medical Transportation (3 round trips -social)

Transportation: ancillary: parking fees, tolls, other.

Three (3) round trips per month. No Prior Authorization required.

Nursing Facility to Community Setting Transition Assistance

Prior Authorization required. Five thousand dollars ($5,000.00) per lifetime

Occupational therapy for adults Prior Authorization required. One (1) evaluation and one (1) re-evaluation per year, and up to seven (7) therapy treatment units per week. APPLICATION OF CASTING OR STRAPPING – two (2) per day;

WHEELCHAIR EVALUATION AND FITTING BY A

PHYSICAL THERAPIST – one (1) every three (3) years

Pet Therapy Prior Authorization required. Unlimited.

AHCA Contract No. FP116, Attachment I, Update 02/01/25, Page 6 of 6

Physical therapy for adults Prior Authorization Required. One (1) evaluation and one (1) re-evaluation per year, and up to seven

(7) therapy treatment units per week;

APPLICATION OF CASTING OR STRAPPING –

two (2) per day WHEELCHAIR EVALUATION AND FITTING BY A PHYSICAL THERAPIST – one (1) every three (3) years

Respiratory Therapy Prior Authorization required. One (1) initial evaluation and one (1) reevaluation per year; one respiratory therapy visit per day.

Speech Therapy Prior Authorization required. One (1) evaluation and re-evaluation per year; one (1) evaluation of oral and pharyngeal swallowing function per year; up to seven (7) therapy treatment units per week; one (1) AAC re-evaluation per year; up to four (4) thirty (30)-minute AAC fitting, adjustment, and training sessions per year.

Transition Assistance – Youth Aging Out of Foster Care

Prior Authorization required. A one-time transitional fund of up to five hundred dollars ($500) per young adult transitioning out of foster care at age eighteen

(18) or transitioning out of extended foster care at age twenty-one (21). This fund may be used toward services and items such as rental deposits, utility service, or household supplies such as kitchen supplies and appliances, linens, or furniture.

Welcome Home Basket Prior Authorization required. Enrollees can select up to fifty dollars ($50.00) worth of items. One (1) per lifetime

AHCA Contract No. FP116, Attachment I, Exhibit I-B, Update 02/01/25, Page 1 of 1

EXHIBIT I-B

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION NUMBERS

Region MMA LTC Specialty1 Specialty2 Specialty3

A 123212600-01 123212100-01 123213000-01

123602800-01

123603400-01

B 123212600-03 123212100-03 123213000-03 123602800-03 123603400-03

C 123212600-05 123212100-05 123213000-05 123602800-05 123603400-05

D 123212600-06 123212100-06 123213000-06 123602800-06 123603400-06

E 123212600-07 123212100-07 123213000-07 123602800-07 123603400-07

F 123212600-08 123212100-08 123213000-08 123602800-08 123603400-08

G 123212600-09 123212100-09 123213000-09 123602800-09 123603400-09

H 123212600-10 123212100-10 123213000-10 123602800-10 123603400-10

I 123212600-11 123212100-11 123213000-11 123602800-11 123603400-11

1. Serious Mental Illness (SMI)

2. HIV/AIDS

3. Child Welfare

AHCA Contract No. FP116, Attachment I, Exhibit I-C, Update 02/01/25, Page 1 of 3

EXHIBIT I-C

MANAGED CARE PLAN RATES – NOT FOR USE UNLESS APPROVED BY CMS

1 All capitation rates and components shown are on a per member per month (PMPM) basis.

MANAGED CARE PLAN RATES - NOT FOR USE UNLESS APPROVED BY CMS

STATEWIDE MEDICAID MANAGED CARE (SMMC) MANAGED MEDICAL ASSISTANCE (MMA) PROGRAM

FEBRUARY 2025 THROUGH SEPTEMBER 2025 RATE YEAR 24/25 CAPITATION RATES BY REGION AND RATE CELL1

GROSS OF PRESCRIBED DRUGS HIGH RISK POOL (PDHRP) WITHHOLD AMOUNTS

Region

Rate Group Rate Cell A B C D E F G H I TANF Non-SMI 0-2 Months $1,874.23 $1,905.63 $2,193.54 $1,960.57 $2,140.43 $2,201.89 $2,393.51 $2,248.48 $3,007.97 TANF Non-SMI 3-11 Months $269.39 $273.63 $312.50 $281.05 $305.33 $313.63 $339.50 $319.92 $422.47 TANF Non-SMI 1-13 Years $187.09 $189.92 $215.91 $194.88 $211.12 $216.67 $233.97 $220.87 $289.44 TANF Non-SMI 14-54 Years Female $209.01 $212.22 $241.71 $217.85 $236.27 $242.57 $262.19 $247.34 $325.13 TANF Non-SMI 14-54 Years Male $154.59 $156.88 $177.89 $160.89 $174.01 $178.50 $192.48 $181.89 $237.31 TANF Non-SMI 55+ Years $412.51 $419.13 $479.87 $430.72 $468.66 $481.63 $522.05 $491.46 $651.68 TANF SMI Non-Specialty 6-13 Years $778.02 $812.71 $879.06 $784.34 $811.08 $1,028.39 $904.50 $886.60 $1,443.62 TANF SMI Non-Specialty 14-54 Years Female $664.63 $694.72 $752.29 $670.11 $693.31 $881.86 $774.36 $758.83 $1,242.13 TANF SMI Non-Specialty 14-54 Years Male $655.05 $684.55 $740.99 $660.42 $683.17 $868.02 $762.63 $747.41 $1,221.23 TANF SMI Non-Specialty 55+ Years $1,668.72 $1,744.22 $1,888.67 $1,682.46 $1,740.69 $2,213.77 $1,944.05 $1,905.09 $3,117.73 TANF SMI Specialty 6-13 Years $805.73 $840.00 $905.55 $811.96 $838.39 $1,053.09 $930.69 $913.00 $1,463.35 TANF SMI Specialty 14-54 Years Female $693.40 $723.13 $780.01 $698.81 $721.74 $908.02 $801.82 $786.47 $1,263.98 TANF SMI Specialty 14-54 Years Male $683.95 $713.10 $768.87 $689.26 $711.74 $894.37 $790.25 $775.20 $1,243.36 TANF SMI Specialty 55+ Years $1,686.96 $1,761.56 $1,904.28 $1,700.54 $1,758.07 $2,225.48 $1,959.00 $1,920.50 $3,118.61 SSI Medicaid Only Non-SMI 0-2 Months $30,691.72 $32,494.32 $37,475.60 $33,992.02 $36,265.98 $40,734.81 $40,498.72 $40,086.74 $44,315.86 SSI Medicaid Only Non-SMI 3-11 Months $5,945.31 $6,293.99 $7,257.52 $6,583.69 $7,023.54 $7,887.95 $7,842.29 $7,762.60 $8,580.64 SSI Medicaid Only Non-SMI 1-13 Years $1,072.94 $1,134.44 $1,304.38 $1,185.53 $1,263.11 $1,415.57 $1,407.52 $1,393.46 $1,537.75 SSI Medicaid Only Non-SMI 14+ Years $896.72 $948.37 $1,091.09 $991.28 $1,056.44 $1,184.48 $1,177.71 $1,165.91 $1,287.08 SSI Medicaid Only SMI Non-Specialty 6-13 Years $1,456.16 $1,642.08 $1,768.06 $1,635.64 $1,619.48 $1,811.20 $1,649.26 $1,772.53 $1,707.80 SSI Medicaid Only SMI Non-Specialty 14+ Years $1,617.46 $1,826.07 $1,967.43 $1,818.85 $1,800.72 $2,015.83 $1,834.13 $1,972.45 $1,899.82 SSI Medicaid Only SMI Specialty 6-13 Years $1,475.75 $1,659.44 $1,783.91 $1,653.08 $1,637.11 $1,826.53 $1,666.53 $1,788.33 $1,724.37 SSI Medicaid Only SMI Specialty 14+ Years $1,635.07 $1,841.19 $1,980.86 $1,834.05 $1,816.13 $2,028.68 $1,849.14 $1,985.81 $1,914.05 SSI Dual Eligible Non-Specialty Under Age 65 Non-SMI $159.76 $210.77 $195.69 $179.24 $180.03 $162.57 $176.28 $199.46 $195.99 SSI Dual Eligible Non-Specialty Age 65+ Non-SMI $242.23 $323.04 $299.15 $273.08 $274.34 $246.67 $268.40 $305.13 $299.62 SSI Dual Eligible Non-Specialty All Ages SMI $495.15 $667.43 $616.50 $560.92 $563.61 $504.61 $550.94 $629.25 $617.50 SSI Dual Eligible Specialty All Ages SMI $525.45 $695.67 $645.35 $590.43 $593.09 $534.80 $580.57 $657.94 $646.34

AHCA Contract No. FP116, Attachment I, Exhibit I-C, Update 02/01/25, Page 2 of 3

1 All capitation rates and components shown are on a per member per month (PMPM) basis.

MANAGED CARE PLAN RATES - NOT FOR USE UNLESS APPROVED BY CMS

STATEWIDE MEDICAID MANAGED CARE (SMMC) MANAGED MEDICAL ASSISTANCE (MMA) PROGRAM

FEBRUARY 2025 THROUGH SEPTEMBER 2025 RATE YEAR 24/25 CAPITATION RATES BY REGION AND RATE CELL1

GROSS OF PRESCRIBED DRUGS HIGH RISK POOL (PDHRP) WITHHOLD AMOUNTS

Region

Rate Group Rate Cell A B C D E F G H I Child Welfare Non-Specialty 0-2 Months $816.97 $1,073.82 $1,339.49 $1,082.52 $1,354.54 $1,083.42 $1,409.32 $1,845.99 $2,148.11 Child Welfare Non-Specialty 3-11 Months $607.08 $796.14 $991.71 $802.55 $1,002.78 $803.21 $1,043.11 $1,364.53 $1,586.92 Child Welfare Non-Specialty 1-13 Years $356.11 $463.45 $574.49 $467.09 $580.77 $467.46 $603.67 $786.17 $912.44 Child Welfare Non-Specialty 14+ Years $400.82 $522.59 $648.56 $526.72 $655.69 $527.15 $681.67 $888.70 $1,031.95 Child Welfare Specialty 0-2 Months $869.71 $1,123.48 $1,385.97 $1,132.07 $1,400.83 $1,132.97 $1,454.97 $1,886.40 $2,184.90 Child Welfare Specialty 3-11 Months $662.05 $848.84 $1,042.06 $855.17 $1,053.00 $855.82 $1,092.84 $1,410.42 $1,630.14 Child Welfare Specialty 1-13 Years $413.74 $519.80 $629.51 $523.40 $635.72 $523.77 $658.34 $838.66 $963.41 Child Welfare Specialty 14+ Years $457.98 $578.30 $702.76 $582.38 $709.80 $582.80 $735.47 $940.02 $1,081.55 HIV/AIDS Non-Specialty Medicaid Only Non-SMI Single Rate $3,405.91 $3,716.98 $3,769.25 $3,715.85 $3,810.39 $3,861.20 $3,991.96 $4,092.16 $3,951.00 HIV/AIDS Non-Specialty Medicaid Only SMI Single Rate $4,189.06 $4,572.03 $4,636.38 $4,570.64 $4,687.04 $4,749.58 $4,910.57 $5,033.93 $4,860.14 HIV/AIDS Specialty Medicaid Only Non-SMI Single Rate $3,420.88 $3,730.08 $3,782.04 $3,728.96 $3,822.94 $3,873.44 $4,003.41 $4,103.01 $3,962.69 HIV/AIDS Specialty Medicaid Only SMI Single Rate $4,199.44 $4,580.11 $4,644.06 $4,578.72 $4,694.42 $4,756.59 $4,916.61 $5,039.23 $4,866.48 HIV/AIDS Dual Eligible Non-Specialty Non-SMI Single Rate $154.83 $156.97 $147.75 $192.04 $170.84 $144.51 $142.13 $187.33 $147.31 HIV/AIDS Dual Eligible Non-Specialty SMI Single Rate $336.85 $341.86 $320.29 $423.90 $374.30 $312.72 $307.14 $412.89 $319.28 HIV/AIDS Dual Eligible Specialty Non-SMI Single Rate $188.91 $191.03 $181.87 $225.89 $204.82 $178.65 $176.28 $221.21 $181.44 HIV/AIDS Dual Eligible Specialty SMI Single Rate $369.88 $374.86 $353.42 $456.41 $407.11 $345.90 $340.35 $445.46 $352.42 LTC Medicaid Only Non-Specialty Under Age 65 Non-SMI $2,301.95 $2,426.28 $2,578.58 $2,474.57 $2,657.64 $2,297.24 $2,684.27 $3,620.81 $2,963.28 LTC Medicaid Only Non-Specialty Age 65+ Non-SMI $1,422.16 $1,498.40 $1,591.80 $1,528.02 $1,640.28 $1,419.27 $1,656.61 $2,230.94 $1,827.71 LTC Medicaid Only Non-Specialty All Ages SMI $2,490.14 $2,624.61 $2,789.34 $2,676.84 $2,874.84 $2,485.04 $2,903.64 $3,916.59 $3,205.41 LTC Medicaid Only Specialty HIV Under Age 65 Non-SMI $2,323.90 $2,447.49 $2,598.87 $2,495.49 $2,677.45 $2,319.22 $2,703.92 $3,634.83 $2,981.25 LTC Medicaid Only Specialty HIV Age 65+ Non-SMI $1,449.11 $1,524.89 $1,617.73 $1,554.33 $1,665.91 $1,446.23 $1,682.15 $2,253.02 $1,852.22 LTC Medicaid Only Specialty HIV All Ages SMI $2,511.04 $2,644.70 $2,808.44 $2,696.62 $2,893.43 $2,505.97 $2,922.06 $3,928.91 $3,222.01 LTC Medicaid Only Specialty SMI All Ages SMI $2,498.08 $2,630.94 $2,793.70 $2,682.55 $2,878.17 $2,493.04 $2,906.63 $3,907.45 $3,204.79 LTC Dual Eligible Non-Specialty Under Age 65 Non-SMI $214.26 $211.63 $194.95 $214.00 $211.21 $194.39 $206.80 $248.75 $280.22 LTC Dual Eligible Non-Specialty Age 65+ Non-SMI $130.50 $129.00 $119.48 $130.35 $128.76 $119.16 $126.24 $150.18 $168.14 LTC Dual Eligible Non-Specialty All Ages SMI $161.42 $159.51 $147.33 $161.23 $159.20 $146.93 $155.98 $186.58 $209.55 LTC Dual Eligible Specialty HIV Under Age 65 Non-SMI $247.99 $245.39 $228.80 $247.74 $244.96 $228.25 $240.58 $282.27 $313.56 LTC Dual Eligible Specialty HIV Age 65+ Non-SMI $164.72 $163.23 $153.76 $164.57 $162.99 $153.45 $160.49 $184.28 $202.14 LTC Dual Eligible Specialty HIV All Ages SMI $195.46 $193.56 $181.46 $195.28 $193.25 $181.05 $190.05 $220.47 $243.30 LTC Dual Eligible Specialty SMI All Ages SMI $195.53 $193.64 $181.61 $195.35 $193.33 $181.21 $190.15 $220.39 $243.08 Medicare Advantage Plan All Ages $275.20 $275.20 $275.20 $275.20 $275.20 $275.20 $302.26 $302.26 $302.26 All Other Plan - Private Duty Nursing 0-20 Years $31,412.58 $30,399.77 $32,931.06 $30,908.77 $32,460.23 $28,822.26 $32,887.60 $33,519.31 $32,359.32 CMS Plan - Private Duty Nursing 0-20 Years $32,167.13 $31,129.92 $33,722.19 $31,651.18 $33,240.02 $29,514.41 $33,677.69 $34,324.61 $33,136.67 CMS Plan - Non-Private Duty Nursing All Ages $1,110.88 $1,886.10 $1,794.28 $2,023.08 $2,279.65 $3,374.10 $2,640.21 $2,960.43 $4,883.96

AHCA Contract No. FP116, Attachment I, Exhibit I-C, Update 02/01/25, Page 3 of 3

Region HCBS Rate Group Non-HCBS Rate Group

A $2,030.51 $6,778.81 B $2,098.67 $6,929.96 C $1,989.13 $6,881.22 D $2,386.38 $6,925.80 E $2,700.50 $6,967.42 F $2,440.00 $6,976.13 G $2,569.53 $7,205.90 H $2,747.60 $7,598.48 I $3,003.99 $7,542.08

MANAGED CARE PLAN RATES - NOT FOR USE UNLESS APPROVED BY CMS

STATEWIDE MEDICAID MANAGED CARE (SMMC) LONG-TERM CARE (LTC) PROGRAM

CAPITATION RATES BY RATE GROUP, NET OF PATIENT RESPONSIBILITY

FEBRUARY 2025 THROUGH SEPTEMBER 2025 RATE YEAR (RY 24/25) RATES

AHCA Contract No. FP116, Attachment I, Exhibit I-D, Update 02/01/25, Page 1 of 1

EXHIBIT I-D

KICK PAYMENT RATES FOR COVERED OBSTETRICAL DELIVERY SERVICES –

NOT FOR USE UNLESS APPROVED BY CMS

Region RY 24/25 Maternity Kick Payment Per Delivery

A $4,863.05 B $4,769.98 C $4,398.21 D $4,661.83 E $4,752.44 F $4,401.94 G $4,348.60 H $4,768.31 I $4,962.35

KICK PAYMENTS FOR COVERED OBSTETRICAL DELIVERY SERVICES- NOT FOR USE UNLESS APPROVED BY CMS

STATEWIDE MEDICAID MANAGED CARE (SMMC) MANAGED MEDICAL ASSISTANCE (MMA ) PROGRAM

FEB…