CN-680000-FP121-A1.pdf

AHCA CONTRACT NO. FP121

AMENDMENT NO. 1

AHCA Contract No. FP121, 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 AETNA BETTER HEALTH 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:

Kasimu Henry Agency for Health Care Administration 2727 Mahan Drive, MS #50 Tallahassee, FL 32308

(850) 412-4068 Kasimu,Henry@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: A46B55B0-1205-44AB-ABDE-3651ADE9D9EF mailto:Jessica.Gramling@ahca.myflorida.com

AHCA CONTRACT NO. FP121

AMENDMENT NO. 1

AHCA Contract No. FP121, Amendment No. 1, Page 2 of 2 April 2020

IN WITNESS WHEREOF, the Parties hereto have caused this five hundred and forty-seven (547) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

AETNA BETTER HEALTH 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 (72 Pages)

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

Jennifer Sweet

CEO

1/30/2025

Jason Weida

Secretary

2/2/2025

AETNA BETTER HEALTH OF FLORIDA INC.

ATTACHMENT I

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

STATEWIDE MEDICAID MANAGED CARE PROGRAM

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 1 of 14

I. Services to be Provided

A. Overview of Contract Structure

Part IV of Chapter 409, F.S. established Florida Medicaid’s statewide managed care program, referred to as statewide Medicaid managed care (SMMC). Contracted managed care plans participate in one, or both, of two SMMC programs: one for managed medical assistance (MMA) and one for long-term care (LTC). Additionally, some managed care plans participating in the MMA program component serve specialty populations who meet specified criteria based on age, condition or diagnosis. The Contract consists of distinct parts as follows:

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

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

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

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

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

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

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

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

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

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

Rates – Not for Use Unless Approved by CMS;

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

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

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

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

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

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 2 of 14

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

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

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

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

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

B. Authorized Regions

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

TABLE 1: AUTHORIZED REGIONS

Region Program Component

MMA LTC Specialty Region A

Region B

Region C

Region D X X X Region E X X X Region F

Region G

Region H

Region I X X X

C. Covered Services

The Managed Care Plan shall ensure the provision of covered services in accordance with the provisions of Attachment II and its Exhibits, summarized in the Required MMA Services Table, Table 2A and/or the Required LTC Services Table, Table 2B, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 3 of 14

TABLE 2A: REQUIRED MMA SERVICES

(1) Advanced Practice Registered Nurse

(2) Ambulatory Surgical Center Services

(3) Assistive Care Services

(4) Behavior Analysis Services

(5) Behavioral Health Services

(6) Birth Center and Licensed Midwife Services

(7) Clinic Services

(8) Chiropractic Services

(9) Child Health Check Up

(10) Immunizations

(11) Early Intervention Services

(12) Emergency Services

(13) Family Planning Services and Supplies

(14) Healthy Start Services

(15) Hearing Services

(16) Home Health Services and Nursing Care

(17) Hospice Services

(18) Hospital Services

(19) Laboratory and Imaging Services

(20) Medical Foster Care Services

(21) Medical Supplies, Equipment, Prostheses and

Orthoses

(22) Nursing Facility Services

(23) Optometric and Vision Services

(24) Physician Assistant Services

(25) Physician Services

(26) Podiatric Services

(27) Prescribed Drug Services

(28) Renal Dialysis Services

(29) Therapy Services

(30) Transportation Services

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 4 of 14

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.

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 5 of 14

TABLE 3: APPROVED EXPANDED BENEFITS

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

Hypoallergenic Bedding, Carpet Cleaning, Pest Control, etc.

X Behavioral Health Integration Services/Collaborative Care Cellular Phone Services

X Child Enrichment Assistance- May include benefits such as After School Activity Stipend, Camp Scholarship etc.

X Disaster Relief Benefit- May include items such as a Grocery and Cleaning Supplies Card, Shelf Stable Meals, etc.

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

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

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

X 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.

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. FP121, Attachment I, Update 02/01/2025, Page 6 of 14

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

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

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

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

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

Sports Physical 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 X Vision + Hearing Flex Card X Waived Copayments

Adult Expanded Benefits - These services are only available for adults because they are already covered for children on Medicaid when medically necessary Activity Therapy- May include benefits such as Art, Equine, and Pet Therapy Acupuncture

X Adult Additional Primary Care Services- May include benefits such as Increased Office Visits

X Adult Visual Aid and Hearing Services- May include benefits such as Contact Lenses, Hearing Aids, etc.

Behavioral- Assessment/Evaluation and Screening Services

Behavioral- Intensive Outpatient Treatment Behavioral Health- Individual Therapy Sessions to

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

Caregiver Support, Education, and Training

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 7 of 14

Chiropractic Services Computerized Cognitive Behavioral Therapy Criminal Expungement Services

X Developmental Disabilities Stipend Financial Literacy Home Health Nursing/Aide Services- May include benefits such as Extra Home Visits Home Visit by a Clinical Social Worker Massage Therapy

X Medical Therapies- May include benefits such as additional Physical, Occupational, Speech and/or Respiratory Therapy

Substance Abuse Treatment or Detoxification Services (Outpatient)

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

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

Individual/Family Therapy Long-Term Care Services - these services are only available for LTC enrollees ALF/AFCH- Bed Hold Days ALF/Home Based Setting Move-In Items Aquatic Therapy Durable Medical Equipment and Misc. Items Benefit- May include benefits such as Mobility Items, Dental Kits, etc.

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 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

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 8 of 14

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

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

Counseling Robotic Therapy Pet

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

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 9 of 14

II. Manner of Service Provision

A. Plan Qualification

The Managed Care Plan is approved to provide contracted services as a qualified entity under s. 409.962(7), F.S., as denoted by “X” in the Plan Qualification Table, Table 4, below.

TABLE 4: PLAN QUALIFICATION

X Health Maintenance Organization (HMO) Provider Service Network (PSN) Exclusive Provider Organization (EPO) Accountable Care Organization (ACO) Other Insurer

B. Plan Type

The Managed Care Plan is approved to provide contracted services as one or more of five plan types, denoted by authorized region(s) in the SMMC Plan Type Table, Table 5, below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

(1) Managed Medical Assistance (MMA) Plan – A Managed Care Plan that is eligible to provide MMA services to recipients who are eligible only for MMA services.

This plan type is not eligible to provide services to recipients who are eligible for LTC Services.

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

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

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

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

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

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

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 10 of 14

TABLE 5: SMMC PLAN TYPE

Region SMMC Program MMA/LTC Specialty 1 Specialty 2

Region A

Region B

Region C

Region D Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

Region E Comprehensive LTC Plus

Serious Mental Illness (SMI)

HIV/AIDS

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 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. FP121, Attachment I, Update 02/01/2025, Page 11 of 14

III. Method of Payment

A. Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $6,865,757,348 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

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, of this Contract.

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

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

E. Faculty Plans of Florida Medical School Faculty Physician Groups Rates – Not for

Use Unless Approved by CMS

The per-member per-month (PMPM) rates for payment of Florida medical school faculty physician groups shall be in accordance with Attachment II and its Exhibits. The PMPM rates are contained in Exhibit I-I, Faculty Plans of Florida Medical School Faculty

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 12 of 14

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. 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. FP121, Attachment I, Update 02/01/2025, Page 13 of 14

IV. Special Provisions

A. Order of Precedence

(1) For all applicable regions as specified in Table 1: Authorized Regions, the Managed Care Plan shall perform its contracted duties in accordance with this Contract, the ITN(s), including all addenda and the Vendor’s response to the ITN(s). In the event of conflict among Contract documents, any identified inconsistency in this Contract shall be resolved by giving precedence in the following order:

a. This Contract, including all attachments;

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

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

B. Plan-Specific Commitments

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

C. Special Terms and Conditions

The Managed Care Plan shall furnish to the Agency a performance bond in the total amount of twenty-one million dollars ($21,000,000) 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

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

D HIV/AIDS $1,000,000

E HIV/AIDS $1,000,000

AHCA Contract No. FP121, Attachment I, Update 02/01/2025, Page 14 of 14

I HIV/AIDS $1,000,000

Total Performance Bond Amount: $21,000,000

AHCA Contract No. FP121, Attachment I, Exhibit I-A, Update: 02/01/2025, Page 1 of 4

EXHIBIT I-A

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

APPROVED EXPANDED BENEFITS COVERAGE AND LIMITATIONS

Approved Benefit Approved Limitations

General Expanded Benefits

After School Activities Fifty dollars ($50) stipend per year for after school activities. No prior authorization required.

Asthma Home Care Hypoallergenic bedding, one hundred fifty dollars ($150) stipend for carpet cleaning and pest control.

Prior authorization required.

Behavioral Health Integration Services Additional payment for care management services received from their primary care team. No prior authorization required.

Blue Jeans for Teens One hundred fifty dollars ($150) stipend per year for teenage and young adult clothing after WCV or in Active Care. Prior authorization required.

Calming Comfort Collection One (1) calming box per year including items to support members with mental health concerns and trauma. Prior authorization required.

Childcare Financial Support One hundred fifty dollars ($150) per quarter to pay for childcare during pregnancy up to twelve (12) months. Prior authorization required.

Diaper Club Forty-five dollars ($45) diaper stipend per month for each child under thirty (30) months of age. Prior authorization required.

Doula Services Unlimited doula services to support prenatal and postpartum services. No prior authorization required.

Durable Medical Equipment Services and Supplies

One (1) automatic blood pressure monitor per year.

Prior authorization required.

AHCA Contract No. FP121, Attachment I, Exhibit I-A, Update: 02/01/2025, Page 2 of 4

Financial Literacy Book One (1) financial literacy book for children and adolescents. No prior authorization required.

Food as Medicine Benefit Fifty Dollars ($50) food stipend per month for members with chronic conditions. Prior authorization required.

Home Delivered Meals- Hurricane Preparedness

Three (3) home delivered meals/day for up to twelve (12) weeks. For HCBS members only. Prior authorization required.

Home Delivered Meals- Post Discharge Three (3) meals/day for up to twelve (12) weeks.

Prior authorization required.

Medication Lockbox Program One (1) lockbox per year to secure medications in the home. No prior authorization required.

Medication Lockbox Program One (1) lockbox per year to secure medications in the home. No prior authorization required.

Member Baby Item Stipend One hundred fifty dollars ($150) stipend per pregnancy for baby items such as crib, stroller and car seat. Prior authorization required.

Newborn Circumcision Once (1) per lifetime for infants up to twenty-eight

(28) days old. No prior authorization required.

Over-the-Counter Period Stipend Twenty dollars ($20) per member per month for menstrual products. No prior authorization required.

Over-the-Counter Sixty-five dollars ($65) per household per month for over-the-counter products. No prior authorization required.

Prenatal Services Breast pump; Expanded prenatal and postpartum visits. No Prior Authorization Required.

Tutoring for Children and Adolescents Unlimited individualized tutoring and mentoring sessions for children and adolescents. No prior authorization required.

Vision + Hearing Flex Card Four hundred dollars ($400) stipend every two (2) years for extra vision and hearing services. No prior authorization required.

AHCA Contract No. FP121, Attachment I, Exhibit I-A, Update: 02/01/2025, Page 3 of 4

Waived Copayments Unlimited waived copayments on all Medicaid covered services.

Young Adult Life Coaching Services Online education to support members with developing life skills as they transition into adulthood. No prior authorization required.

Adult Expanded Benefits

Adult Additional Primary Care Services Unlimited primary care visits for adults .

Adult Visual Aid Services

Six (6) months' supply of contact lenses with prescription lenses; frames and an eye exam once

(1) per year. No prior authorization required.

Career Closet

One hundred dollars ($100) clothing stipend per member, One (1) time only, to support workforce development. Prior authorization required.

Stipend for Developmentally Disabled Adults

Five Hundred Dollars ($500) stipend may be used to cover the member’s expenses related to -education/job training, pursuing volunteer opportunities or faith-based activities, amenities/services that provide improvements for the home, and supports that address barriers to access to care such as additional transportation or provider consultations not otherwise covered by Medicaid. For HCBS members only. Prior

GED Support and Job Skills Training

Access to job skills training platform with costs covered for preparation courses, materials, and tests to help members pass GED. No prior

Grooming and Hygiene Stipend

For members in active care will receive a fifty dollars ($50) stipend per quarter to support workforce activities. Prior authorization required.

Hardship Grants

One thousand dollars ($1000) stipend per year to support members with crisis events that impact housing stability or maintenance. Prior authorization required.

HCBS Housing/Utility Stipend

Five hundred dollars ($500) stipend for members in need of assistance with housing incidentals such as utility payments. Prior authorization required.

AHCA Contract No. FP121, Attachment I, Exhibit I-A, Update: 02/01/2025, Page 4 of 4

Hearing Services for Adults

One (1) hearing exam and a set of hearing aids, One (1) per every two (2) years. No prior

Laundromat stipend

Twenty-five dollars ($25) stipend per quarter for laundromat services for members in active care.

Prior authorization required.

Legal Services Access to legal services related to housing issues.

No prior authorization required.

Non-Emergency Transportation - Non- Medical Purposes

Ten (10) one-way trips per month to access additional resources such as food banks, local organizations, faith-based groups and other activities. No prior authorization required.

Occupational Therapy for Adults

Occupational Therapy evaluation and re-evaluation every year, up to seven (7) therapy treatment units per week, and wheelchair fitting once (1) every two

(2) years. Prior authorization required.

Physical Therapy for Adults

Physical therapy evaluation and re-evaluation every year, up to seven (7) therapy treatment units per week; wheelchair fitting once (1) every two (2) years. 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. FP121, 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

C

D 123367200-06 123367600-06 123367700-06 123604100-06 E 123367200-07 123367600-07 123367700-07 123604100-07 F

G

H

I 123367200-11 123367600-11 123367700-11 123604100-11

1. Serious Mental Illness (SMI)

2. HIV/AIDS

The Agency will provide Medicaid Provider Identification Numbers to the Managed Care Plan subsequent to the Agency’s completion of a plan-specific readiness review and prior to enrolling recipient in the Managed Care Plan in each authorized region.

SCOPE OF SERVICES -- UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP121, Attachment I, Exhibit I-C, Update: 02/01/2025, Page 3 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

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

Region HCBS Rate Group Non-HCBS Rate Group

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

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

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

CAPITATION RATES BY RATE GROUP, NET OF PATIENT RESPONSIBILITY

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

AETNA BETTER HEALTH OF FLORIDA INC

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP121, 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

SCOPE OF SERVICES – UPDATE: FEBRUARY 1, 2025

AHCA Contract No. FP121, Attachment I, Exhibit I-E, Update: 02/01/2025, Page 1 of 1

EXHIBIT I-E

VALUE-BASED PURCHASING PERFORMANCE TARGETS

TABLE 4

INCREMENTAL INCREASE IN EXPENDITURES IN VALUE-BASED PURCHASING

AGREEMENTS WITH PROVIDERS*

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

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.

AHCA Contract No. FP121, Attachment I, Exhibit I-F, Update 02/01/2025, 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 10% 25% Contract Year 2 15% 30% Contract Year 3 20% 35% Contract Year 4 25% 40% Contract Year 5 30% 45% Contract Year 6 35% 50%

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

EXHIBIT I-G

AFTER-HOURS AND TELEMEDICINE TARGETS

By the end of Contract Year 1, and in every subsequent Contract Year, the Managed Care Plan agrees that at least the target percentages of the required providers (as required by the Managed Medical Assistance Provider Network Standards Table 4 in Exhibit II-A), in each region, offer after-hours appointment availability.

Regions Provider Type A B C D E F G H I Pediatrics 50% 55% 60% Child Psychiatrists 75% 65% 75% Adult Psychiatrists 75% 75% 75% Licensed Practitioner of the Healing Arts (LPHA)

75%

75%

80%

By the end of Contract Year 1, and in every subsequent Contract Year, the Managed Care Plan agrees that at least the target percentages of the required providers (as required by the Managed Medical Assistance Provider Network Standards Table 4 in Exhibit II-A), in each region, offer telemedicine appointments.

Regions Provider Type A B C D E F G H I Pediatrics 40% 40% 40% Child Psychiatrists 75% 75% 75% Adult Psychiatrists 50% 50% 50% Licensed Practitioner of the Healing Arts (LPHA)

50%

AHCA Contract No. FP121, Attachment I, Exhibit I-G, Update: 02/01/2025, Page 1 of 1

EXHIBIT I-H

PUBLIC HOSPITAL PHYSICIAN UNIFORM PAYMENT INCREASE - NOT FOR USE UNLESS

APPROVED BY CMS

{PENDING FINALIZATION}

AHCA Contract No. FP121, Attachment I, Exhibit I-H, Update 02/01/2025, Page 1 of 1

AHCA Contract No. FP121, Attachment I, Exhibit I-I, Update 02/01/2025, Page 1 of 1

EXHIBIT I-I

FACULTY PLANS OF FLORIDA MEDICAL SCHOOL FACULTY PHYSICIAN GROUPS RATES –

NOT FOR USE UNLESS APPROVED BY CMS

AHCA Contract No. FP121, Attachment I, Exhibit I-J, Update 02/01/2025, Page 1 of 1

EXHIBIT I-J

FLORIDA CANCER HOSPITAL MINIMUM FEE SCHEDULE RATES - NOT FOR USE UNLESS APPROVED BY CMS

AHCA Contract No. FP121, Attachment I, Exhibit I-K, Update 02/01/2025, Page 3 of 3

EXHIBIT I-K

MMA PHYSICIAN INCENTIVE PROGRAM (MPIP)

AGENCY MPIP MODEL

Option 1 Qualifications for Pediatric Primary Care Physicians (PCP)

A site has been recognized by one of the following organizations as a Patient-Centered Medical Home (PCMH) with a recognition date on or before October 1, 2024:

National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC)

The Joint Commission (TJC) Utilization Review Accreditation Commission (URAC)

OR

Option 2 Qualifications for Pediatric Primary Care Physicians (PCP)

A site with at least fifty (50) panel members must achieve or exceed the benchmarks for the following metrics. All measures below must be calculated using HEDIS Measurement Year 2023 specifications/Child Core Set specifications for Measurement Year 2023 services.

Measure

Measure Description

HEDIS Measurement Year

Benchmark to Qualify

Child and Adolescent Well-Care Visits (3-21 yrs.)

Percentage of members 3–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

2023 55.59%

Child and Adolescent Well-Care Visits (3-11 yrs.)

Percentage of members 3–11 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

2023 62.24%

Child and Adolescent Well-Care Visits (12- 17 yrs.)

Percentage of members 12-17 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

2023 53.71%

Child and Adolescent Well-Care Visits (18- 21 yrs.)

Percentage of members 18-21 years of age who had at least one comprehensive well-care visit with a PCP or

2023 27.94% an OB/GYN practitioner during the measurement year.

Well Child Visits in the First 30 Mos. (0-15 mos.) – 6 or more visits

Percentage of members who had the following number of well-child visits with a PCP for Age 0 Months–15 Months: six or more visits

2023 58.68%

Well Child Visits in the First 30 Mos. (15-30 mos.) – 2 or more visits

Percentage of members who had the following number of well-child visits with a PCP for Age 15 Months–30 Months: two or more visits

2023 76.50%

Lead Screening Percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

Children turning 2 years old in 2023

72.34%

Option 1 Qualifications for Obstetrician/Gynecologist (OB/GYN)

A site has been recognized as a Patient Centered Specialty Practice (PCSP) by the National Committee for Quality Assurance (NCQA) or by one of the following organizations as a Patient-Centered Medical Home (PCMH) with a recognition date on or before October 1, 2024:

National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC)

The Joint Commission (TJC) Utilization Review Accreditation Commission (URAC)

OR

Option 2 Qualifications for Obstetrician/Gynecologist (OB/GYN)

A site must achieve or exceed the benchmark for all three of the following:

Measure

Measure Description

Measurement Period

Benchmark to Qualify

Timeliness of Prenatal Care

The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization using HEDIS Measurement Year 2022 specifications

HEDIS

Measurement Year

83.53%

Postpartum Care Percentage of deliveries in which women had a postpartum visit on or between 7 and 84 days after delivery using HEDIS Measurement Year 2022 specifications

HEDIS

Measurement Year

76.18%

Florida Medicaid Cesarean Section Rate

The percentage of single live-born Medicaid births in a practice (pay to provider) that were delivered via cesarean section (C-section), using the 2023 Florida Medicaid Cesarean Section Rate Calculation Specifications, as provided in Attachment 1 to this policy transmittal.

CY 2023 <35%

Specialists

All physicians who are Specialists, regardless of board certification. No additional qualification measures are required.

AHCA Contract No. FP121, Attachment I, Exhibit I-L, Update 02/01/2025, Page 1 of 1

SCOPE OF SERVICES

EXHIBIT I-L

HOSPITAL UNIFORM PERCENTAGE INCREASE PAYMENTS– NOT FOR USE UNLESS APPROVED BY CMS

<PENDING FINALIZATION>

AHCA Contract No. FP121, Attachment I, Exhibit I-M, Update 02/01/2025, Page 1 of 1

EXHIBIT I-M

PUBLIC EMERGENCY MEDICAL TRANSPORTATION UNIFORM INCREASE PAYMENTS –

NOT FOR USE UNLESS APPROVED BY CMS

<PENDING FINALIZATION>

AHCA Contract No. FP121, Attachment I, Exhibit I-N, Update 02/01/2025, Page 1 of 38

SCOPE OF SERVICES -UPDATE: FEBRUARY 1, 2025

EXHIBIT I-N

PLAN-SPECIFIC COMMITMENTS