CN-680000-FP117-A1.pdf

AHCA CONTRACT NO. FP117

AMENDMENT NO. 1

AHCA Contract No. FP117, 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 HUMANA MEDICAL PLAN, 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:

Leanne Peoples Agency for Health Care Administration 2727 Mahan Drive, MS #50 Tallahassee, FL 32308

(850) 412-4041 Leanne.Peoples@ahca.myflorida.com

2. 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.

3. 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.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

Docusign Envelope ID: 2F1F8D01-D596-42F6-8C1D-D65553F2D587 mailto:Leanne.Peoples@ahca.myflorida.com

AHCA Contract No. FP117, Amendment No. 1, Page 2 of 2

April 2020

AHCA CONTRACT NO. FP117

AMENDMENT NO. 1

IN WITNESS WHEREOF, the Parties hereto have caused this five hundred and forty-four (544) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

HUMANA MEDICAL 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

Attachment II

Scope of Services - Update: February 1, 2025, Statewide Medicaid Managed Care Program (69 Pages)

Scope of Service - Core Provisions Update: February 1, 2025 (473 Pages)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

Docusign Envelope ID: 2F1F8D01-D596-42F6-8C1D-D65553F2D587

John Edward Barger III

PRESIDENT Humana Medicaid

2/6/2025

Jason Weida

Secretary

2/6/2025

HUMANA MEDICAL PLAN, INC.

ATTACHMENT I

SCOPE OF SERVICES -- UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 1 of 14

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;

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 2 of 14

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

(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; and

(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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 3 of 14

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

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 4 of 14

(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 Table, Table 3, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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.

Behavioral Health Integration Services/Collaborative Care X Cellular Phone Services

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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 5 of 14

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.

X 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 and/or Caregiver Transportation; Library, Social, and other ancillary services.

Nursing Mothers Support Items 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 X Sensory/Comfort Item Benefit- May include items such as

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 6 of 14

X 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, etc.

X 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

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

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

Caregiver Support, Education, and Training Chiropractic Services Computerized Cognitive Behavioral Therapy

X Criminal Expungement Services Developmental Disabilities Stipend

X Financial Literacy Home Health Nursing/Aide Services- May include benefits such as Extra Home Visits Home Visit by a Clinical Social Worker 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)

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 7 of 14

X 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.

Robotic Therapy Pet Sensory/Comfort Item Benefit

X Support to Stay in Community Living 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.

Legal Guardianship Assistance New Placement- Family Night Package

X Nutrition Shakes Peer Support Counseling- Individual and Group

Counseling Robotic Therapy Pet

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 8 of 14

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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 9 of 14

(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.

TABLE 5: SMMC PLAN TYPE

Region SMMC Program

MMA/LTC Specialty 1 Specialty 2 Region A Comprehensive LTC

Plus Serious Mental

Illness (SMI)

HIV/AIDS

Region B Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region C Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region D Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region E Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region F Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region G Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region H Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region I Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

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, Birth Outcomes 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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 10 of 14

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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 11 of 14

III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $28,214,518,334 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.

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 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 II-D, Kick Payment Rates for Covered Obstetrical Services – Not for Use Unless Approved by CMS, of this Attachment.

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

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. FP117, Attachment I, Update 02/01/25, Page 12 of 14

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 Plan Summary

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

H. 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.

I. 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. FP117, Attachment I, Update 02/01/25, Page 13 of 14

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 [amount] million dollars ($63,000,000) 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:

AHCA Contract No. FP117, Attachment I, Update 02/01/25, Page 14 of 14

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 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

Total Performance Bond Amount: $63,000,000

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 1 of 11

EXHIBIT I-A

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

Approved Benefit Approved Limitations

General Expanded Benefits

Baby and Me Meals Up to two (2) pre-cooked home-delivered meals per day for ten (10) weeks for high-risk pregnancies.

Prior Authorization Required.

Convertible Car Seat or Portable Crib Pregnant enrollees who enroll and actively participate in the Humana Beginnings Case Management program can select one (1) convertible car seat or portable crib per infant, per pregnancy.

Disaster Preparedness Meals One box of fourteen (14) shelf-stable meals before or after a natural disaster twice per year. Member must not live in a residential or nursing facility and the Governor must declare the disaster for the member to be eligible for the meals. Prior Authorization Required.

Doula Services Doula assistance to provide emotional and physical support to the laboring mother and her family, five

(5) prenatal visits, three (3) postpartum visits and one (1) visit for delivery assistance per pregnancy.

No Prior Authorization Required.

Financial Literacy Coaching Up to six (6) life coaching sessions for money management and budgeting. No Prior Authorization Required.

GED Test Preparation Assistance GED test preparation assistance, including a bilingual advisor, access to guidance and study materials, and unlimited use of practice tests. Test preparation assistance, including tutoring, is provided virtually to allow maximum flexibility for members. Also includes test pass guarantee to provide members multiple attempts at passing the test.

Home Delivered Prepared Meals Fourteen (14) refrigerated meals (home-delivered) following discharge from an inpatient or residential facility. No limit on the number of discharges per year. Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 2 of 11

Humana Tranquility Goods Enrollees can receive supplies to calm the impact of trauma including a sound machine, light therapy products, or weighted blanket. Once (1) per year.

Enrollees can qualify through the following event/diagnosis: Children/Adolescents with an emotional and/or behavioral diagnosis, such as Acute Stress Disorder, Disinhibited Social Engagement Disorder, Adjustment Disorder, Unclassified and Unspecified Trauma Disorder, Reactive Attachment Disorder, and/or PTSD. Prior Authorization Required.

Maternal and Infant Virtual Care Pregnant enrollees and enrollees with a child up to one (1) year of age, unlimited access to a smartphone application that provides 24/7 access to a proprietary, video-enabled call routing system that allows enrollees to connect with a lactation consultant or a physician extender for on-demand assistance. No Prior Authorization Required.

Newborn Circumcision One (1) per lifetime for members ages Zero (0) to twenty-eight (28) days old. No Prior Authorization Required.

NMT for Behavioral Health Parent/Guardian

Four (4) in-state round trips (eight (8) in-state one-way trips) per month for an enrollee’s parent and/or guardian to visit the enrollee while in a behavioral health residential setting or a statewide inpatient psychiatric program (SIPP). Excludes enrollees’ parents and guardians that have their own means of transportation. No Prior Authorization Required.

Nutrition Shakes Enrollees living with HIV deemed malnourished by their provider and unable to prepare meals, may receive a package of twenty-one (21) nutritional shakes twice (2) per year. Prior Authorization Required.

Online Tutoring Services Members ages five (5)-nineteen (19) may access online tutoring services up to two (2) hours per week as well as ACT/SAT test preparation.

Over-the-Counter (OTC) Medications and Supplies

The Managed Care Plan shall provide a monthly OTC benefit limit of fifty dollars ($50) per household.

No Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 3 of 11

Prenatal Services For members ages ten (10) to fifty-nine (59):

Fourteen (14) prenatal visits for low-risk pregnancies and Eighteen (18) prenatal visits for high-risk pregnancies. Three (3) postpartum visits within ninety (90) days following delivery; One (1) well-woman visit between ninety (90) days and twelve

(12) months following delivery in preparation to transition the member back to their primary care medical home; Non-hospital grade breast pump -one (1) per two (2) years, rental, no Prior Authorization Required; Hospital grade breast pump

– one (1) rental per year, Prior Authorization Required.

Respite Services for Enrollees on HCBS Waiver Waiting List

Enrollees with developmental disabilities who have a caregiver and are on a waiver waiting list for home and community-based services (HCBS) may be eligible for up to sixty (60) hours per year of respite services. Prior Authorization Required.

Respite Services for Medically Complex Children

Members may be eligible for up to two hundred forty

(240) hours of respite services per year to afford temporary relief to family caregivers. Respite care services are provided on a short-term basis as a temporary support to the recipient's family. It may be provided in the absence of or for relief of the recipient’s family. Respite care may be used to meet a range of recipient needs. These include family emergencies, planned absences, such as vacations, hospitalizations, or business trips, relief from the stresses of caregiving; and giving the child respite from his family. Respite care may be provided in the recipient's home, place of residence or a Nursing Facility. Members must first exhaust services covered through HCBS Waivers they are enrolled

on. Prior Authorization Required.

Return to Home Meals for Families of NF Children

Home-delivered meals for family members of nursing facility members when transitioning to the home. Members may receive up to two (2) meals per day for one (1) week. Family members must primarily reside in the member’s home. No Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 4 of 11

Smartphone Service Smartphones can provide easy access to health-related information and enable members to stay connected to their care team and health plan.

Humana members that qualify for the Federal Lifeline program are eligible to receive a free smartphone with monthly talk minutes, text and data. No Prior Authorization Required.

Sports Physical One (1) sports physical per year. No Prior Authorization Required.

Swimming Lessons (Drowning Prevention) Members will be reimbursed up to two hundred dollars ($200) per year. Limited to the first one thousand (1,000) members per year. Prior Authorization Required.

Therapy for Families of NF Children Family members of nursing facility members transitioning to the home may receive individual/group therapy as needed three (3) months prior to and up to one (1) year after transition.

Family members must primarily reside in the member’s home. Prior Authorization Not Required.

Transition Assistance Deposit for NF Children

Members may be eligible to receive up to one thousand five hundred dollars ($1,500) per lifetime to assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household that do not constitute room and board, such as: Security deposits required to obtain a lease on an apartment or home, Coverage for utilities including set up fees or deposits, first month coverage, or back payments, First months and last month’s rent as required by landlord for occupancy or housing maintenance, Services necessary for the individual’s health and safety, such as pest eradication. Services must be identified as reasonable and necessary in the members individualized housing. Members must first exhaust services covered through HCBS Waivers they are enrolled on. Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 5 of 11

Virtual Exercise Classes Enrollees living with HIV can access virtual fitness classes including over one thousand (1,000) on-demand classes across multiple exercise modalities including high-intensity interval training, core-strength, cycling, yoga, and other specialty fitness classes. Classes will be offered in a wide variety of intensities and class lengths (from five (5) minutes to sixty (60) minutes) to help enrollees achieve their health and wellness goals. The digital fitness content will include adaptive workouts and classes suitable for those with chronic conditions and mobility challenges. This offering will improve accessibility of exercise programming and address barriers (transportation, mobility, etc.) that may prevent enrollees from engaging in in-person fitness. No prior Authorization Required.

Waived Copayments The Managed Care Plan shall waive copayments as a standard expanded benefit.

Workforce Management Financial Assistance

Pathway members who are participating in Humana's workforce management program may receive financial assistance with covering the cost of professional licensure and/or certification for the following professions: Licensed practical nurse - up to one hundred five dollars ($105) (Department of Health), Certified nursing assistant (CNA) - up to one hundred fifty-five dollars ($155) (Board of Nursing), Barber - up to one hundred fifty-five dollars ($155) (Department of Business and Professional Regulation), Cosmetology - up to fifty-five dollars ($55) (Department of Business and Professional Regulation), Child care home license - up to seventy-five dollars ($75) (Department of Children & Families).Member must submit evidence they completed the education and/or training required by profession. Allowance is limited to once per year.

Prior Authorization Required.

Adult Expanded Benefits

Adult Additional Primary Care Services Unlimited per month for non-pregnant members. No Prior Authorization Required.

Adult Visual Aid Services One (1) eye exam per year; Members can only have glasses or contacts, not both during the plan year.

One (1) set of frames every year, member pays any cost over seventy-five dollars ($75) for luxury frames.

Six-month (6) supply of contact lenses with a prescription. No Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 6 of 11

Assisted Living Facility - Move-In Basket Up to fifty-dollars ($50) worth of items once (1) per lifetime. A move-in basket is available to enrollees 18 and older who: Live in an assisted living facility, or transition/move into an assisted living facility.

Enrollees can pick between two baskets: Basket 1:

An insulated tumbler, rainbow medication tray, and plush Sherpa home throw blanket inside a clear casual tote bag; Basket 2: A bottle holder, green carabineer, copper vacuum insulated bottle, Arctic Zone thermal copper mug and a domino set inside a black tote bag. Prior Authorization Required. For LTC Enrollees only.

Assisted Living Facility- Bed Hold Bed hold for up to 30 days; Enrollees must intend to return to the Adult Living Facility (ALF)/ Adult Family Care Home (AFCH). Enrollees must maintain room and board and share of cost payments while away.

Enrollee must live in the ALF/AFCH for at least thirty

(30) days between each episode. The ALF/AFCH must inform the plan within twenty-four (24) hours of the enrollee leaving to be eligible for this EB. Prior Authorization Required. For LTC Enrollees only.

Behavioral Health - Individual Therapy Sessions to Caregivers

Therapeutic behavioral services as needed, for family caregivers of members ages eighteen (18) and older. Prior Authorization Not Required.

Criminal Expungement Services Enrollee reimbursement of up to seventy-five dollars ($75) for criminal record expungement, as allowed per www.fdle.state.fl.us/Seal-and-Expunge-Process, one (1) per lifetime.

Durable Medical Equipment (DME) Services and Supplies

Members that are under care management with blood pressure monitoring included in their care plan, may receive one (1) digital blood pressure cuff every three (3) years. Prior Authorization Required.

Fall Prevention Kit Enrollees who are at risk for falls may receive a Fall Prevention kit once (1) per lifetime. Kit contains:

Non-Slip Socks, Reacher/Grabber, Bathmat, and Stair Treads. Enrollee must not reside in a residential facility or nursing facility. Prior Authorization Required. For LTC Enrollees only.

http://www.fdle.state.fl.us/Seal-and-Expunge-Process

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 7 of 11

Hearing Services for Adults Hearing assessment and reassessment – one (1) every two (2) years. Hearing aid fitting/checking – one (1) every two (2) years. Hearing aids and dispensing fee: Monaural In Ear hearing aid – one

(1) per ear every year; Behind Ear Bicros hearing aid – one (1) per ear every two (2) years; Behind Ear Binaural hearing aid – one (1) per ear every two

(2) years; Behind Ear Cros hearing aid – one (1) per ear every two (2) years; Behind Ear hearing aid – one (1) per ear every two (2) years; In Ear Binaural hearing aid – one (1) per ear every two (2) years. No Prior Authorization Required.

Home Delivered Prepared Meal Fourteen (14) meals per year. Prior Authorization Required.

Home-Based Asthma Interventions Asthmatic members in Care Management or Disease Management programs can receive reimbursement up to two hundred fifty ($250) per year for allergen free bedding and/or an air purifier.

Prior Authorization Required.

Hospital Services - Outpatient The one thousand five hundred ($1,500) fiscal year dollar limit for non-emergency outpatient services is waived. No Prior Authorization Required.

Housing Assistance Up to five hundred dollars ($500) per household per year (unused allowance does not roll over to the next year) to assist with the following housing expenses: Apartment rent or mortgage payment (late payment notice required), Utility payment for electric, water, gas or internet (late payment notice required), Trailer Park and lot rent if this is your permanent residence (late payment notice required), Moving expenses via licensed moving company when transitioning from a public housing authority.

Member must not live in a residential facility or nursing facility. Funds will not be paid directly to the member. If the bill is in the spouse's name, a marriage certificate may be submitted as proof. Prior Authorization Required.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 8 of 11

Non-Emergency Transportation Up to six (6) round trips (twelve (12) one-way trips) up to thirty (30) miles for non-medical transportation per year to locations such as job/vocational training, social support groups, wellness classes, WIC and SNAP appointments, and food banks. This benefit also offers transportation to locations providing social benefits and community integration for members such as community and neighborhood centers, parks, recreation areas, and churches. No Prior Authorization Required.

Non-Emergency Transportation: Ancillary:

Meals for Recipient and Escort

Reimbursement for two hundred dollars ($200) per day, up to one thousand dollars ($1,000) per year for medical trips greater than one hundred (100) miles. Prior Authorization Required.

Occupational therapy for adults One (1) evaluation per year; one (1) re-evaluation per year; Up to seven (7) therapy treatment units per week. No Prior Authorization Required for initial assessment. Prior Authorization Required for ongoing treatment.

Physical Therapy for Adults One (1) evaluation per year; One (1) re-evaluation per year; Up to seven (7) therapy treatment units per week. No Prior Authorization Required for initial assessment. Prior Authorization Required for ongoing treatment.

Support to Stay in Community Living One thousand dollars ($1,000) allowance to support LTC enrollees remain in their home or transition into an assisted living facility (ALF). Once (1) per lifetime. Approved expenses may include utilities (gas, water, electric), internet, furniture, or rent with a long-term financial plan. Enrollees must meet the following criteria: Enrollee must live in the community and be at risk for long-term institutional placement; Enrollee must live alone or with spouse (other living situations may be approved on a case-by-case basis upon Case Manager review). Enrollee must show proof of potential loss of dwelling or risk of losing home due to inability to pay utilities, late bills/disconnection notices, etc.; Benefit allowed only for items that place enrollee at risk for custodial placement; Benefit cannot be used concurrently with SMI Specialty Housing Assistance benefit. Prior Authorization Required. For LTC Enrollees only.

Therapy - Respiratory Services One (1) evaluation per year; One (1) re-evaluation per year; One (1) therapy treatment per day. No Prior Authorization Required for initial assessment.

Prior Authorization Required for ongoing treatment.

AHCA Contract No. FP117, Attachment I, Exhibit I-A, Update 02/01/2025, Page 9 of 11

Transition Assistance into Community Living

Enrollees who are moving from a nursing facility into their own home may receive up to up to five thousand dollars ($5,000) per lifetime. Assistance for paying with security and utility deposits, household furnishings/supplies, and moving expenses. Enrollee must be responsible for their own living expenses. Prior Authorization Required.

For LTC Enrollees only.

Transportation Ancillary: Parking Fees, Tolls, other.

Two (2) round trips (four (4) one-way) per month within the members local area for those who live in a home or community-based setting. Prior Authorization Required. LTC Only.

Specialty Line of Business

Housing Assistance Members who are homeless, at imminent risk of becoming homeless, or members transitioning from a BH IP or residential facility without stable housing in the community may be eligible for housing assistance up to two thousand five hundred dollars ($2,500) once (1) per lifetime. Member must: Meet the Housing and Urban Development (HUD) definition of homeless: literally homeless; imminent risk of homelessness; homeless under other Federal statues; or fleeing/attempting to flee domestic violence, be engaged in either Humana's Care Management program or a targeted case management program within the community, or a community housing case manager, Be engaged with a plan housing specialist, housing provider and/or local continuum of care, be able to continue paying for their living expenses upon award of this one-time benefit, voluntarily consents to housing assistance, be ambulatory or able to self-transfer from wheelchair to bed and back if needed, does not exhibit severe suicidal, homicidal, or acute mood symptoms/thought disorder, in imminent danger of harm to self or others, nor requires more intensive level of care. Prior Authorization Required.

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.

AHCA Contract No. FP117, 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

A 123134100-01 123136800-01 123136900-01 123610300-01 B 123134100-03 123136800-03 123136900-03 123610300-03 C 123134100-05 123136800-05 123136900-05 123610300-05 D 123134100-06 123136800-06 123136900-06 123610300-06 E 123134100-07 123136800-07 123136900-07 123610300-07 F 123134100-08 123136800-08 123136900-08 123610300-08 G 123134100-09 123136800-09 123136900-09 123610300-09 H 123134100-10 123136800-10 123136900-10 123610300-10 I 123134100-11 123136800-11 123136900-11 123610300-11

1. Serious Mental Illness (SMI)

2. HIV/AIDS

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.

AHCA Contract No. FP117, Attachment I, Exhibit I-D, Update 02/01/25, Page 1 of 1

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

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…