CN-680000-FP118-A1.pdf

AHCA CONTRACT NO. FP118

AMENDMENT NO. 1

AHCA Contract No. FP118, Amendment No. 1, Page 1 of 2

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

1. 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.

2. 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: 8994C015-5434-4598-A780-F9E30C986C84

AHCA CONTRACT NO. FP118

AMENDMENT NO. 1

AHCA Contract No. FP118, Amendment No. 1, Page 2 of 2

IN WITNESS WHEREOF, the Parties hereto have caused this six hundred and fourteen (614) Page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

FLORIDA COMMUNITY CARE, LLC 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 (73 Pages)

Attachment II Scope of Service – Core Provisions Update: February 1, 2025 (539 Pages)

Chairman & CEO

Nestor Plana

2/6/2025

Kimberly Smoak

Deputy Secretary HQA

2/25/2025

FLORIDA COMMUNITY CARE, LLC

ATTACHMENT I

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP118, Attachment I, Update 02/01/2025, Page 1 of 17

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.

Section 409.9855, F.S. established Florida’s comprehensive intellectual and developmental disabilities (IDD) managed care pilot program, referred to as the Comprehensive IDD Pilot Program. The selected plan provides comprehensive MMA, LTC waiver services, and Florida Developmental Disabilities Individual Budgeting (iBudget) waiver services for eligible persons who meet specified criteria based on age, county of residence, 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;

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(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 Payment 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;

(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)

(c) Exhibit II-C, Comprehensive Intellectual and Developmental

Disabilities (IDD) Managed Care Pilot Program (i.e., the Comprehensive IDD Pilot Program Exhibit) (if applicable)

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

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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.

Program Component

REGION MMA LTC Pilot

COMPREHENSIVE

IDD PILOT PROGRAM

Region A X X

X X

Region B X X

X X

Region C X X

Region D X X X Region E X X

Region F X X

Region G X X

Region H 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, and the Required Comprehensive IDD Pilot Services, Table 2C, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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

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(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

(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

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(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

TABLE 2C: REQUIRED COMPREHENSIVE IDD PILOT PROGRAM

SERVICES

(1) Adult Day Health Care

(2) Adult Dental Services*

(3) Assisted Living

(4) Behavior Analysis Services

(5) Behavior Assistant Services

(6) Care Coordination

(7) Caregiving Training

(8) Companion Care

(9) Consumable Medical Supplies

(10) Dietitian Services

(11) Durable Medical Equipment

(12) Environmental Accessibility Adaptations

(13) Home Delivered Meals

(14) Hospice

(15) Life Skills Development Level 1-Companion

(16) Life Skills Development Level 2-Supported Employment

(17) Life Skills Development Level 3-Adult Day Training

(18) Life Skills Development Level 4-Prevocational Services

(19) Medication Administration

(20) Medication Management

(21) Occupational Therapy

(22) Personal Emergency Response System (PERS)

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(23) Personal Supports

(24) Physical Therapy

(25) Private Duty Nursing

(26) Residential Habilitation (Standard)

(27) Residential Habilitation (Behavior Focused)

(28) Residential Habilitation (Intense Behavior)

(29) Residential Habilitation (Enhanced Intensive Behavior)

(30) Residential Nursing

(31) Respiratory Therapy

(32) Respite

(33) Skilled Nursing

(34) Specialized Medical Equipment and Supplies

(35) Special Medical Home Care

(36) Specialized Mental Health Counseling

(37) Speech Therapy

(38) Supported Employment

(39) Supported Living Coaching

(40) Transportation

*Coverage of dental services through the Comprehensive IDD Pilot Program is secondary to the dental services provided by the Statewide Medicaid Managed Care Dental Program and associated expanded benefits.

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, and Approved Comprehensive IDD Pilot Program Expanded Benefits Table, Table 3A, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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TABLE 3: APPROVED EXPANDED BENEFITS

General Expanded Benefits - Available for children and/or adults 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.

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.

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

Financial Literacy 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 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

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Update 02/01/2025, Page 8 of 17

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.

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.

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.

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.

X Behavioral- Assessment/Evaluation and Screening

Services X Behavioral- Intensive Outpatient Treatment

Behavioral Health- Individual Therapy Sessions to Caregivers

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

X Caregiver Support, Education, and Training X Chiropractic Services

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Computerized Cognitive Behavioral Therapy Criminal Expungement Services Developmental Disabilities Stipend 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)

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

X 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 ALF/Home Based Setting Move-In Items Aquatic Therapy Durable Medical Equipment and Misc. Items Benefit- May include benefits such as Mobility Items, Dental Kits, etc.

X 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

Sensory/Comfort Item Benefit 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

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Update 02/01/2025, Page 10 of 17

TABLE 3A: APPROVED COMPREHENSIVE IDD PILOT PROGRAM

EXPANDED BENEFITS

X Assisted Living Facility/Adult Family Care Home/Group

Home – Bed Hold Days X Caregiver Transportation X Cooking at Home Catalog X Dental Desensitization Kits X Digital Library Membership X Emotional Well-Being Program for Caregivers/TCare X Gym Membership X Healthy Grocery Card for Caregivers X Hygiene and Wound Care Kit X Legal Guardianship X Portable Fall Prevention Supports X Recreational Therapy X Specialized Camps and Social Opportunities

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 Nutrition Shakes Peer Support Counseling- Individual and Group

Counseling Robotic Therapy Pet

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

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Update 02/01/2025, Page 11 of 17

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

Health Maintenance Organization (HMO) X 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.

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(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.

(6) Pilot Plans- Plans that provide covered services specified in the MMA Exhibit including those covered under s. 409.973(1)(a) through (cc), F.S.

and in the LTC Exhibit, including those covered under s. 409.98(1) through (19), F.S., in accordance with the approved federal waivers, only to eligible recipients who meet specified criteria as defined in Attachment II and its Exhibits.

TABLE 5: SMMC PLAN TYPE

Region

SMMC Program MMA/LTC Specialty 1 Specialty 2 Pilot Program

Region A Comprehensive LTC Plus Plan

Serious Mental Illness (SMI)

HIV/AIDS

Region B Comprehensive LTC Plus Plan

Serious Mental Illness (SMI)

HIV/AIDS

Region C Comprehensive LTC Plus Plan

Serious Mental Illness (SMI)

HIV/AIDS

Region D Comprehensive LTC Plus Plan

Serious Mental Illness (SMI)

HIV/AIDS Comprehensive IDD Pilot Program

Region E Select Comprehensive

Region F Select

Region G Select

Region H Select

Region I Comprehensive LTC Plus Plan

Serious Mental Illness (SMI)

HIV/AIDS Comprehensive IDD Pilot Program

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.

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AHCA Contract No. FP118, Attachment I, Update 02/01/2025, Page 13 of 17

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.

E. After Hours Access and Telemedicine Targets

The Managed Care Plan shall meet the 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.

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

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III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $51,151,005,711 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.

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 Services - Not for Use Unless Approved by CMS.

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.

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

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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 Managed Care Plan’s MMA Physician Incentive Program (MPIP) 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.

J. Comprehensive Intellectual and Developmental Disabilities (IDD) Managed Care Pilot

The Managed Care Plan shall perform the Comprehensive Intellectual and Developmental Disabilities (IDD) Managed Care Pilot program enhancements in accordance with the Managed Care Plan’s accepted response to the Agency’s Invitation to Negotiate (ITN) 009-23/24, contained in the Agency’s procurement records. The per-member per-month (PMPM) rates for the Comprehensive IDD Managed Care Pilot payment shall be in accordance with Exhibit I-C, Managed Care Plan Rates –Not for Use Unless Approved by CMS of this Attachment.

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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 fifty-six million dollars ($56,000,000) in accordance with Attachment II, Section XV.W. of this Contract. The total performance bond amounts are specified in the Total Performance Bond Amount Table, Table 6 below:

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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 Select Comprehensive $5,000,000 F Select Comprehensive $5,000,000 G Select Comprehensive $5,000,000 H Select Comprehensive $5,000,000

I

Comprehensive LTC Plus $5,000,000

D CIDD Pilot Program $500,000 I CIDD Pilot Program $500,000 A HIV/AIDS Specialty $1,000,000 B HIV/AIDS Specialty $1,000,000 C HIV/AIDS Specialty $1,000,000 D HIV/AIDS Specialty $1,000,000 I HIV/AIDS Specialty $1,000,000 A Serious Mental Illness $1,000,000 B Serious Mental Illness $1,000,000 C Serious Mental Illness $1,000,000 D Serious Mental Illness $1,000,000 I Serious Mental Illness $1,000,000

Total Performance Bond Amount: $56,000,000

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, 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

ALF/AFCH - Bed Hold Days Up to thirty-one (31) days per month. Available for LTC members only. No Prior Authorization Required.

Caregiver Transportation Four (4) one-way trips or two (2) round trips a month up to forty (40) miles per month. Available for LTC members only. No Prior Authorization Required.

Doula Services Doula services as outlined in Enrollee’s plan of care.

Prior Authorization Required.

Durable Medical Equipment (DME) Services and Supplies

Automated blood pressure device: For enrollees residing at home or in an ALF with history of High Blood Pressure, as outlined in the Enrollee's Plan of Care. Prior Authorization Required.

Food Assistance One (1) shelf-stable meal package (ten (10) meals) per disaster. No Prior Authorization Required.

Home Delivered Meals – Post-Facility Discharge (Hospital or Nursing Facility)

Up to ten (10) meals per event; Prior Authorization Required.

Home Delivered Meals (General) For the first one thousand (1,000) pregnant women in compliance with prenatal visits. Prior Authorization Required.

Housing Assistance Housing support allowance for enrollees needing assistance with housing costs; Available for all enrollees who are homeless or at risk of homelessness. Up to three hundred dollars ($300) per year.

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, Page 2 of 6

Joy for All Joy For All is a “Companion” Robotic Pet used to stimulate conversation and communication in withdrawn seniors, calm anxiety and soothe those that are agitated, increase quality of life for those with dementia or who are socially isolated and can improve behavior without the use of drugs. Members can receive one robotic pet. Available for LTC members only. Prior Authorization Required.

Meals – Non-Emergency Transportation Day-Trips

Up to twenty dollars ($20) per meal, up to three (3) meals per day, up to one hundred twenty dollars ($120) per day, up to one thousand dollars ($1,000) per year for trips over one hundred (100) miles. Prior Authorization Required.

Newborn Circumcision One per lifetime for newborn males up to 28 days old. No Prior Authorization Required if completed before hospital discharge.

Non-Medical Transportation Transportation for non-medical trips, such as shopping or social events; For all enrollees. One (1) round trip per month, up to thirty (30) miles. No Prior Authorization Required.

Over-the-Counter (OTC) Medications and Supplies

The Managed Care Plan shall provide a monthly OTC benefit limit of sixty-five dollars ($65) per household. No Prior Authorization Required.

Pathways to Purpose-PURPOSEful Connections

A benefit for LTC enrollees that live at home and are screened as at risk for feelings of isolation. Includes a starter kit with hand-written letter, games, social activities available in their community, pens, paper, and prepaid envelopes to send letters back to the plan and create a personal pen-pal relationship.

One (1) per year for eligible Enrollees as outlined in the Enrollee's Plan of Care. Available for LTC members only. Prior Authorization Required.

Prenatal Services For pregnant enrollees: Hospital type breast pump (one (1) rental per year); Standard breast pump (one

(1) rental every two (2) years); Fourteen (14) visits for low-risk pregnancies; Eighteen (18) visits for high-risk pregnancies; Three (3) visits within Ninety

(90) days following delivery. No Prior Authorization Required.

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, Page 3 of 6

Stress Relief Support Up to twenty-five dollars ($25) one-time purchase per year for educational/emotionally supportive toys/games to develop awareness of emotions and coping mechanisms. Prior Authorization Required.

Swimming Lessons (Drowning Prevention) Two hundred dollars ($200) per year for the first one thousand (1,000) members (children aged three (3)– sixteen (16) years old). Prior Authorization Required.

Tcare Assist and Tcare Connect (LTC Enrollees)

Home Care Training, Family/Non-Family; One (1) assessment session and three (3) quarterly follow-ups as Outlined in Enrollee's Plan of Care. Prior Authorization Required.

Tcare Assist and Tcare Connect (MMA Enrollees-Pathways to Possibility)

Home Care Training, Family/Non-Family; One (1) assessment session and three (3) quarterly follow-ups as Outlined in Enrollee's Plan of Care. Prior Authorization Required.

Transition Assistance - Nursing Facility to Community Setting

Up to five-thousand dollars ($5,000) per transition.

Available for LTC members only. Prior Authorization Required.

Transportation Services to a Vaccination Site for Covered Vaccines

Two (2) round trips per year up to twenty (20) miles each round trip. Available for LTC members only.

No Prior Authorization Required.

Tutoring, Vocational Training, and/or Job Readiness

One time, one hundred twenty-eight dollars ($128) voucher for GED Test Fees and assistance in locating free study resources to help prepare for the GED test for enrollees twenty-one (21) years and older who submit a request for a voucher. No more than five hundred (500) enrollees per year.

Weighted Blanket Weighted Blanket, any size; One (1) per year. No Prior Authorization Required.

Adult Expanded Benefits

Adult Visual Aid Services Contact lenses – Six (6)-month supply without needing to prove medical necessity (as required by Medicaid).

Frames-one (1) per year. No Prior Authorization Required.

Adult Additional Primary Care Services Unlimited office visits to a Primary Care Provider for enrollees twenty-one (21) years and older. No Prior Authorization Required.

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, Page 4 of 6

Physical Therapy for Adults For enrollees twenty-one (21) years of age and older, in addition to the Medicaid covered wheelchair evaluation services, FCC will provide:

One (1) evaluation per year; One (1) reevaluation per year; Up to three (3) therapy visits per week (maximum of four (4) units per day). Prior Authorization Required.

Hearing Services for Adults For enrollees twenty-one (21) years of age and older once (1) every two (2) years: One (1) hearing aid assessment to determine candidacy and most appropriate hearing aid; One (1) hearing evaluation;

One (1) hearing aid fitting/checking; One (1) hearing aid per ear; One (1) hearing aid dispensing fee.

Prior Authorization Required.

Occupational Therapy for Adults For enrollees twenty-one (21) years of age and older, in addition to the Medicaid covered wheelchair evaluation services, FCC will provide:

One (1) evaluation per year; One (1) reevaluation per year; Up to three (3) therapy visits per week (maximum of four (4) units per day). Prior Authorization Required.

Expanded Benefits for Pregnant Women Intensive outpatient services with therapy and treatment to help with alcohol and/or drug abuse; For pregnant female members ages twenty-one (21) and older for up to eight (8) weeks. This includes services for three (3) hours a day, three (3) days a week. Prior Authorization Required.

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

Acupuncture Service must be provided by a professional certified in Acupuncture up to forty-eight (48) units (fifteen

(15) minutes per unit), per year as deemed medically necessary. Prior Authorization Required.

Assessment/Evaluation Services – Behavioral

Unlimited with No Prior Authorization.

Behavioral Health Medical Services (Drug Screening)

Unlimited with Prior Authorization.

Behavioral Health Medical Services (Verbal Interaction)

Unlimited for verbal interaction, medication management, and drug screening. Prior Authorization Required.

Behavioral Health Screening Services Unlimited for verbal interaction. Prior Authorization

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, Page 5 of 6

Cellular Phone Services One (1) cellphone; Three hundred fifty (350) minutes; unlimited text messages; Sixteen (16) GB data; No Prior Authorization Required.

Chiropractic Services Up to twenty-eight (28) visits in addition to basic MMA benefit of twenty-four (24) visits for a total of up to fifty-two (52) visits per year, as deemed medically necessary. Prior Authorization Required.

Home Health Nursing/Aide Services Unlimited as deemed medically necessary. Prior Authorization Required.

Home Visit by a Clinical Social Worker Up to forty-eight (48) hours per year, as deemed medically necessary. Prior Authorization Required.

Massage Therapy Unlimited as deemed medically necessary. Prior Authorization Required.

Nutritional Counseling Unlimited as deemed medically necessary. Prior Authorization Required.

Outpatient Hospital Services Unlimited as deemed medically necessary for certain services. Prior Authorization Required.

Respiratory Therapy One (1) initial therapy evaluation or re-evaluation per year; One (1) respiratory therapy visit per day.

Prior Authorization Required.

Speech Therapy Evaluation/ reevaluation, one (1) per year; Evaluation of swallowing, one (1) per year; Speech therapy visit, up to seven (7) therapy treatment units per week;

Augmentative Alternative Communication (AAC) initial evaluation, one (1) per enrollee; AAC reevaluation, one (1) per year; AAC fitting, adjustment, and training visit, up to four (4) thirty minute (30) sessions per year. Prior Authorization Required.

Therapy - Art Unlimited as deemed medically necessary. Must be delivered by a behavioral health clinician with art therapy certification. Prior Authorization Required.

Therapy/Psychotherapy (Group) Therapeutic behavioral services; Group psychotherapy (other than of a multiple-family group); Unlimited. Prior Authorization Required.

Therapy/Psychotherapy (Individual/Family) Brief individual medical psychotherapy; Family psychotherapy; Unlimited. Prior Authorization

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP118, Attachment I, Exhibit I-A, Update 02/01/2025, Page 6 of 6

Comprehensive IDD Pilot Program Services – these services are only available for enrollees participating in the CIDD Pilot Program Assisted Living Facility/Adult Family Care Home/Group Home – Bed Hold Days

Up to thirty-one (31) bed hold days per month;

without prior authorization.

Caregiver Transportation Four (4) round trips or eight (8) one way trips monthly, up to forty (40) miles per round trip, or up to twenty (20) miles one way, per trip.

Prior authorization required to visit a member who is residing at an ALF, AFCH, or Group Home for Eligible Caregivers who need transportation to see loved ones in an ALF, AFCH, or Group Home.

Cooking at Home Catalog Members can select one (1) item including: air fryer, toaster, pot and pan set, blender, and more, with prior authorization.

Dental Desensitization Kits One (1) kit annually; and as needed.

Digital Library Membership with eReader One (1) membership per enrollee, hundreds of thousands of books available in the catalog;

Prior authorization required.

Emotional Well-Being Program for Caregivers/TCare

Risk screening of identified and consenting caregivers; in-depth assessment and personal counseling for high-risk caregivers. One (1) assessment session and three (3) quarterly follow-ups, with prior authorization.

Gym Membership Up to fifty dollars ($50.00) per month, with prior authorization.

Healthy Grocery Card for Caregivers One hundred dollar ($100.00) Healthy Card per year, with prior authorization.

Hygiene and Wound Care Kit As medically necessary, with prior authorization.

Legal Guardianship Up to one thousand dollars ($1,000.00) to obtain guardianship; Up to two-hundred fifty dollars ($250.00) each year to maintain guardianship, with prior authorization.

Portable Fall Prevention Supports Portable fall prevention supports include the following items: grab bar with medical grade suction cups, non-skid bathmat and tub liner, and shower chair; with prior authorization.

Information on fall prevention is also included.

Recreational Therapy Up to thirty (30) hours per year, with prior authorization. Recreational therapy includes activities such as: arts and crafts, adapted sports, social activities and other recreational activities; and fees for participation in classes or activities, including uniforms, sports equipment , and other items.

Specialized Camps and Social Opportunities Fifteen hundred dollars ($1,500.00) per year, with prior authorization.

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

EXHIBIT I-B

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION NUMBERS

Region MMA LTC Specialty 1 Specialty 2 IDD 3

Program A 122966300-01 122967000-01 122968000-01 123610200-01

B 122966300-03 122967000-03 122968000-03 123610200-03

C 122966300-05 122967000-05 122968000-05 123610200-05

D 122966300-06 122967000-06 122968000-06 123610200-06 12129170-06 E 122966300-07 122967000-07

F 122966300-08 122967000-08

G 122966300-09 122967000-09

H 122966300-10 122967000-10

I 122966300-11 122967000-11 122968000-11 123610200-11 12129170-11

1. Serious Mental Illness (SMI)

2. HIV/AIDS

3. Intellectual and Developmental Disabilities (IDD)

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 recipients in the Managed Care Plan in each authorized region.

AHCA Contract No. FP118, Attachment I, Exhibit I-B, Update 02/01/2025, 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.

AHCA Contract No. FP118, Attachment I, Exhibit I-C, Update 02/01/2025, Page 1 of 4

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.

AHCA Contract No. FP118, Attachment I, Exhibit I-C, Page 2 of 4

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…