Exhibit 10.19
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HealthEase of Florida, Inc.
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Medicaid Reform HMO
Contract
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AHCA CONTRACT NO.
FAR001
AMENDMENT NO. 11
THIS CONTRACT, entered into between the STATE
OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION , hereinafter
referred to as the "Agency" and HEALTHEASE OF FLORIDA, INC.
, hereinafter referred to as the "Vendor," is hereby amended as
follows:
1.
Attachment II, Table of Contents, is hereby
amended as follows:
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Section IV
Enrollee Services and Marketing is hereby amended to now
read:
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Section IV Enrollee Services, Community Outreach
and Marketing
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Section IV,
Item B. is hereby amended to now read:
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Community
Outreach and Marketing
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section I, Item A.,
Definitions, is hereby amended as follows:
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The definition
of Community Outreach Representative is hereby included as
follows:
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Community
Outreach Representative – A person who provides Community
Outreach, including health information, information that
promotes healthy lifestyles, information that provides guidance
about social assistance programs, and information that provides
culturally and linguistically appropriate health or nutritional
education. Such representatives must be appropriately
trained, certified and/or licensed, including but not limited to,
social workers, nutritionists, physical therapists and other health
care professionals.
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The definition
of Community Outreach is hereby included as follows:
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Community
Outreach – The
provision of health or nutritional information, or information for
the benefit and education of, or assistance to, a community in
regard to health-related matters or public awareness that promotes
healthy lifestyles. Community Outreach also includes the
provision of information about health care services, preventive
techniques and other health care projects and the provision of
information related to health, welfare, and social services or
social assistance programs offered by the State of Florida or local
communities.
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The definition
of Community Outreach Materials is hereby included as
follows:
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Community
Outreach Materials – Materials regarding health or
nutritional information, or information for the benefit and
education of, or assistance to, a community in regard to
health-related matters or public awareness that promotes healthy
lifestyles; such materials are specifically meant for the community
at-large and may also include information about health care
services, preventive techniques and other health care projects and
the provision of information related to health, welfare, and social
services or social assistance programs offered by the State of
Florida or local communities. Community Outreach
Materials are limited to brochures, fact sheets, posters, and ad
copy for radio, television, print or the Internet.
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The definition
of Market Area is hereby amended to read as follows:
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Market
Area – The geographic area in which the Health
Plan is authorized to conduct Community Outreach.
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The definition
of Marketing Representative is hereby deleted in its
entirety.
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AHCA Contract No. FAR001,
Amendment No. 11, Page 1 of 11
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HealthEase of Florida, Inc.
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Medicaid Reform HMO
Contract
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-- The
definition of Pre-Enrollment is hereby amended to read as
follows:
Pre-Enrollment – The provision of Marketing materials to
a Medicaid Recipient.
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The definition
of Pre-Enrollment Application is hereby deleted in its
entirety.
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The definition
of Public Event is hereby amended to read as follows:
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Public
Event – An
event that is organized or sponsored by an organization, for the
benefit and education of, or assistance to, a community in regard
to health-related matters or public awareness.
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The definition
of Remediation is hereby included as follows:
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Remediation - Remediation of encounter claims; where
remediation is “the act or process of correcting a fault or
deficiency.”
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The definition
of Request for Benefit Information (RBI)is hereby deleted in its
entirety.
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section I, Item B.,
Acronyms, is hereby amended as follows:
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The acronym
ACCESS is hereby included as follows:
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ACCESS – Automated Community Connection to
Economic Self-Sufficiency: The Department of Children
and Families’ (DCF’s) public assistance service
delivery system.
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The acronym
SNIP is hereby included as follows:
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SNIP – Strategic National Implementation
Process
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The acronym
WEDI is hereby included as follows:
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WEDI – Workgroup for Electronic Data
Interchange
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section III,
Eligibility and Enrollment, Item C., Disenrollment, sub-item
2.a.(4), is hereby amended as follows:
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A substantiated
Marketing or Community Outreach violation has occurred.
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section IV, Enrollee
Services and Marketing, is hereby retitled “Enrollee
Services, Community Outreach and Marketing.”
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section IV, Enrollee
Services, Community Outreach and Marketing, Item A., Enrollee
Services, sub-item 11.d.(3), the first sentence is hereby amended
to read as follows:
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The Health Plan
may not include the redetermination date information in any file
viewable by customer service or Community Outreach
staff.
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Attachment II,
Medicaid Reform Health Plan Model Contract, Section IV, Item B.,
Marketing, is hereby deleted in its entirety and replaced as
follows:
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Community
Outreach and Marketing
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AHCA Contract No. FAR001,
Amendment No. 11, Page 2 of 11
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HealthEase of Florida, Inc.
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Medicaid Reform HMO
Contract
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The Health
Plan’s Community Outreach Representative(s) may provide
Community Outreach at Health Fairs/Public events as noticed by the
Health Plan to the Agency in accordance with sub-item 4. of this
Section. The main purpose of a Health Fair/Public Event
shall be to provide Community Outreach and shall not be for the
purpose of Medicaid Health Plan Marketing.
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For each new
Contract Period, the Health Plan shall submit to the Agency Bureau
of Managed Health Care for written approval, all Community Outreach
material no later than sixty (60) Calendar Days prior to Contract
renewal, and for any changes in the Community Outreach material, no
later than thirty (30) Calendar Days prior to
implementation. All materials developed shall be
governed by the requirements set forth in this Section.
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To announce
participation at a specific event (Health Fair/Public Event), the
Health Plan shall submit a notice to the Agency in accordance with
sub-item B.3., Permitted Activities.
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The Health Plan
shall be responsible for developing and implementing a written plan
designed to control the actions of its Community Outreach
Representatives.
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All of the
Community Outreach policies set forth in this Contract apply to
staff, Subcontractors, Health Plan volunteers and all persons
acting for or on behalf of the Health Plan.
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The Health Plan
is vicariously liable for any Outreach and Marketing violations of
its employees, agents or Subcontractors. Any violations
of this section shall subject the health plan to administrative
action by the Agency as determined by the Agency. The
health plan may dispute any such administrative action pursuant to
Section XVI, Item I., Disputes.
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Nothing in this
Section shall preclude a Health Plan from otherwise donating to or
sponsoring an event with a community organization where time, money
or expertise is provided for the benefit of the
community. At such events no Community Outreach
materials or Marketing materials may be distributed by the Health
Plan, but the Health Plan may engage in brand-awareness activities,
including the display of Health Plan or Product
logos. Inquiries at such events from prospective
enrollees must be referred to the Health Plan’s member
services section and the Agency’s Choice Counselor/Enrollment
Broker.
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The Health Plan
is prohibited from engaging in the following non-exclusive list of
activities:
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Marketing for
Enrollment to any potential members or conducting any
Pre-Enrollment activities not expressly allowed under this
Contract.
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Any of the
prohibited practices or activities listed in Section 409.912,
F.S.
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Engaging in
activities for the purpose of recruitment or Enrollment.
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In accordance
with sections 409.912 and 409.91211, F.S., practices that are
discriminatory, including, but not limited to, attempts to
discourage Enrollment or reenrollment on the basis of actual or
perceived health status.
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Direct or
indirect Cold Call Marketing or other solicitation of Medicaid
Recipients, either by door-to-door, telephone or other means, in
accordance with section 4707 of the Balanced Budget Act of 1997,
and section 409.912, F.S.
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AHCA Contract No. FAR001,
Amendment No. 11, Page 3 of 11
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HealthEase of Florida, Inc.
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Medicaid Reform HMO
Contract
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In accordance
with section 409.912, F.S., activities that could mislead or
confuse Medicaid Recipients, or misrepresent the Health Plan, its
Community Outreach Representatives, or the Agency. No
fraudulent, misleading, or misrepresentative information shall be
used in Community Outreach, including information regarding other
governmental programs. Statements that could mislead or
confuse include, but are not limited to, any assertion, statement
or claim (whether written or oral) that:
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The Medicaid
Recipient must enroll in the Health Plan in order to obtain
Medicaid, or in order to avoid losing Medicaid benefits;
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The Health Plan
is endorsed by any federal, State or county government, the Agency,
or CMS, or any other organization which has not certified its
endorsement in writing to the Health Plan;
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Community
Outreach Representatives are employees or representatives of the
federal, State or county government, or of anyone other than the
Health Plan or the organization by whom they are
reimbursed;
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The State or
county recommends that a Medicaid Recipient enroll with the Health
Plan; and/or
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A Medicaid
Recipient will lose benefits under the Medicaid program, or any
other health or welfare benefits to which the Recipient is legally
entitled, if the Recipient does not enroll with the Health
Plan.
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Granting or
offering of any monetary or other valuable consideration for
Enrollment.
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Offers of
insurance, such as but not limited to, accidental death,
dismemberment, disability or life insurance.
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Enlisting the
assistance of any employee, officer, elected official or agent of
the State in recruitment of Medicaid Recipients except as
authorized in writing by the Agency.
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Offers of
material or financial gain to any persons soliciting, referring or
otherwise facilitating Medicaid Recipient
Enrollment. The Health Plan shall ensure that no plan
staff market the Health Plan to Medicaid Recipients at any location
including State offices or DCF ACCESS centers.
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Giving away
promotional items in excess of $5.00 retail value. Items
to be given away shall bear the Health Plan's name and shall only
be given away at Health Fairs/Public Events. In
addition, such promotional items must be offered to the general
public and shall not be limited to Medicaid Recipients.
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Providing any
gift, commission, or any form of compensation to the Choice
Counselor/Enrollment Broker, including the Choice
Counselor/Enrollment Broker's full-time, part-time or temporary
employees and Subcontractors.
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Provide
information, prior to the Enrollment, about the incentives that
shall be offered to the Enrollee as described in Section VIII.B.7.,
Incentive Programs. The Health Plan may inform Enrollees
on or after their Enrollment effective date about the specific
incentives or programs available.
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Discussing,
explaining or speaking to a potential member about
Health-Plan-benefit-specific information other than to refer all
Health Plan inquiries to the Member Services section of the Health
Plan or the Agency’s Choice Counselor/Enrollment
Broker.
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AHCA Contract No. FAR001,
Amendment No. 11, Page 4 of 11
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HealthEase of Florida, Inc.
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Medicaid Reform HMO
Contract
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Distributing
any Community Outreach Materials without prior written notice to
the Agency except as otherwise allowed under Permitted Activities
and Provider Compliance subsections.
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Distributing
any Marketing materials.
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Subcontract
with any brokerage firm or independent agent as defined in Chapters
624 – 651, F.S., for purposes of Marketing or Community
Outreach.
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Pay commission
compensation to Community Outreach Representatives for new
Enrollees. The payment of a
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