CN-680000-FP119-A1.pdf

AHCA CONTRACT NO. FP119

AMENDMENT NO. 1

AHCA Contract No. FP119, 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 UNITEDHEALTHCARE OF FLORIDA, 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:

Tasha Gallon Agency for Health Care Administration 2727 Mahan Drive, MS #50 Tallahassee, FL 32308

(850) 412-4266 Tasha.Gallon@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: DAD2F025-3758-48B3-93E9-D0F0BD409442 mailto:Tasha.Gallon@ahca.myflorida.com

AHCA CONTRACT NO. FP119

AMENDMENT NO. 1

AHCA Contract No. FP119, Amendment No. 1, Page 2 of 2

April 2020

IN WITNESS WHEREOF, the Parties hereto have caused this five hundred twenty-four (524) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

UNITEDHEALTHCARE OF FLORIDA, INC.

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

SIGNED

BY:

SIGNED

BY:

NAME: NAME:

TITLE: TITLE:

DATE: DATE:

List of Attachments included as part of this Amendment:

Specify Type Number Description Attachment I Scope of Services - Update: February 1, 2025, Statewide Medicaid

Managed Care Program (49 Pages) Attachment II Scope of Service - Core Provisions Update: February 1, 2025

(473 Pages)

2/10/2025

Michael Lawton

CEO

2/25/2025

Deputy Secretary HQA

Kimberly Smoak

ATTACHMENT I

SCOPE OF SERVICES -- UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 1 of 13

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 Arrangement PMPM

Component of Capitation Rates – Not for Use Unless Approved by CMS;

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

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

(m) Exhibit I-M, Public Emergency Medical Transportation Provider Uniform Increase

Payment -- Not for Use Unless Approved by CMS;

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 2 of 13

(2) Attachment II, Core Contract Provisions, includes contract provisions that apply to all managed care plans unless specifically noted otherwise.

(3) Exhibits to Attachment II, include contract provisions that are unique to the specific component of SMMC:

(a) Exhibit II-A, Managed Medical Assistance (MMA) Program, i.e. the MMA Exhibit

(b) Exhibit II-B, Long-Term Care (LTC) Managed Care Program, i.e. the LTC Exhibit

B. Authorized Regions

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

TABLE 1: AUTHORIZED REGIONS

Region Program Component MMA LTC Specialty

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 3 of 13

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.

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 4 of 13

TABLE 2B: REQUIRED LTC SERVICES

(1) Adult Companion Care

(2) Adult Day Health Care

(3) Assistive Care Services

(4) Assisted Living

(5) Attendant Nursing Care

(6) Behavioral Management

(7) Caregiver Training

(8) Care Coordination/Case Management

(9) Home Accessibility Adaptation Services

(10) Home Delivered Meals

(11) Homemaker Services

(12) Hospice

(13) Intermittent and Skilled Nursing

(14) Medical Equipment and Supplies

(15) Medication Administration

(16) Medication Management

(17) Nutritional Assessment/Risk Reduction Services

(18) Nursing Facility Services

(19) Personal Care

(20) Personal Emergency Response Systems (PERS)

(21) Respite Care

(22) Occupational Therapy

(23) Physical Therapy

(24) Respiratory Therapy

(25) Speech Therapy

(26) Transportation

D. Approved Expanded Benefits

The Managed Care Plan shall provide the following expanded benefits, in accordance with the provisions of Attachment II and its Exhibits and the coverage and limitations specified in Exhibit I-A of this Attachment, denoted by “X” in the Approved Expanded Benefits Table, Table 3, 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. FP119, Attachment I, Update 02/01/2025, Page 5 of 13

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.

Disaster Relief Benefit- May include items such as a

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

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

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

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

Financial Literacy Fitness Benefit- May include benefits such as Gym

Memberships, Virtual Exercise Classes, etc.

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.

Meals- Non-Emergency Transportation Day-Trips

X 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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 6 of 13

TABLE 3: APPROVED EXPANDED BENEFITS

X Nutritional Counseling X 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 Sensory/Comfort Item Benefit- May include items such as

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

Sports Physical 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

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 Behavioral- Intensive Outpatient Treatment

X Behavioral Health- Individual Therapy Sessions to Caregivers

X 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 Computerized Cognitive Behavioral Therapy

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 7 of 13

TABLE 3: APPROVED EXPANDED BENEFITS

Criminal Expungement Services Developmental Disabilities Stipend Financial Literacy 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.

X Psychosocial Rehabilitation X 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

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 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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 8 of 13

TABLE 3: APPROVED EXPANDED BENEFITS

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

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 9 of 13

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. FP119, Attachment I, Update 02/01/2025, Page 10 of 13

(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 Region B Comprehensive

LTC Plus Serious Mental

Illness (SMI)

HIV/AIDS

Region C Region D Comprehensive

LTC Plus Serious Mental

Illness (SMI)

HIV/AIDS

Region E Region F Region G Region H 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.

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.

III. Method of Payment

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 11 of 13

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $14,572,353,082 to the Managed Care Plan in accordance with Attachment II and its Exhibits. The Agency shall make payments through its fiscal agent using the Medicaid Provider Identification Numbers specified in Exhibit I-B.

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

The capitation rate payment shall be in accordance with Attachment II and its Exhibits.

The capitation rates are contained in Exhibit I-C, Managed Care Plan Rates – Not for Use Unless Approved by CMS, of this Attachment.

Actuarial Notes:

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

Application of adjustments to apply specifically to February through September

2025;

Addition of Behavior Analysis services;

Refined adjustments to reflect final redetermination impacts;

Updated legislative appropriation amounts;

Updated trends due to consideration of more recent experience and additional drug treatments; and Other updates due to plan or Agency feedback.

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

Approved by CMS

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

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

The per-member per month rates (PMPM) 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.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 12 of 13

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

The per-member per-month rates (PMPM) 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 Approved by CMS

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 Approved by

CMS

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

J. Public Emergency Medical Transportation Provider Uniform Increase Payments – Not for Use Unless Approved by CMS

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

AHCA Contract No. FP119, Attachment I, Update 02/01/2025, Page 13 of 13

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 twenty-one million dollars ($21,000,000) 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:

TABLE 6: TOTAL PERFORMANCE BOND AMOUNT

Awarded Region Plan Type

Performance Bond Amount

B Comprehensive LTC Plus $5,000,000 D Comprehensive LTC Plus $5,000,000 I Comprehensive LTC Plus $5,000,000 B Serious Mental Illness (SMI) $1,000,000 D Serious Mental Illness (SMI) $1,000,000 I Serious Mental Illness (SMI) $1,000,000

B HIV/AIDS $1,000,000

D HIV/AIDS $1,000,000

I HIV/AIDS $1,000,000

Total Performance Bond Amount: $21,000,000

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 1 of 6

EXHIBIT I-A

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATION

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

Approved Benefit Approved Limitations

General Expanded Benefits Baby Scripts and Healthy First Steps Rewards

The program ends at fifteen (15) months post-delivery. Enrollees receive rewards at specific milestones, including gift cards and baby-related items ranging in value from ten dollars ($10) to thirty dollars ($30). No prior authorization required.

Diaper Starter Pack New mothers during the first twelve (12)-months, post-delivery. Maximum fifty dollars ($50) for diapers. No prior authorization required.

Doula Program Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.

Home visit for postnatal assessment and follow-up care. Home visit for newborn care and assessment.

Unlisted home visit service or procedure. Prior authorization required.

Food Assistance New mothers returning home after giving birth to a newborn, access to fourteen (14) home-delivered meals per year; Enrollees with a primary diagnosis of congestive heart failure (CHF), diabetes, chronic obstructive pulmonary disease (COPD), cancer and recently discharged from a hospital stay, access to fourteen (14) home-delivered meals per year. Prior authorization not required.

Housing Assistance Peer support promoting skills for coping with and managing symptoms while utilizing natural resources and the preservation and enhancement of community living skills with the assistance of a peer support specialist. No prior authorization required.

Newborn circumcision Circumcision Neonate. One (1) per lifetime. 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.

Peer Support Doula Program Access to certified BH and SUD peer supports who are trained and certified maternity peer doulas who support their pregnant peers living with SUD and SMI throughout the prenatal and postpartum processes to enhance the health and well-being.

Prior authorization required.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 2 of 6

Wellhop Virtual Support Group Group video conversations with a trained facilitator and members at the same stage in pregnancy.

Evidence-based information on pregnancy and postpartum, educational articles, videos, podcasts and more. No prior authorizations required.

Waived Copayments The Managed Care Plan shall waive copayments as a standard expanded benefit. Prior authorization is N/A.

Adult Expanded Benefits Adult additional primary care services Office/outpatient visit est; nursing fac care subseq;

prev visit; per pm reeval est pat 65+ yr; self-measured blood pressure monitoring. No prior authorization required.

Adult visual aid services Contact lens, frame, eye exam; Contact lens – six (6) months' supply with prescription; frame, eye exam – one (1) per year. No prior authorization required.

Assessment/Evaluation Services – Behavioral

Various assessment, evaluation and testing codes.

No prior authorization required.

Assisted Living Facility/Adult Family Care Home - Bed Hold Days

Assist Living Waiver/Month/ Res, Nos Waiver Per Diem; This benefit allows enrollees who are temporarily absent from their rehabilitation facility, assisted living facility or adult family care home to hold their bed for up to thirty (30) days so the enrollee does not lose their placement in the facility. Prior authorization required.

Behavioral Health Day Services/Day Treatment

Behavioral Health Day Services/Day Treatment, Day Care Services, Adult; Per Diem. Prior authorization required.

Behavioral Health Medical Services (Drug Screening)

Behavioral Health Medical Services (Alcohol and Other Drug Screening Specimen Collection). No prior authorization required.

Behavioral Health Medical Services (Medication Management)

Medication Management. No prior authorization required.

Behavioral Health Medical Services (Verbal Interaction)

Behavioral Health Medical Services (Verbal Interaction), Mental Health/Substance Abuse. No prior authorization required.

Behavioral Health Screening Services Behavioral Health Screening Services. No prior authorization required.

Careforth for Caregivers Careforth coaches design a person-centered program for each enrollee after completing an assessment that evaluates the knowledge, skills and needs of the caregiver and the enrollee’s health risks and behavioral challenges. Caregivers of enrollees in an HCBS setting have access to clinical

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 3 of 6 recommendations and caregiver support services and coaching. No prior authorization required.

Caregiver Transportation Caregivers of enrollees in an HCBS setting can access four one-way trips to visit an enrollee residing in an assisted living or nursing facility. Prior authorization required.

Cellular Phone Services

One (1) cellphone, unlimited talk and text; 1 GB of data. Prior authorization required.

Chiropractic Services Unlimited with prior authorization Durable medical Equipment (DME) services and supplies

Automatic blood pressure monitor. No prior authorization required.

Hearing services for adults Assessment for hearing aid; hearing aid fitting/checking; hearing aid monaural in ear; behind ear hearing aid; hearing aid dispensing fee; in ear binaural hearing aid; behind ear binaur hearing aid;

dispensing fee binaural; behind ear cros hearing aid ; cros hearing aid dispens fee; behind ear bicros hearing aid; dispensing fee bicros; hearing evaluation; 1 every 2 years. Prior authorization required.

Home Visit by a Clinical Social Worker Various. One additional visit per day. No prior authorization required.

Individual Therapy for Caregivers Up to two therapeutic behavioral services sessions per calendar year. No prior authorization required.

Medication Assisted Treatment Services Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program). No prior authorization required.

Non-Medical Transportation Transportation assistance beyond required nonemergency services for adults eighteen (18) and older. Trips must be approved and within a thirty (30)-mile radius of the enrollee’s home; twenty (20) one-way or Ten (10) round trips per year; sixty (60)-day bus pass stipend after job is secured, once per year for adults eighteen (18) and older; Fifty dollars ($50) gas gift card after job secured in geographies where public transportation is unavailable for adults eighteen (18) and older. Prior authorization not required.

Nursing facility to Community Setting Transition Assistance

We support enrollees transitioning to a community setting by providing home essentials like furniture, safety equipment or assistance to secure housing.

Up to a maximum of five thousand dollars ($5,000) per enrollee per lifetime. Prior authorization required.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 4 of 6

Occupational therapy for adults Occupational therapy evaluation low to high complexity; occupational therapy re- evaluation;

occupational therapy treatment visit; application of casting or strapping; wheelchair evaluation and fitting by an occupational therapist. One (1) evaluation per year; One (1) evaluation per year; Up to seven (7) therapy treatment units per week. Prior authorization required.

Outpatient Hospital Services No limits for: PET Scan, Pharmacy Services, Professional, PT/OT Therapy, Radiology Services, Routine Dental Services, Sleep Studies, Speech Therapy, Sterilization Services, Supplies - med Surg, Therapeutic Radiology, Therapeutic, Transplant, Treatment/OBS Room Services, and Urgent Care Services. Unlimited with prior authorization. Prior authorization required.

Physical therapy for adults Physical therapy evaluation; physical therapy re-evaluation; physical therapy treatment visit;

application of casting or strapping; wheelchair evaluation and fitting by a physical therapist. One (1) evaluation per year; One (1) evaluation per year; Up to seven (7) therapy treatment units per week. Prior authorization required.

Prenatal Services Hospital grade breast pump; breast pump;

antepartum management; postpartum care. Max of One (1) per year (rental, PA is required); One (1) per two (2) years (rental, no PA required); fourteen (14) visits for low-risk pregnancies and eighteen (18) visits for high-risk pregnancies; three (3) visits within ninety (90) days following delivery, and One (1) well-woman visit between ninety (90) days and twelve

(12) months following delivery in preparation to transition back to the primary care medical home. No prior authorization required.

Psychosocial Rehabilitation Psychosocial rehabilitation services. No prior authorization required.

Speech Therapy Various assessment, evaluation and testing codes.

One (1) evaluation per year, One (1) evaluation per year, up to seven (7) therapy treatment units per week, One (1) evaluation per year, One (1) evaluation per year, up to four (4) Thirty-minute (30) AAC fitting, adjustment and training session per year. Prior authorization required.

Targeted Case Management Targeted Case Management. No prior authorization required.

Therapy/Psychotherapy (Group) Group Therapy, Brief Group Medical Therapy. No prior authorization required.

Therapy/Psychotherapy (Individual/Family) Unlimited, No prior authorization required.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 5 of 6

Tutoring, Vocational Training, and/or Job Readiness

GEDWorks: GED testing, education advisors, study frameworks and exam preparation; Goodwill:

Employment advisory services, technical assistance and support to job seekers in finding employment or advancing enrollee careers. Access to career navigators, connecting enrollees to employers in their community; Secure Advantage: Enrollees can receive guidance and support from a money coach who provides objective information and clear action steps to help them make informed decisions about their finances. No prior authorization required.

Specialty Line of Business

Acupuncture

Acupuncture, one or more needles, without electrical stimulation, initial fifteen (15) minutes of personal one-on-one contact with the patient. Acupuncture, one or more needles, without electrical stimulation, initial fifteen (15) minutes of personal one-on-one contact with the patient. Prior authorization required.

Condition Specific DME

DME and other supplies to help children manager their symptoms, like additional weighted blankets or enuresis alarms. Limited to one hundred dollars ($100) annually. No prior authorization required.

Food Assistance

Medical Nutrition Group/ Meals per diem; not otherwise specified; Enrollees diagnosed with SMI who are discharged from a hospital or facility, access to fourteen (14) home-delivered meals per year. No prior authorization required.

Massage Therapy

Hot and cold pack therapy. Neuromuscular therapy.

Fifteen (15)-minute massage, including mobilization, manipulation, manual lymphatic drainage, manual traction, one or more regions. Fifteen (15)-minute massage, including effleurage, petrissage and tapotement

Nutritional Counseling

Nutrition Class. Medical Nutrition Indiv InMed Nutrition Indiv SubseqMedical Nutrition GroupMnt Subs Tx For Change Dx; Group Mnt 2 Or More 30 Mins; A comprehensive approach to medical nutrition therapy (MNT) services, provided by registered dietitians or other qualified health care professionals. This program evaluates an enrollee’s nutritional status and develops personalized nutrition plans while educating them on healthy eating habits.

Three MNT visits per year, no more than one unit per day. Prior authorization required.

Sensory Toys for Children Living with

ADHD

Sensory toys can help children living with ADHD with their focus, relaxation and overall development. No prior authorization required.

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-A, Update 02/01/2025, Page 6 of 6

TAY (Transitional Age Youth) Flex Fund

Incidentals such as cash assistance for rental deposit(s), rent, utilities, moving expenses, etc.;

Provides a maximum of $250 per year to support the completion of necessary, required health care services through virtual connectivity, with the criteria that the enrollee must be in an emerging health risk level or higher, and the support must help strengthen their natural system 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. FP119, Attachment I, Exhibit I-B, Update 02/01/2025, Page 1 of 1

EXHIBIT I-B

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION NUMBERS

Region MMA LTC Specialty1 Specialty2

A B 123376600-03 123376700-03 123376900-03 123610100-03 C D 123376600-06 123376700-06 123376900-06 123610100-06 E F G H I 123376600-11 123376700-11 123376900-11 123610100-11

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 recipients in the Managed Care Plan in each authorized region.

AHCA Contract No. FP119, Attachment I, Exhibit I-C, Update 02/01/2025, Page 1 of 3

EXHIBIT I-C

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

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

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

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

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

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

Region

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

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-C, Update 02/01/2025, Page 2 of 3

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

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

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

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

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

Region

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

AHCA Contract No. FP119, Attachment I, Exhibit I-C, Update 02/01/2025, Page 3 of 3

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-D, Update 02/01/2025, Page 1 of 1

EXHIBIT I-D

KICK PAYMENT RATES FOR COVERED OBSTETRICAL DELIVERY SERVICES –

NOT FOR USE UNLESS APPROVED BY CMS

Region RY 24/25 Maternity Kick Payment Per Delivery

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

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

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

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

NOT APPLICABLE TO DUAL ELIGIBLE MEMBERS OR CMS PLAN MEMBERS

AHCA Contract No. FP119, Attachment I, Exhibit I-E, Update 02/01/2025, Page 1 of 1

Contract Period VBP LAN 3A+ VBP LAN 3B+ VBP LAN 4A+ Year 1 10% 10% 0% Year 2 20% 15% 1% Year 3 25% 20% 2.5% Year 4 30% 25% 5% Year 5 35% 30% 7.5% Year 6 40% 35% 10%

The Managed Care Plan shall expend a minimum percentage of payments to providers through VBP agreements in accordance with Table 4, Incremental Increase in Expenditures in Value- Based Purchasing Agreements with Providers. The percentage of payments in various LAN risk levels are calculated by dividing the measured claim-based expenditures in VBP agreements by the total claim-based expenditures for all enrollees as reported in the Achieved Savings Rebate (ASR). If capitation is paid to providers in lieu of fee-for-service claim reimbursement, then the capitation payment amounts shall be included in the numerator and the denominator. If the Managed Care Plan falls below these minimum percentages, the Agency shall assess liquidated damages pursuant to Section XIII., Liquidated Damages, as determined by the Agency.

TABLE 4

INCREMENTAL INCREASE IN EXPENDITURES IN VALUE-BASED PURCHASING

AGREEMENTS WITH PROVIDERS*

*The percentages are minimum targets. The plus sign indicates the inclusion of greater risk levels. For example, "3A+" includes LAN risk levels 3A, 3B, 4A, 4B, and 4C.

EXHIBIT I-E

VALUE-BASED PURCHASING PERFORMANCE TARGETS

AHCA Contract No. FP119, Attachment I, Update 02/01/2025m Exhibit I-F, Page 1 of 1

EXHIBIT I-F

BIRTH OUTCOMES TARGETS

Screening, Brief Intervention, and Referral to Treatment

(SBIRT)

Medication Assisted Treatment

(MAT)

Contract Year 1 15% 35% Contract Year 2 20% 40% Contract Year 3 25% 45% Contract Year 4 30% 50% Contract Year 5 35% 55% Contract Year 6 40% 60%

SBIRT = Percentage of pregnant enrollees who receive SBIRT (H0049, H0050, 99408, 99409, G0396, or G0397)

MAT = Percentage of pregnant and postpartum enrollees diagnosed with OUD who are prescribed MAT

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP119, Attachment I, Exhibit I-G, Update 02/01/2025, Page 1 of 1

Provider Type A B C D E F G H I Pediatrics 40% 40% 40% 40% 40% 40% 40% 40% 40% Child Psychiatrists 40% 40% 40% 40% 50% 40% 40% 40% 40% Adult Psychiatrists 40% 40% 40% 40% 50% 40% 40% 40% 40% Licensed Practitioner of the Healing Arts…