General SRC #02, Attachment 3: Affidavit for Service Area Expansion

Via Federal Express

October 16, 2017

Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #26 Tallahassee, FL 32308

Magellan COMPLETE CARE

Re: Florida MHS, Inc. (d/b/a Magellan Complete Care), Expansion of Service Area

To Whom It May Concern:

Enclosed please find a completed Application/Affidavit for Expansion of Service Area. We are seeking state-wide service coverage with a requested effective date of August 1, 2017.

Should you require additional information, please contact me at (410) 953-2048 or via email at UCollison@magellanhealth.com.

Sincerely,

Lorie Collison

Compliance Analyst

Enclosure

Magellan Health, Inc., Corporate Compliance Department, 6950 Columbia Gatew ay Drive, Columbia, MD 21046

STATE OF FLORIDA

,Ji fiHCA AGENCY FOR HEALTH CARE ADMINISTRATION

AFFIDAVIT BY HMOJPHC/EPO FOR EXPANSION OF SERVICE AREA

STATE OF FLORIDA COUNTY OF Miami-Dade ~~~~~~~~~~-

Pursuant to Chapter 64l, Part IJI, Florida Statutes, and Cbapter 59A-12 of the Florida Administrative Code, or section 627.6472, Florida Statutes, affidavit for service area expansion is hereby submitted.

I I. ORGA.SIZ.ATIO:" IDE~TIFICATIOK Legal Name of Organization Florida MHS, lnc. ( d/hia MagelJan Complete Care)

Address 7600 NW Corporate Center Drive, Suire 600

Street Miami

City Federal TD Number 45-4229574

FL

State

Miami-Dade

County 33126

Zip Code

~~~~~~~~~~~~~~~~~~~~-

II. CURRE~T SERVICE AREAS APPRO\-ED (indicate dates and partial zip code royals, where a Alachua

J Baker ~Bay

Bradford ./ Brevard .I Broward

T calhoun Charlotte Citrus

_L_Clay Collier Columbia

./ Dade DeSoto Dixie

/ Duval Escambia

licablt-) _L_Flagler L__Franklin T Gadsden

Gilchrist Glades

_L_Gulf Hamilton ~Hardee __ Hendry

Hernando _{_Highlands _£_Hillsborough £ Holmes ./ Indian River

T Jackson ./ Jefferson __ Lafayette

Lake Lee

-rLeon _ _ Levy _L_Liberty _LMadison _i_Manatee

Marion _LMartin _L_Monroe _{_Nassau

Okaloosa ~Okeechobee ~OranQ.e ./ Osce~Ja

__LPalm Beach _L_Pasco

_L__ Pinellas _LPolk

Putnam Santa Rosa Sarasota

./ Seminole _L_ St. Johns _L__ St. Lucie

Sumter Suwannee

I Taylor Union

_L_ Volusia 1-_Wakulla

Walton ./ Washington

Broward, Dade, Palm Beach appr).=?v.ep 9/24/12; remainder approved 5/22/14 - a.-~'<i, p I

_ 2_72_7_M_a_h-an-D-ri,-·e-.-M-ai-l -St_o_p_li_26----,:::~~ri~ l 'isi1 AHCA online at age

Tallahassee, FL 32308 _.~~,:- http.-/lwww.ahca.myjl.orida.com

AJiCA. form 3 \60-1005. Marth 2005

I III. LIST OF SERVICES TO BE PRO\.IDED I~ REQCESTED SERVICE AREA

_{_Emergency Services and Care _i_ln-patient Hospital _L_Physician ./ Ambulatory Diagnostic

_L Skilled Nursing _.f_ Rehabilitation _{_Vision

_L_Dental _L_Hearing

I Ambulance -r Home Health ,/ Pharmacy

_L_ DME/supplies _{__Mental health

IV. SER\ ICE AREA(S) REQC'ESTED (indicate included zip codes, if requesting partial county)

.. __ Flagler _£_Lake Pinellas _v _ _ Alachua

Baker Franklin _L_Lee Polk --__ Bay Gadsden Leon I Putnam ~Bradford ~Gilchrist _L_Levy / Santa Rosa

--Brevard ./ Glades _ _ Liberty ./ Sarasota

--Broward Gulf __ Madison Seminole Calhoun ___L_Hamilton Manatee __ St Johns

./ Charlotte Hardee ./ Marion St. Lucie _L_Citrus _L_Hendry --Martin ,/ Sumter _ _ Clay ~Hernando __ Monroe J._Suwannee

/ Collier _ _ Highlands Nassau _ _ Taylor ./ Columbia _ _ Hillsborough

- , - , _ll_ Okaloosa _y_Union

Dade Holmes _ _ Okeechobee Volusia --I DeSoto Indian River _ _ Orange _ _ Wakulla - ,- --

Dixie Jackson _ _ Osceola __ Walton Duval Jefferson Palm Beach __ Washington

_L_Escambia ./ Lafayette --Pasco

jv. IDENTIFICATION OF i\'ETWORK

A. Subscriber Enrollment. It is understood that the method of subscriber enrollment may impact compliance with access timeframes to the provider network. It is therefore the intent of this organization to enroll subscribers based upon:

r/ Subscriber's county of residence Subscriber's county of employment

r Both of the above

~i·{i~~~ ----------~ "'"1l-Us

2727 M a han Dri v e• Mail S to p 1126 :;. ~ .. " ' $ Tallahassee, FL 32 308 ;: .• . ...., .­

··.~~~~~~ AHC/I Form 3 l 6!H 005. March 20t))

Pag~l

l'isi1 AHCA onlllle OT

http://"www. ahca.myjlorida. com

I

R Network Composition. It is understood that if an organization offers different insurance products that require the utilization of different provider networks, each network must be approved by the agency. Indicate the foJlowing:

Will more than one network be utilized? J' No Yes (identify and explain)

Are there any restrictions/limitations to subscriber access? 7 No Yes (identify and explain)

c. Identification of delegated responsibilities and oversight.

MageUan Complete Care (MCC) is responsible for all work petformed under the Contract with AHCA, but may eoler into subconlracts for perfocmance cl work required under the Contract with AHCA. Wilh the foregoing in mind, MCC does not delegate any key functions lhal it is required to pelform under the Contract, induding all administrative services {i.e. claims. quality. etc.); however, AHCA is aware and previously approved select ancillaty se1Vioe subcontractors (Transportation. Vision Services. and Dental Semces) to petform OOf!ain functions with MCC oversight. These subeontmctors have been given sul>-delegated limited responsibi~ty for contracling lhe networic, credentialing. and paying claims (Vision Vendor does not pay claims) for said services. MCC has a Delegation Oversight Policy and Procedure and au vendors are closely moniored fClf oompiaoc:e to our policies and to lhe oontract

D. Identification of product types (EPO, PHC, HMO traditional. HMO with POS option in same subscriber contract, direct access, open access, Medicare)

HMO Traditional Medicaid

E. Quality Assurance. The organization must demonstrate or affirm the use of Agency­approved quality assurance policies and procedures that exist in approved counties will be used in expanded counties.

Magellan Complete Care affirms that the use of Agency-approved quality assurance policies and procedures that exist in approved counties will be used in expanded counties.

~~~~~~~~~~~~~~~~~~.~-,~~~~ __ i,. 2727 Mahan Drive• Mail Stop 1126 _ . t.k _ Tallahassee, FL 32308 " •

.. ~.!). ,~·

Pagel

f 'isfl AHCA <>nline ar

http:IA.1•ww.ahca.myflorida.com

AHCA form 3160-1005, March 2005

I VI. AFFIDAVIT

·. I (Lcg;i1N;imeormo'PKCIEPO)

. • • . • Florida Im:. 'd/b/a Ma!rellan The umler.ngned, undo< oath, says, it"' the mteotion of MBS, e • J to expand its geographic service area to include the above defilgnated county(ies) effective I (~;:;;veD#)~ I

'1 1 I J' -_ Af!iants s1a1e that the und=igned are two offi=s of the

organization who have the authority to legally bind the organi7.ation. Affiants further state that

said HMO/PHC/EPO has the capability to provide comprehensive health cere services in the new

geographical area listed above by virtue of the included description of how servi~ will be

provided. Furthermore, 15 days prior to the effective date written above, the HMO/PHC/EPO

will demonstrate through documentation or otherwise that it will be capable of providing

services to its projected subscnl>ers for at least the first 60 days of operation.

,,--; th , I .:4 .. Signature.tr/~. /~Signature

I Stiaron M. Muscarella Anne M. McCabe

Title Interim CEO Title \lice President

Sworn to and subscribed to before me, at ·J'1, tJ rrJ l fl , tbis _ _,/~~-<-!IJ __ day of

Cfltab/J c2D I 1 _'

Notary Public, State of Florida at L My Commission Expires: 4z "~ •

Personally Known V -or ID Produced __ __,· Type of ID

Produ.ced'------ -------

:;: Note: Each organization shall notify the agency of its intent to expand its geographic area at least 60 days prior to the date it plans to begin providing health care services in the new area.

2727 Mahan Urive o Mail Stop #26 Tallahassee, FL 32308

AHCA Fonn 3160-1005, Man:h2005

Yi~ii Aflc.d on/inc at http:llwww.ahca.myjlorida.com