CN-680000-FP120-A1.pdf

AHCA CONTRACT NO. FP120

AMENDMENT NO. 1

AHCA Contract No. FP120, 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 SIMPLY HEALTHCARE PLANS, 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:

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

(850) 412-4041

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: BE93E5F6-5C4E-41AA-A8E3-5D1C78C92C4F

AHCA CONTRACT NO. FP120

AMENDMENT NO. 1

AHCA Contract No. FP120, Amendment No. 1, Page 2 of 2

IN WITNESS WHEREOF, the Parties hereto have caused this five hundred sixty-seven (567) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

SIMPLY HEALTHCARE PLANS, 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 (92 Pages)

Attachment II Scope of Service – Core Provisions Update: February 1, 2025 (473 Pages)

CEO/Plan President

2/6/2025

Dana Gryniuk Jason Weida

Secretary

2/6/2025

SIMPLY HEALTHCARE PLANS, INC.

ATTACHMENT I

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP120, Attachment I, Update 02/01/25, 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 (1), or both, of two (2) SMMC programs: one (1) for managed medical assistance (MMA) and one (1) for long-term care (LTC). Additionally, some managed care plans participating in the MMA program component serve specialty populations who meet specified criteria based on age, condition or diagnosis. The Contract consists of distinct parts as follows:

(1) Attachment I, Scope of Services, includes contract provisions that are unique to the particular managed care plan.

(a) Exhibit I-A, Approved Expanded Benefits Coverage and Limitations;

(b) Exhibit I-B, Medicaid Provider Identification Numbers;

(c) Exhibit I-C, Managed Care Plan Rates – Not for Use Unless Approved by CMS;

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

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

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

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

(h) Exhibit I-H, Public Hospital Physician Uniform Payment Increase – Not for Use Unless Approved by CMS;

(i) Exhibit I-I, Faculty Plans of Florida Medical School Faculty Physician Groups

Rates – Not for Use Unless Approved by CMS;

(j) Exhibit I-J, Florida Cancer Hospital Minimum Fee Schedule Rates – Not for Use Unless Approved by CMS;

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

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

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

Increase Payment -- Not for Use Unless Approved by CMS;

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 2 of 17

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

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

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

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

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

B. Authorized Regions

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

TABLE 1: AUTHORIZED REGIONS

Region Program Component

MMA LTC Specialty Region A X X X Region B X X X Region C X X X Region D X X X Region E X X X Region F X X X Region G X X X Region H X X X Region I X X X

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 3 of 17

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 programs in the authorized regions 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

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 4 of 17

TABLE 2B: REQUIRED LTC SERVICES

(1) Adult Companion Care

(2) Adult Day Health Care

(3) Assistive Care Services

(4) Assisted Living

(5) Attendant Nursing Care

(6) Behavioral Management

(7) Caregiver Training

(8) Care Coordination/Case Management

(9) Home Accessibility Adaptation Services

(10) Home Delivered Meals

(11) Homemaker Services

(12) Hospice

(13) Intermittent and Skilled Nursing

(14) Medical Equipment and Supplies

(15) Medication Administration

(16) Medication Management

(17) Nutritional Assessment/Risk Reduction Services

(18) Nursing Facility Services

(19) Personal Care

(20) Personal Emergency Response Systems (PERS)

(21) Respite Care

(22) Occupational Therapy

(23) Physical Therapy

(24) Respiratory Therapy

(25) Speech Therapy

(26) Transportation

D. Approved Expanded Benefits

The Managed Care Plan shall provide the following expanded benefits, in accordance with the provisions of Attachment II and its Exhibits and the coverage and limitations specified in Exhibit I-A of this Attachment, denoted by “X” in the Approved Expanded Benefits- Comprehensive Table, Table 3, below, to enrollees of the applicable SMMC programs in the authorized regions specified in Table 1.

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 5 of 17

TABLE 3: APPROVED EXPANDED BENEFITS

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

Hypoallergenic Bedding, Carpet Cleaning, Pest Control, etc.

Behavioral Health Integration Services/Collaborative Care 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.

X 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 X 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.

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 6 of 17

X Nursing Mothers Support Items 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.

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

X 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 Behavioral- Intensive Outpatient Treatment

X 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

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 7 of 17

X Chiropractic Services 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)

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 X ALF/Home Based Setting Move-In Items

Aquatic Therapy

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

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

Visits, Kenneling, etc.

Robotic Therapy Pet

X 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.

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 8 of 17

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

TABLE 3: APPROVED EXPANDED BENEFITS

Collaborative Care

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

Legal Guardianship Assistance X 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

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.

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 9 of 17

(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.

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

TABLE 5: SMMC PLAN TYPE

Region SMMC Program MMA/LTC Specialty 1 Specialty 2

Region A Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region B Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region C Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region D Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region E Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region F Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region G Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region H Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS Region I Comprehensive LTC Plus Serious Mental Illness (SMI) HIV/AIDS

C. Value-Based Purchasing Performance Targets

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

D. Birth Outcomes Targets

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

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 10 of 17

E. After Hours Access and Telemedicine Targets

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

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 11 of 17

III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $25,466,957,345 to the Managed Care Plan in accordance with Attachment II and its Exhibits. The Agency shall make payments through its fiscal agent using the Medicaid Provider Identification Numbers specified in Exhibit I-B.

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

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

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

Actuarial Notes:

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

• Application of adjustments to apply specifically to February through September

2025;

• Addition of Behavior Analysis services;

• Refined adjustments to reflect final redetermination impacts;

• Updated legislative appropriation amounts;

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

• Other updates due to plan or Agency feedback.

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

Approved by CMS

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

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

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 Medical School Faculty Physician Groups Rates – Not for Use Unless Approved by CMS, of this Attachment.

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 12 of 17

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. Behavioral Health and Supportive Housing Assistance Pilot

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

I. Hospital Uniform Percentage Increase Payments-Not for Use Unless 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. FP120, Attachment I, Update 02/01/25, Page 13 of 17

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 sixty-three million dollars ($63,000,000) in accordance with Attachment II, Section XV.W.

of this Contract. The total performance bond amount is specified in the Total Performance Bond Amount Table, Table 6, below:

TABLE 6: TOTAL PERFORMANCE BOND AMOUNT

Awarded Region Plan Type

Performance Bond Amount

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

AHCA Contract No. FP120, Attachment I, Update 02/01/25, Page 14 of 17

C Serious Mental Illness (SMI) $1,000,000 D Serious Mental Illness (SMI) $1,000,000 E Serious Mental Illness (SMI) $1,000,000 F Serious Mental Illness (SMI) $1,000,000 G Serious Mental Illness (SMI) $1,000,000 H Serious Mental Illness (SMI) $1,000,000 I Serious Mental Illness (SMI) $1,000,000

A HIV/AIDS $1,000,000

B HIV/AIDS $1,000,000

C HIV/AIDS $1,000,000

D HIV/AIDS $1,000,000

E HIV/AIDS $1,000,000

F HIV/AIDS $1,000,000

G HIV/AIDS $1,000,000

H HIV/AIDS $1,000,000

I HIV/AIDS $1,000,000

Total Performance Bond Amount: $63,000,000

SCOPE OF SERVICES -UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 1 of 14

EXHIBIT I-A

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

Approved Benefit Approved Limitations

General Expanded Benefits

Activity Therapy Our Activity Therapy expanded benefit offers eligible enrollees unlimited therapy sessions for art, dance, equine, and pet therapy services based on medical necessity. Prior Authorization Required.

Asthma- COPD Toolkit Improved our existing hypoallergenic bedding expanded benefit to enable more enrollee choice and to better support the needs of enrollees with asthma and COPD. Through our Asthma and COPD Toolkit, enrollees can select one asthma and COPD relief product to best suit their health needs, including inhaler vaporizer kits, travel nebulizer compressor systems, hypoallergenic bedding, pillow and mattress covers, HEPA air filters, and asthma monitoring devices. Prior Authorization Required.

Carpet Cleaning Simply understands that without proper management, asthma can result in frequent ED visits, hospitalizations, and premature deaths.

Carpet cleanings can help reduce dander, dust, and other potential allergens that may trigger enrollees with asthma. We will cover the cost of carpet cleanings twice a year for enrollees with asthma.

Prior Authorization Required.

Disaster Relief Benefit One Hundred Dollars ($100) grocery and cleaning supplies card per household; Five (5) shelf-stable meals. These meals are delivered directly to the enrollee’s home, which is especially important for enrollees living alone. The expanded benefit may help avoid triggering events that can lead to hospitalization or institutional care. In addition to food, the meal packages also include dry milk and juice. No Prior Authorization Required.

Doula Services Enrollees who are pregnant can receive unlimited home visits for prenatal and postnatal monitoring, screening, and follow-up care, and newborn care and screening. Unlimited per Pregnancy. No Prior Authorization Required.

Emergency Preparedness Kit Enrollees can receive an Emergency Preparedness Kit after completing a disaster plan. The kit includes

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 2 of 14 items such as a multi-function tool, light stick, flashlight, mini first aid kit, emergency survival blanket. waterproof poncho, hand warmers, matches, tissues, towelettes, hand sanitizer, emergency whistle with carabiner, and dust mask.

Kits will be offered one (1) per household, per lifetime. No Prior Authorization Required.

Employment Connections Program Enrollees ages 16 and older that join the Employment Connections Program can receive financial support through the Employment Basics expanded benefit to cover the costs for one (1) of the following items below. This is a once per lifetime benefit: Completion of an industry certification;

Purchase of a uniform or specific attire required in certain vocations; Grooming pass to a hair salon or barber shop in addition to a voucher towards styling supplies; Purchase of tools required in certain vocations: Industry Certification, Work-related uniform, Grooming Pass.

Fresh Food Connect Eligible enrollees can choose one of the following items annually: One hundred fifty dollars ($150) Healthy Grocery Card, Annual (Sams Club or Costco) Membership, Three boxes of Produce Delivery. No Prior Authorization Required.

Healthy Grocery Card One hundred dollars ($100) Healthy Grocery Card for enrollees that join our Job Connections program;

once per year. No Prior Authorization Required.

Healthy Lifestyle Aids Enrollees can select up two (2) items, such as reachers/grabbers, clip-on lamps, pulse oximeters, heart rate monitor, abdominal binders, diabetic insoles and socks, lumbar support items, activity trackers, memory foam pillows, and more. The medical supplies allow enrollees to better manage and take an active part in their personal progress toward healthy living. Members can take advantage of this benefit, once (1) per lifetime and choose up to two (2) items.

Home Delivered Meals - Disaster Relief Five shelf-stable meals. These meals are delivered directly to the enrollee’s home, which is especially important for enrollees living alone. The expanded benefit may help avoid triggering events that can lead to hospitalization or institutional care. In addition to food, the meal packages also include dry milk and juice. No Prior Authorization Required.

Home Delivered Meals - Post Facility Discharge

Home Delivered Meals Post-Discharge expanded benefit enables enrollees, recently discharged from the hospital to focus on recovery, alleviate stress, AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 3 of 14 and reduce their likelihood of hospital readmission.

We offer home-delivered medically tailored meals customized to enhance recuperation for each enrollee and include options such as low-sodium and low-fat, diabetic-friendly, gluten-free, vegetarian, pureed, and cancer support meals. No Prior Authorization Required.

Home Delivered Meals - Pregnant Moms Pregnant members who are up to date with their prenatal care and at risk of malnutrition or require in home support, can receive up to one hundred (100) home-delivered meals to allow them to focus on a healthy pregnancy. No Prior Authorization Required.

Job Connections Program Job Connections Program is an innovative, wrap-around approach that includes education and training supports to help enrollees prepare, choose, obtain and sustain a livable-wage career. Our Program includes a dedicated Pathways Support Employment Specialist who coaches and mentors members throughout the program. Total Expanded Benefit units, amount, and frequency are determined on a case-by-case basis by Employment Specialist based on the situation and the needs of the enrollee.

Medicine Safety Kit Eligible enrollees and their families will receive our Medicine Safety Kit, which includes a lockable medicine box, Rx destroyer gel, childproof prescription caps, and pill case covers that reset when opened. These items help parents and guardians keep medications safe from children and youth, help prevent accidental ingestion or stealing of prescription medicines, and encourage conversations about responsible medication use among families. No Prior Authorization Required.

Mom & Baby Essentials Pregnant or newly delivered enrollees and infants up to twelve (12) months can receive two hundred dollars ($200) to purchase items per pregnancy that support a healthy pregnancy and healthy environment for baby. No Prior Authorization Required.

NEMT Day Trip Meals To make sure enrollees have access to food during medical visits more than one hundred (100) miles from their home, the expanded benefit provides up to two hundred dollars ($200) per day toward the cost of meals. Prior Authorization Required.

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 4 of 14

NEMT Services - Non-Medical Purposes Unlimited transportation for non-medical purposes to all enrollees so that they can quickly and easily get to community events, health and wellness activities, local dental clinics, places of worship, libraries, social and group activities, support groups, job coaching, and GED prep courses. Up to twenty-five

(25) miles per one-way trip. In addition, we will offer eight one-way rides per month for all enrollees to use for trips in the community to run errands, go to the hair salon or barber shop, etc. up to twenty-five

(25) miles per one-way trip. No Prior Authorization Required.

Newborn Circumcision In support of data and expert recommendations that elective circumcisions may offer preventive health benefits, including reduced risk of urinary tract infections, SHP offers newborn circumcisions as an expanded benefit. One for infants up to twenty-eight

(28) days old. No Prior Authorization Required.

Non-emergency Transportation - Non- Medical Purposes /Community Transportation Benefit

MMA (including specialty products): Unlimited non-medical transportation is available to educational classes (swimming lessons/ drowning prevention, diabetes, GED Prep Course), smoking cessation, weight control programs, women infants children (WIC), job coaching and GED prep courses. LTC and HIV/AIDs specialty product: Eight (8) one-way rides per month for enrollees to use for trips in the community to run errands, go to the hair salon or barber shop, etc.; Maximum of seventy-two (72) one-way rides per member per year. Up to twenty-five (25) miles. No Prior Authorization Required.

Nursing Support Nursing Support expanded benefit allows enrollees to choose one of the following items that best suit their needs: Breast pump accessory kit (disposable nursing pads, extra milk storage bags, and bottles).

Boppy pillow. Breast-feeding support kit (infant support nursing pillow, washable nursing pads, and nursing cover). Microwave sterilizer. No Prior Authorization Required.

Online SUD Recovery Support Program Unlimited through Simply's Online SUD Recovery Support Program. 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.

Pest Control Pest Control expanded benefit to reduce or eliminate pests in the home, which can exacerbate asthma symptoms in enrollees. To address this, enrollees with asthma can receive an initial pest

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 5 of 14 control visit and three (3) maintenance visits per year per household. Prior Authorization Required.

Pregnancy Food Assistance Up to one hundred (100) meals annually for the first one thousand (1,000) MMA pregnant enrollees and first fifty (50) HIV/AIDS specialty product enrollees who are current on their prenatal visits. Must have CM approval.

Prenatal Services Fourteen (14) prenatal visits for enrollees and eighteen (18) prenatal visits for enrollees with high-risk pregnancies as well as three (3) postpartum visits for enrollees within ninety (90) days of delivery. Prior Authorization Required.

School Supply Assistance Fifty-dollars ($50) annually towards the purchase of school supplies, per member per year. Prior Authorization Required.

Sensory Solutions Up to seventy-five dollars ($75) worth of sensory, such as Compression Garments, Weighted Lap Blankets, Texture Fidgets, Sensory Books, per eligible enrollee per year. No Prior Authorization Required.

STEM Puzzle Set Enrollees up to age eighteen (18) can receive a STEM puzzle set and a one hundred dollars ($100) book gift card to purchase developmental, summer reading, and other educational books. Enrollees ages eleven (11) to eighteen (18) can opt to receive a digital e-reader device with a thirty dollars ($30) digital library card in in lieu of the one hundred dollars ($100) book gift card. No Prior Authorization Required.

Therapy (Individual/Family) Up to ten (10) visits with prior authorization; brief individual psychotherapy-unlimited with prior authorization

Tutorial Services Virtual tutoring services in language arts, math, science, social studies, and foreign languages for enrollees that are at risk for failing a class, up to two

(2) hours per week with prior authorization.

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

Water Safety Benefit water safety expanded benefit that covers up to one hundred sixty dollars ($160) in swim lessons. No Prior Authorization Required.

Adult Expanded Benefits

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 6 of 14

Acupuncture Acupuncture is a treatment that can ease enrollees' physical, mental, and emotional conditions. To assure access to this beneficial treatment, we will offer unlimited acupuncture visits, based on medical necessity, as an expanded benefit for enrollees ages twenty-one (21) and older. Prior Authorization Required.

Adult Additional Primary Care Services Unlimited primary care visits for enrollees ages twenty-one (21) and over. Prior Authorization Required.

Adult Visual Aid Services Eligible enrollees can receive an eye exam and glasses annually or a six-month (6) supply of prescription contact lenses. No Prior Authorization Required.

Alzheimer's Reading Support This expanded benefit provides enrollees diagnosed with Alzheimer's with a fifty dollar ($50) book gift card to purchase activity and engagement books to reduce cognitive decline. Prior Authorization Required.

Assessment Services Simply enrollees ages twenty-one (21) and older can receive unlimited assessment services, including psychiatric evaluations, in-depth assessments for mental health or substance use, psychological testing, drug screening, medication management, and more based on medical necessity. Prior Authorization Required.

Assisted Living Facility - Bed Hold Maximum of thirty-one (31) days; enrollee must reside in the facility for a minimum of thirty (30) days between episodes; enrollee must intend to return to the facility and continue to make all room and board and/or patient responsibility payments; providers must notify the Managed Care Plan within forty-eight

(48) hours of the enrollee leaving the facility to be eligible for reimbursement under this benefit.

Assisted Living Facility Transition Catalog Enrollees current living in an ALF and new enrollees transitioning/moving into an ALF can select up to fifty dollars ($50) worth of items. One benefit per lifetime; requires Case Manager referral

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 7 of 14

Behavioral Health Services - Drug Screening

To assure enrollees receive the right level of support, Simply enrollees ages twenty-one (21) and older can receive unlimited assessment services, including psychiatric evaluations, in-depth assessments for mental health or substance use, psychological testing, drug screening, medication management, and more based on medical necessity. Prior Authorization Required.

Behavioral Health Services - Medication Management

To assure enrollees receive the right level of support, Simply enrollees ages twenty-one (21) and older can receive unlimited assessment services, including psychiatric evaluations, in-depth assessments for mental health or substance use, psychological testing, drug screening, medication management, and more based on medical necessity. Prior Authorization Required.

Caregiver Respite To reduce caregiver stress and anxiety and prevent caregiver burnout, we will offer the following supports for caregivers of enrollees ages eighteen

(18) and older: Short-term caregiver respite. Prior Authorization Required.

Caregiver Supports Annual subscription to a meditation and sleep app to caregivers reduce anxiety and stress. Prior Authorization Required.

Chiropractic Care To help alleviate acute and chronic symptoms, as well as correct underlying mechanical dysfunctions to help enrollees become, and stay, pain-free, we will offer enrollees ages twenty-one (21) and older unlimited chiropractic services as an alternative main management therapy based on medical necessity. Prior Authorization Required.

Community Reintegration Support Transition Assistance - Nursing Facility to Community Setting /Community Re-integration Support; Maximum of six thousand dollars ($6,000.00) allowance per member, per lifetime.

Prior Authorization Required. For LTC Enrollees only.

Durable medical Equipment (DME) Services and Supplies

Enrollees can receive a free automatic (biometric) blood pressure monitor through our DME expanded benefit. Prior Authorization Required.

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 8 of 14

Eviction Prevention Program The Eviction Prevention Program partners with legal aid services to ensure that enrollees are treated fairly and have their rights protected by providing legal representation, counseling, advocacy, and funds for legal fees. Our dedicated Pathways Support Housing team provides tenants with the support and resources they need to avoid eviction and maintain their housing. Total Expanded Benefit units, amount, and frequency are determined on a case-by-case basis by Housing Specialist based on the situation and the needs of the enrollee.

Hearing Services for Adults Hearing Services for Adults expanded benefits covers an enrollee's hearing evaluation and screening, one (1) hearing aid per ear, a hearing aid fitting/check, and the hearing aid dispensing services fee every two (2) years. No Prior Authorization Required.

Home Health Nursing/Aide Services One (1) additional visit per day. No Prior Authorization Required.

Home Visit by a Clinical Social Worker Forty-eight (48) visits per year with prior authorization Housing Assistance Provides financial support to prevent housing instability and helps enrollees with unmet housing related needs. This funding helps enrollees address barriers to housing such as application fees, deposits, housing related documentation, utility hook ups, rental and utility arrears, and essential furniture and/or household goods. Total Expanded Benefit units and frequency are determined on a case-by-case basis by Housing Specialist based on the situation and the needs of the enrollee. Plan will provide up to five hundred dollars ($500) for enrollees in the MMA, LTC, Child Welfare and HIV/AIDs specialty products. Recognizing enrollees with SMI may have greater challenges in securing and maintaining stable housing, we will provide up to two thousand five hundred dollars ($2,500) for enrollees in the SMI specialty product.

AHCA Contract No. FP120, Attachment I, Exhibit I-A, Update 02/01/25 Page 9 of 14

Housing Stabilization Program Housing Stabilization Program supports enrollees with housing insecurity and helps them to secure and maintain affordable housing so they can live independently in the setting of their choice. Our dedicated Pathways Support Housing team support enrollees’ long-term housing goals by working with them to identify housing preferences, aiding in their development of independent living skills, and creating housing support plan with ongoing monitoring. Total Expanded Benefit units, amount, and frequency are determined on a case-by-case basis by Housing Specialist based on the situation and the needs of the enrollee.

Individual Therapy Sessions for Caregivers

Unit of service is fifteen (15) minutes; limit of four (4) units per day, a maximum of twelve (12) days per year. Prior Authorization Required.

Massage Therapy Unlimited with prior authorization.

NEMT Caregiver Transportation For caregivers of enrollees ages eighteen (18) and older: Transportation for caregivers to visit enrollees in an ALF, Adult Family Care Home, or Nursing Home (up to four (4) one-way rides each month).

Prior Authorization Required.

Non-emergency Transportation- Volunteering and Mentoring

Four (4) one-way rides per month for volunteering and mentoring; forty-eight (48) one-way rides annually.

Nutritional Counseling Unlimited counseling sessions for enrollees ages 21 and older. Prior Authorization Required.

Occupational Therapy for Adults Eligible enrollees ages twenty-one (21) and older can receive an annual evaluation and re-evaluation and up to seven therapy sessions per week. No Prior Authorization Required.

Physical Therapy for Adults Enrollees ages twenty-one (21) and older can receive an annual evaluation, re-evaluation, and up to seven (7) therapy sessions per week to promote healthy outcomes. No Prior Authorization Required.

Post-Secondary Education Support Members in 11th or 12th grade (and attest to attending a university, college, community college, or trade school within the next year) are eligible to receive up to a two hundred dollars ($200) allowance towards the items below. This is a once per lifetime benefit. SAT/ACT Guide (Note: this is a gift card to purchase guides, etc.), College application fees, Textbooks, Dorm room items. No Prior Authorization required.

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Respiratory Supplies Eligible enrollees can receive various DME respiratory products to help improve their breathing ability and open airways and improve their quality of life. Prior Authorization Required.

Speech Therapy/Speech Language Pathology

One (1) evaluation and re-evaluation per year. One

(1) evaluation of oral and pharyngeal swallowing function per year. Up to seven (7) therapy treatment units per week. One (1) initial Augmentative and Alternative Communication (AAC) evaluation per year. One (1) AAC re-evaluation per year. Up to four

(4) 30-minute sessions for AAC fitting, adjustment, and training sessions per year. No Prior Authorization Required.

Transportation Essentials Eligible enrollees can choose one of the following items once per household annually: Ride Share Gift Card. Eligible enrollees will receive up to one hundred dollars ($100) in Uber gift cards to help them with their transportation needs; Gas Card.

Enrollees with their own cars can receive up to one hundred dollars ($100) in gas cards; Public Transportation. Eligible enrollees can receive a bus pass to help them with their transportation needs.

No Prior Authorization Required.

Specialty Line of Business

New Placement - Family Night Package Family Night Package offers enrollees ages five (5)-seventeen (17) the opportunity to spend a carefree night with their family where they can focus on fun and quality time together. Enrollees can choose from one of the following options: Family Game Night Package. Enrollees can receive fifty dollars ($50) to purchase a card game, jumbo playing dice, jigsaw puzzle, and classic board game, along with a fifty dollars ($50) restaurant gift card; Family Movie Night. Enrollees can receive a fifty dollars ($50) movie theatre gift card and a fifty dollars ($50) restaurant gift card.

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. FP120, Attachment I, Exhibit I-B, Update 02/01/25, Page 1 of 1

EXHIBIT I-B

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION NUMBERS

Region MMA LTC Specialty1 Specialty2

A 123235300-01 123235400-01 123236100-01 123603800-01 B 123235300-03 123235400-03 123236100-03 123603800-03 C 123235300-05 123235400-05 123236100-05 123603800-05 D 123235300-06 123235400-06 123236100-06 123603800-06 E 123235300-07 123235400-07 123236100-07 123603800-07 F 123235300-08 123235400-08 123236100-08 123603800-08 G 123235300-09 123235400-09 123236100-09 123603800-09 H 123235300-10 123235400-10 123236100-10 123603800-10 I 123235300-11 123235400-11 123236100-11 123603800-11

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. FP120, Attachment I, Update 02/01/25, Exhibit I-C, Page 2 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…